A multicenter, epidemiological study of the treatment patterns, comorbidities and hypoglycemia events of patients with type 2 diabetes and moderate or severe chronic kidney disease - the 'LEARN' study

Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Prospective Observational Study

BACKGROUND

Glycemic management in patients with type 2 diabetes mellitus (T2DM) and CKD can become complicated. One factor that may affect treatment is hypoglycemia. Hypoglycemia risk may be increased by several biologic processes in CKD. The objective of this study was to determine the frequency, severity, and risk factors for hypoglycemia in patients with T2DM and CKD.

METHODS

The design was a prospective observational study. A continuous glucose monitor (CGM) was worn by 80 patients for up to 14 days; glucose was measured every 15 minutes. Patients with T2DM and eGFR <45 ml/min were enrolled. Patients on dialysis were excluded. The primary outcome was to assess the frequency of hypoglycemic episodes during the study period. Hypoglycemic episodes were defined as a reduced glucose concentration (<70 mg/dl) lasting ≥15 minutes. Secondary outcomes included assessment of severity of hypoglycemia and risk factors for its development.

RESULTS

A total of 80 patients wore the CGM for a mean of 12.7±2.9 days. Hypoglycemic events occurred in 61 of 80 patients (76%) with glucose <70 mg/dl, and 49 of 80 (61%) with glucose <60 mg/dl. Prolonged hypoglycemic events (CGM glucose <54 mg/dl for ≥120 consecutive minutes) occurred in 31 patients (39%) with 118 total events. Most hypoglycemic episodes occurred overnight, from 1:00 am to 9:00 am. By multivariate analysis, lower hemoglobin A1c and treatment with insulin were two modifiable risk factors for hypoglycemic events.

CONCLUSIONS

Patients with T2DM and CKD have frequent periods of hypoglycemia that can be severe and prolonged. Hemoglobin A1c does not portray the full scope of hypoglycemia risk. This study illustrates the need for careful monitoring of glucose levels in patients with T2DM and CKD.

Goal attainment and renal outcomes in patients enrolled in the chronic kidney disease care program in Taiwan: a 3-year observational study

OBJECTIVE

To analyze the effects of chronic kidney disease (CKD) care programs on clinical outcomes.

DESIGN

An observational, retrospective study with medical record review.

SETTING

Kaohsiung Chang Gung Memorial Hospital.

PARTICIPANTS

Patients diagnosed with CKD.

INTERVENTIONS

CKD care programs conducted by nephrologists-based team from 2006 to 2013 in our hospital.

MAIN OUTCOME MEASURES

We set 10 goals with treatment target ranges based on the guidelines suggested by the following organizations: Kidney Disease Improving Global Outcomes (2012) and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (2003).

RESULTS

In total, 1486 patients were enrolled. Their average estimated glomerular filtration rate (ml/min/1.73 m2) was 31.9 at baseline and declined to 28.9 in Year 3 (P < 0.001). The all-goals attainment rate increased from 59.4% at baseline to 60.5% in Year 3, with an especially significant improvement for low-density lipoprotein (from 46.8% to 67.0%) and glycated hemoglobin (from 55.0% to 64.0%). Achievement rates decreased for hemoglobin (from 34.2% to 31.0%), calcium (from 94.6% to 92.3%) and phosphate (from 89.9% to 82.5%) between baseline and Year 3. Albuminuria was the least achieved goal (from 23.4% to 24.0%). Subgroup analysis revealed that estimated glomerular filtration rate did not decline in patients who had a good achievement rate, but decreased significantly in patients with a poor achievement rate.

CONCLUSION

Enrolment in CKD care programs resulted in a significant improvement in goal attainment by patients. Further, a good achievement rate was associated with better preservation of residual renal function.