Treatment of diabetes in patients with advanced chronic kidney disease or kidney failure

Chronic kidney disease (CKD) is common in both type 1 and type 2 diabetes and complicated glycemic control due to fluctuating insulin resistance and metabolism. In advanced CKD (stage 4 and stage 5, or estimated glomerular filtration rate <30 mL/min/1.73 m2), reduced kidney clearance of insulin can lower or eliminated insulin needs, but glycemic control remains challenging. This article reviews optimal glycemic targets, monitoring and current therapeutic recommendations for patients with severe CKD or on dialysis, addressing the lack of efficacy data for many antihyperglycemics in this population.