Diabetes Management In Patients With Renal Insufficiency

Chronic complications of Diabetes mellitus (DM), which are present in as many as 50% of the diabetic patients at the time of diagnosis, are a major burden for both the patients and the healthcare system at large. It is estimated that, more than two-third of healthcare expenditure related to diabetes is mainly attributed to chronic complications of the disease (Hahr & Molitch 2015). This problem is further aggravated by poor lifestyle, aging population, and urbanization makes the situation even more challenging. Chronic kidney diseases (CKD) affects nearly 40% of individuals with diabetes in the UK, making it one of the most common complications related to the diseases (Berns et al. 2015). The risk of renal failure is 25% high in a diabetic patient than the non-diabetic individuals. As such, individuals with renal failure and diabetes presents a special risk group as they have high morbidity and mortality, and are at a higher risk of hypoglycaemia than diabetic patients with normal renal functions (Hahr & Molitch 2015). Therefore, physicians need to formulate a comprehensive management plan to counter complications presented by renal failure in diabetic patients.

Advanced renal disease among diabetic patients is a life threatening condition low survival rates and numerous complications. The kidneys are no longer able to support a reasonable health state, and immediate dialysis or kidney transplantation is needed. However, this not achieved easily as compared to non-diabetic patients because of the high susceptibility to infections, problems with vascular access, fool ulcer ad hemodynamic instability during haemodialysis (HD). Nevertheless, comparing kidney transportation and dialysis(both peritoneal and haemodialysis), the former, remains to be one of the most preferred therapy for diabetic patients with end state renal disease (ESRD) as it is associated with high survival rates and high quality life compared to the latter.

Diabetes and ERSD synergistically boosts the risk of cardiovascular disease (CVD). Individuals with diabetic nephropathy are highly predisposed to CVD compared to diabetic patient with no kidney disease. Well document research shows that patients with significantly reduced kidney function are not only subjected to the Framingham risk factors, but also a host of renal related factors, which further accelerate the advancement of cardiovascular disease (Wang 2011). Another study shows that cardiovascular disease-related mortality is higher for patients with diabetic nephropathy than individuals without diabetes (Chang et al 2014). Understanding the different risk factors of cardiovascular in these group of patient is important in its management. There is a strong evidence that demonstrate a strong linear relationship between high blood pressure and CVD. As such, maintaining the blood pressure within the nominal limits will help in reducing the risk of having CVD. Optimum blood pressure can be reducing through adjusting lifestyle such living a active life, avoiding smoking or excessive use of alcohol. Other pharmacological treatments can be applied to treat hypertension.

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Oral agents, particularly insulin are regarded as the best choice to improve glycaemic control in patients with renal failure. However, specific information regarding dose adjustments and differences in insulin profiles in this group of patients is limited because of the few studies carried out in individuals with significant renal insufficiency. Further,there is no consensus about the choice of various preparation of insulin in patients with CKD. However, based on clinical practice, there exist minimal difference between the principles of insulin therapy for general diabetic patients and CKD patients. When the glomerular filtration rate (GFR) is between 10-50mL/min/1.73m^2, the total insulin dose administered should be reduced by 25% (Perkovic et al. 2016). However, when the GFR is 10ml/min, the dose should be reduced by 50% that of the general diabetic patients. As renal failure progresses, proximal tubule should be used to increase the insulin uptake to compensate for decrease in insulin clearance by the kidney. Insulin analogues preparation should be adopted over regular and NPH insulin preparation methods as they are less likely to cause hypoglycemia (Betonico et al 2016). In most cases rapid-acting insulin analogues such as the Lispro, Aspart and Glulisine are ideal for quick correction of elevated blood sugars as they are renal impairment does not affect the pharmacokinetics of insulin analogues in a clinically significant manner.

Metformin is one of the pharmacological treatment popularly used in type 2 patients with reduced GFR. The drug is eliminated through kidney and its clearance rate decreases by 75% once the GFR falls below 60. As such, to minimize the risk of lactic acidosis, various guidelines have advised against using this drug in women and men with serum creatinine of more than 1.4mg/dl and 1.5mg/dl respectively. Although metformin is mainly cleared by the kidneys, the compound level generally remains within the beneficial range minimal increase in lactate concentrations in patients with renal insufficiency of 30-60ml/min, thus making the overall incidence of lactic acidosis manageable (Betonico et al 2016). Clinical studies have also suggested other potential benefits of the drug on macrovascular outcome, even in individuals with prevalent renal contraindications for its use. However, studies shows that an abrupt drop in GFR leads to accumulation metformin. As such, individuals should avoid using metformin in conditions with inherent risk of acute kidney injury such as diarrhoea, dehydration, fever and severe bouts.

Additionally, management of diabetic patients with advanced renal failure and the associated complications include date with protein restriction. In individuals suffering from type 1 diabetes, a dietary pattern in these patients should include whole grains, vegetables, legumes, and carbohydrates from fruits. Besides, carbohydrates should be monitored through counting, exchanges, or experienced –based estimation should be carried out to maintain a stable body weight and glycemic control (Sampanis 2008). Type 2 diabetic patients, on the other hand are normally obese with high insulin resistance and impaired insulin secretion. Ass such, these individuals must be encouraged to lose weight with hypocaloric diet and exercise. Protein restriction is replaced by fat or carbohydrates so as to maintain an adequate caloric intake. However, care should be taken not to increase carbohydrates intake beyond 55% since the patient may develop a condition referred to as hypertriglyceridemia (Kovesdy & Kalantar‐Zadeh 2010). It is also good to note that good dietary management for diabetic patients with CKD calls a partnership between the diabetologist, dietician and nephrologist.

Summarily, management of` complications of diabetes in patients with established renal failure involves both pharmacological and nonpharmacological therapies, with the former including dietary modification, exercise and weight reduction. Pharmacological on the other hand involves use of oral agents such as insulin and other drugs. The two highlighted pharmacological treatments are not exhaustive and exist other drugs such as Glipizide, Repaglinide among others. Besides, glycaemic control is one of the various ways of managing diabetic patients with an end state renal disease (ERSD). ERSD significantly alters glycaemic control and excretion of antidiabetic medications, making the levels of blood glucose to fluctuate thus presenting a challenging to the physicians.

References

1. Betonico, C.C., Titan, S.M., Correa-Giannella, M.L.C., Nery, M. and Queiroz, M., 2016. Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. Clinics, 71(1), pp.47-53. Berns, J.S., Glickman, J.D., Golper, T.A., Nathan, D.M., Lam, A.Q. and Mulder, J.E., 2015. Management of hyperglycemia in patients with type 2 diabetes and pre-dialysis chronic kidney disease or end-stage renal disease. Golper T, Nathan D (Ed), Uptodate, Waltham, MA, 2018.[Citado el 8 de diciembre de 2018].
2. Chang, Y.T., Wu, J.L., Hsu, C.C., Wang, J.D. and Sung, J.M., 2014. Diabetes and end-stage renal disease synergistically contribute to increased incidence of cardiovascular events: a nationwide follow-up study during 1998–2009. Diabetes care, 37(1), pp.277-285.
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