NDT Advance Access originally published online on October 12, 2005
Nephrology Dialysis Transplantation 2006 21(2):553-554; doi:10.1093/ndt/gfi205
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Insulin analogue usage in a haemodialysis patient with type 2 diabetes mellitus
Email: alpersoy{at}uludag.edu.trSir,
Diabetes mellitus has been increasingly recognized as a cause of end-stage renal disease, world-wide as in our country. Tight glycaemic control leads to decreased long-term micro and macrovascular complication rates. In advanced stages of renal insufficiency, there are various and somewhat contrasting abnormalities affecting glucose and insulin metabolism. With decreased clearance and catabolism of insulin, the metabolic effects of both rapid and longer-acting traditional insulin preparations persist longer and the potential for symptomatic hypoglycaemia increases [1].
A 62-year-old woman, suffering from type 2 diabetes mellitus for 25 years, was included in the haemodialysis programme in November 1998. She had recurring diabetic foot, retinopathy operated on three times for vitreous haemorrhagia and neuropathy. Her left big toe was amputated in 2003. Throughout this period, she received traditional intensive insulin therapy consisting of preprandial regular and bedtime NPH insulin at four doses. Her blood glucose control was poor with hypoglycaemic and hyperglycaemic episodes. She was admitted to the emergency service because of fever and impaired general status in August 2004. She had cellulitis in the right anterior cruris region and a purulent-necrotic lesion on the amputated stump. Her initial laboratory tests revealed a leucocyte count of 23 000/mm3, serum glucose 620 mg/dl, pH 7.33 and CRP 28 mg/dl. She suffered from hypotension. Klebsiella pneumoniae and methicillin-resistant Staphylococcus haemolyticus were present in the blood cultures. Sepsis was treated with appropriate antibiotic therapies. Her blood glucose was regulated with adequate amounts of insulin infusion. Her treatment was changed to insulin analogues (three doses of insulin lispro preprandially and one dose of insulin glargine at bedtime) for better glycaemic control. She remained well for 1 year after her discharge. Figures 1 and 2 show the changes in blood glucose and HbA1c levels during her follow-up. She had her right small toe amputated in May 2005 during which time her glycaemic control worsened.
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Traditional insulin absorption profiles are erratic, creating day-to-day fluctuations in glycaemic control and their delayed onset of action and peak activity requires coordination of injection and meals [2]. Uraemic patients are threatened by hyperinsulinaemia and severe hypoglycaemic episodes when receiving traditional insulin treatment [3]. Insulin analogues characterized by action profiles afford more flexible treatment regimens with a lower risk of the development of hypoglyacemia [4]. Rapidly acting analogues, lispro and aspart, are active within minutes and peak in about 1 h, mimicking normal mealtime insulin release. Long-acting analogues, glargine, provides a peakless, continuous release over 24 h that approximates a normal basal pattern [2]. There are limited data in the literature concerning insulin analogue usage in diabetic haemodialysis patients. Aisenpreis et al. showed that the pulsatile pharmacokinetic profile of insulin lispro may not only facilitate the correction of hypoglycaemia, but may also decrease the risk of late hypoglycaemic episodes, which are of particular clinical relevance in haemodialysed type 1 and type 2 diabetic patients [5].
We observed that intensive insulin analogue treatment provided better glycaemic control in our patient without long-term hypoglycaemia risk. Although the cost is a disadvantage, insulin analogues can be preferred in selected haemodialysis patients with diabetes mellitus.
1 Uludag University Medical Faculty Nephrology, Bursa, Turkey2 Uludag University Medical Faculty Endocrinology and Metabolism Bursa, Turkey
References
- Snyder RW, Berns JS. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease. Semin Dial 2004; 17: 365–370[CrossRef][Web of Science][Medline]
- Mayfield JA, White RD. Insulin therapy for type 2 diabetes: rescue, augmentation, and replacement of beta-cell function. Am Fam Physician 2004; 70: 489–500[Medline]
- Amico JA, Klein I. Diabetic management in patients with renal failure. Diabetes Care 1981; 4: 430–434[Abstract]
- Hirsch IB. Insulin analogues. N Engl J Med 2005; 352: 174–183
[Free Full Text] - Aisenpreis U, Pfutzner A, Giehl M, Keller F, Jehle PM. Pharmacokinetics and pharmacodynamics of insulin Lispro compared with regular insulin in haemodialysis patients with diabetes mellitus. Nephrol Dial Transplant 1999; 14 [Suppl 4]: 5–6
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