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Glycaemic control is a key element in the management of patients with chronic renal insufficiency, associated of course with treatment of all the other associated factors. Dietary management should not merely be wishful thinking but a reality, involving the control of body weight, the maintenance of lean body mass, the observance of a sufficient carbohydrate intake and the control of protein intake, which, always tends to be excessive in diabetics. Drug treatment with oral antidiabetics may be given without risk of iatrogenic effects: glitazone has no effect on renal metabolism but may increase water retention; glinides are insulin secretagogues without renal metabolism so there is no risk of hypoglycaemia in the event of impaired renal function; if not insulin remains an excellent alternative with, however, a change in its half-life with the elevated creatinine clearance. In all cases, the goal remains the control of glycosylated haemoglobin without iatrogenic effects.

Diabetologists and nephrologists must cooperate to improve uraemic diabetic patient's outcome, with a special attention to their nutritional status. We describe the management of these patients at the CHU of Bordeaux since 2001, and its first results. Renal function is assessed by the glomerular filtration rate, predicted by the Cockcroft-Gault formula according to clinical guidelines. We compared its results to reference isotopic measurements (51Cr-EDTA) in one hundred and twenty two patients. This comparaison showed clearly a bias because the GFR calculated by the formula is proportionnal to body weight: the prediction is overestimated by 55% in obese (BMI30) and 15% in overweighted (25BMI30) patients, who represent the majority of type 2 diabetic patients; the MDRD equation is not affected by this bias. Nutritional follow-up is based on body composition assessment by DEXA, but more simple methods (Skinfold thickness, bio-impedancemetry) have given similar results in our first forty nine patients. After 2 years of follow-up, no patient have lost fat or fat-free mass, except seven patients who have lost 6 kg fat-free mass during the 6 months after starting hemodialysis. The kind of this fat-free mass loss (muscular loss, or correction of hyperhydratation) remains a matter of discussion.