To the Editor: In their Clinical Applications article about the initial dose of a basal-prandial insulin regimen, Drs DeWitt and Dugdale1 did not mention the importance of assessing renal function. Insulin duration of action is increased in renal insufficiency as a result of decreased renal insulin degradation and clearance.2 In addition, renal gluconeogenesis may be impaired, possibly due to limitation of the amino acid substrate alanine.3 Furthermore, many patients with renal failure have decreased caloric intake due to the accompanying anorexia. Indeed, insulin therapy and renal dysfunction have been reported to be the 2 most frequent diagnoses associated with hypoglycemia in hospitalized patients.4 Unfortunately, similar data from outpatients are lacking, in part because of exclusion of patients with various degrees of renal failure from diabetes clinical trials.
In our experience, renal insufficiency is an important factor that predisposes patients with diabetes to iatrogenic hypoglycemia. This is true in those receiving antidiabetic treatment in general, and insulin therapy in particular. Therefore, in the presence of renal insufficiency, we recommend using the smallest possible starting dose of insulin, then, if needed, increasing the dose in small increments to avoid hypoglycemia.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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