What is the management plan for a patient with Chronic Kidney Disease (CKD) and Type 1 Diabetes Mellitus (T1DM) admitted to the hospital?

Management Plan for Type 1 Diabetes Mellitus with CKD in the Hospital

For a hospitalized patient with Type 1 Diabetes and CKD, insulin remains the cornerstone of glycemic management, with dosing adjusted for reduced renal clearance, while simultaneously implementing comprehensive cardiovascular and renal protective strategies including ACE inhibitor/ARB therapy (if hypertensive with albuminuria), statin therapy, and preparation for potential renal replacement therapy. 1

Glycemic Management

Insulin Therapy

• Insulin is the primary and essential treatment for all Type 1 Diabetes patients, regardless of CKD stage 1, 2
• Use basal-bolus regimen with long-acting basal insulin analogs (glargine or detemir) plus rapid-acting insulin analogs (aspart, lispro, or glulisine) for prandial coverage 3, 4, 2
• Reduce insulin doses by 25% or more when eGFR <45 mL/min/1.73 m² due to decreased renal insulin clearance 5, 3
• Avoid sliding-scale insulin (SSI) regimens as monotherapy—these are ineffective and exclude necessary basal insulin coverage 4

Glycemic Targets

• Target HbA1c between <6.5% and <8.0%, individualized based on hypoglycemia risk, life expectancy, and comorbidities 1, 6
• In the hospital setting, maintain blood glucose between 140-180 mg/dL for most patients 4
• Hypoglycemia risk increases substantially in advanced CKD due to decreased renal gluconeogenesis and reduced insulin clearance—monitor closely 5, 3

Monitoring

• Perform frequent blood glucose monitoring (SMBG) to guide insulin adjustments and avoid hypoglycemia 1, 4, 2
• Use fasting plasma glucose to titrate basal insulin; use both fasting and postprandial glucose to titrate mealtime insulin 2
• Consider continuous glucose monitoring when HbA1c becomes unreliable in advanced CKD 5

Cardiovascular and Renal Protection

Blood Pressure Management

• Initiate or continue ACE inhibitor or ARB if the patient has hypertension and albuminuria, titrated to maximum tolerated dose 1, 6
• Target blood pressure <140/90 mmHg for CKD stage 5 6
• Monitor potassium and creatinine carefully when using RAS blockade 5

Lipid Management

• Initiate statin therapy in all patients with Type 1 Diabetes and CKD 1, 6
• Use moderate-intensity statin for primary prevention or high-intensity statin if established cardiovascular disease is present 1

Additional Considerations

• SGLT2 inhibitors are NOT recommended for Type 1 Diabetes in standard guidelines 1
• The evidence for novel glucose-lowering agents (SGLT2i, GLP-1 RA) is sparse in Type 1 Diabetes with CKD; defer to insulin-based regimens 1

Lifestyle and Supportive Measures

Nutritional Management

• Maintain protein intake of 0.8 g/kg/day for CKD patients not on dialysis 1, 6
• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1, 6
• Emphasize diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; lower in processed meats, refined carbohydrates, and sweetened beverages 1

Physical Activity

• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1

Smoking Cessation

• Strongly advise all patients who use tobacco to quit immediately 1

Comprehensive Complication Screening

Diabetic Complications

• Screen regularly for diabetic retinopathy, neuropathy, and foot complications 6
• Perform comprehensive foot examination including visual inspection, Semmes-Weinstein monofilament testing, 128-Hz tuning fork for vibratory sensation, and pedal pulse evaluation 6

Patient Education and Team-Based Care

Self-Management Education

• Implement structured self-management educational program covering insulin administration, injection technique, glucose monitoring, recognition and management of hypoglycemia and hyperglycemia, and sick-day management 1
• Educate on proper insulin storage, handling, and injection site rotation to prevent lipohypertrophy 2
• Use shortest needles (4-mm pen or 6-mm syringe needles) to minimize pain and avoid intramuscular injection 2

Multidisciplinary Approach

• Utilize team-based integrated care with endocrinology, nephrology, nursing, dietitian, and diabetes educator involvement 1

Preparation for Advanced CKD

Renal Replacement Therapy Planning

• Provide structured, monitored, individualized patient education regarding dialysis options and kidney transplantation as CKD stage 5 approaches end-stage kidney disease 6
• Begin discussions early about vascular access planning if hemodialysis is anticipated 6

Critical Pitfalls to Avoid

• Never use metformin when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 1, 5
• Do not abruptly discontinue other medications when starting or adjusting insulin—risk of rebound hyperglycemia 2
• Avoid injecting insulin into areas of lipohypertrophy as this distorts absorption 2
• Do not rely solely on HbA1c in advanced CKD—it becomes unreliable; use frequent glucose monitoring 5
• Watch for early warning symptoms of hypoglycemia, which may be blunted in long-standing diabetes or with beta-blocker use 3