The estimated number of people with diabetes and CKD has grown in proportion to the rising of prevalence of diabetes itself, this is driven largely by obesity, sedentary life, an epidemic of type 2 diabetes and increasing incidence of type1 diabetes. For people with diabetes, CKD is potentially devastating condition, markedly increasing cardiovascular risk and potentially leading to kidney failure requiring dialysis or a kidney transplant. However recent development suggests new approaches to improve outcomes. The past 10 years have provided new hope for improved prevention and treatment of CKD among people with diabetes. New drugs and technologies provide improved options to control glycemia and prevent CKD and its progression when added to a healthy lifestyle and other standers of care management if implemented in most effective and evidence -based manner. Pharmacologic management of glycaemia is one aspect of care that differs substantially by diabetes type; however, complications can occur with both types according to degree of uncontrolled glycaemic status, CKD considered one of the major complications, which end or turns in a viscus circle with cardiovascular involvement. CKD is defined as persistently elevated urine albumin excretion (more than or equal 30 mg/g), persistently reduced estimated glomerular filtration rate eGFR < 60 ml/min per or 3 1.73 m square, or both for greater than 3 months, in accordance with current KDIGO guidelines. Prevention and screening of diabetes occur mostly in primary care and endocrinology settings. They advocate multifactorial management with a focus on good glycaemic control to prevent microvascular complications as well as yearly screening for CKD with assessment of urine albumin excretion and e GFR. Diagnostically, CKD occurring among people with diabetes is usually attributed to diabetes, unless other causes are readily evident. Certainly, cases of CKD among people with diabetes are heterogeneous and some are caused by other process. Kidney biopsy and biomarkers play a crucial role in determining and classification of CKD with DM as well as other causes affecting the kidney. Work up is never end in the field of kidney disease with diabetes by researchers and studies of global groups aiming for more development and nonstop revolution in approach of CKD with diabetes.
Patients with diabetes and kidney disease should be treated with a Comprehensive strategy to reduce risk of kidney disease progression and cardiovascular disease. Glycaemic control is based on insulin for type 1 diabetes and a combination of metformin and sodium glucose cotransporters 2 (SGLT2i) for type 2 diabetes when e GFR > 30 ml/min. Renin -angiotensin system (RAS) inhibition is recommended for patients with albuminuria and hypertension. Aspirin generally should be used lifelong for secondary prevention among those with established cardiovascular disease and may be considered for primary prevention among high-risk individuals. With dual antiplatelets therapy used in patients after acute coronary syndrome or percutaneous coronary intervention. Smoking cessation is highly recommended, moreover, physicians and healthcare providers should counsel patients with diabetes and CKD to reduce second-hand smoke exposure.
Haemoglobin A1C (Hb A 1c) is usually used to monitor glycaemic control in patients with diabetes and CKD, it is considered as reasonable parameter to be checked twice per year and may also be measured as often as 4 times per year if the glycaemic target is not met or after a change in anti hyperglycaemic therapy. Accuracy and precision of Hb AIC measurement declines with advance CKD late stages, particularly among patients treated with dialysis as Hb AIC have low reliability. Daily glycaemic monitoring or self-monitoring of blood glucose may help prevent hypoglycaemia and improve glycaemic control when antihyperglycemic therapies associated with risk of hypoglycaemia are used. Target of HbA1C ranging from <6.5% to <8 % in patients with diabetes and CKD not treated with dialysis. A recent study found that patients on dialysis had poorer survival rate with Hg A1C > 8.5 % Compared to those with Hg A1C (6.5-7.4 %). Moreover, patients with advance kidney diseases and those on dialysis are at increased risk of hypoglycaemia due to decreased clearance of insulin and most of oral hypoglycaemic agents as well asimpairment of renal gluconeogenesis from lower kidney mass. The kidney is responsible for about 30 to 80 % of insulin
removal, so reduced kidney function prolongs insulin half-life and decrease insulin requirements.
