Maruyama Noriaki, Abe Masanori
Contrib Nephrol. 2018;196:37-43. doi: 10.1159/000485695. Epub 2018 Jul 24.
For diabetes patients without nephropathy, glycemic control is important to reduce the risk or delay the progression of diabetes complications, including nephropathy. In diabetes patients on hemodialysis, good glycemic control is necessary to improve prognosis. Many factors influence the blood glucose level of diabetes patients on hemodialysis, such as factors associated with end-stage kidney disease and factors related to hemodialysis. Therefore, since glucose metabolism in diabetes patients on hemodialysis has unique characteristics, it is necessary to manage blood glucose in these patients with specific guidelines. Here, we describe the targets and therapeutics for glycemic control in diabetes patients on hemodialysis.
According to the guidelines of the Japanese Society for Dialysis Therapy (JSDT) regarding the treatment of diabetes in hemodialysis patients, the target casual plasma glucose level (predialysis blood glucose level) is less than 180-200 mg/dL, the target glycated albumin value is less than 20.0% (less than 24.0% in patients at risk of hypoglycemia). When glycemic control is poor and the plasma glucose level before dialysis is high, hemodialysis-induced hyperglycemia may occur, in which plasma glucose decreases during hemodialysis and appears to rise after hemodialysis. On the other hand, hemodialysis patients with diabetes tend to develop hypoglycemia due to various factors. In addition, autonomic nervous system disorders may complicate the manifestation of hypoglycemia so that these patients may not exhibit symptoms. Thus, particular caution is necessary to prevent hypoglycemia. Key Messages: The plasma glucose level of hemodialysis patients with diabetes may fluctuate under the influence of many factors, such as the state of kidney function, delay in metabolism and excretion of diabetes medicine, and hemodialysis parameters. In particular, patients with poor glycemic control are susceptible to various influences, leading to a wider fluctuation in plasma glucose, with increased risk of both hyperglycemia and hypoglycemia. Since hypoglycemia may lead to a poorer prognosis and quality of life, it is necessary to control plasma glucose levels with the aim of improving the prognosis while avoiding hypoglycemia.
对于无肾病的糖尿病患者，控制血糖对于降低糖尿病并发症（包括肾病）的风险或延缓其进展至关重要。对于接受血液透析的糖尿病患者，良好的血糖控制对于改善预后是必要的。许多因素会影响接受血液透析的糖尿病患者的血糖水平，如与终末期肾病相关的因素以及与血液透析相关的因素。因此，由于接受血液透析的糖尿病患者的糖代谢具有独特特征，有必要依据特定指南来管理这些患者的血糖。在此，我们描述接受血液透析的糖尿病患者血糖控制的目标和治疗方法。
根据日本透析治疗学会（JSDT）关于血液透析患者糖尿病治疗的指南，随机血浆葡萄糖水平（透析前血糖水平）的目标值低于180 - 200mg/dL，糖化白蛋白值的目标值低于20.0%（有低血糖风险的患者低于24.0%）。当血糖控制不佳且透析前血浆葡萄糖水平较高时，可能会发生血液透析诱导的高血糖，即血液透析期间血浆葡萄糖降低而透析后似乎升高。另一方面，糖尿病血液透析患者由于各种因素容易发生低血糖。此外，自主神经系统紊乱可能使低血糖的表现复杂化，以至于这些患者可能不表现出症状。因此，预防低血糖需要格外谨慎。关键信息：糖尿病血液透析患者的血浆葡萄糖水平可能受到许多因素的影响而波动，如肾功能状态、糖尿病药物代谢和排泄延迟以及血液透析参数。特别是血糖控制不佳的患者易受各种影响，导致血浆葡萄糖波动更大，发生高血糖和低血糖的风险增加。由于低血糖可能导致更差的预后和生活质量，有必要控制血浆葡萄糖水平，以改善预后同时避免低血糖。
