Insulin Management for Patients with Kidney Disease and Diabetes

Assessment and Recommendations

For patients with kidney disease, diabetes, and hypertension, a basal-plus-correction insulin regimen is more appropriate than sliding scale insulin alone, according to the American Diabetes Association 1, 2
Patients with kidney disease, diabetes, and hypertension may experience glucose spikes despite good overall glycemic control, as indicated by an A1c of 5.5% 1
Renal impairment is a significant factor in medication selection and dosing, and the American College of Clinical Endocrinologists recommends considering renal function when selecting medications 1

A basal-plus approach consisting of a single dose of basal insulin along with correction doses of rapid-acting insulin is preferred for patients with renal failure and mild hyperglycemia, with a recommended total daily insulin dose of 0.1-0.25 U/kg per day 1, 3
The American Diabetes Association recommends adding correction doses of rapid-acting insulin for pre-meal hyperglycemia, with a modified correction scale for patients with renal impairment 3, 4

Metformin should be discontinued if eGFR is less than 30 mL/min per 1.73 m², according to the National Kidney Foundation 1
Patients with renal failure are at higher risk for hypoglycemia and require lower insulin doses, with a 4-6 times higher risk of hypoglycemia with basal-bolus insulin compared to sliding scale insulin therapy alone 1, 3

The American Association of Clinical Endocrinologists recommends monitoring blood glucose before meals and at bedtime, and adjusting basal insulin dose based on fasting and pre-meal glucose patterns 2, 4
It is essential to have a clear plan for treating hypoglycemia, and to document all glucose readings and insulin doses administered, as recommended by the American Diabetes Association 5, 4