The management of diabetic neuropathy in CKD.

Diabetic nephropathy is the leading cause of end stage renal disease (ESRD) requiring renal replacement therapy in the U.S.1A The progression of diabetes to advanced stages of chronic kidney disease is associated with the progression of multiple other micro and macrovascular complications of diabetes including diabetic neuropathies1. Diabetic peripheral neuropathy is a common complication of diabetes associated with high morbidity, poor quality of life and high risk of lower-extremity amputation. Similarly, cardiac autonomic neuropathy is associated with life-threatening consequences, such as silent myocardial ischemia and high mortality 2-4. In this review we will examine the characteristics of cardiac autonomic neuropathy and diabetic peripheral neuropathy in diabetic patients with stage 4-5 chronic kidney disease (CKD) or end stage renal disease (ESRD) undergoing dialysis. We will describe the evidence supporting the available therapeutic options and the challenges associated with providing adequate care for these patients and discuss future directions for investigation.