Insulin use in chronic kidney disease and the risk of hypoglycemic events

Management of diabetes in people with advanced chronic kidney disease

Diabetes is the commonest cause of end stage kidney disease globally, accounting for almost 40% of new cases requiring renal replacement therapy. Management of diabetes in people with advanced kidney disease on renal replacement therapy is challenging due to some unique aspects of assessment and treatment in this group of patients. Standard glycaemic assessment using glycated haemoglobin may not be valid in such patients due to altered red blood cell turnover or iron/erythropoietin deficiency, leading to changed red blood cell longevity. Therefore, use of continuous glucose monitoring may be beneficial to enable more focussed glycaemic assessment and improved adjustment of therapy. People with advanced kidney disease may be at higher risk of hypoglycaemia due to a number of physiological mechanisms, and in addition, therapeutic options are limited in such patients due to lack of experience or license. Insulin therapy is the basis of treatment of people with diabetes with advanced kidney disease due to many other drugs classes being contraindicated. Targets for glycaemic control should be adjusted according to co-morbidity and frailty, and continuous glucose monitoring should be used in people on dialysis to ensure low risk of hypoglycaemia. Post-transplant diabetes is common amongst people undergoing solid organ transplantation and confers a greater risk of mortality and morbidity in kidney transplant recipients. It should be actively screened for and managed in the post-transplant setting.

HbA1c overestimates the glucose management indicator: a pilot study in patients with diabetes, chronic kidney disease not on dialysis, and anemia using isCGM

Introduction

There are multiple mechanisms by which HbA1c values can be altered in chronic kidney disease (CKD), which limits its usefulness as a strategy to assess glycemic control in this population.

Methods

Concordance and agreement study between two diagnostic tests: HbA1c and glucose management indicator (GMI) measured by intermittently scanned continuous glucose monitoring (isCGM), based in a prospective cohort of patients with diabetes, CKD (glomerular filtration rate between 15 and 60 ml/min/1.73 m²), and anemia. The isCGM was performed for 3 months, and the GMI was compared with the HbA1c levels taken at the end of isCGM. Agreement was evaluated using Bland-Altman graph analysis and Lin's concordance correlation coefficient (CCC). The concordance of the measures with good glycemic control (<7%) was also evaluated.

Results

A total of 74 patients were enrolled (median age 68.5 years, 51.3% female, 64.9% with CKD stage 3, hemoglobin 11.1 ± 1.2 g/l). The Bland-Altman analysis shows a mean difference between GMI and HbA1c of 0.757 ± 0.687% (95% limits of agreement: -0.590 and 2.105). Difference was greater as the values of GMI and HbA1c increased. The agreement was poor [CCC 0.477; 95% confidence interval (CI): 0.360-0.594], as well as the concordance of values with good glycemic control according to GMI versus HbA1c (67.5% versus 29.7%, p < 0.001) (Kappa 0.2430; 95% CI: 0.16-0.32).

Conclusion

The HbA1c overestimates the GMI values with highly variable ranges of difference, which prevents a precise correction factor. isCGM probably is a safer option for monitoring and decision-making in this population, especially in patients treated with insulin where the risk of hypoglycemia is greater.

The role of basal insulins in the treatment of people with type 2 diabetes and chronic kidney disease: A narrative review

The majority of cases of chronic kidney disease (CKD) worldwide are driven by the presence of type 2 diabetes (T2D), resulting in an increase in CKD rates over the past few decades. The existence of CKD alongside diabetes is associated with increased burden of cardiovascular disease and increased risk of death. Optimal glycaemic control is essential to prevent progression of CKD, but achieving glycaemic targets in people with CKD and diabetes can be challenging because of increased risk of hypoglycaemia and limitations on glucose-lowering therapeutic options. This review considers the challenges in management of T2D in people with impaired kidney function and assesses evidence for use of basal insulin analogues in people with CKD.

Hypoglycemia: Turning the tide on crashing blood glucose

ABSTRACT

Primary care NPs are central to the management of diabetes mellitus, which carries with it the risk of hypoglycemia. Fully understanding risk factors, prevention strategies, and treatment assist in reducing hypoglycemic events. This article details hypoglycemia, risk factors for hypoglycemia, prevention strategies, and appropriate treatment plans.

Rare presentation of BRASH syndrome with hypoglycemia and altered mental status

BACKGROUND

BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia) is a rare clinical condition with potentially severe outcomes. Patients with BRASH syndrome can present with diverse signs and symptoms and are usually in critical condition, but if recognized early, the syndrome is treatable and may have a favorable prognosis.

CASE PRESENTATION

This case study presents a 74-year-old patient with a history of multiple chronic conditions who was brought to the emergency department with a suspected cerebrovascular accident, altered mental status, and bradycardia. A head computed tomography scan was unremarkable but laboratory results showed hyperkalemia, acidosis, and renal failure with concomitant progressive hypoglycemia. The patient was diagnosed with a BRASH syndrome characterized by a vicious cycle of atrioventricular nodal blockade induced by the potentiated effect of beta-blockers or calcium channel blockers, in combination with progressive hypoglycemia due to the suspected accumulation of anti-diabetic medications, which influenced the presentation and initial triage in the emergency department. She was admitted to the intensive care unit for further management, where she continued to improve and was ultimately discharged in a relatively stable condition.

CONCLUSION

This case study highlights the importance of considering rare and atypical presentations of medical conditions, particularly in elderly patients who may have multiple comorbidities. Early recognition and prompt management of such cases are crucial for improving patient outcomes.

Fasting Ramadan in Chronic Kidney Disease (CKD), Kidney Transplant and Dialysis Patients: Review and Update

Chronic kidney disease (CKD) is a common disease in the Islamic regions. Dehydration occurs after prolonged fasting, particularly in hot and humid climates. In the Arabic months’ calendar, Ramadan is a month of maximum given deeds, where Muslims are required to fast from dawn till sunset. Depending on where you live and when the Ramadan month falls, fasting might last anywhere from 10 to 20 hours or more. In certain circumstances, such as poorly controlled diabetes and advanced CKD patients who are allowed to break their fast, the Ramadan fasting amendment is viable. Some Muslims, however, continue fasting despite these circumstances, placing themselves at risk, which is not allowed in the Islamic religion.

There are no medical recommendations that specify who should and should not fast. Nonetheless, the recommendations have been extracted from several published studies. The authors searched EMBASE, PubMed, Google Scholar, and Google for publications, research, and reviews. All authors debate and analyze the related articles. Each author was assigned a part or two of the topics to read, study, and summarize before creating the final draft of their given section. Then this comprehensive review was completed after discussion sessions.

In conclusion, by the Islamic religion view, fasting Ramadan is mandatory for every wise adult person. People who have chronic diseases or that may deteriorate by fasting are exempted from fasting. It seems that fasting and the associated disease hours are determinant factors to fasting or not fasting. Up to our knowledge, there are no established guidelines for CKD patients and physicians to follow; however, the International Diabetes Federation and Diabetes and Ramadan (IDF-DAR) Practical Guidelines 2021 have been issued for CKD diabetic patients and fasting.