b'Diabetes Patients With CKD UseMore Insulin, Even Though the Combination Heightens Risk of Severe HypoglycemiaConventional wisdom holds that patients with advanced chronic kidney disease need less insulin to control blood sugar. A new study not only demonstrated that the belief is false but also found that insulin use was greater in Type 2 diabetes patients with more advanced CKD. Both insulin and CKD heighten the risk of hypoglycemia.By Brenda L. MooneySALT LAKE CITYThe use of insulin was greater1.74 to 1.88) of subsequent insulin use compared in Type 2 diabetes patients with advanced chronicto eGFR 90 group. Using a model with propensity kidney disease, according to a new study, which alsoscore-matching for baseline insulin use in 305,570 found that both insulin therapy and advanced CKDpatients, they determined that both insulin use (HR were independent risk factors for serious hypoglyce- 2.34, 95% CI 2.24 to 2.44) and advanced CKD (HR mic events. 2.28, 95% CI 2.07 to 2.51 for comparison of eGFR The report in BMC Nephrology pointed out that, 30toeGFR90 ml/min/1.73 m2groups)were compared to patients with preserved kidney func- linkedwithincreasedriskofsubsequentserious tion and not on insulin, insulin users who had eGFRhypoglycemic events. 30 ml/min/1.73 m2faced a nearly 5.3-fold higherIn T2D, more advanced CKD was associated with risk of dangerous hypoglycemia. greater insulin use. Both insulin use and advanced Researchers from the VA Salt Lake City HealthcareCKDwereriskfactorsforserioushypoglycemic System and the University of Utah Health Sciencesevents, the authors concluded. The safety of insu-soughttodeterminewhether,ingeneral,patientslincomparedtonewerglycemicagentsinmore with more advanced CKD and T2D increased theiradvanced CKD needs further study.hypoglycemia risk by using insulin. Background information in the article advised that Todothat,theyanalyzedrecordsofanationalmore than 30 million adults in the United States have cohort of 855,133 veterans with T2D seen at VAsdiabetes mellitus (DM), which is the leading cause clinicsbetweenJan.1,2008,andDec.31,2010,of CKD; nearly 1 in 3 of diabetes patients develop withatleasttwoserumcreatininemeasurements.kidney disease.For purposes of the study, data on insulin use wasYet, according to the article, Despite the public pulled from pharmacy records and ICD-9/10 codeshealth importance of kidney disease in persons with from emergency room visits or hospitalizations thatType 2 diabetes (T2D), there is a paucity of data on occurred until Dec. 31, 2016, were searched for evi- optimal treatment for glycemic control in this pop-dence of serious hypoglycemic events. ulation. Fundamental questions such as the role of Participants mean age was 6611 years and 97%insulin in glycemic control in CKD still need to be were men. Their mean baseline eGFR was 7322 ml/ addressed.min/1.73 m 1 . The researchers pointed out that, while it is often With653,200veteranswithoutinsulinuseatassumedthatinsulinrequirementsgodownwith baseline,researchersdeterminedthattheeGFRadvanced CKD because insulin is cleared by the 30 group had higher hazard (HR 1.80, 95% CIkidney,cross-sectionalstudiesindicatehigher Continued on Page 86 u82'