Chapter 9

Glycemic Control and CKD: Evaluation of the Risk/Benefit Ratio: Optimal Therapeutic Strategies

Gül Bahtiyar, Harold Lebovitz and Alan Sacerdote

Abstract

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.

Total Pages: 162-195 (34)

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