Anyone got the answer to this?

My T1 husband had a disastrous appointment at thee local diabetes clinic, with a doctor who obviously doesn’t read patient notes or know the difference between T1 and T2… We’re in England under the NHS and there isn’t another clinic within a decent distance. One thing she said I’d like to find out about.
She told T1 husband to reduce his Lantus from 2 doses of 20 units each to 1 dose of 18 units. I only found out after he got worried he couldn’t keep his BG out of double figures.
It wasn’t the only inhelpful thin she said. Most of them I can solve for him, but she said to reduce the Lantus, because his kidney disease prevents the insulin from being metabolised from his body.
Please, who knows this one?
Hana

Wow. If you are not too insulin resistant and your pancreas does not produce any insulin then you need about 0.5 unit per kg per day. and if you read “using insulin” it is split about 1/2 and 1/2 into basal and bolus. Read an Australian blog that with kidney disease the patient was advised to minimize insulin dosage. Not sure why and do not have any personal experience with this.

Ps I am thinking of limiting my insulin to “just” 30 units of lantus twice a day this is because of uncontrollable weight gain. This will result in worst blood sugars. If weight gain is not a problem I do not see any logic in cutting the insulin and getting double digit BG (in our units) surely this will destroy the kidneys.

Hana

Give this a read : http://www.australianprescriber.com/magazine/30/1/17/20/

I talks about tailoring drugs to renal function makes some sense is the major route for elimination is the kidneys. It does mention insulin specifically. Still if BG is high I would not think insulin is too much.

Reducing your insulin to lose weight? That’s called “diabulimia”.

Now, you shouldn’t be taking too much insulin, either, because that causes hypos. If you take too much insulin and then eat all the time to prevent hypos, that probably falls into some kind of eating disorder too.

Hana, is there any chance of getting your husband on an insulin pump? If so, that would eliminate the need for Lantus altogether, as an insulin pump supplies the basal insulin in a more controlled, steady, and above all smaller (but constant) amount of short-acting insulin that might be more tolerable for his kidneys. It’s worth looking into, anyway. Anthony is right, though, that basal and bolus insulin should be about a 50-50 split (40-60, at the worst) so if she insists on such a radical reduction of Lantus, he’s going to need to make a corresponding radical reduction in bolus doses.

The real difficulty is that with lower bolus doses, your main option for controling blood sugars is to lower carb intake, which often means eating more protein… and a high protein diet is hard on the kidneys, which are already compromised. Can you get in to see a dietician who works with people with diabetes? Such a person might be able to suggestion dietary alterations to limit the need for additional bolus insulin and help in reducing his basal needs that way, without focusing on higher protein foods that could do more damage to the kidneys’ function. An exercise program, also, which could increase the demand for glucose such that less insulin is required to manage the glucose load is another option. Doesn’t have to be something high-energy like aerobics, just walking or swimming or some other form of exercise that can be done an hour after eating, when the glucose load is highest and he’s presumably got active insulin in his system to process it. More exercise after eating = less bolus insulin & lower overall base BG = less need for basal insulin = less Lantus.

That’s quite a dose reduction. I’ve been told to do increases/reductions by small increments. Important for kidney disease to keep tight BG control. I wouldn’t follow advice that sent my blood sugar high. Seems counterproductive & contradictory to take less insulin. I’ve been told to do increases/reductions slowly. Two doses of basal works better for me, especially when I used Lantus because it caused lows.

Did she also reduce his bolus insulin?

Hoping someone else can give you an answer about kidney diease & metabolizing insulin. I’ve not heard that before.

T1s with insulin resistance have used Metformin with success. Don’t know about Metformin & kidney disease.

Yeah, the kidneys are an important site of insulin metabolism and clearance. If kidney function is affected, insulin half-life will be affected as well.

Not sure at all about the rest. =/

PS if you can’t see a dietician, your husband would do well to make sure he gets most of his carbs from low glycemic index veggies and avoid high glycemic index sources like flour, sugars (and I include fruit juice in that as well as honey, though he should be OK with whole fruits since they have sufficient fiber to keep them from shooting his BG high) and potatoes. The less he raises his blood glucose while eating, the better. There’s a lot on the web about what foods are low glycemic index, so just look around. Focusing on low glycemic carbs generally gives you a pretty good diet for overall health too.

But I thought that the liver cleared circulating insulin??

I thought that also.

Couple of references:

Renal metabolism of Insulin
http://www.springerlink.com/content/k416219254462563/

“The kidney plays a pivotal role in the clearance and degradation of circulating insulin and is also an important site of insulin action. The kidney clears insulin via two distinct routes. The first route entails glomerular filtration and subsequent luminal reabsorption of insulin by proximal tubular cells by means of endocytosis. The second involves diffusion of insulin from peritubular capillaries and subsequent binding of insulin to the contraluminal membranes of tubular cells, especially those lining the distal half of the nephron.”

Diabetes and renal metabolism of insulin
http://content.karger.com/ProdukteDB/produkte.asp?Doi=180518

“The renal extraction of insulin is 200 ml/min in man, and it is estimated that 6-8 U are removed and degraded by the kidney in 24 h.”

“In diabetic patients, progressive renal disease is accompanied by decreasing insulin requirements.”

Overall, I believe about half of insulin is removed by the liver, and the rest by the kidneys and any other process.

Didn’t know that