Metformin gfr
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Metformin and Glomerular Filtration Rate (GFR): A Comprehensive Overview
Introduction to Metformin and GFR
Metformin is a widely used medication for managing type 2 diabetes mellitus (T2DM). Its use in patients with varying levels of kidney function, particularly those with chronic kidney disease (CKD), has been a subject of extensive research. The primary concern with metformin in CKD patients is the risk of lactic acidosis, a rare but serious complication. This article synthesizes recent research findings on the relationship between metformin and glomerular filtration rate (GFR), a key indicator of kidney function.
Metformin in Polycystic Kidney Disease and GFR
A study on autosomal dominant polycystic kidney disease (ADPKD) evaluated the safety and efficacy of metformin in patients with an estimated GFR (eGFR) over 50 ml/min/1.73 m². The trial found that metformin was safe and tolerable, with a slight reduction in the decline of eGFR compared to placebo, although the difference was not statistically significant. This suggests that metformin may have a potential role in managing ADPKD, but larger trials are needed to confirm its efficacy.
Metformin and GFR in Type 1 Diabetes
In adolescents with type 1 diabetes (T1D), metformin was associated with a significant increase in eGFR measured by serum creatinine, but not by cystatin C. This indicates that metformin may improve kidney function markers in T1D patients, although further studies with directly measured GFR are necessary to validate these findings.
Pragmatic eGFR Thresholds for Metformin Prescribing
Renal impairment is a contraindication for metformin due to the risk of lactic acidosis. Current guidelines recommend using eGFR instead of serum creatinine to assess kidney function more accurately. Research supports establishing pragmatic eGFR limits to guide metformin prescribing, ensuring safer use in patients with varying degrees of renal impairment.
Metformin Use During Coronary Angiography
A study investigated the safety of continuing metformin in diabetic patients with a GFR > 60 ml/min/1.73 m² undergoing coronary angiography. The results showed no significant increase in the risk of metformin-associated lactic acidosis (MALA), suggesting that metformin can be safely continued in these patients during the peri-angiography period.
Metformin Dosing in Chronic Kidney Disease
The intact nephron hypothesis (INH) was explored as a model for metformin dosing in CKD patients. The study found a linear relationship between metformin renal clearance and eGFR, supporting the idea that proportional dose reduction based on GFR is reasonable for CKD patients.
FDA Label Change and Disparities in Metformin Prescription
The FDA's 2016 label change from serum creatinine-based to eGFR-based contraindications for metformin use aimed to reduce racial and sex disparities in metformin prescription among CKD patients. The change significantly attenuated these disparities, particularly in patients with moderate kidney dysfunction.
Long-term Effects of Metformin on Renal Function
In a long-term study comparing metformin, rosiglitazone, and glyburide, metformin was found to have a slower rise in albumin/creatinine ratio (ACR) and a stable eGFR over five years. This suggests that metformin may have a protective effect on renal function compared to other diabetes medications.
New Guidelines for Metformin Use in Reduced Renal Function
New guidelines recommend the use of metformin down to a GFR of 30 ml/min, with dose adjustments as necessary. The risk of lactic acidosis is considered very low, even with the administration of iodine contrast media, provided that metformin is stopped when GFR is below 45 ml/min .
Conclusion
The body of research indicates that metformin can be safely used in patients with varying levels of kidney function, with appropriate dose adjustments based on eGFR. The risk of lactic acidosis is minimal when guidelines are followed, making metformin a viable option for managing diabetes in patients with CKD. Further studies are needed to refine dosing strategies and confirm long-term benefits on renal function.
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