Editor – We read with interest the article ‘Perioperative diabetes care’ by Ketan Dhatariya and Nicholas Levy.1
We wanted to highlight the challenges involved in management of diabetic patients with chronic kidney disease (CKD), acute kidney injury (AKI) and AKI on CKD. We believe that it is important to note the role CKD and AKI play in the management of patients with diabetes. There is a well-known association between diabetes and development of CKD. Mathew et al found that CKD was an independent risk factor for postoperative morbidity and mortality, with a strength of association similar to that of diabetes, stroke or coronary disease.2
The risk of side effects of some antidiabetic medications, such as metformin and thiazolidinediones, increases in patients with CKD. Zanchi et al have concluded that only sitagliptin, saxagliptin and linagliptin may be used in advanced kidney disease, while GLP-1 agonists are contraindicated.3
Furthermore, there are multiple mechanisms by which surgery can lead to the development of AKI, especially in patients with a known history of CKD. The use of non-steroidal anti-inflammatory drugs for pain management, contrast-media for imaging studies and volume depletion during surgery are all contributing factors. Hobson et al recommend using different predictive strategies, including scoring systems and clinical judgement to determine the risk of AKI in patients undergoing surgery.4 Some hospitalised patients are on anticoagulants for various reasons. Anticoagulation-related nephropathy is a significant but underdiagnosed complication of anticoagulant treatment. It is most commonly associated with warfarin but some studies suggest its association with novel anticoagulants as well.5
There is a known strong association between type 2 diabetes and atrial fibrillation, increasing the likelihood that the patients have been prescribed anticoagulants. We therefore believe that more detailed guidelines are needed to determine the best approach to perioperative management of patients with diabetes and comorbid kidney disease, including finding the best AKI prevention strategies, reducing the risk of medication side effects, finding the optimal anticoagulation regimen and ensuring long-term renal protection.
References
- 1.Dhatariya K, Levy N. Perioperative diabetes care. Clin Med 2019;19:437–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mathew A, Devereaux PJ, O'Hare A, et al. Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis. Kidney Int 2008;73:1069–81. [DOI] [PubMed] [Google Scholar]
- 3.Zanchi A, Lehmann R, Philippe J. Antidiabetic drugs and kidney disease–recommendations of the Swiss Society for Endocrinology and Diabetology. Swiss Med Wkly 2012;142:w13629. [DOI] [PubMed] [Google Scholar]
- 4.Hobson C, Ruchi R, Bihorac A. Perioperative acute kidney injury: risk factors and predictive strategies. Crit Care Clin 2017;33:379–96. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Wheeler DS, Giugliano RP, Rangaswami J. Anticoagulation-related nephropathy. J Thromb Haemost 2016;14:461–7. [DOI] [PubMed] [Google Scholar]