الفهرس 
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Abstract
Summary and conclusion
Among dialysis patients, target an HbA1c goal of 7 to 8 percent, with the specific goal in individual patients based upon the risk of hypoglycemia and presence of comorbid conditions. For patients who are relatively young (<50 years) and without significant comorbid conditions, we target an HbA1c goal that is close to 7 percent (ie, 7 to 7.5). However, among older patients with multiple comorbid conditions, the HbA1c target is closer to 8 percent (ie, 7.5 to 8).
For most hemodialysis patients, we use insulin rather than oral agents. This is consistent with the 2005 K/DOQI guidelines, which suggest that, among dialysis patients, newer insulin regimens and insulin preparations should be used rather than oral agents for glycemic control (K/DOQI Workgroup,2005). This is due to the lack of adequate data concerning the use of oral agents in dialysis patients and their inability to adequately excrete many such agents.
Some clinicians prefer to use oral agents rather than insulin, especially among patients who are already on these agents and have achieved acceptable glycemic control. The preferred agents are glipizide or repaglinide since they are primarily metabolized by the liver, since inactive or only very weakly active metabolites are excreted in the urine, and since the risk of hypoglycemia is lower than with other oral agents (Tzamaloukas ,et al;2001).
Metformin which is a preferred agent in patients without kidney disease, should not be used among CKD patients with eGFR <30 mL/min/1.73 because of an increased risk of lactic acidosis (Garg R,et al ;2013). However we found two patients on dialysis in our study using metformin for control of blood sugar and without any observed complications .
Metformin can be used without dose reduction with an eGFR >60 ml/min/1.73 m2( Hahr ,et al 2015). we agree with the 2012 Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines that metformin may be used among patients with an eGFR >45 mL/min/1.73 [National Kidney Foundation 2012]. If eGFR ≥45–59 ml/min/1.73 m2, it is prudent to continue use of metformin but take caution with dosing and follow the renal function more closely, such as every 3 to 6 months.
The use of metformin among patients with eGFR between 30 and 44 mL/min/1.73 is left up to the discretion of the clinician, although the K/DOQI guidelines suggest that its use among individual patients be reviewed. If the eGFR is ≥30–44 ml/min/1.73 m2, again use caution with dosing, such as limiting its dose to a maximum of 1000 mg daily or using a 50 % reduction, follow renal function every 3 months and avoid newly initiating metformin ( Hahr ,et al; 2015).
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines for CKD, which have been reviewed and endorsed by the 2006 Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference and the KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of chronic Kidney Disease (KDIGO 2012), recommend that all individuals should be assessed as part of routine health examinations to determine whether they are at increased risk for developing CKD (National Kidney Foundation,2002&Levey AS,et al; 2007 ).
However, the American College of Physicians (ACP) has recommended that patients with or without diabetes who are already taking either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) should not be tested for proteinuria (Qaseem A,et al ;2013), although this recommendation is controversial (Molitoris BA.et al ;2014).
Our study was carried out in the period between Feb 2016 to Feb 2017 in El Minia governorate.
The total number of ESRD patients on dialysis was 1700 patients according to records of the ministry of health .only 755(44.4%) patients agree to participate in our study.
Patients in our study were divided into 3 groups as follow:
group (1) include non diabetic patients.
group (2) include patients with blood glucose controlled : ( Groups A,B,C,D ) :
A) include diabetic patients with blood glucose controlled without any blood glucose lowering medications.
B) include diabetic patients with blood glucose controlled with insulin only.
C) include diabetic patients with blood glucose controlled with both insulin and oral hypoglycemic drugs.
D) include diabetic patients with blood glucose controlled with oral hypoglycemic drugs only.
group (3) include patients with blood glucose uncontrolled : (Groups A,B,C,D )
group (A) include diabetic patients with blood glucose not controlled with insulin .
group (B) include diabetic patients with blood glucose not controlled with oral hypoglycemic drugs.
group (C) include diabetic patients with blood glucose not controlled with both oral hypoglycemic drugs and insulin.
group (D) includediabetic not controlled without any blood glucose lowering medications.
The mean age of all patients in our study was 50.4±14.3 years.The results showed that the incidence of ESRD was more in male patients 62.3% (n=470) than female patients 37.7% (n=285)
In our study the overall prevalence of diabetes in hemodialysis patients were 116 out of 755 with percentage of 15.4% and 639 not diabetic (84.6%) with P 0.001* . there is male excess in diabetes , 67 males in number were affected with DM (57.8%) and 49 female in number were affected with DM (42.2%) and family history of diabetes was observed in 48 patients with percentage 6.3%.
Out of 116 ,there were 60 patients receiving insulin only (51.7%) , 30 patients receving oral hypoglycemic drugs (25.9%), 2 receving both oral hypoglycemic drugs and insulin (1.7%) and 24 patients not receiving any medications (20.7%).
In our study there was 63 hemodialysis patients with blood glucose controlled (by HbA1c) with percentage of 54.3% and 53 hemodialysis patients were uncontrolled with percentage of 45.7% .
Of controlled patients there were 14 patients with blood glucose controlled without any medications , 32 controlled with insulin only,2 with both insulin and oral hypoglycemic drugs and 15 controlled with oral hypoglycemic drugs only.
Of uncontrolled patients there were 28 patients with blood glucose not controlled with insulin only,15 not controlled with oral hypoglycemic drugs, 10 not controlled because they were not receiving any medications.
In our study,we discovered that hypertension is the most common cause of renal failure (64.8% ) followed by obstructive uropathy ( 16%) followed by diabetes mellitus ( 15.4%).
In accordance with our study,A history of diabetes, hypertension, or cardiovascular disease (CVD) confers the highest risk for developing CKD, and individuals who have such a history should be screened (Levey AS,et al; 2007).
In our study , we discovered that retinopathy is the most common complications of DM in hemodialysis patients (26.7%) followed by nephropathy (17%) followed by hypoglycemia ( 11.2%). And the least complications of DM that observed in our study is diabetic ketoacidosis (3.4% ).
Also in our study we found that HCV was positive in 376 patients out of total 755 by percentage 49.8%.