b'resistanceiscommonin CKD. They said that could beassociatedpro-inflam-matorycytokinessuchas interleukin-6andtumor necrosis factor- and oxi-dative stressall of which might be involved in insu-lin resistance.Another possibility, they wrote,isthatpancreatic beta-isletcellshavelow expressionofantioxidant enzymesand,asaresult, areextremelysensitive tooxidativestress.The authors referred to experi-mentaldatapositingthatFig. 3 Kaplan-Meier curves for probability of serious hypoglycemic event by insulin and eGFR groupsbetacelldysfunctionSource: Grube, D., Wei, G., Boucher, R. et al. Insulin use in chronic kidney disease and the risk of hypoglycemic events. BMC Nephrol 23, 73 (2022). mightbemadeworseinhttps://doi.org/10.1186/s12882-022-02687-wCKD because of increased oxidativestressfromtheaccumulationofuremicCKD needs to be further examined in randomized toxins. controlled trials to determine optimal glycemic con-The researchers also pointed out that many of thetrol therapy in this population.anti-diabeticmedicationsarecontraindicatedinThe researchers concluded, In summary, contrary advanced CKD, explaining, Thus, this combinationtowidelyheldassumptionthatadvancedCKDis of decreased insulin production, peripheral insulinassociated with decreased need for insulin, we found resistanceandcontraindicationsforothermedica- thatinsulinusewasgreaterin T2Dpatientswith tions could increase the need for exogenous insulinmore advanced CKD. Furthermore, this study also for glycemic control in CKD. found that both insulin use and CKD are independent Intermsoftheapparentlinkbetweenadvancedfactors for risk of hypoglycemia, with patients with CKD and higher risk of hypoglycemia, the authorsadvanced CKD who use insulin being at the highest noted that renal gluconeogenesis is essential in coun- risk for a hypoglycemic event. Future randomized tering hypoglycemia in healthy adults. controlled trials are needed to determine the safety PeoplewithmoderatetosevereCKDhaveofinsulincomparedtonewerglycemicagentsin reduced kidney mass and therefore, a reduced capac- patients with T2D and advanced CKD.ity for glucose release from the kidneys, which might1Grube, D., Wei, G., Boucher, R. et al. Insulin use in chronic kidney increase the risk for hypoglycemia, they advised.disease and the risk of hypoglycemic events. BMC Nephrol 23, 73 However, the previous data on whether CKD is a(2022). https://doi.org/10.1186/s12882-022-02687-w risk factor for hypoglycemia has been conflicting.2Moen MF, Zhan M, Hsu VD, Walker LD, Einhorn LM, Seliger SL, Some of the previous studies noted such an associa- Fink JC. Frequency of hypoglycemia and its significance in chronic kidney disease. Clin J Am Soc Nephrol. 2009 Jun;4(6):1121-7. doi: tion but not all. 10.2215/CJN.00800209. Epub 2009 May 7. PMID: 19423569; PM-The study also discussed the dangers of hypogly- CID: PMC2689888.cemia, which raises the risk of mortality, cardiovas- 3Ahmad I, Zelnick LR, Batacchi Z, Robinson N, Dighe A, Manski-cular disease, cognitive impairment and progressionNankervis JE, Furler J, ONeal DN, Little R, Trence D, Hirsch IB, of CKD. The authors urged that the safety profile ofBansal N, de Boer IH. Hypoglycemia in People with Type 2 Diabetes and CKD. Clin J Am Soc Nephrol. 2019 Jun 7;14(6):844-853. doi: insulin compared to newer glycemic agents such as10.2215/CJN.11650918. Epub 2019 Apr 17. PMID: 30996047; PM-SGLT-2 inhibitors and GLP-1 analogs in advancedCID: PMC6556736.87'