Abstract
Background and Aims
Co-existence of diabetes mellitus (DM) and kidney disease is common. In-patient hypo- and hyperglycaemia are associated with adverse outcomes and, for hypoglycaemia, an increased length of inpatient stay (LOS). NICE and the National Patient Safety Agency recommend in-patients with DM previously established on insulin be allowed to self-prescribe to reduce hypo and hyperglycaemia. It is unclear how this occurs in clinical practice in patients under nephrology care.
We sought to describe glycaemic control and diabetes management in patients admitted to our nephrology service.
Method
All patients admitted to the Glasgow Renal and Transplant Unit between June and August 2020 were identified. In those with a previous diagnosis of DM, demographic data were collected including reason for admission and use of insulin. Self-prescription of insulin, blood sugar levels and episodes of hypo (BM <4mmol/L) and hyperglycaemia (BM >14mmol/L) were identified. Analysis was undertaken in SPSS v 27.0.1.0.
Results
One hundred and sixty-seven patients with a diagnosis of DM were admitted over the three month period.
The remaining results refer only to the 90(54%) patients established on insulin before the index admission. Mean age was 58±7.1 years, 56% (n=50) were male and 77% (n=69) self-prescribed insulin throughout admission. Table 1 shows type of DM and regular insulin regimen. Mean HbA1C pre-admission was 68±6.4mmol/mol. Fifty-one (57%) patients were on dialysis and 12 (13%) had a functioning transplant. Reasons for admission included infection (n=21), to undergo a procedure eg arteriovenous fistula creation (n=21), AKI (n=10) and fluid overload (n=8).
These 90 patients accounted for 113 admissions with a median LOS of 5 (2-9) days. In 46 (41%) admissions, there was at least one episode of hypoglycaemia and in 95 (84%) at least one episode of hyperglycaemia. During 12 (13%) admissions, there were neither hypo nor hyperglycaemic episodes.
Insulin self-prescribers were younger (56±12.7 ‘v’ 60±9.7 years, p=0.04) and more likely to experience hypoglycaemia than those who did not self-prescribe (p=0.03). There was no significant increase in hyperglycaemia nor in median LOS between the groups. Episodes of hypoglycaemia were more likely with a lower mean fasting blood sugar (fbs), regardless of self-prescription of insulin (11±3.8 ‘v’ 13±5.1mmol/L, p=0.02)
Conclusion
Most patients with DM admitted under the care of nephrology, self-prescribe insulin. These patients are more likely to have an episode of hypoglycaemia and hypoglycaemia is more likely to occur if the fbs is <13mmol/L. It is unclear how our experience differs from that of other specialties. However, reducing renal function, eg in the setting of dialysis or AKI, and uncertainties regarding the carbohydrate content of hospital food may play a role in predisposing to hypoglycaemia. In order to facilitate safe management of DM in the inpatient nephrology wards, whilst preserving patients’ autonomy, attention should be paid to the fbs level and self-prescription of insulin should be permitted within a narrow range of the patients’ regular dosing regimen.
Blood Sugar Levels are Not Necessary to Predict the Population at Risk for Atherothrombotic Disease
