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OBJECTIVE-Lowering hemoglobin A1c to <7% reduces the risk of microvascular complications of diabetes, but the importance of maintaining this target in diabetes patients with kidney failure is unclear. We evaluated the relationship between A1c levels and mortality in an international prospective cohort study of hemodialysis patients. RESEARCH DESIGN AND METHODS-Included were 9,201 hemodialysis patients from 12 countries (Dialysis Outcomes and Practice Patterns Study 3 and 4, 2006-2010) with type 1 or type 2 diabetes and at least one A1c measurement during the first 8 months after study entry. Associations between A1c and mortality were assessed with Cox regression, adjusting for potential confounders. RESULTS-The association between A1c and mortality was U-shaped. Compared with an A1c of 7-7.9%, the hazard ratios (95%CI) for A1c levels were 1.35 (1.09-1.67) for <5%, 1.18 (1.01- 1.37) for 5-5.9%, 1.21 (1.05-1.41) for 6-6.9%, 1.16 (0.94-1.43) for 8-8.9%, and 1.38 (1.11- 1.71) for⩾9.0%, after adjustment for age, sex, race, BMI, serumalbumin, years of dialysis, serum creatinine, 12 comorbid conditions, insulin use, hemoglobin, LDL cholesterol, country, and study phase. Diabetes medications were prescribed for 35% of patients with A1c,6% and not prescribed for 29% of those with A1c ⩾9%. CONCLUSIONS-A1c levels strongly predicted mortality in hemodialysis patients with type 1 or type 2 diabetes. Mortality increased as A1c moved further from 7-7.9%; thus, target A1c in hemodialysis patients may encompass values higher than those recommended by current guidelines. Modifying glucose-lowering medicines for dialysis patients to target A1c levels within this range may be a modifiable practice to improve outcomes. [ABSTRACT FROM AUTHOR]

Taking a public health approach to the prevention of end-stage renal disease: The NKF Singapore Program. The National Kidney Foundation Singapore (NKFS) provides subsidized dialysis care to approximately 70% of the country's total end-stage renal disease (ESRD) population, based entirely on charitable donations. Because of the exponential increase in prevalent dialysis patients receiving care through the NKFS' chronic dialysis program, and with the anticipated epidemic rise in incident ESRD patients, an accelerated comprehensive strategy for the prevention of renal and its associated chronic diseases was developed. Presented is the NKFS' public health plan, which incorporates primary, secondary and tertiary approaches to the prevention of chronic kidney disease. Components of this comprehensive strategy include: screening populations at risk for the development and progression of renal disease, the documentation of existing standards of care for chronic diseases associated with renal disease, and the institution of disease management programs that facilitate the systematic management of patients with chronic diseases that lead to ESRD, including the development of community-based “Prevention Centers.” Finally, longitudinal follow-up of the participating population is being performed in order to provide benchmarks for improvement and to determine future directions of the program. Such long-term monitoring also will facilitate the establishment of its efficacy in improving clinical outcomes, reducing the cost of care, and delaying the development and progression of chronic kidney disease. [ABSTRACT FROM AUTHOR]

Paradigms of public-private partnerships in end-stage renal disease care: The National Kidney Foundation Singapore. Novel forms of funding chronic renal replacement therapy and other chronic kidney disease programs are urgently required in order to address the increasing global burden of end-stage renal disease (ESRD). For areas of infectious disease control in less-developed countries, the formation of public-private partnerships has successfully yielded short-term improvement in clinical outcomes. This article reviews the concept of public-private partnerships and its various formats. We argue that similar partnerships play an important role in addressing the public health problem of chronic kidney disease. Through its establishment of numerous paradigms of partnerships with private for-profit corporations in building a nationwide chronic dialysis program and through partnerships with other non-governmental institutions and healthcare institutions in order to create a new entity characterized by a separate management structure, the NKFS has been able to provide chronic dialysis care to over 70% of the country's total ESRD population. This extensive network of partnerships is currently being applied as the NKFS continues to expand its programs to focus on the prevention of chronic kidney disease at a nationwide level. [ABSTRACT FROM AUTHOR]

