Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support

Abstract

Objective: To evaluate glycemic control for critically ill, hyperglycemic trauma patients with renal failure who received concurrent intensive insulin therapy and continuous enteral nutrition (EN) or parenteral nutrition (PN).

Methods: Adult trauma patients with renal failure who were given EN or PN concurrently with continuous graduated intravenous regular human insulin (RHI) infusion for at least 3 d were evaluated. Our conventional RHI algorithm was modified for those with renal failure by allowing greater changes in blood glucose (BG) concentrations before the infusion rate was escalated. BG concentration was determined every 1 to 2 h while receiving the insulin infusion. BG control was evaluated on the day before RHI infusion and for a maximum of 7 d while receiving RHI. Target BG during the RHI infusion was 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Glycemic control and incidence of hypoglycemia for those with renal failure were compared with a historical cohort of critically ill, hyperglycemic trauma patients without renal failure given our conventional RHI algorithm.

Results: Twenty-one patients with renal failure who received the modified RHI algorithm were evaluated and compared with 40 patients without renal failure given our conventional RHI algorithm. Average BG concentration was significantly greater for those with renal failure (133±14 mg/dL or 7.3±0.7 mmol/L) compared with those without renal failure (122±15 mg/dL or 6.8±0.8 mmol/L), respectively (P<0.01). Patients with renal failure showed worsened glycemic variability, with 16.1±3.3 h/d within the target BG range, 6.9±3.2 h/d above the target BG range, and 1.4±1.1 h/d below the target BG range compared with 19.6±4.7 h/d (P<0.001), 3.4±3.0 h/d (P<0.001), and 0.7±0.8 h/d (P<0.01) for those without renal failure, respectively. Moderate hypoglycemia (<60 mg/dL or<3.3 mmol/L) occurred in 76% of patients with renal failure compared with 35% without renal failure (P<0.005). Severe hypoglycemia (BG<40 mg/dL or<2.2 mmol/L) occurred in 29% of patients with renal failure compared with none of those without renal failure (P<0.001).

Conclusion: Despite receiving a modified RHI infusion, critically ill trauma patients with renal failure are at greater risk for developing hypoglycemia and have more glycemic variability than patients without renal failure.