Management of Hyperglycemia in Patients with Chronic Kidney Disease and Dialysis

The incidence of diabetes mellitus (DM) is growing rapidly. It is well known that intensive glycemic control prevents or delays progression of the micro and macrovascular complications in patients with DM, but it is not clear in patients with DM and chronic kidney disease (CKD). The guidelines recommend a target HbA1c < 7.0% for prevention of diabetic complications. Management of hyperglycemia is very difficult in these patients and it is recommended that lifestyle modifications (cessation of smoking, weight reduction, increased physical activity and dietary changes) be used in all patients with DM, whether medication is used or not. Sulfonylurea's and meglinides are associated with a risk of hypoglycemia. Metformin should not be used when eGFR (estimated glomerular filtration rate) is <30 ml/min per/1.73 m². Glitazones may cause fluid overload and should be avoided in CKD. Newer DPP-IV inhibitors may be used in CKD, but experience is as yet very limited. Physicians recommend avoiding GLP-1 analogs when eGFR is <60 mL/min/1.73 m². The SGLT-2 inhibitors are only effective with intact kidney function and are contraindicated in dialysis patients. Management of hyperglycemia is very complicated and should be individualized in patients with CKD. In this review, we will discuss non-insulin and insulin-based therapies in patients both CKD and dialysis.