REVIEW Assessing Glycemic Control in Patients With Diabetes and End-Stage Renal Failure Adeel Ansari, MB, BS, Stephen Thomas, FRCP, and David Goldsmith, FRCP ● Blood glucose monitoring is important in optimizing long-term outcomes in diabetic patients. Reliance on near-patient testing and the use of longer term measures of glycation are the current cornerstones. However, as this review details, there are significant problems using blood tests as measures of metabolic control in uremic diabetic patients. Am J Kidney Dis 41:523-531. © 2003 by the National Kidney Foundation, Inc. INDEX WORDS: Diabetes; glucose; metabolic control; dialysis; glycation. D IABETIC NEPHROPATHY accounts for approximately one third of new cases of end-stage renal failure (ESRF) and is now the most common single disorder leading to ESRF. 1 Management of diabetes in kidney failure is complicated by the increased risk for hypoglyce- mia and hyperglycemia; insulin sensitivity and duration of action are altered, and type of renal replacement therapy also has an affect on glu- cose homeostasis. 2 Maintenance of tight glycemic control in pa- tients with diabetes is important in preventing the development and progression of microvascu- lar and macrovascular complications in both type 1 and type 2 diabetes. 3,4 There is some evidence that good glycemic control prevents progression of nephropathy. 5,6 Good glycemic control in pa- tients with ESRF caused by diabetes reduces the risk for developing other complications. How- ever, a randomized interventional trial to show the importance of tight diabetic control with respect to future morbidity and mortality in ure- mia is notable by its absence (as it is for control of increased blood pressure and dyslipidemia). Common sense suggests that good metabolic control is likely to benefit patients. This is sup- ported by one single-center prospective observa- tional trial that enrolled 150 subjects with end- stage renal disease and diabetes (109 men, 41 women; age at hemodialysis [HD] therapy initia- tion, 60.5  10.2 years) at the start of HD therapy between January 1989 and December 1997. Subjects were divided into groups accord- ing to their glycemic control level at inclusion, as follows: good (hemoglobin A 1c [HbA 1c ] level  7.5%; n = 93; group G) and poor (HbA 1c  7.5%; n = 57; group P). Survival was followed up for a mean of 2.7 years. Group G had better survival than group P (the control group; P = 0.008). At inclusion, there was no significant difference in age, sex, systolic blood pressure, body mass index, cardio-thoracic ratio on chest x-ray, or serum creatinine or hemoglo- bin levels between the two groups. After adjust- ment for age and sex, HbA 1c level was a signifi- cant predictor of survival (hazard ratio, 1.133 per From the Department of Nephrology and Diabetes, Guy’s Hospital; and the Department of Diabetes, King’s College Hospital, London, UK. Received July 15, 2002; accepted in revised form October 17, 2002. Address reprint requests to David Goldsmith, FRCP, Con- sultant Nephrologist, Guy’s Hospital Renal Unit, London SE1 9RT, UK. E-mail: david.goldsmith@kcl.ac.uk © 2003 by the National Kidney Foundation, Inc. 0272-6386/03/4103-0001$30.00/0 doi:10.1053/ajkd.2003.50114 The Official Journal of the National Kidney Foundation VOL 41, NO 3, MARCH 2003 AJKD American Journal of Kidney Diseases American Journal of Kidney Diseases, Vol 41, No 3 (March), 2003: pp 523-531 523