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Hyperglycemia, the defining feature of diabetes, is a fundamental cause of vascular target-organ complications, including kidney disease.
Diabetes mellitus is the most common cause of kidney failure in the United States4 and is among the most common causes in the rest of the world. Most of the evidence for this guideline comes from studies of intensive glycemic control in people with type 1 and 2 diabetes and CKD stages 1 and 2 (Table 19 and Table 20). Observational studies have shown a similar association of poor glycemic control with the development of elevated albuminuria in type 2 diabetes.369-373 Three major intervention studies also have been carried out. For all these studies in both type 1 and type 2 diabetes, the overall numbers of individuals with microalbuminuria who developed macroalbuminuria were small, but less with intensive therapy.
A few long-term observational studies have shown that poorer glycemic control is associated with a greater rate of decrease in GFR in patients with type 1 diabetes.374-376 In studies of other interventions, such as ACE inhibitors or ARBs, HbA1c levels often were included as covariates.
Most prospective randomized studies used as evidence for the effect of glycemic control on kidney function are limited by the small number of patients reaching an outcome of a decrease in GFR.
Several relatively small short-term studies have evaluated whether thiazolidinediones (TZDs) decrease albuminuria more than standard therapy with other oral agents (metformin or sulfonylureas) or dietary treatment for hyperglycemia in patients with type 2 diabetes and microalbuminuria (Table 21).379-382 Albuminuria was decreased or trends in this direction were observed with TZD treatment in all these studies. This guideline is consistent with the ADA guidelines,34 which recommend that adults with diabetes achieve an HbA1c level less than 7.0% or as close to normal as possible without excessive episodes of hypoglycemia, with the goal of reducing all complications of diabetes.
An overall glycemic goal for people with diabetes of less than 7.0% is very strongly supported by substantial data from large prospective randomized studies of both type 1 and type 2 diabetes.
The major risk for patients attaining HbA1c levels less than 7.0% is the increasing development of hypoglycemia with lower glucose concentrations. Patients with decreased kidney function (CKD stages 3 to 5) have increased risks for hypoglycemia for 2 reasons: (1) decreased clearance of insulin and some of the oral agents used to treat diabetes, and (2) impaired kidney gluconeogenesis.
With progressive decreases in kidney function, decreased clearances of the sulfonylureas or their active metabolites also have been found,385-387 necessitating a decrease in drug dosing to avoid hypoglycemia. An additional factor that may hinder good glycemic control in patients with progressive kidney disease is some degree of inaccuracy of the HbA1c measurement in reflecting ambient glucose concentrations.
The patient on long-term dialysis therapy no longer needs to achieve good glycemic control to prevent deterioration of kidney function. In the opinion of the Work Group, assessment of glycemic control in diabetes and CKD should follow the standards set by the ADA (Table 25).34 In people receiving multiple insulin injections, SMBG is recommended 3 or more times daily (before meals and at bedtime).
Other microvascular and macrovascular complications of diabetes are common in those with CKD. Surgery not to be seen as silver bullet solution, says doctor who wants it part of treatment options together with lifestyle changes and medication. LONDON: Gastric surgery should be offered as a standard treatment option for people with diabetes and could help them control their condition for years without medication, the world’s leading diabetes organisations said yesterday.
In a joint statement which they said constituted one of the biggest shifts in diabetes treatment guidelines since the advent of insulin, the 45-strong group said bariatric, or metabolic, surgery could have a significant benefit for thousands of patients.
Dr Francesco Rubin, a professor and chair of metabolic and bariatric surgery at King’s College London and one of the authors of the new guidelines, said many countries across the world are in the midst of “an epidemic of diabetes”. While surgery would not be suitable for all, and should not be seen as a silver bullet solution for the global diabetes problem, Dr Rubino said patients should be offered a range of options – including lifestyle changes, medications and surgery. A recent World Health Organisation study found that the number of adults with diabetes has quadrupled in the past four decades to 422 million. The new guidelines say surgery designed to reduce the stomach and induce weight loss should be recommended to treat all diabetes patients whose body mass index (BMI) is 40 or over, regardless of their blood glucose control, as well as those with a BMI of 30 and over whose blood sugar levels are not being controlled by lifestyle changes or medications. The guidelines, published in the journal Diabetes Care, were endorsed by 45 international organisations, diabetes specialists and researchers, including the IDF, the American Diabetes Association, the Chinese Diabetes Society and Diabetes India. Obesity surgery involves the removal of part of the stomach or the re-routing of the small intestine in a bypass operation. The guidelines are based on a substantial body of evidence, including 11 randomised trials, showing that in most cases surgery can lead to reductions in blood glucose levels below the Type 2 diabetes diagnosis threshold or to a substantial improvement in blood glucose levels.

