Alteration of Glycaemic Balance due to Chronic Kidney Disease

Abstract

The incidence of diabetes in patient populations requiring dialysis is constantly increasing. Metabolic disturbances in this group need focussed attention, particularly as carbohydrate balance is affected by specific disease-related factors. Beta-cell dysfunction, insulin resistance, and advanced glycation end-product accumulation are increasingly detected in the period preceding dialysis. Glycaemic control is also linked to the health of bone metabolism and control of renal failure-related anaemia. Novel opportunities in the assessment of glucose homeostasis, including continuous glucose monitoring systems, skin autofluorescence, and investigation of the metabolome, have resulted in significant developments in diagnostics and therapy. Regarding antidiabetic control, the major therapeutic goal for patients on haemodialysis (HD) is the alleviation of glycaemic fluctuation during the post-dialytic phase. The periodicity in antidiabetic regimes on HD and non-HD days is the preferable tool. For patients on peritoneal dialysis, the adverse impact of glucose originated from the standard solutions should be counterbalanced. This review focusses on the relationship between diabetes and HD or peritoneal dialysis and provides clinical suggestions to support the planning of individualised therapy. Nowadays, the number of patients with advanced renal failure is increasing. In current medical training, nephrological and diabetic education is separated within the internal curriculum. Thus, an average nephrologist is not trained in diabetic issues that would enable them to control the carbohydrate metabolism of a patient with renal insufficiency at different stages of glomerular filtration rate narrowing, and additionally is not permitted to change the choice of therapy. Conversely, a general diabetologist is not aware of the effects of kidney failure and dialysis on glycaemic control and is not familiar with the technological details of renal replacement therapies: special alterations related to nephrological factors are therefore not taken into account when treating diabetic patients with kidney disease. The article deals with the theoretical and practical issues of this clinical border area, helping the clinician to choose individual treatment for a particular patient. Guidelines for choice of oral and insulin therapy in this patient group, based on clinical experiences and theoretical considerations, are under continuous development, and definitive results are expected in the near future.