Weight gain and insulin requirement in type 2 diabetic patients during the first year after initiating insulin therapy dependent on baseline BMI

AIM

The aim of this study was to determine differences, if any, in weight gain and increased insulin requirements in insulin-treated type 2 diabetic patients with a normal and an elevated body mass index (BMI).

METHODS

A total of 192 patients with newly insulinized type 2 diabetes were included in the study. The patients were divided into three groups: those with BMI <26 (n = 102), BMI 26-30 (n = 50) and those with BMI >30 (n = 40). At the beginning of insulin therapy and 12 months later, we compared HbA1c, BMI and required insulin doses in each group and evaluated weight gain and the increase in insulin requirement during the observation period. Moreover, we investigated the influence of additional metformin therapy on weight gain and insulin requirement.

RESULTS

Body weight increased in the group with normal BMI from 68.8 +/- 9.2 to 70.8 +/- 9.4 kg (+2.9%) and in the other groups from 79.0 +/- 9.3 to 81.2 +/- 8.4 (+2.8%) and from 96.2 +/- 11.2 to 99.1 +/- 16.5 kg (+3.0%) respectively. The differences between the groups were not significant. The insulin requirement increased by 22% in the normal-weighted group and by 23% in both groups with overweight. The reduction in mean HbA1c was similar in the three groups (22, 18 and 22%). Under additional metformin therapy, the increment of insulin requirement of all patients (n = 40) was significantly lower (11 vs. 26%, p < 0.01), and there was no significant difference between the groups with different BMIs. During the same period, the gain in body weight and the decrease of HbA1c were not significantly different in the patients with and without metformin independent on the BMI.

CONCLUSIONS

The risk for weight gain and increase in insulin requirement is similar in insulin-treated type 2 diabetic patients with normal and elevated BMI. Additional metformin therapy reduces insulin requirement in patients with and without overweight.

[Congo red-negative light chain disease with intractable diarrhea]

A 56-year-old man was admitted due to chronic diarrhea with progressive weight loss (30 kg within 1 year). All results of medical investigations were normal. The suspected diagnosis of a neuroendocrinological neoplasm could not be established; there was also no evidence for a lymphoma or amyloidosis. Chronic diarrhea and weight loss persisted over the ensuing weeks. Additionally, impairment of renal function and heart insufficiency with consecutive pericardial effusion as well as peripheral facial paralysis and peripheral neuropathy could be observed. Six months after hospital admission, the patient died due to progressive multiple organ failure. Postmortem examination revealed normal bone marrow. Only with additional immunohistochemical investigations of all organs could the diagnosis of a systemic Congo red-negative light chain disease be established.

Decreased insulin requirement in relation to GFR in nephropathic Type 1 and insulin-treated Type 2 diabetic patients

AIMS

In the presence of impaired renal function, patients require less insulin mainly because insulin clearance is prolonged. The aim of this study was to evaluate the insulin requirement related to glomerular filtration rate (GFR) in nephropathic Type 1 and Type 2 diabetic patients.

METHODS

In a retrospective study we compared insulin requirement in 20 nephropathic Type 1 diabetic patients and 20 insulin-treated Type 2 diabetic patients from the onset of overt nephropathy until the final stage of renal disease. All patients had proteinuria > 0.5 g/24 h and creatinine clearance >/= 80 ml/min per 1.73 m2 at baseline. Creatinine clearance, urinary protein excretion, glycated haemoglobin and the required insulin doses were determined 3- to 6-monthly, basal C-peptide was measured at the beginning and the end of the observation period. The required insulin doses were evaluated at creatinine clearance rates of 80, 60, 40, 20 and 10 ml/min per 1.73 m2 (or at the initiation of dialysis treatment).

RESULTS

The insulin requirement of patients with Type 1 diabetes was reduced from 0.72 +/- 0.16 IU/kg per day at a creatinine clearance rate of 80 ml/min, to 0.45 +/- 0.13 IU/kg per day at a creatinine clearance rate of 10 ml/min (decrement of 38%, P < 0.001). The insulin dose required by Type 2 diabetic patients was reduced from 0.68 +/- 0.28 IU/kg per day at a creatinine clearance rate of 80 ml/min to 0.33 +/- 0.19 IU/kg per day at a clearance rate of 10 ml/min (decrement 51%, P < 0.001). The fall in GFR, urinary protein excretion and glycated haemoglobin levels was similar in the two groups. In patients with Type 2 diabetes, C-peptide levels at the beginning and the end of renal function impairment were 2.2 (0.4-7.3) vs. 2.7 (0.1-4.9) ng/ml (NS). The reduction in insulin requirement was approximately the same in patients with an initial C-peptide level < 1.0 and in those >/= 1.0 ng/ml (decrement 57% vs. 46%).

CONCLUSIONS

The reduction in insulin requirement in renal insufficiency is similar in Type 1 and insulin-treated Type 2 diabetic patients. In subjects with Type 2 diabetes, the residual insulin secretion has no impact on the reduction in insulin requirement dependent on the GFR.

[Risk for hyperkalemia during long-term treatment with angiotensin-converting enzyme inhibitors in insulin-dependent type 2 diabetics in relation to the glomerular filtration rate]

BACKGROUND AND OBJECTIVE

The risk for hyperkalaemia during therapy with angiotensin-converting enzyme inhibitors is especially increased in the elderly diabetic because of a decrease in glomerular filtration rate (GFR), as well as the occurrence of hyporeninaemic hypoaldosteronism. We evaluated the risk for hyperkalaemia under long-term angiotensin-converting enyzme inhibition in 86 insulin-dependent type 2 diabetic patients in relation to their GFR.

PATIENTS AND METHODS

We compared the influence of a 3 to 6 months long treatment with angiotensin-converting enzyme inhibitors on the serum potassium levels, the creatinine clearance and the urinary albumin excretion in insulin-dependent type 2 diabetic patients with an initial creatinine clearance < 50 ml/min/1.73m(2) (n = 15, age 66 +/- 6 years) and >/= 50 ml/min/1.73m(2) respectively (n = 71, age 61 +/- 10 years). In addition, we also investigated the influence on the metabolic control and the blood pressure values in both groups of patients.

RESULTS

In the patients with creatinine clearance >/= 50 ml/min/1,73m(2) the mean potassium level increased from 4.3 +/- 0.2 to 4.6 +/- 0.4 mmol/l (P < 0,01), while the incidence of a potassium level > 5 mmol/l was 17 %. In the group with a creatinine clearance < 50 ml/min/1.73m(2) the potassium level rose from 4.5 +/- 0.2 to 5.0 +/- 0.4 mmol/l (P < 0.01). The incidence of potassium levels > 5 mmol/l was 66 % (P < 0,01). In both patient groups the creatinine clearances did not change significantly during angiotensin-converting enzyme inhibition, and the urinary albumin excretion as well as the HbA(1c) values and blood pressure showed only a tendency towards a decrease.

CONCLUSION

Long-term treatment with angiotensin-converting enzyme inhibitors in insulin-dependent type 2 diabetic patients leads to a significant increase in serum potassium. The incidence of hyperkalaemia with potassium levels > 5 mmol/l is significantly higher in the patients with initial creatinine clearance < 50 ml/min/1.73m(2). Severe hyperkalaemia with potassium levels > 6 mmol/l was not observed.