In many cases this would lead to patients being able to give up or significantly reduce their diabetes medications. Novo Nordisk, Sanofi and Eli Lilly are the world’s leading suppliers of insulin and other diabetes drugs. This site uses cookies to store information on your computer, which will improve your experience. Join today and you can easily save your favourite articles, join in the conversation and comment, plus select which news your want direct to your inbox. Weight-loss surgery should be a standard treatment for people with type 2 diabetes, a coalition of international experts have announced in a radical departure from the conventional approach to tackling the chronic disease pandemic.The guidelines,A published on Wednesday and hailed as the biggest change to the treatment of the disease in almost a century, could result in more type 2 patients going under the knife to curb their weight gain and control their blood sugar levels. There are policy measures which would help reduce diabetes says Professor Steven Colagiuri, the Australian contributor to the WHO report just released. Critics have argued surgical options - which bind or remove a portion of the stomach or intestines - could be seen by patients as a quick fix, and derail efforts to encourage lifestyle changes, such asA diet and exercise, to manage the condition.The joint statement endorsed by 45 medical and scientific groups, including Australian experts, recommends surgery as standard treatment for obese type 2 diabetes patients - with a BMI over 35 - who can't control their blood sugar levels through other means. The benefits of metabolic surgery for type 2 diabetes patients extended beyond weight loss. While, type 2 diabetes is most prevalent among lower socioeconomic groups, the surgery costsA upwards of $9000A and is almost exclusively offered in private hospitals. An estimated 1.2 million Australians have been diagnosed with type 2 diabetes -A the vast majority of whom are overweight or obese.
Intensive treatment of hyperglycemia prevents DKD and may slow the progression of established kidney disease. A large number of epidemiological studies and controlled trials have defined risk factors for progression of DKD and response to treatment.3 The purpose of this guideline is to review this literature with respect to glycemic control and translate the results into practical strategies for clinicians who treat people with diabetes and CKD, either due to DKD or other causes. Cumulative Incidence of DKD After 6 Years of Follow-up in Patients with Type 2 Diabetes Treated by Intensive (solid line) and Conventional (dashed line) Insulin Injection Therapy in the Primary-Prevention Cohort of the Kumamoto Study. Cumulative Incidence of DKD After 8 Years of Follow-up in Patients with Type 2 Diabetes Treated by Intensive (solid line) and Conventional (dashed line) Insulin Injection Therapy in the Primary-Prevention Cohort of the Kumamoto Study. Accordingly, differences in progression rates from microalbuminuria to macroalbuminuria with intensive therapy compared with conventional treatment generally were not statistically significant, although the trends were to reduce progression.
Although the ADA does not have a separate guideline for patients with DKD, it recognizes that certain populations may require special considerations and that less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia.
Much of this support stems from benefits for some of the other major complications of diabetes, especially retinopathy. This is particularly true for those with type 1 diabetes being treated with insulin.132, 138, 384 Although the risk is increased in those with type 2 diabetes being treated with insulin,134, 137 the magnitude of the risk is considerably less. Table 22 provides recommendations for dosing of drugs used to treat hyperglycemia in patients with CKD stages 3 to 5. Doses are not specified by level of kidney function, but should be adjusted based on frequent monitoring to balance goals of glycemic control with avoiding hypoglycemia.
Factors that may contribute to falsely decreased values include a reduced red blood cell lifespan, hemolysis, and iron deficiency, whereas falsely increased values may occur due to carbamylation of the hemoglobin and acidosis. However, good control may still prevent or slow the progression of retinopathy, neuropathy, and possibly macrovascular disease. In those receiving less frequent insulin injections, oral agents, or medical nutrition therapy alone, SMBG is useful in achieving glycemic goals.
Assessment and management of CVD is addressed in the Background section of these guidelines.
