Emory University School of Medicine, Division of Endocrinology, Atlanta, Georgia.
Jaeb Center for Health Research, Tampa, Florida.
Endocr Rev. 2020 Oct 1;41(5):756-74. doi: 10.1210/endrev/bnaa017.
Glucose and insulin metabolism in patients with diabetes are profoundly altered by advanced chronic kidney disease (CKD). 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 counterregulatory hormone responses (cortisol, growth hormone), nutritional deprivation, and variability of exposure to oral antihyperglycemic 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 not fully validated. Therefore, HbA1c remains the preferred glycemic biomarker despite its limitations. Based on observational data for associations with mortality and risks of hypoglycemia with intensive glycemic control regimens in advanced CKD, an HbA1c range of 7% to 8% appears to be the most favorable. Emerging data on the use of continuous glucose monitoring in this population suggest promise for more precise monitoring and treatment adjustments to permit fine-tuning of glycemic management in patients with diabetes and advanced CKD.
糖尿病患者的葡萄糖和胰岛素代谢在慢性肾脏病（CKD）晚期会发生深刻变化。肾脏糖异生衰竭、肾脏清除胰岛素受损、尿毒症导致胰岛素降解缺陷、血液透析期间红细胞葡萄糖摄取增加、拮抗激素反应（皮质醇、生长激素）受损、营养缺乏以及口服降糖药和外源性胰岛素暴露的变异性，都会增加低血糖的风险。终末期肾病患者经常经历广泛的血糖波动，低血糖和高血糖都很常见。糖化血红蛋白（HbA1c）评估血糖受到多种 CKD 相关因素的影响，这些因素会使测量结果偏向低值或高值。替代的血糖生物标志物，如糖化白蛋白或果糖胺，尚未完全验证。因此，尽管存在局限性，但 HbA1c 仍然是首选的血糖生物标志物。基于观察性数据，与晚期 CKD 中强化血糖控制方案的死亡率和低血糖风险相关联，HbA1c 范围在 7%至 8%似乎是最有利的。在该人群中使用连续血糖监测的新数据表明，有希望更精确地监测和调整治疗，以允许对糖尿病和晚期 CKD 患者的血糖管理进行微调。
