Commentary by Mary Vouyiouklis MD, Fellow, and Ann Danoff MD, Director, Division of Endocrinology, Diabetes and Metabolism, NYU Medical Center
Welcome to Case 4 of our special diabetes series intended to highlight the essentials of diabetes care in the inpatient setting. Over the last several weeks, we have been presenting individual cases followed by some management questions and answers.
Case 4: The Case of Mr. Gary
Mr. Gary is a 54 year-old diabetic male admitted with acute renal failure who is being evaluated for long-term dialysis. His insulin regimen at home was 8 units of rapid-acting insulin qAC and 9 Units of NPH before breakfast and 9 Units of NPH at 10 PM. He is now being worked up for an AV fistula in anticipation for hemodialysis. What are some things that need to be considered in his transition from renal insufficiency to renal failure?
Insulin requirements often decrease dramatically in the setting of advanced renal failure. This has been largely attributed to decreased renal degradation of insulin, perhaps compounded by decreased appetite and associated decreased p.o. intake. Therefore, continuing on the usual doses of insulin can potentially result in hypoglycemia. In the setting of renal failure, it is prudent to assume the patient will be “sensitive” to administered insulin, and to estimate low TDD insulin requirements when instituting a regimen. Appropriate adjustments should then be made based on feedback from fingerstick monitoring.