Many patients can manage their diabetes with medication and diet, but the disease is often life-long and is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. International Diabetes Federation (IDF) estimates that by 2040 this will rise to 642 million.
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Caring doctors should tell them," said physician and diabetes researcher John Dixon at Baker IDI Heart and Diabetes Institute."It's the responsibility now for health services to include this as standard therapy for these patients," Professor Dixon said. By 2030, the number of people with diabetes worldwide is expected to rise to 472 million, according to the International Diabetes Federation. Very few studies addressed the benefits and risks of intensive glycemic control in later stages of CKD, let alone in patients who are undergoing dialysis or have received kidney transplants. 132, 368 To assess whether their reduced risk of DKD persisted long term, 1,349 of these subjects were evaluated as part of the EDIC study at the year 7 to 8 post-DCCT visit.133 Data were analyzed according to the original intensive- versus conventional-treatment groups, and the primary-prevention and secondary-intervention cohorts were combined. With respect to kidney outcomes, data are very strong for the development of microalbuminuria. First-generation sulfonylureas (eg, chlorpropamide, tolazamide, and tolbutamide) generally should be avoided in patients with CKD because these agents rely on the kidney to eliminate both the parent drug and active metabolites, resulting in increased half-lives and risk of hypoglycemia. Other considerations that are not specific to the level of kidney function include avoiding or minimizing the occurrence of interactions with drugs used to lower blood glucose. Postprandial SMBG testing also may be helpful, particularly in patients with gastroparesis, to achieve postprandial glucose goals and in patients using rapid insulin injections before meals to adjust the dose-meal calculation. Screening and treatment of retinopathy and foot care also are essential to the care of patients with diabetes and kidney disease. We want our readers to be responsible while commenting and to consider how their views could be received by others.
The numbers of patients progressing to more advanced outcomes, such as macroalbuminuria and decreases in GFR, are decreased significantly with improved glycemic control, but much of this decrease is related to the smaller number developing microalbuminuria to begin with. About one third of insulin degradation is carried out by the kidney, and impaired kidney function is associated with a prolonged half-life of insulin.
Of the second-generation sulfonylureas (eg, glipizide, gliclazide, glyburide, and glimepiride), glipizide and gliclazide are preferred agents because they do not have active metabolites and do not increase the risk of hypoglycemia in patients with CKD. The optimal frequency of SMBG has not been established in patients with type 2 diabetes treated by oral agents, but the ADA recommends testing sufficiently often to reach glycemic goals. In the absence of specific data in the diabetes and CKD population, the Work Group recommends following the standards set by the ADA (Table 26).34 An ophthalmologist or optometrist who is knowledgeable and experienced in the diagnosis and management of diabetic retinopathy should perform a comprehensive dilated eye examination annually in all people with diabetes. Please be polite and do not use swear words or crude or sexual language or defamatory words. 137 The UKPDS randomly assigned newly diagnosed patients with type 2 diabetes to intensive management using a sulfonylurea or insulin or to conventional management with diet alone.
Nonetheless, even for those with more advanced disease, evidence supports reaching the recommended HbA1c target. In addition, HbA1c levels should be determined at least twice per year in stable patients who are achieving glycemic goals and more often, approximately every 3 months, in patients whose therapy has changed or who are not reaching goals. Recently, nonmydriatic digital stereoscopic retinal imaging has proved to be a sensitive and specific method to screen and diagnose retinopathy, and it is being used in many facilities. FMT also holds the right to remove comments that violate the letter or spirit of the general commenting rules.The views expressed in the contents are those of our users and do not necessarily reflect the views of FMT. Rosiglitazone is cleared by the liver and does not have to be reduced with impaired kidney function.392 Therefore, rosiglitazone does not increase the risk of hypoglycemia in patients with CKD, but it has the potential, along with pioglitazone, to worsen fluid retention. In a recent study, sensitivity was 98% and specificity was 100%.397 Patients should be educated about the importance of foot surveillance and ulcer prevention, with an emphasis on self-management as discussed in CPR 4.
A comprehensive foot and vascular examination including visual inspection, Semmes-Weinstein monofilament testing, use of a 128-Hz tuning fork for testing of vibratory sensation, and evaluation of pedal pulses should be performed annually.
Because the risk of ulcers and amputations is high in those with diabetes and CKD, referral to foot-care specialists for annual examinations and preventive care is encouraged.

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