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Guided Reading Across the world, there are more and more patients with kidney failure due to diabetes
.
At the same time, diabetes and chronic kidney disease (CKD) can increase the risk of morbidity and death from cardiovascular disease
.
In addition, CKD can change blood sugar levels and change the patient's response to some drugs
.
Therefore, with the progress of CKD, the type and/or dosage of drugs used will change, requiring continuous attention from doctors
.
On September 29, 2021, AJKD invited two medical professors from Northwestern University Feinberg School of Medicine to analyze two cases from the perspective of endocrinology and kidney disease, and answer related questions, hoping to promote the combination of diabetic nephropathy and diabetes Management of CKD patients
.
The main content of this article is blood glucose management in patients with diabetes and CKD
.
Case patient, male, 65 years old
.
He had a 9-year history of type 2 diabetes, and his glycosylated hemoglobin (HbA1c) was 8.
7%
.
Medication history: daily taking 10 mg of glibenclamide and 1000 mg of metformin (twice a day), while taking candesartan and atorvastatin
.
Physical examination: body mass index (BMI) is 29kg/㎡, blood pressure is 138/78mmHg, and peripheral neuropathy is present
.
Laboratory examination: Estimated glomerular filtration rate (eGFR) is 33ml/min/1.
73㎡, urine protein-creatinine ratio (UACR) is 317mg/g
.
Question answer and analysis Question 1 correct answer: C.
<8.
0% Analysis Blood glucose control can slow down the progression of cardiovascular disease and CKD
.
The American Diabetes Association (ADA) recommends that the HbA1c target value for non-pregnant adult patients is <7.
0%, but certain patients can set a higher target, such as <8.
0%
.
These specific patients are usually those with a shorter life expectancy, a history of severe hypoglycemia, more comorbidities, and late complications
.
However, the American Association of Clinical Endocrinologists recommends setting a more stringent standard for healthier patients, that is, HbA1c<6.
5%.
However, they emphasize that personalized setting of the HbA1c target value is the best choice
.
These recommendations are based on several clinical trials
.
The DCCT/EDIC trial showed that among patients with stage 3 CKD, the rate of proteinuria progression in patients with HbA1c=7.
2% was lower than that of patients with HbA1c=9.
1%
.
Tests such as UKPDS and VADT have shown that, for patients with type 2 diabetes, intensive blood glucose control can reduce the incidence of CKD and the progression of kidney disease, but the impact on cardiovascular disease is limited
.
In general, experts believe that HbA1c<7.
0% seems to provide the best risk/benefit ratio.
Unless patients have serious hypoglycemia tendency after using hypoglycemic drugs, they should insist on HbA1c<7.
0%
.
However, if it is a CKD patient, then the goal of glycosylated hemoglobin will be greatly changed
.
In 2007, KDIGO diabetes and CKD guidelines stipulated that HbA1c was less than 7.
0%, but in 2012 KDIGO set the index as HbA1c around 7.
0%
.
Since then, at the KDIGO conference on diabetic nephropathy, it was pointed out that there is insufficient evidence for the ideal blood glucose control goal for patients with CKD stage 3 or more severe
.
But they found that for patients receiving renal replacement therapy, HbA1c>7.
0% and <8.
0%, the greatest benefit
.
If it is lower than 7.
0% or higher than 8.
0%, it will increase the patient's risk of all-cause or cardiovascular death
.
So the best answer to this question C
.
The above information can be summarized as shown in the figure below (Figure 1)
.
Figure 1 HbA1c personalized target gradient suggestion diagram Remarks: 1.
HbA1c is glycosylated hemoglobin; 2.
CKD is chronic kidney disease; 3.
Whether hypoglycemia can be dealt with in time is whether the patient can seek medical treatment in time within the scope of the patient’s daily activities, on the other hand One aspect is whether the patient and his family are capable of dealing with hypoglycemia
.
The correct answer to question 2: C.
