Pattern of Pharmacotherapy and Glycemic Control Status in Diabetic Patients with Different Stages of CKD in A Tertiary Care Centre in Kerala

Background: Type 2 Diabetes Mellitus (T2DM) is a leading cause of Chronic Kidney Disease (CKD), with approximately 20–30% of diabetic patients developing moderate-to-severe renal impairment. Management of diabetes in CKD is clinically challenging due to altered insulin metabolism, reduced renal clearance of anti-diabetic drugs, and increased risk of both hyperglycemia and hypoglycemia. Although guidelines such as ADA, KDIGO, and KDOQI recommend an HbA1c target of <7% to retard CKD progression, optimal glycemic targets in advanced CKD remain controversial.

Aim: To assess the pattern of pharmacotherapy and glycemic control status in diabetic patients with different stages of CKD attending a tertiary care center in Kerala, and to evaluate the association of CKD severity with microvascular and macrovascular complications.

Methods: This cross-sectional study included 104 patients with T2DM and established CKD (eGFR <60 mL/min/1.73m²) attending endocrinology and nephrology outpatient departments. Data collected from electronic medical records included demographic variables, laboratory parameters (HbA1c, hemoglobin, serum creatinine), comorbidities, diabetic complications, imaging findings, and treatment details. Statistical analysis was performed using SPSS version 21.0. A p-value <0.05 was considered statistically significant.

Results: The mean age was 69.89 ± 5.46 years, with a mean diabetes duration of 15.09 ± 6.4 years. Mean HbA1c was 8.31 ± 1.79%, indicating suboptimal glycemic control. The mean eGFR was 26.06 ± 16.00 mL/min/1.73m², with 32.7% of patients in stage 5 CKD (<15 mL/min). Systemic hypertension was present in 94%, dyslipidemia in 67%, coronary artery disease (CAD) in 56%, diabetic retinopathy (DR) in 67.1%, and peripheral vascular disease (PVD) in 67% of patients.

When categorized by treatment modality, 13 patients were on oral hypoglycemic agents (OHA) alone, 48 on insulin alone, and 43 on combination therapy. Insulin use increased significantly with declining eGFR. Sulfonylureas were the most commonly prescribed OHA, followed by gliptins, metformin, and SGLT2 inhibitors. Premixed insulin was the most frequently used insulin regimen. Better glycemic control was observed in the OHA-only group compared to insulin-treated groups. Among insulin regimens, basal insulin showed relatively better HbA1c control.

Patients with eGFR <30 mL/min had significantly higher prevalence of dyslipidemia (p=0.037) and diabetic retinopathy (p=0.009). CAD also showed a higher prevalence in advanced CKD, though statistical significance was borderline.

Conclusion: This study highlights suboptimal glycemic control among diabetic CKD patients in a tertiary care outpatient setting, with increasing reliance on insulin therapy in advanced stages. Sulfonylureas and premixed insulin were the most commonly prescribed agents. Screening gaps for end-organ complications and underutilization of ACE inhibitors and statins were observed. Despite limitations including small sample size and retrospective design, this study provides a cross-sectional overview of real-world management patterns in diabetic kidney disease and underscores the need for guideline-based comprehensive care.