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Glycemic Control in Diabetic Dialysis Patients and the Burnt-Out Diabetes Phenomenon

  • Microvascular Complications—Nephropathy (B Roshan, Section Editor)
  • Published:
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Abstract

Diabetes mellitus (DM) is the most common cause of end-stage kidney disease and a major risk of morbidity and mortality. It is not clear whether medical management of DM has any significant beneficial effect on clinical outcomes at the end-stage of diabetic nephropathy with full-blown micro- and macro-angiopathic complications. Both loss of kidney function and dialysis treatment interfere with glucose homeostasis and confound glycemic control. Given the unique nature of uremic milieu and dialysis therapy related alterations, there have been some debates about reliance on the conventional measures of glycemic control, in particular the clinical relevance of hemoglobin A1c and its recommended target range of <7 % in diabetic dialysis patients. Moreover, a so-called burnt-out diabetes phenomenon has been described, in that many diabetic dialysis patients experience frequent hypoglycemic episodes prompting cessation of their anti-diabetic therapies transiently or even permanently. By reviewing the recent literature we argue that the use of A1c for management of diabetic dialysis patients should be encouraged if appropriate target ranges specific for these patients (e.g. 6 to 8 %) are used. We also argue that “burnt-out diabetes” is a true biologic phenomenon and highly prevalent in dialysis patients with established history and end-stage diabetic nephropathy and explore the role of protein-energy wasting to this end. Similarly, the J- or U-shaped associations between A1c or blood glucose concentrations and mortality are likely biologically plausible phenomena that should be taken into consideration in the management of diabetic dialysis patients to avoid hypoglycemia and its fatal consequences in diabetic dialysis patients.

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Acknowledgments

The work is supported by K. Kalantar-Zadeh’s NIH (NIDDK) grants K24-DK091419, R0-DK078106 and R21-DK077341 and by a philanthropic grant from Mr. Harold Simmons. M.Z. Molnar received grants from the National Developmental Agency (KTIA-OTKA-EU 7KP-HUMAN-MB08-A-81231) from the Research and Technological Innovation Fund, and is recipient of the Hungarian Eötvös Scholarship (MÖB/77-2/2012).

Disclosure

Conflicts of interest: J. Park: none; P. Lertdumrongluk: none; M.Z. Molnar: none; C.P. Kovesdy: has been a consultant for Apotex; has received grant support from Abbott, Shire; receives royalties from UpToDate; and has received payment for development of educational presentations including service on speakers’ bureaus from Health Diagnostic Laboratories; K. Kalantar-Zadeh: has been a consultant for Abbott, Amgen, Genzyme, Shire, Vifor; has been an expert witness for law firms; has received grant support from NIH, NKF, Abbott, Shire; receives royalties from UpToDate; and has received payment for development of educational presentations including service on speakers’ bureaus from Abbott, Amgen, Genzyme, Otsuka, Shire.

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Authors and Affiliations

  1. Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson Street, C1-Annex, Torrance, CA, 90509-2910, USA

    Jongha Park, Paungpaga Lertdumrongluk, Miklos Z. Molnar & Kamyar Kalantar-Zadeh

  2. Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

    Jongha Park

  3. Institute of Pathophysiology, Semmelweis University, Budapest, Hungary

    Miklos Z. Molnar

  4. Division of Nephrology, University of Virginia, Charlottesville, VA, USA

    Csaba P. Kovesdy

  5. Division of Nephrology, Salem VA Medical Center, Salem, VA, USA

    Csaba P. Kovesdy

  6. David Geffen School of Medicine at UCLA, and Fielding School of Public Health at UCLA, Los Angeles, CA, USA

    Kamyar Kalantar-Zadeh

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  1. Jongha Park
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  2. Paungpaga Lertdumrongluk
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  3. Miklos Z. Molnar
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  4. Csaba P. Kovesdy
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  5. Kamyar Kalantar-Zadeh
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Correspondence to Kamyar Kalantar-Zadeh.

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Park, J., Lertdumrongluk, P., Molnar, M.Z. et al. Glycemic Control in Diabetic Dialysis Patients and the Burnt-Out Diabetes Phenomenon. Curr Diab Rep 12, 432–439 (2012). https://doi.org/10.1007/s11892-012-0286-3

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