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Diabetestherapie bei Niereninsuffizienz

Besonderheiten und Limitationen

Diabetes treatment in kidney disease

Special considerations and limitations

  • Leitthema
  • Published:
Der Diabetologe Aims and scope

Zusammenfassung

Hintergrund

Die Komorbidität von Diabetes mellitus (DM) und chronischer Niereninsuffizienz (CNI) ist häufig, 20–40 % der DM-Patienten entwickeln im Krankheitsverlauf eine CNI. Das bei DM ohnehin erhöhte kardiovaskuläre Risiko nimmt dann deutlich zu.

Ziel dieser Arbeit

Es wird ein Überblick über die aktuell verfügbaren Therapeutika und deren Limitationen bei CNI mit spezieller Beachtung der kardiovaskulären Sicherheit der Präparate gegeben.

Material und Methoden

Es erfolgten Literaturrecherchen in PubMed und MEDLINE („medical literature analysis and retrieval system online“).

Ergebnis und Diskussion

Ziel der individuell festzulegenden Diabetestherapie ist, neben der Kontrolle des Blutzuckerspiegels ein Fortschreiten der CNI zu verhindern, aber auch Hypoglykämien zu vermeiden, da diese mit einer erhöhten Mortalität assoziiert sind. Der angestrebte HbA1c-Korridor (HbA1c: Glykohämoglobin Typ A1c) liegt in der Regel bei 6,5–7,5 %. Nach Änderung des Lebensstils ist neuerdings auch bei CNI Metformin Mittel der 1. Wahl. Es kann bei entsprechender Vorsicht bis zu einer GFR (glomeruläre Filtrationsrate) von 30 ml/min in reduzierter Dosis eingesetzt werden. Ergänzend oder alternativ verordnen wir Empagliflozin und/oder Liraglutid, da beide die kardiovaskuläre Morbidität und Mortalität reduzieren. Gliptine können dosisreduziert auch in höheren Stadien der CNI zur Anwendung kommen, allerdings ist für sie kein kardiovaskulärer Zusatznutzen belegt. Die Datenlage zum Einsatz der weiteren verfügbaren oralen Antidiabetika ist bei höhergradiger CNI eher dünn, sodass wir sie weitgehend vermeiden. Im Erkrankungsverlauf ist eine Insulintherapie häufig unvermeidbar, wobei v. a. bei progredienter CNI mit der Zeit oft eine Dosisreduktion zur Vermeidung von Hypoglykämien notwendig ist.

Abstract

Background

Comorbidity between diabetes mellitus and chronic kidney disease (CKD) is common; 20%–40% of diabetic patients develop CKD during their lifetime. This is accompanied by a further increase in cardiovascular risk.

Objectives

To give an overview of available antidiabetic drugs and their limitations in CKD, with particular attention to their cardiovascular safety.

Materials and methods

Literature searches were conducted in Pubmed and Medline (medical literature analysis and retrieval system online).

Results and Conclusions

Besides controlling blood sugar levels, the aim of individualized therapy is to prevent the progression of CKD without increasing the risk of hypoglycemia, since this is associated with higher mortality. The desired HbA1c (HbA1c: glycohemoglobin A1c) lies in the range of 6.5%–7.5%, depending on further comorbidities. Following lifestyle changes, the first-line therapy is metformin, which is now also approved down to a GFR (glomerular filtration rate) of 30 ml/min at a reduced dose. In addition or as an alternative, empagliflozin and/or liraglutide are prescribed, since they significantly reduce cardiovascular morbidity and mortality. Gliptins can be given at more advanced stages of CKD at a reduced dosage; however, no cardiovascular benefits have been shown for their use. Since data on the use of other oral antidiabetics in higher-grade CKD is limited, their use is generally avoided. Over time, many patients will require insulin; however, a reduction in insulin dosage needs to be considered as CKD progresses in order to avoid hypoglycemia.

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Authors and Affiliations

  1. Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97070, Würzburg, Deutschland

    U. Dischinger,  M. Fassnacht &  A.-C. Koschker

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  1. U. Dischinger
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  3. A.-C. Koschker
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Correspondence to U. Dischinger.

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U. Dischinger, M. Fassnacht und A.-C. Koschker geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Dischinger, U., Fassnacht, M. & Koschker, AC. Diabetestherapie bei Niereninsuffizienz . Diabetologe 14, 86–92 (2018). https://doi.org/10.1007/s11428-018-0311-5

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  • DOI: https://doi.org/10.1007/s11428-018-0311-5

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