47 years old AAM
Past surgical Hx:
Lt AKA (1 year ago)
Rt AVF (radial artery)
Rt Big toe amputation
Lt IJ Dialysis catheter (3/10/2007)
Resident at Cleveland Rehab
Denies any Hx of:
Insulin aspart 5 units S.Q. Q AC
Lantus 20 units S.Q. QHS
Hydralazine 100mg P.O. Q8hr
Lisinopril 20mg P.O. QD
Lopressor 50mg P.O. BID
Norvasc 10mg P.O. QD
Renagel 800mg P.O. TID
Nephrocap 1 tab P.O. QD
Neurontin 300mg P.O. Q 8hr
Fluoxetine 20mg P.O. QD
Vancomycin 600mg I.V. with HD
V/S : 36- 120/56 - 62 – 17 - SPO2= 86% on RA
Pt is drowsy, dehydrated, not in distress
Chest: Bil crackles, no wheezing + decreased air entry.
CVS: S1 + S2 + no M
ABD: soft, distended epigastric, tenderness, no rebound, BS+.
EXT: no edema , Lt AKA, Rt Big toe amputation, AVF on the Lt
•Ansari, A, Thomas, S, Goldsmith, D. Assessing glycemic control in patients with diabetes and end-stage renal failure. Am J
Kidney Dis 2003; 41:523
•Joy, MS, Cefalu, WT, Hogan, SL, Nachman, PH. Long-term glycemic control measurements in diabetic patients receiving
hemodialysis. Am J Kidney Dis 2002; 39:297.
•K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 4(Suppl 3):S1.
•Coronary-artery calcification is common and
progressive in young adults with end-stage renal
disease who are undergoing dialysis. (N Engl J
INSULIN resistance 2 nd to uremia
1) Increased hepatic gluconeogenesis.
2) Reduced hepatic and/or skeletal muscle glucose uptake.
3) Impaired intracellular glucose metabolism.
4) abnormalities in phosphate and vitamin D metabolism
•Mak, RH, DeFronzo, RA. Glucose and insulin metabolism in uremia. Nephron 1992; 61:377.
•McCaleb, ML, Izzo, MS, Lockwood, DH. Characterization and partial purification of a factor from
uremic human serum that induces insulin resistance. J Clin Invest 1985; 75:391.
Decreased insulin degradation
Decreased until GFR of 15-20 ml/min.
Uremia will be higher and this will lead to an increase in
resistance to insulin when GFR 10 ml/min.
No dose adjustment is required if the GFR is above 50 mL/min.
The insulin dose should be reduced to approximately 75% of baseline when the
GFR is between 10-50 mL/min.
The dose should be reduced by as much as 50% when the GFR is less than 10
in pt HD patients the insulin requirement in any given patient will depend upon
the net balance between improving tissue sensitivity and restoring normal
hepatic insulin metabolism.
•Snyder, RW, Berns, JS. Use of insulin and oral hypoglycemic medications in patients with diabetes
mellitus and advanced kidney disease. Semin Dial 2004; 17:365.
DKA + ESRD + Questions
1. Metabolic Acidosis could be from multiple sources.
2. Insulin doses
3. Importance of HD
4. Role of IVF
5. Role central venous pressure and (risk / benefit)
6. Treatment of Hyperkalemia / Hypokalemia
7. Role of HCO3