Inpatient Hypoglycemia in Patients With Chronic Kidney Disease

Background: Inpatient hypoglycemia has been shown to be associated with increased mortality, more complications, and greater length of stay [1]. Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are at greater risks for hypoglycemia due to their decreased degradation of insulin, reduced glycogen stores, and decreased renal gluconeogenesis. With the association between inpatient hypoglycemia and increased morbidity and mortality, it is valuable to determine other risks factors that may contribute to hypoglycemia in the hospital setting. Objective: Determine the rates of hypoglycemia (glucose <70 mg/dl) and severe hypoglycemia (glucose <54 mg/dl) along with risk factors, such as type of insulin used and initial hyperglycemia at admission, for patients with diabetes mellitus (DM) and CKD/ESRD. Methods: A retrospective cohort analysis was conducted on 74,266 hospitalized patients who had DM and CKD/ESRD or DM alone, within 155 HCA Healthcare hospitals from January 2019 through June 2019. Results: Among hospitalized patients with DM, hypoglycemia was more common in patients with ESRD (n=5234) compared to patients with CKD without ESRD (n=18659) and patients without CKD/ESRD (n=52373) (34.37% vs. 23.66% vs. 12.91%, respectively, p<0.01). Similarly, severe hypoglycemia was more common in patients with ESRD compared to patients with CKD without ESRD, and patients without CKD/ESRD (18.09% vs. 11.19% vs. 5.28%, respectively, p<0.01). When evaluating patients with ESRD, a higher point of care (POC) glucose at time of admission was associated with an increased risk of subsequent hypoglycemia. Within the first 24 hours of hospital admission, hypoglycemia was more common if the patient’s initial POC glucose was greater than 300 with an incidence of 13.67% compared to 11.21% (n=955, p=0.033). Among patients with ESRD and an admission glucose > 300, having an order for dialysis within the first 24 hours of admission was associated with increased risk of hypoglycemia (OR= 1.2181, p=0.0014). Diabetics with subsequent hypoglycemia had higher initial glucose levels on admission when compared to diabetics who did not experience hypoglycemia during their hospital stay. Mean = 221.61±82.32 vs 205.54±74.51 (p=0.000002). Conclusion: In hospitalized patients with DM, CKD and ESRD are associated with increased risk of hypoglycemia. Amongst diabetics, patients with ESRD and CKD account for over 50% of cases of severe hypoglycemia. Severe hypoglycemia occurred in 18% of patients who had both diabetes and ESRD. An elevated glucose at admission is associated with a subsequent hypoglycemia in patients with ESRD. It is important to manage DM in patients with CKD and ESRD carefully as they may be more likely to experience hypoglycemia due to overcorrection and decreased clearance of insulin. 1.Hulkower et al., Diabetes Manag 2014 Mar;4(2):165–176.