Is insulin beneficial for patients with Chronic Kidney Disease (CKD)?

From the Guidelines

Insulin can be beneficial for patients with Chronic Kidney Disease (CKD) who have diabetes, as it helps manage blood glucose levels without being metabolized by the kidneys. For CKD patients with diabetes, insulin is often preferred over certain oral antidiabetic medications that may accumulate in the body due to decreased kidney function 1. Dosing typically requires adjustment as kidney function declines, with patients often needing reduced insulin doses due to decreased insulin clearance and impaired renal gluconeogenesis. Regular blood glucose monitoring is essential, as CKD patients face an increased risk of hypoglycemia, particularly when treated with insulin and/or sulfonylureas 1.

Key Considerations for Insulin Therapy in CKD

• Insulin regimens vary based on individual needs but may include basal insulin (like glargine or detemir) once daily, with or without mealtime rapid-acting insulin (like lispro or aspart) 1.
• The benefits of insulin therapy in CKD patients include effective glycemic control without kidney metabolism concerns, potential protection against further kidney damage through better glucose control, and flexibility in dosing adjustments as kidney function changes.
• However, insulin therapy should be managed carefully with regular monitoring of both kidney function and blood glucose levels, especially considering the risk of hypoglycemia, which may require dose adjustments of insulin and/or other medications like sulfonylureas 1.

Comparison with Other Therapies

• Other therapies such as SGLT2 inhibitors (e.g., empagliflozin, canagliflozin, dapagliflozin) have shown beneficial effects on slowing CKD progression and cardiovascular outcomes in patients with type 2 diabetes, but their ability to lower glucose levels declines with decreasing eGFR 1.
• GLP-1 receptor agonists are recommended for patients with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i treatment, or who are unable to use those medications 1.
• Metformin is a preferred agent for those with CKD due to its efficacy and safety profile, but it should not be started in those with eGFR < 45 mL/min/1.73 m2 and should be stopped once eGFR is < 30 mL/min/1.73 m2 1.

From the FDA Drug Label

Some studies with human insulin have shown increased circulating levels of insulin in patients with renal impairment Careful glucose monitoring and dose adjustments of insulin, including HUMALOG, may be necessary in patients with renal dysfunction Individuals with renal impairment showed no difference in pharmacokinetic parameters as compared to healthy volunteers However, literature reports have shown that clearance of human insulin is decreased in renally impaired patients. Careful glucose monitoring and dose adjustments of insulin, including LEVEMIR, may be necessary in patients with renal dysfunction

The use of insulin in patients with Chronic Kidney Disease (CKD) requires careful consideration. While insulin can be beneficial for managing blood glucose levels, patients with CKD may require dose adjustments due to decreased insulin clearance.

• Key considerations for using insulin in patients with CKD include:
  • Careful glucose monitoring
  • Potential need for dose adjustments
  • Increased risk of hypoglycemia It is essential to weigh the benefits and risks of insulin therapy in patients with CKD and to closely monitor their condition to ensure optimal management of their diabetes and kidney disease 2 3.

From the Research

Insulin Therapy in Chronic Kidney Disease

• Insulin is beneficial for patients with Chronic Kidney Disease (CKD), as it helps to achieve glycemic control and reduce the risk of hypoglycemia 4, 5.
• The consensus statement on insulin therapy in CKD recommends individualization, adjustment, and titration of insulin doses depending on the severity of kidney disease 4.
• Insulin glargine U100 has been shown to improve glycemic control and reduce nocturnal hypoglycemia in patients with type 2 diabetes mellitus and CKD stages 3 and 4 5.

Glycemic Control and Insulin Therapy

• Glycemic control is particularly hard to achieve in patients with CKD due to slower insulin degradation by the kidney 5.
• Insulin therapy can help to achieve glycemic control and reduce the risk of hypoglycemia in patients with CKD 4, 5.
• The choice of insulin regimen (basal, prandial, premix, and basal-bolus) should be based on the individual patient's needs and the severity of their kidney disease 4.

Safety and Efficacy of Insulin Therapy

• Insulin glargine U300 has been shown to be safe and effective in patients with type 2 diabetes and CKD, with a low rate of severe hypoglycemia 6.
• The safety profile of insulin therapy in patients with CKD is generally favorable, although the risk of hypoglycemia may be increased in patients with advanced kidney disease 7.
• More high-quality studies are needed to fully understand the safety and efficacy of insulin therapy in patients with CKD 7.

Comparison with Other Glucose-Lowering Agents

• SGLT2 inhibitors and GLP-1 agonists have been shown to be efficacious for glucose-lowering in patients with CKD, although the safety profile of these agents is not fully understood 7.
• DPP-4 inhibitors may be efficacious for glucose-lowering in patients with CKD, although the evidence is limited 7.
• Insulin therapy may be preferred in patients with advanced kidney disease or those who are at high risk of hypoglycemia 4, 5.