Novel approaches to hypoglycemia and burnt-out diabetes in chronic kidney disease

Purpose of review Diabetes mellitus is a leading cause of chronic kidney disease (CKD) that confers faster kidney disease progression, higher mortality, and various metabolic derangements including hypoglycemia. Recent findings Even in the absence of diabetes mellitus, growing research demonstrates that CKD patients are at heightened risk for hypoglycemia via multiple pathways. In CKD patients transitioning to end-stage renal disease (ESRD), spontaneous resolution of hyperglycemia and frequent hypoglycemia resulting in reduction and/or cessation of glucose-lowering medications are frequently observed in a phenomenon described as 'burnt-out diabetes'. In non-CKD patients, it is well established that hypoglycemia is causally associated with mortality, with pathways including arrhythmias, sudden cardiac death, stroke, and seizures. Increasing evidence shows that, in CKD and ESRD patients with and without diabetes mellitus, hypoglycemia is associated with cardiovascular complications and mortality risk. Given the high prevalence of hypoglycemia in CKD patients and the morbidity and mortality associated with this metabolic complication, a multimodal strategy is needed to prevent dysglycemia, including individualization of glycemic targets, selection of glucose-lowering medications less likely to induce hypoglycemia, medical nutrition therapy administered by trained dietitians, and accurate and precise hypoglycemia detection methods, such as self-monitored blood glucose or continuous glucose monitoring including during dialysis treatment.

Automated summary

Diabetes mellitus is a leading cause of chronic kidney disease (CKD), and recent studies have shown that even CKD patients without diabetes mellitus are at heightened risk for hypoglycemia. In patients transitioning to end-stage renal disease (ESRD), the phenomenon of "burnt-out diabetes" is observed, where hyperglycemia resolves and hypoglycemia becomes frequent. Hypoglycemia is causally associated with mortality, and it is important to implement strategies to prevent dysglycemia in CKD and ESRD patients.