Treatment of diabetes in patients with kidney disease

The management of hyperglycemia in patients with chronic kidney disease (CKD) is complex, and the goals and methods for glycemic control are not clearly defined. Although tight glycemic control seems to slow the onset and progression of renal damage in early diabetic nephropathy, data in patients with advanced CKD (including end-stage renal disease) are lacking. In addition, diabetic patients with renal disease frequently have cardiovascular complications and are at high risk of hypoglycemic episodes, both conditions challenging their management. Thorough know - ledge of the pharmacokinetics and side effects of all hypoglycemic drugs is needed in order to identify not only the goals but also the most appropriate therapy. Among oral diabetic agents, metformin can be safely used in patients with mild/moderate renal insufficiency, with the appropriate dosage reduction. DDP-4 inhibitors currently seem to be the most promising oral drug for these patients, particularly because of their low risk of hypoglycemia. In diabetic patients with advanced CKD, insulin plays a central role but close blood glucose monitoring is essential to avoid the risk of hypoglycemia.