Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil.
Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil; Endocrine Unit, Hospital de Clínicas de Porto Alegre, RS, Brazil.
J Diabetes Complications. 2021 Feb;35(2):107774. doi: 10.1016/j.jdiacomp.2020.107774. Epub 2020 Oct 23.
Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.
糖尿病是终末期肾病的主要病因，而未得到控制的高血糖与该环境下的死亡率增加直接相关。随着肾功能下降，控制血糖变得更加困难，因为低血糖的风险增加。由于食欲下降、血糖稳态变化以及抗高血糖药物的肾脏排泄减少，尽管在晚期肾病中存在胰岛素抵抗的悖论，但低血糖仍更容易发生。因此，对于使用胰岛素和/或口服抗高血糖药物的患者，通常需要进行药物剂量减少或药物转换的动态调整。此外，除了考虑这些药代动力学改变之外，在这种情况下选择具有明确心肾获益的药物至关重要，例如钠-葡萄糖共转运蛋白 2 抑制剂和胰高血糖素样肽 1 受体激动剂。在这篇综述中，我们总结了在存在晚期糖尿病肾病（DKD）和透析的情况下，可用的抗高血糖药物的适应证和禁忌证、剂量调整和副作用，并强调了不同药物的风险和获益。此外，还将评估 DKD 患者的基本肾功能评估和血糖控制监测，以指导药物使用并确定要达到的血糖目标。
