To the Editor: In their Clinical Applications
article about the initial dose of a basal-prandial insulin regimen, Drs DeWitt
and Dugdale1 did not mention the importance
of assessing renal function. Insulin duration of action is increased in renal
insufficiency as a result of decreased renal insulin degradation and clearance.2 In addition, renal gluconeogenesis may be impaired,
possibly due to limitation of the amino acid substrate alanine.3 Furthermore,
many patients with renal failure have decreased caloric intake due to the
accompanying anorexia. Indeed, insulin therapy and renal dysfunction have
been reported to be the 2 most frequent diagnoses associated with hypoglycemia
in hospitalized patients.4 Unfortunately,
similar data from outpatients are lacking, in part because of exclusion of
patients with various degrees of renal failure from diabetes clinical trials.
Mikhail N, Cope D. Antihyperglycemic Therapy for Patients With Renal Failure. JAMA. 2003;290(8):1026–1027. doi:10.1001/jama.290.8.1026-a
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