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This chapter details diabetes mellitus management in patients with end-stage renal disease (ESRD) during the perioperative period for renal transplant. As patients transition from the preoperative to postoperative stage, medication management as it pertains to glycemic control is of the utmost importance. For information on electrolyte and hemodynamic homeostasis, please review Chapter 40.


ESRD is a microvascular consequence of diabetes. Diabetes is the leading cause of ESRD in the United States, eventually requiring dialysis or renal transplant.1 Patients with ESRD are defined as having an effective glomerular filtration rate (eGFR) less than 15 mL/min/1.73 m2, with sustained hyperglycemia worsening outcomes via increased proteinuria, decreased eGRF, decreased protein filtration, and ultimately fluid overload (see Chapter 40).1 Optimizing glycemic control is the mainstay focus of management. The National Kidney Foundation recommends an HbA1c goal of 7.0%, as more stringent glucose control increases the risk of hypoglycemia.2 Table 16-1 summarizes pharmaceutical guidelines for hypoglycemic agents when treating patients with ESRD.

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TABLE 16-1 Medical Management of Diabetes in End-Stage Renal Disease (ESRD)1



Cautions and Contraindications


Preferred treatment, especially in those with advanced kidney disease

Doses may need to be decreased, as insulin metabolism is prolonged


Contraindicated in patients with eGFR<30 mL/min/1.73 m3, not recommended to be initiated for patients with eGFR<45 mL/min/1.73 m3

Sulfonylureas (glipizide, glyburide, glimepiride)

Glyburide NOT recommended, as it has a longer half-life and commonly causes hypoglycemia

Meglitinides (repaglinide, nateglinide)

Not metabolized by the kidneys, so can be used in ESRD

Nateglinide has an active metabolite which is cleared by the kidney, so repaglinide is preferred

Thiazolidinedione (TZD) (pioglitazone, rosiglitazone)

Commonly causes fluid retention, use in caution in patients with heart failure and nephrotic syndromes

Alpha-glucosidase inhibitor (acarbose)

Do not use if eGFR <30

DPP4i (sitagliptin, saxagliptin, linagliptin, alogliptin)

Must be renally dosed according to kidney stage, except linagliptin, which is not renally cleared

GLP1RA (liraglutide, dulaglutide, exenatide, semaglutide, lixisenatide)

Exenatide and lixisenatide should not be used in those with eGFR <30 or ESRD

SGLT2i (canagliflozin, empagliflozin, dapagliflozin, ertugliflozin)

Renal and cardiac benefits (decreases albumin excretion and renal glucose absorption)

  • Ertugliflozin should only be used in those with a GFR>60

  • Dapagliflozin should only be used in those with a GFR>25

  • Empagliflozin should only be used in those with a GFR>45

  • Canagliflozin should only be used in GFR >30

Additionally, all patients with an eGRF <60 mL/min/1.73 cm2 should consult a nutritionist and limit protein intake to 0.8 g/kg/day.1


The Night Before and the Morning of Surgery

In the perioperative period, it is important for collaboration between endocrine and transplant surgery to avoid both hypoglycemia and hyperglycemia. Guidelines for medical management the day ...

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