Hypoglycemia in People with Type 2 Diabetes and CKD

Abstract

Background and objectivesAmong people with diabetes mellitus, CKD may promote hypoglycemia through altered clearance of glucose-lowering medications, decreased kidney gluconeogenesis, and blunted counter-regulatory response. We conducted a prospective observational study of hypoglycemia among 105 individuals with type 2 diabetes treated with insulin or a sulfonylurea using continuous glucose monitors.Design, setting, participants & measurementsWe enrolled 81 participants with CKD, defined as eGFR<60 ml/min per 1.73 m2, and 24 control participants with eGFR≥60 ml/min per 1.73 m2 frequency-matched on age, duration of diabetes, hemoglobin A1c, and glucose-lowering medications. Each participant wore a continuous glucose monitor for two 6-day periods. We examined rates of sustained level 1 hypoglycemia (<70 mg/dl) and level 2 hypoglycemia (<54 mg/dl) among participants with CKD. We then tested differences compared with control participants as well as a second control population (n=73) using Poisson and linear regression, adjusting for age, sex, and race.ResultsOver 890 total days of continuous glucose monitoring, participants with CKD were observed to have 255 episodes of level 1 hypoglycemia, of which 68 episodes reached level 2 hypoglycemia. Median rate of hypoglycemic episodes was 5.3 (interquartile range, 0.0–11.7) per 30 days and mean time spent in hypoglycemia was 28 (SD 37) minutes per day. Hemoglobin A1c and the glucose management indicator were the main clinical correlates of time in hypoglycemia (adjusted differences 6 [95% confidence interval, 2 to 10] and 13 [95% confidence interval, 7 to 20] fewer minutes per day per 1% higher hemoglobin A1c or glucose management indicator, respectively). Compared with control populations, participants with CKD were not observed to have significant differences in time in hypoglycemia (adjusted differences 4 [95% confidence interval, −12 to 20] and −12 [95% confidence interval, −29 to 5] minutes per day).ConclusionsAmong people with type 2 diabetes and moderate to severe CKD, hypoglycemia was common, particularly with tighter glycemic control, but not significantly different from groups with similar clinical characteristics and preserved eGFR.

Glucose time in range and peripheral neuropathy in type 2 diabetes mellitus and chronic kidney disease

“…The Continuous Glucose Monitoring to Assess Glycemia in Chronic Kidney Disease (CANDY) study was a prospective observational cohort study designed to examine hyperglycemia, glycemic variability and biomarkers of glycemic control among people with type 2 DM and CKD 19. Participants with type 2 DM were enrolled between 7 August 2015 and 12 July 2017 from Nephrology clinics, the Diabetes Care Center and referring clinics associated with the University of Washington, Seattle, Washington, USA.…”

Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Prospective Observational Study

“…Recently, Ahmad et al reported the frequent occurrence of hypoglycemia in a population with type 2 DM and CKD. For entry, patients were required to be treated with sulfonylurea or insulin, creating a cohort with enriched risk for hypoglycemia (9). In the current study we extend these findings to indicate that hypoglycemia, including prolonged and severe events, are common among the more general population of patients with CKD.…”

“…Recently, Ahmad et al reported the frequent occurrence of hypoglycemia in a population with type 2 DM and CKD. For entry, patients in Ahmad's study were required to be treated with sulfonylurea or insulin, creating a cohort with enriched risk for hypoglycemia (9). We believed that it was important to study a broader CKD population including those treated with other diabetic medications or no diabetic medications.…”

Temporal Relationship of Glycemia With Cardiac Arrhythmias in Patients With Type 2 Diabetes and CKD

“…We demonstrated that hypoglycemia is common in patients with chronic kidney disease (CKD) and T2D; 5 and these patients have high rates of cardiac arrythmias. 6 However, the association of glycemia with arrythmias in patients with CKD and T2D remains poorly elucidated; and even small relative differences in glucose may be important.…”

“…The Continuous Glucose Monitoring to Assess Glycemia in Chronic Kidney Disease (CANDY) study is an observational study of CKD patients with T2D. 5 A total of 38 participants underwent simultaneous CGM and mobile cardiac telemetry for up to two 6-day periods. Please see Supplemental Methods for details.…”