From the Guidelines
The patient's hyperglycemia, potential renal involvement, and slightly elevated bilirubin levels should be managed with a comprehensive approach, focusing on glycemic control with metformin and an SGLT2 inhibitor, as recommended by the 2020 KDIGO clinical practice guideline 1.
Key Management Strategies
- Glycemic control:
- Renal function assessment:
- Comprehensive tests including serum creatinine, BUN, eGFR, urinalysis for proteinuria, and albumin-to-creatinine ratio should be performed to assess renal function.
- Elevated bilirubin management:
- Liver function tests (ALT, AST, alkaline phosphatase) should be obtained to determine the cause of elevated bilirubin levels.
Lifestyle Interventions
- Moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week is recommended for patients with diabetes and CKD 1.
- Sodium intake should be restricted to <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with diabetes and CKD 1.
- Protein intake should be maintained at 0.8 g protein/kg (weight)/d for those with diabetes and CKD not treated with dialysis 1.
Additional Considerations
- Blood pressure control is essential, preferably with ACE inhibitors or ARBs if albuminuria is present.
- Dietary modifications including carbohydrate counting are important to manage hyperglycemia.
- Hydration with intravenous fluids may be necessary, particularly if the patient has diabetic ketoacidosis or hyperosmolar hyperglycemic state. This multifaceted approach addresses the hyperglycemia while protecting renal function and monitoring hepatic issues, with treatment adjustments based on the severity of each condition and underlying causes.
From the FDA Drug Label
Metformin decreases liver uptake of lactate increasing lactate blood levels which may increase the risk of lactic acidosis, especially in patients at risk. The risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney. Before initiating metformin hydrochloride tablets, obtain an estimated glomerular filtration rate (eGFR). Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2
The patient has hyperglycemia with glucose levels of 111,95,99, and 103 mg/dL, potential renal involvement with eGFR levels of 86,107,104, and 107 mL/min/1.73, and slightly elevated bilirubin levels with total bilirubin levels of 1.6,1.4,1.5, and 1.4 mg/dL. Given the patient's eGFR levels are above 30 mL/min/1.73, metformin can be considered. However, it is crucial to monitor renal function and lactate levels due to the risk of lactic acidosis. The patient's renal function should be assessed more frequently due to the potential renal involvement. Hemodialysis is recommended if metformin-associated lactic acidosis is suspected. General supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of metformin. It is essential to educate the patient about the symptoms of lactic acidosis and the importance of reporting any symptoms to their healthcare provider. 2
From the Research
Patient Management
The patient's laboratory results indicate hyperglycemia, with glucose levels ranging from 95 to 103 mg/dL, which is above the normal range of 70-99 mg/dL. The patient's blood urea nitrogen (BUN) and creatinine levels are within normal limits, but the BUN/creatinine ratio is slightly elevated, suggesting potential renal involvement. The patient's bilirubin levels are also slightly elevated, which may indicate liver dysfunction.
Hyperglycemia Management
According to the study by 3, aggressive and early therapeutic intervention is key to improving and maintaining glycemic control and preventing micro- and macrovascular complications. The American Diabetes Association recommends the following treatment goals:
- Fasting plasma glucose levels of 80 to 120 mg/dL
- Initial treatment of diet, self-care management, education, and exercise
- Additional treatment recommended at FPG > 140 mg/dL
- Goal HbA1c levels < 7%, with treatment changes recommended at > 8%
- Therapy with either insulin secretagogues or insulin sensitizers if poor glycemic control persists after 2-3 months
Renal Involvement
The study by 4 highlights the kidneys' role in glucose regulation, including the reabsorption of glucose at the level of the proximal tubule. In hyperglycemia, the kidneys may play an exacerbating role by reabsorbing excess glucose, ultimately contributing to chronic hyperglycemia and the risk of microvascular consequences.
Insulin Therapy
The studies by 5 and 6 emphasize the importance of insulin in glucose metabolism and its potential role in managing hyperglycemia. Insulin regulates glucose levels in the bloodstream and induces glucose storage in the liver, muscles, and adipose tissue. The study by 7 provides an integrated perspective on insulin action and resistance, highlighting the importance of understanding normal insulin action and the pathophysiology of insulin resistance in developing novel therapies for type 2 diabetes.
Key Considerations
- Monitor the patient's glucose levels closely and adjust treatment as needed to achieve optimal glycemic control
- Consider the patient's renal function and potential renal involvement in hyperglycemia management
- Evaluate the patient's liver function and consider the potential impact of hyperglycemia on liver dysfunction
- Develop a comprehensive treatment plan that addresses the patient's hyperglycemia, potential renal involvement, and liver dysfunction, and includes lifestyle modifications, medication, and regular monitoring.