Rhee Connie M, Leung Angela M, Kovesdy Csaba P, Lynch Katherine E, Brent Gregory A, Kalantar-Zadeh Kamyar
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California.
Semin Dial. 2014 Mar;27(2):135-45. doi: 10.1111/sdi.12198.
Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) in the U.S. and many countries globally. The role of improved glycemic control in ameliorating the exceedingly high mortality risk of diabetic dialysis patients is unclear. The treatment of diabetes in ESRD patients is challenging, given changes in glucose homeostasis, the unclear accuracy of glycemic control metrics, and the altered pharmacokinetics of glucose-lowering drugs by kidney dysfunction, the uremic milieu, and dialysis therapy. Up to one-third of diabetic dialysis patients may experience spontaneous resolution of hyperglycemia with hemoglobin A1c (HbA1c) levels <6%, a phenomenon known as "Burnt-Out Diabetes," which remains with unclear biologic plausibility and undetermined clinical implications. Conventional methods of glycemic control assessment are confounded by the laboratory abnormalities and comorbidities associated with ESRD. Similar to more recent approaches in the general population, there is concern that glucose normalization may be harmful in ESRD patients. There is uncertainty surrounding the optimal glycemic target in this population, although recent epidemiologic data suggest that HbA1c ranges of 6% to 8%, as well as 7% to 9%, are associated with increased survival rates among diabetic dialysis patients. Lastly, many glucose-lowering drugs and their active metabolites are renally metabolized and excreted, and hence, require dose adjustment or avoidance in dialysis patients.
糖尿病是美国及全球许多国家终末期肾病（ESRD）的主要病因。血糖控制改善对降低糖尿病透析患者极高死亡风险的作用尚不清楚。鉴于葡萄糖稳态的变化、血糖控制指标准确性不明以及肾功能不全、尿毒症环境和透析治疗导致降糖药物药代动力学改变，ESRD患者的糖尿病治疗具有挑战性。高达三分之一的糖尿病透析患者可能会出现糖化血红蛋白（HbA1c）水平<6%的高血糖自发缓解，这一现象被称为“耗竭性糖尿病”，其生物学合理性仍不明确，临床意义也未确定。ESRD相关的实验室异常和合并症会干扰传统的血糖控制评估方法。与普通人群中最近的方法类似，人们担心血糖正常化对ESRD患者可能有害。尽管最近的流行病学数据表明，HbA1c范围在6%至8%以及7%至9%与糖尿病透析患者生存率提高相关，但该人群的最佳血糖目标仍存在不确定性。最后，许多降糖药物及其活性代谢产物经肾脏代谢和排泄，因此，透析患者需要调整剂量或避免使用。
