End-stage renal failure and management of diabetes

When ESKD complicates the management of diabetes mellitus

Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.

A Retrospective Observational Study of Insulin Glargine in Type 2 Diabetic Patients with Advanced Chronic Kidney Disease

Background

The majority of type 2 diabetes mellitus (T2DM) subjects are on multiple oral antidiabetic drugs (OADs) but as kidney dysfunction progresses, many of them become inappropriate. Basal insulin, such as glargine, is generally recommended as first-line insulin therapy by most guidelines. However, there is limited data on the safety and efficacy of the use of glargine in diabetic kidney disease (DKD).

Objectives

To evaluate the efficacy and safety of insulin glargine in T2 DM patients with Stage 3 or 4 chronic kidney disease (CKD).

Material and methods

This single-centered, retrospective, observational study evaluates the efficacy and safety of insulin glargine in DKD with estimated glomerular filtration rate (eGFR) 60 and below. Non-pregnant T2DM patients with DKD receiving insulin glargine for 24 weeks and beyond were included for analysis. Data relating to anthropometric measurements, blood pressure, renal parameters, and glycemic control were analyzed. Sixty patients were in CKD Stage 3 (group A) and 35 patients were in CKD Stage 4 (group B). Glargine was started at an initial dose of 10 units daily as per the standard of care followed by the institute and up-titrated or down-titrated using a prespecified algorithm to maintain fasting plasma glucose between 90 mg/dl and 130 mg/dl.

Results

The study achieves (1.2%) (13.2 mmol/mol) of glycosylated hemoglobin (HbA1C) reduction in both groups (Group A and Group B) and a significant reduction in fasting and postprandial glucose values without a significant weight change over the study period. Out of 95 patients, 32 (33.68%) had documented hypoglycemia; out of them, 9 (28.2%) had severe hypoglycemia, and 8 (25%) had nocturnal hypoglycemia (either mild or severe). No change in weight, blood pressure, or eGFR was observed during the study period.

Conclusions

Treatment with glargine-based basal insulin therapy in diabetes with Stage 3 or Stage 4 CKD was efficacious in reducing glycemic parameters and was safe without significant changes in weight and hypoglycemia.

Effectiveness of Dose Adjustment of Insulin in Type 2 Diabetes among Hemodialysis Patients with End-Stage Renal Disease: A Randomized Crossover Study

Determining insulin requirements for hemodialysis patients with end-stage renal disease (ESRD) is difficult. We performed a randomized crossover study among type 2 diabetes (T2DM) patients with ESRD on continuous hemodialysis and receiving standard insulin for glycemic control. The patients were randomized in 2 groups: daily insulin needed on the day after hemodialysis and a 25% decrease in daily insulin needed on the day after hemodialysis. A total of 51 T2DM patients with ESRD were enrolled. The adjusted-insulin group had higher plasma glucose levels at the 2nd hour of dialysis than those of the nonadjusted-insulin group. Incidence of hypoglycemia per dialysis session (3.3% vs. 0.7%, P = 0.02) and symptoms related to hypoglycemia (6.9% vs. 0.7%, P = 0.001) were more frequent in the nonadjusted-insulin group. A reduced insulin administration of 25% among T2DM patients undergoing hemodialysis on the day of dialysis was associated with sustained glycemic efficacy and the production of fewer hypoglycemic symptoms. This trial is registered with TCTR20180724002.

Insulin therapy in renal disease

Diabetes mellitus (DM) is the main cause of end-stage renal disease (ESRD). Conversely, chronic renal failure (CRF) is also associated with diverse alterations in carbohydrate and insulin metabolism. CRF-induced metabolic disorders should be borne in mind when treating diabetic patients, to ensure the introduction of adequate therapy adjustments that are in line with the onset of renal function decline. Moreover, several specific therapies employed in CRF may also influence pharmacological therapy of DM in uraemic patients. Adequate glycaemic control has also been associated with a reduction in the onset and progression of diabetic nephropathy as well as in the morbidity and mortality in uraemic diabetic patients during dialysis. Intensive insulin therapy can notably improve glycemic control and it should be considered part of the management of insulin-treated CRF diabetic patients. Insulin analogues have been recently evaluated in CRF diabetic patients, with encouraging results. In this study, we review the more relevant aspects related to insulin therapy in diabetic patients with different degrees of renal failure and in patients with ESRD, both in conservative therapy and dialysis.

Diabetes, glycaemic control and mortality risk in patients on haemodialysis: the Japan Dialysis Outcomes and Practice Pattern Study

AIMS/HYPOTHESIS

There are few data on the target level of glycaemic control among patients with diabetes on haemodialysis. We investigated the impact of glycaemic control on mortality risk among diabetic patients on haemodialysis.

SUBJECTS AND METHODS

Data were analysed from the Dialysis Outcomes Practice Pattern Study (DOPPS) for randomly selected patients on haemodialysis in Japan. The diagnosis of diabetes at baseline and information on clinical events during follow-up were abstracted from the medical records. A Cox proportional hazards model was used to evaluate the association between presence or absence of diabetes, glycaemic control (HbA(1c) quintiles) and mortality risk.

RESULTS

Data from 1,569 patients with and 3,342 patients without diabetes on haemodialysis were analysed. Among patients on haemodialysis, those with diabetes had a higher mortality risk than those without (multivariable hazard ratio 1.37, 95% CI 1.08-1.74). Compared with those in the bottom quintile of HbA(1c) level, the multivariable-adjusted hazard ratio for mortality was not increased in the bottom second to fourth quintiles of HbA(1c) (HbA(1c) 5.0-5.5% to 6.2-7.2%), but was significantly increased to 2.36 (95% CI 1.02-5.47) in the fifth quintile (HbA(1c) > or = 7.3%). The effect of poor glycaemic control did not statistically correlate with baseline mortality risk (p = 0.27).

CONCLUSIONS/INTERPRETATION

Among dialysis patients, poorer glycaemic control in those with diabetes was associated with higher mortality risk. This suggests a strong effect of poor glycaemic control above an HbA(1c) level of about 7.3% on mortality risk, and that this effect does not appear to be influenced by baseline comorbidity status.

Diabetic control after total pancreatectomy

BACKGROUND

Diabetes after total pancreatectomy is commonly described as 'brittle' with most series reporting outcomes after resection for pancreatitis alone. The aim of this study was to determine glycaemic control in patients resected for benign and malignant disease.

METHODS

A retrospective analysis of all patients undergoing total pancreatectomy (1989-2003) from a single institution was done. Data of diabetic control were obtained from case notes, general practitioners and telephonic consultation. Comparison was made against a matched type 1 diabetic population.

RESULTS

Forty-seven patients with a median age of 59 years (range 17-85 years) and median follow-up of 50 months (range 5-136 months) were identified. Thirty-five underwent primary resection with 11 receiving completion procedures. Thirty were for malignancy (19 deceased) and 17 for benign/indeterminate histology (2 deceased). Thirty-three patients were available for detailed follow-up. There was no significant difference between median HbA(1c) of the study group and the control (8.2% versus 8.1%). The majority of patients reported diabetic control and daily performance as excellent or good. Resection for pancreatitis gave poorer subjective control (p < 0.05) than those resected for malignancy. Two patients required in-patient treatment for diabetic complications, with no deaths related to diabetes observed.

CONCLUSION

Diabetes after total pancreatectomy is not necessarily associated with poor glycaemic control and in the majority results in equivalent biochemical control compared to a normal type 1 diabetic population.