Overcoming Challenges of Glycaemic Management in Diabetic Patients with Kidney Disease

Abstract

A common occurrence encountered in clinical practice is the patient with hyperglycaemia and chronic kidney disease (CKD). Many times there are challenges with achieving and/or maintaining stable glycaemic control with patients’ blood glucose swinging from hyperglycaemia to hypoglycaemia. There is an alteration in glucose homeostasis in patients with worsening kidney disease due to decreased renal and hepatic clearance of insulin, decreased renal gluconeogenesis, poor dietary intake, increased half-life of insulin, loss of body weight and fat mass, decreased levels of cathecolamines, effects of dialysis and presence of other co-morbidities. HbA1c in spite of some limitations is still regarded as a good long-term measure of glycaemic control in patients with progressive renal failure, especially in well dialysed subjects. Although not finally settled, a HbA1c target between 7-8% (or fasting blood glucose of 120-140 mg/dl) would be appropriate during treatment. Insulin is the most commonly used anti-hyperglycemic drug once renal failure has set in. This is probably because the drug does not have a deleterious effect on the kidney per se, and it is easier to titrate for stabilization or withheld if hypoglycaemia occurs. Treatment should be individualized in every case based on such factors as the age of the patient, duration of diabetes, stage of kidney disease and whether on renal replacement therapy (RRT) or the type of RRT. Among the noninsulin drugs, extreme caution is indicated in the use of metformin because of its potential to cause lactic acidosis. Most of these drugs require dose adjustment in the context of advancing renal failure. As far as glycaemic management is concerned low protein diet
still, has a beneficial effect in diabetic patients with renal failure.