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2. The Kidneys and Diabetes – Dealing
with Hypoglycaemia

Professor Per Henrik Groop Dr Merlin Thomas
University of Helsinki Danielle Alberti Memorial Centre for Diabetic
Folkhälsan Research Centre Complications
Helsinki, Finland Baker Medical Research Institute
Melbourne, Australia

Hypoglycaemia is the most frequent complication of diabetes manage-
ment, affecting up to one quarter of all patients with type 2 diabetes,
at least once a year. Although permanent damage or mortality due
1
to hypoglycaemia is uncommon, even minor hypoglycaemic events
can have a major effect on diabetes management. Hypoglycaemia
(or a “hypo”) is cited as the most important (and feared) complication
of diabetes by patients themselves, more important than kidney failure
or heart disease. Hypoglycaemia is often the most important barrier to
good glucose control, as attempts to avoid it result in therapeutic iner-
tia and (reluctant) tolerance of higher glucose levels. 2

Although the kidney is primarily regarded as an excretory organ, it
also plays an important role in glucose homoeostasis. Impaired kidney
function is associated with abnormal glucose metabolism, including
decreased sensitivity to insulin, inadequate insulin secretion, and al-
tered gluconeogenesis. Kidney disease also directly or indirectly alters
the pharmacokinetics and pharmacodynamics of all agents used to
treat type 2 diabetes. Combined, these contribute to an increased in-
3
cidence and severity of hypoglycaemic episodes (Figure 1). This chap-
ter will examine some of the reasons for this association, and the op-
portunities to reduce the risk of hypoglycaemic events in patients with
chronic kidney disease (CKD).

Figure 1. Factors that contribute to the increased incidence of hypoglycaemia in diabetic
patients with chronic kidney disease.

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