|Year : 2016 | Volume
| Issue : 4 | Page : 84
Clinical questions: Responses to queries from readers: Chronic Renal Failure
Professor, Department of Nephrology, CMC, Vellore, India
|Date of Web Publication||22-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Varughese S. Clinical questions: Responses to queries from readers: Chronic Renal Failure. Curr Med Issues 2016;14:84
Should a person with chronic renal failure / kidney transplant with diabetes mellitus be treated with insulin only or can he/she be on oral antiglycemic agents? Is metformin safe in such cases?
Dr. V. L. Ganapathy, Bangalore, Karnataka.
In advanced chronic kidney disease (CKD), there is decreased insulin degradation that can cause markedly decreased insulin requirement or even stoppage of insulin therapy. This needs individualization as the insulin dose cannot be predicted and the patients are prone for hypoglycemia. Strict sugar control has no survival advantage in advanced CKD.
Until estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m 2 (i.e., CKD Grade 3 and above), oral hypoglycemic agents may be used safely. Beyond this stage, insulin is safer. However, personally, experience has shown that if we do not try for strict control and close monitoring is possible, oral hypoglycemic agents may be used. Other drugs that can be used are meglitinides such as repaglinide and gliclazide. Dipeptidyl peptidase 4 (DPP-4) inhibitors have been used (but data are limited), and of these, linagliptin does not require dose adjustment. Metformin is avoided in patients with eGFR <30 ml/min/1.73 m 2 . Drugs that are preferred are the short-acting sulfonylureas like glipizide. (glibenclamide/glyburide is not recommended).
New onset diabetes after transplantation is treated similar to Type II diabetes mellitus. Sulfonylureas and meglitinides are preferred. DPP-4 inhibitors can be used in those who do not tolerate sulfonylureas or as per physician preference. Thiazolidinediones are generally not used unless there are no other alternatives. In our unit, we tend to use metformin in most of our patients, but there is no worldwide consensus on this. Insulin is given to those whose sugars are uncontrolled despite oral hypoglycemic agents, those with poor renal allograft function, and in those with brittle blood sugar levels.
| Suggested Reading|| |
- Arnouts P, Bolignano D, Nistor I, Bilo H, Gnudi L, Heaf J, et al. Glucose-lowering drugs in patients with chronic kidney disease: a narrative review on pharmacokinetic properties. Nephrol Dial Transplant 2014;29:1284-300.
- Berns JS, Glickman JD. Management of Hyperglycemia in Patients with Type 2 Diabetes and Pre-dialysis Chronic Kidney Disease or End-stage Renal Disease. Available from: http://www.uptodate.com/contents/management-of-hyperglycemia-in-patients-with-type-2-diabetes-and-pre-dialysis-chronic-kidney-disease-or-end-stage-renal-disease. [Last accessed on 2016 Sep 11].
- Tobin GS, Klein CL, Brennan DC. New-onset Diabetes after Transplant (NODAT) in Renal Transplant Recipients. Available from: http://www.uptodate.com/contents/new-onset-diabetes-after-transplant-nodat-in-renal-transplant-recipients. [Last accessed on 2016 Sep 11].