[Not Available].

Diabetic nephropathy is the most common cause of end-stage renal disease and is associated with a high morbidity and mortality. Early diagnosis is important as tight control of albuminuria and hypertension improves the renal prognosis. Similarly, good control of hyperglycemia is critical, but emphasis should be given on individualization of treatment goals. Once the estimated GFR is < 60 ml/min/1.73 m2 the antidiabetic medication needs to be reviewed and a dose reduction of many drugs is necessary. The risk for hypoglycemia is particularly high for the sulfonylureas glibenclamide and glimepiride and they are contraindicated once the GFR is < 60 ml/min/1.73 m2. Because of the increased risk of lactic acidosis, metformin requires a dose adjustment if the GFR is < 60 ml/min/1.73 m2 and the drug should be stopped once the GFR falls < 45 ml/min/1.73 m2. In addition, metformin needs to be paused if acute renal failure is imminent. Inhibitors of the DPP-4 enzyme can be employed with impaired renal function, but their use usually requires dose adjustments. Prescription of GLP-1 receptor agonists is possible with a moderately impaired renal function but they should be discontinued if the GFR falls < 30/min/1.73 m2. From the new class of SGLT2 inhibitors canagliflozin and empagliflozin can be used in an adjusted dose as long as the GFR is > 45 ml/min/1.73 m2.