Division of Endocrinology, Banner-MD Anderson Cancer Center, Gilbert, Arizona.
Kidney Research Institute.
Clin J Am Soc Nephrol. 2019 Jun 7;14(6):844-853. doi: 10.2215/CJN.11650918. Epub 2019 Apr 17.
Among 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 & MEASUREMENTS: We enrolled 81 participants with CKD, defined as eGFR<60 ml/min per 1.73 m, and 24 control participants with eGFR≥60 ml/min per 1.73 m 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 (=73) using Poisson and linear regression, adjusting for age, sex, and race.
Over 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).
Among 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.
在患有糖尿病的人群中，CKD 可能通过改变降糖药物的清除率、降低肾脏糖异生以及减弱代偿性反应来促进低血糖。我们使用连续血糖监测仪对 105 名接受胰岛素或磺酰脲类药物治疗的 2 型糖尿病患者进行了一项前瞻性观察性研究，以评估低血糖的发生情况。
设计、地点、参与者和测量方法：我们纳入了 81 名 CKD 患者（定义为 eGFR<60 ml/min/1.73 m2）和 24 名 eGFR≥60 ml/min/1.73 m2 的对照组患者，两组患者在年龄、糖尿病病程、糖化血红蛋白和降糖药物方面进行了频率匹配。每位参与者佩戴连续血糖监测仪进行两次为期 6 天的监测。我们评估了 CKD 患者发生持续 1 级（<70 mg/dl）和 2 级（<54 mg/dl）低血糖的发生率。然后，我们使用泊松和线性回归检验了与对照组以及另一个对照组（=73）的差异，同时调整了年龄、性别和种族的影响。
在总共 890 天的连续血糖监测中，CKD 患者共发生 255 次 1 级低血糖发作，其中 68 次达到 2 级低血糖。低血糖发作的中位频率为 5.3（四分位间距，0.0-11.7）/30 天，每天低血糖发作的平均时间为 28（标准差 37）分钟。糖化血红蛋白和血糖管理指标是低血糖发作时间的主要临床相关因素（调整后的差异分别为每增加 1%糖化血红蛋白或血糖管理指标 6 [95%置信区间，2 到 10]和 13 [95%置信区间，7 到 20]分钟/天）。与对照组相比，CKD 患者的低血糖发作时间无显著差异（调整后的差异分别为 4 [95%置信区间，-12 到 20]和-12 [95%置信区间，-29 到 5]分钟/天）。
在患有 2 型糖尿病且 CKD 处于中重度的人群中，低血糖很常见，尤其是在血糖控制更严格时，但与具有相似临床特征且 eGFR 保留的患者相比，并无显著差异。
