Glucose and insulin metabolism in patients with diabetes are profoundly altered by advanced chronic kidney disease. Risk of hypoglycemia is increased by failure of kidney gluconeogenesis, impaired insulin clearance by the kidney, defective insulin degradation due to uremia, increased erythrocyte glucose uptake during hemodialysis, impaired counter-regulatory hormone responses (cortisol, growth hormone), nutritional deprivation and variability of exposure to oral anti-hyperglycemic agents and exogenous insulin. Patients with end stage kidney disease frequently experience wide glycemic excursions, with common occurrences of both hypoglycemia and hyperglycemia. Assessment of glycemia by glycated hemoglobin (HbA1c) is hampered by a variety of CKD-associated conditions that can bias the measure either to the low or high range. Alternative glycemic biomarkers, such as glycated albumin or fructosamine, are even less reliable than HbA1c. Therefore, HbA1c remains the preferred glycemic biomarker despite its limitations. Based upon observational data for associations with mortality and risks of hypoglycemia with intensive glycemic control regimens in advanced CKD, a HbA1c range of 7-8% appears to be most favorable. Emerging data on the use of continuous glucose monitoring in this population brings promise for more precise monitoring and treatment adjustments to permit fine-tuning of glycemic management in patients with diabetes and advanced CKD.
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