If eGFR<30ml/min/1.
73㎡, the true value of HbA1c is 0.
5% to 1.
0% lower than the measured value
.
Analysis For patients with stable blood sugar and reaching the standard, a blood glucose test every 6 months is sufficient, but for patients with unstable or under-standard, the level of glycosylated hemoglobin should be checked every 3 months
.
The risk of hypoglycemia increases as GFR decreases
.
For patients taking hypoglycemic drugs or insulin, the risk is higher, because as GFR decreases, the clearance rate of insulin and oral hypoglycemic drugs will decrease
.
At the same time, uremic toxins affect the appetite of patients, cause weight loss, and increase the risk of hypoglycemia
.
When the eGFR of CKD patients is close to 30ml/min/1.
73㎡, the measured value of HbA1c will no longer be accurate
.
On the one hand, red blood cell life is shortened, hemolysis and anemia will reduce HbA1c; on the other hand, hemoglobin carbamylation and acidosis will increase HbA1c
.
In addition, glycated albumin represents the patient's blood glucose level within 2 weeks
.
However, for CKD patients, especially dialysis patients, glycosylated albumin is superior to HbA1c
.
However, HbA1c is still an important reference indicator
.
Kidney disease may affect glycated albumin, that is, the decrease of plasma albumin level due to proteinuria, but also the decrease of glycated albumin level
.
However, kidney disease does not affect hemoglobin levels
.
When eGFR <30ml / min / 1.
73㎡, the true value lower than the measured value of HbA1c from 0.
5 to 1.
0%, so the answer selected from the group C
.
Finally, experts suggest that for CKD patients who are using insulin, it is recommended to measure blood glucose levels multiple times a day, which can effectively assess the level of blood glucose control and avoid hypoglycemia
.
References: 1.
HahrAJ, Molitch ME.
Management of Diabetes Mellitus in Patients With CKD: CoreCurriculum 2022.
Am J Kidney Dis.
2021 Sep 29:S0272-6386(21)00762-9.
.
At the same time, diabetes and chronic kidney disease (CKD) can increase the risk of morbidity and death from cardiovascular disease
.
In addition, CKD can change blood sugar levels and change the patient's response to some drugs
.
Therefore, with the progress of CKD, the type and/or dosage of drugs used will change, requiring continuous attention from doctors
.
On September 29, 2021, AJKD invited two medical professors from Northwestern University Feinberg School of Medicine to analyze two cases from the perspective of endocrinology and kidney disease, and answer related questions, hoping to promote the combination of diabetic nephropathy and diabetes Management of CKD patients
.
The main content of this article is blood glucose management in patients with diabetes and CKD
.
Case patient, male, 65 years old
.
He had a 9-year history of type 2 diabetes, and his glycosylated hemoglobin (HbA1c) was 8.
7%
.
Medication history: daily taking 10 mg of glibenclamide and 1000 mg of metformin (twice a day), while taking candesartan and atorvastatin
.
Physical examination: body mass index (BMI) is 29kg/㎡, blood pressure is 138/78mmHg, and peripheral neuropathy is present
.
Laboratory examination: Estimated glomerular filtration rate (eGFR) is 33ml/min/1.
73㎡, urine protein-creatinine ratio (UACR) is 317mg/g
.
Question answer and analysis Question 1 correct answer: C.
<8.
0% Analysis Blood glucose control can slow down the progression of cardiovascular disease and CKD
.
The American Diabetes Association (ADA) recommends that the HbA1c target value for non-pregnant adult patients is <7.
0%, but certain patients can set a higher target, such as <8.
0%
.
These specific patients are usually those with a shorter life expectancy, a history of severe hypoglycemia, more comorbidities, and late complications
.
However, the American Association of Clinical Endocrinologists recommends setting a more stringent standard for healthier patients, that is, HbA1c<6.
5%.
However, they emphasize that personalized setting of the HbA1c target value is the best choice
.
