Management of hyperglycemia in patients with diabetes mellitus and chronic renal failure

Abstract

Diabetes mellitus is recognized as a leading cause of chronic kidney disease and end-stage renal failure. Chronic renal failure is associated with insulin resistance and, in advanced renal failure, decreased insulin degradation. Both of these abnormalities are partially reversed with the institution of dialysis. Except for diet with protein restriction, patients with diabetes should be preferably treated with insulin. The management of the patients with hyperglycemia and chronic renal failure calls for close collaboration between the diabetologist and the nephrologists. This collaboration is very important so that the patient will not be confused and will not lose confidence to the doctors. Furthermore good glycemic control in these patients seems to reduce microvascular and macrovascular complications.

Keywords: chronic kidney disease; diabetes; hyperglycemia therapy.

Figure 1.. Metabolism of insulin. Insulin is freered at the glomerulus and then extensively reabsorbed by the proximal tubule. Of the total renal insulin clearance, approximately 60% occurs by glomerular filtration and 40% by extraction from peritubular vessels. (Adapted from Rabkin R et al. The renal metabolism of insulin. Diabetoligia 1984; 27: 351-357)

Figure 2.. Intrarenal pathways of insulin removal. Filtrered insulin is internalized by by endocytosis and thereafter degraded into amino acids into the peritubular vessls. Insulin removed from postglomerular peritubular vessels binds to the contraluminal cell membrave. This process in both receptor and non-reveprot mediated. (Adapted from Rabkin R et al. The renal metabolism of insulin. Diabetoligia 1984; 27: 351-357)