Paradigms of public-private partnerships in end-stage renal disease care: The National Kidney Foundation Singapore. Novel forms of funding chronic renal replacement therapy and other chronic kidney disease programs are urgently required in order to address the increasing global burden of end-stage renal disease (ESRD). For areas of infectious disease control in less-developed countries, the formation of public-private partnerships has successfully yielded short-term improvement in clinical outcomes. This article reviews the concept of public-private partnerships and its various formats. We argue that similar partnerships play an important role in addressing the public health problem of chronic kidney disease. Through its establishment of numerous paradigms of partnerships with private for-profit corporations in building a nationwide chronic dialysis program and through partnerships with other non-governmental institutions and healthcare institutions in order to create a new entity characterized by a separate management structure, the NKFS has been able to provide chronic dialysis care to over 70% of the country's total ESRD population. This extensive network of partnerships is currently being applied as the NKFS continues to expand its programs to focus on the prevention of chronic kidney disease at a nationwide level. [ABSTRACT FROM AUTHOR]

Taking a public health approach to the prevention of end-stage renal disease: The NKF Singapore Program. The National Kidney Foundation Singapore (NKFS) provides subsidized dialysis care to approximately 70% of the country's total end-stage renal disease (ESRD) population, based entirely on charitable donations. Because of the exponential increase in prevalent dialysis patients receiving care through the NKFS' chronic dialysis program, and with the anticipated epidemic rise in incident ESRD patients, an accelerated comprehensive strategy for the prevention of renal and its associated chronic diseases was developed. Presented is the NKFS' public health plan, which incorporates primary, secondary and tertiary approaches to the prevention of chronic kidney disease. Components of this comprehensive strategy include: screening populations at risk for the development and progression of renal disease, the documentation of existing standards of care for chronic diseases associated with renal disease, and the institution of disease management programs that facilitate the systematic management of patients with chronic diseases that lead to ESRD, including the development of community-based “Prevention Centers.” Finally, longitudinal follow-up of the participating population is being performed in order to provide benchmarks for improvement and to determine future directions of the program. Such long-term monitoring also will facilitate the establishment of its efficacy in improving clinical outcomes, reducing the cost of care, and delaying the development and progression of chronic kidney disease. [ABSTRACT FROM AUTHOR]

Objective: Lowering hemoglobin A(1c) to <7% reduces the risk of microvascular complications of diabetes, but the importance of maintaining this target in diabetes patients with kidney failure is unclear. We evaluated the relationship between A(1c) levels and mortality in an international prospective cohort study of hemodialysis patients.Research Design and Methods: Included were 9,201 hemodialysis patients from 12 countries (Dialysis Outcomes and Practice Patterns Study 3 and 4, 2006-2010) with type 1 or type 2 diabetes and at least one A(1c) measurement during the first 8 months after study entry. Associations between A(1c) and mortality were assessed with Cox regression, adjusting for potential confounders.Results: The association between A(1c) and mortality was U-shaped. Compared with an A(1c) of 7-7.9%, the hazard ratios (95% CI) for A(1c) levels were 1.35 (1.09-1.67) for <5%, 1.18 (1.01-1.37) for 5-5.9%, 1.21 (1.05-1.41) for 6-6.9%, 1.16 (0.94-1.43) for 8-8.9%, and 1.38 (1.11-1.71) for ≥9.0%, after adjustment for age, sex, race, BMI, serum albumin, years of dialysis, serum creatinine, 12 comorbid conditions, insulin use, hemoglobin, LDL cholesterol, country, and study phase. Diabetes medications were prescribed for 35% of patients with A(1c) <6% and not prescribed for 29% of those with A(1c) ≥9%.Conclusions: A(1c) levels strongly predicted mortality in hemodialysis patients with type 1 or type 2 diabetes. Mortality increased as A(1c) moved further from 7-7.9%; thus, target A(1c) in hemodialysis patients may encompass values higher than those recommended by current guidelines. Modifying glucose-lowering medicines for dialysis patients to target A(1c) levels within this range may be a modifiable practice to improve outcomes. [ABSTRACT FROM AUTHOR]