Diabetic control becomes difficult as renal impairment
progresses. Treatment with metformin should be
withdrawn when creatinine is higher than 150 μmol/L (1.7 mg/dL), as the risk of lactic acidosis is increased.
Long-acting sulphonylureas should be replaced by short acting
agents that are metabolised rather than excreted.
Renal replacement therapy (p. 492) may benefit diabetic
patients at an earlier stage than other patients
with ESRF, although it may carry additional difficulties.
Renal transplantation can dramatically improve the
life of many, and any recurrence of diabetic nephropathy
in the allograft is usually too slow to be a serious
problem, but associated macrovascular and microvascular
disease elsewhere may still progress. Pancreatic
transplantation (generally carried out at the same time
as renal transplantation) can produce insulin independence
and slow or reverse microvascular disease, but
the supply of organs is very limited and this is available
to few. For further information on management,
see Chapter 17.