Patients with diabetes and CKD should consume an individual diet high in vegetables, fruits whole grains, fiber, legumes, plant-based protein, unsaturated fats, and nuts and lower in processed meats, refined carbohydrates and sweetened beverages. Patients treated with haemodialysis should consume between 1.0 and 1.2 g protein /kg body weight/d. Shared decision making should be a cornerstone of patient, accredited nutrition providers, registered dietitians and diabetes educators peer counsellors or other health worker should be engaged in the multidisciplinary nutrition care of those patients. Physical activity should consider age, ethnic background, presence of other comorbidities and access to resources. Sedentary behaviour should be avoided. Obese overweight, diabetes and CKD should be encouraged to lose weight particularly when eGFR >30 ml/min per 1.73 m square.
Insulin preparations is the main pharmacological line in treating type 1 diabetes, uncontrolled type 2 diabetes and in some cases such as infection, diabetic ketoacidosis and other conditions required hospitalisation. all available preparations can be used in patients with CKD. Rapid-acting insulin analogs aspart lispro and glulisine are the quickest absorbed and are ideal for rapid correction of high blood sugar or for prandial insulin needs. Patients with advanced renal dysfunction or who are on dialysis have some delayed gastric emptying giving rapid acting insulin after meal, may be helpful matching the insulin peak with the time of post prandial blood glucose peak. The short -acting insulin available is regular crystalline insulin which has an onset of action at 30-60 min, peak action at 2-3 h and duration up to 5-8 h, therefore should be given 30 mins prior to a meal. Intermediate -acting insulin available example is isophane or NPH which take 2-4 HRS to act, peak at 4-10 h while the long acting-insulin analoges act similarly 2-4 hr but peak at 20-24 h so it is usually taken once/d, examples glargine and determir . Premixed preparations that have a fixed percentage of an intermediate and a rapid or short acting insulin are also available considering that they also have
two separate peaks. Glycaemic management of patients with T2DM and CKD should include lifestyle therapy, first line treatment with metformin and a sodium -glucose co transporters 2 inhibitor and additional drug therapy as needed for glycaemic control. Most patients with T2DM with CKD and e GFR >30 would benefit from treatment with both metformin and SGLT2i. Metformin should be adjusted when e GFR <45 ml/min. Vitamin B12 should be monitored when metformin used more than 4 years. For patients in whom additional glucose -lowering agents may increase risk for hypoglycaemia such as those treated with insulin or sulfonylureas, it may be necessary to stop or reduce the dose of an antihyperglycemic drug as well as in during times of prolonged fasting, surgery or critical medical illness when patients maybe at greater risk for ketosis. Patients who are unable to use those medications, GLP-1RA (Glucagon-like peptide -1 receptor agonist) will be a reasonable choice particularly with documented cardiovascular risk, starting with low doses should be advised to minimize gastrointestinal side effects, commonly used drugs are dulaglutide, Exenatide, liraglutide and semaglutide (oral and injectable).
The most reasonable target range of hgb A1c for diabetic dialysis patients should be limited to 6_8 % or 7_9 %, given higher mortality risks observed with <6 % and the potential implications of burnt-out diabetes and the high death risk associated with hypoglycaemia in these patients. Few oral agents that can be used safely in patients on dialysis, particularly in mild cases, most others will need insulin. Clearance of insulin maybe affected by timing of haemodialysis, patient’s glycaemic responses during HD are quite idiosyncratic, so insulin regimens need to be individualised with frequent measurements of blood sugar at starting the dialysis session, mid & post -HD depending on the previous abnormal readings to manage accordingly.
Future outlook for patients with diabetes is promising as researchers are working hard on the diabetes , hopefully , the prevention and cure will develop further , in the meantime , the regular screening program remained the corner stone in detecting diabetes , determining the microalbuminuria , and start timed treatment to avoid further damage of the internal vital organs , Moreover ,the multifactorial approach in handling diabetic patients
through a well team -based integrated care supported by decision – makers should be delivered by physician and non-physician personnel , trained nurses , pharmacist , dietician and health care assistants community workers , all work together to provide comprehensive care for diabetic patients with CKD including those on dialysis .