These recommendations are based on several clinical trials
.
The DCCT/EDIC trial showed that among patients with stage 3 CKD, the rate of proteinuria progression in patients with HbA1c=7.
2% was lower than that of patients with HbA1c=9.
1%
.
Tests such as UKPDS and VADT have shown that, for patients with type 2 diabetes, intensive blood glucose control can reduce the incidence of CKD and the progression of kidney disease, but the impact on cardiovascular disease is limited
.
In general, experts believe that HbA1c<7.
0% seems to provide the best risk/benefit ratio.
Unless patients have serious hypoglycemia tendency after using hypoglycemic drugs, they should insist on HbA1c<7.
0%
.
However, if it is a CKD patient, then the goal of glycosylated hemoglobin will be greatly changed
.
In 2007, KDIGO diabetes and CKD guidelines stipulated that HbA1c was less than 7.
0%, but in 2012 KDIGO set the index as HbA1c around 7.
0%
.
Since then, at the KDIGO conference on diabetic nephropathy, it was pointed out that there is insufficient evidence for the ideal blood glucose control goal for patients with CKD stage 3 or more severe
.
But they found that for patients receiving renal replacement therapy, HbA1c>7.
0% and <8.
0%, the greatest benefit
.
If it is lower than 7.
0% or higher than 8.
0%, it will increase the patient's risk of all-cause or cardiovascular death
.
So the best answer to this question C
.
The above information can be summarized as shown in the figure below (Figure 1)
.
Figure 1 HbA1c personalized target gradient suggestion diagram Remarks: 1.
HbA1c is glycosylated hemoglobin; 2.
CKD is chronic kidney disease; 3.
Whether hypoglycemia can be dealt with in time is whether the patient can seek medical treatment in time within the scope of the patient’s daily activities, on the other hand One aspect is whether the patient and his family are capable of dealing with hypoglycemia
.
The correct answer to question 2: C.
If eGFR<30ml/min/1.
73㎡, the true value of HbA1c is 0.
5% to 1.
0% lower than the measured value
.
Analysis For patients with stable blood sugar and reaching the standard, a blood glucose test every 6 months is sufficient, but for patients with unstable or under-standard, the level of glycosylated hemoglobin should be checked every 3 months
.
The risk of hypoglycemia increases as GFR decreases
.
For patients taking hypoglycemic drugs or insulin, the risk is higher, because as GFR decreases, the clearance rate of insulin and oral hypoglycemic drugs will decrease
.
At the same time, uremic toxins affect the appetite of patients, cause weight loss, and increase the risk of hypoglycemia
.
When the eGFR of CKD patients is close to 30ml/min/1.
73㎡, the measured value of HbA1c will no longer be accurate
.
On the one hand, red blood cell life is shortened, hemolysis and anemia will reduce HbA1c; on the other hand, hemoglobin carbamylation and acidosis will increase HbA1c
.
In addition, glycated albumin represents the patient's blood glucose level within 2 weeks
.
However, for CKD patients, especially dialysis patients, glycosylated albumin is superior to HbA1c
.
However, HbA1c is still an important reference indicator
.
Kidney disease may affect glycated albumin, that is, the decrease of plasma albumin level due to proteinuria, but also the decrease of glycated albumin level
.
However, kidney disease does not affect hemoglobin levels
.
When eGFR <30ml / min / 1.
73㎡, the true value lower than the measured value of HbA1c from 0.
5 to 1.
0%, so the answer selected from the group C
.
Finally, experts suggest that for CKD patients who are using insulin, it is recommended to measure blood glucose levels multiple times a day, which can effectively assess the level of blood glucose control and avoid hypoglycemia
.
References: 1.
HahrAJ, Molitch ME.
Management of Diabetes Mellitus in Patients With CKD: CoreCurriculum 2022.
Am J Kidney Dis.
2021 Sep 29:S0272-6386(21)00762-9.
