ORLANDO — For hemodialysis patients with diabetes who refuse to take insulin at home, delivering insulin during dialysis is a good way to improve glycemic control, researchers reported at a meeting sponsored by the National Kidney Foundation.
Patients with diabetes make up roughly half of the end-stage renal disease (ESRD) population in the United States, and good glycemic control is essential to slow the progression of both microvascular and macrovascular disease.
But sometimes, having to take insulin is just too much for these patients, said Dr. Kalyana Janga of Maimonides Medical Center, New York. “It's like the straw that broke the camel's back. Dialysis patients with diabetes can be very noncompliant. They have to take so many different medications and they can be very dissatisfied with the complexity of their treatment.”
When such a patient came to his dialysis center, Dr. Janga and his associates decided to try a novel approach for delivering insulin. Postulating that Lantus, a long-acting insulin, would continue to exert its effect until the next dialysis treatment and thereby improve glycemic control, they persuaded the patient to allow the dialysis nurse to give him his insulin after his dialysis session.
The patient was 72 years old and had been on maintenance hemodialysis for 3 years. In addition to being hypertensive and having coronary artery disease, the patient had poor glycemic control despite being on maximum doses of two oral hypoglycemic agents. He had had type 2 diabetes for 20 years, Dr. Janga said.
“His fasting glucose was more than 200 mg/dL, and greater than 250 mg/dL prelunch. His hemoglobin A1c was 13.3%. He refused to take insulin at home; he was afraid to take it.”
The patient was placed on a regimen of Lantus three times a week post dialysis. Lantus was begun at 5 units and progressively increased to 17 units after each dialysis, based on fasting glucose levels which the patient measured at home, and on prelunch glucose levels measured at dialysis.
After 3 months, the fasting blood glucose levels dropped to 100–110 mg/dL and the prelunch glucose levels decreased to 125–135 mg/dL. After 4 months, hemoglobin A1c levels decreased from 13.3% to 8.4%, and at 8 months, hemoglobin A1c had decreased even further, to 7.9%, Dr. Janga reported.
So successful was this treatment regimen that the patient was actually able to come off dialysis and became a kidney transplant recipient. “His wife donated a kidney. He's surviving and doing very well. We are so happy to see him when he visits us at the clinic,” Dr. Janga said.
He added that this type of regimen should be considered in all diabetics who are noncompliant with their insulin therapy. “Giving them their insulin when they show up at the dialysis center reduces the cost and complexity burden to these patients … If we can at least take care of their diabetes, we can do something of major importance” for them.