Abstract
Diabetes mellitus is the leading cause of renal failure in incident dialysis patients in several countries around the world. The quality of life for patients with diabetes in maintenance hemodialysis (HD) treatment is in general poor due to disease complications. Nephrologists have to cope with all these problems because of the “total care model” and strive to improve their patients’ outcome. In this review, an updated overview of the aspects the nephrologist must face in the management of these patients is reported. The conventional marker of glycemic control, hemoglobin A1c (HbA1c), is unreliable. HD itself may be responsible for dangerous hypoglycemic events. New methods of glucose control could be used even during dialysis, such as a continuous glucose monitoring (CGM) device. The pharmacological control of diabetes is another complex topic. Because of the risk of hypoglycemia, insulin and other medications used to treat diabetes may need dose adjustment. The new class of antidiabetic drugs dipeptidyl peptidase 4 (DPP-4) inhibitors can safely be used in non-insulin-dependent end-stage renal disease (ESRD) patients. Nephrologists should take care to improve the hemodynamic tolerance to HD treatment, frequently compromised by the high level of ultrafiltration needed to counter high interdialytic weight gain. Kidney and pancreas transplantation, in selected patients with diabetes, is the best therapy and is the only approach able to free patients from both dialysis and insulin therapy.
Highlights
The European Renal Association–European Dialysis and Transplant Association (ERAEDTA) Report for the year 2019 stated that among the different underlying nephropathies of patients entering into maintenance hemodialysis (HD) in Europe, the incidence of diabetes was 21% [1].This number, only represents the tip of the iceberg, since it regards cases of reasonably documented diabetic nephropathy
Patients experience volume expansion instead of reduction, and excessive thirst will result in large weight gains due to fluid overload, which correlates with poor glycemic control between dialysis treatments [8]
hemoglobin A1c (HbA1c) remains the measurement of choice in clinical practice, in combination with home blood glucose monitoring (BGM), as a cornerstone of diabetes management in both chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients [25–27]
Summary
The European Renal Association–European Dialysis and Transplant Association (ERAEDTA) Report for the year 2019 stated that among the different underlying nephropathies of patients entering into maintenance hemodialysis (HD) in Europe, the incidence of diabetes was 21% [1]. This number, only represents the tip of the iceberg, since it regards cases of reasonably documented diabetic nephropathy. Patients experience volume expansion instead of reduction, and excessive thirst will result in large weight gains due to fluid overload, which correlates with poor glycemic control between dialysis treatments [8]. Additional metabolic effects of dialysis include improvement in sensitivity to insulin and, in some cases, a decrease in counter-regulatory hormones
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