Nearly a quarter of the diabetic population has comorbid chronic kidney
disease (CKD) and this number is increasing worldwide due to the increasing
prevalence of obesity. More advanced stages of CKD present us with the twin
competing challenges of both insulin resistance and an increased risk for
hypoglycemia. Glycemic control is essential to delay or prevent the onset of CKD.
However, the management of hyperglycemia in patients with CKD is complex and
presents us with therapeutic challenges in terms of goals and monitoring of glycemic
control. Although intensive glycemic control (hemoglobin A1c ≤ 7%) in patients
without CKD reduces the development of microalbuminuria and the progression from
microalbuminuria to macroalbuminuria, it does not stop the progression of kidney
disease in patients with diabetes in whom the glomerular filtration rate is reduced, the
serum creatinine is elevated or there is progression to end stage renal disease. Recent
data indicate the intensive glucose control in CKD stages 1-3 may result in increased
cardiovascular and all cause mortality. Patients with diabetes and CKD stages 3-5 have
increased risk of hypoglycemia. These data reveal that glycemic goals for patients with
diabetes and CKD must be individualized depending on the characteristics of the
patient.
In this chapter we review the current views on the goals and methods of glycemic
control, monitoring tools and risk of hypoglycemia in diabetic patients at various stages
of CKD. We address the treatment options including the best lifestyle adjustments,
nutrition, supplements, surgical interventions and pharmacologic agents. This chapter
will provide clinical guidance in order to provide individualized glycemic goals and
therapy for diabetic patients with CKD and end stage renal disease and will be an
indicator of where additional research is needed.
Keywords: Chronic kidney disease (CKD), Diabetes mellitus (DM), End-stage
renal disease (ESRD), Hemodialysis (HD), Hemoglobin A1c (HbA1c).
