Hypoglycemia in People with Type 2 Diabetes and CKD

Background and objectives Among people with diabetes mellitus, CKD may promote hypoglycemia through altered clearance of glucose-lowering medications, decreased kidney gluconeogenesis, and blunted counterregulatory response. We conducted a prospective observational study of hypoglycemia among 105 individuals with type 2 diabetes treated with insulin or a sulfonylurea using continuous glucose monitors. Design, setting, participants& measurementsWeenrolled81 participantswithCKD, defined as eGFR, 60 ml/min per 1.73m2, and 24 control participantswith eGFR$ 60ml/min per 1.73m2 frequency-matched on age, duration of diabetes, hemoglobin A1c, and glucose-lowering medications. Each participant wore a continuous glucose monitor for two 6-day periods. We examined rates of sustained level 1 hypoglycemia (, 70 mg/dl) and level 2 hypoglycemia (, 54 mg/dl) among participants with CKD. We then tested differences compared with control participants as well as a second control population (n= 73) using Poisson and linear regression, adjusting for age, sex, and race. Results Over 890 total days of continuous glucose monitoring, participants with CKD were observed to have 255 episodes of level 1 hypoglycemia, of which 68 episodes reached level 2 hypoglycemia. Median rate of hypoglycemic episodes was 5.3 (interquartile range, 0.0-11.7) per 30 days andmean time spent in hypoglycemia was 28 (SD 37) minutes per day. Hemoglobin A1c and the glucose management indicator were the main clinical correlatesof timeinhypoglycemia (adjusteddifferences 6 [95% confidence interval, 2 to 10] and13 [95% confidence interval, 7 to 20] fewer minutes per day per 1% higher hemoglobin A1c or glucose management indicator, respectively). Compared with control populations, participants with CKD were not observed to have significant differences in time in hypoglycemia (adjusted differences 4 [95% confidence interval, 212 to 20] and 212 [95% confidence interval, 229 to 5] minutes per day). Conclusions Among people with type 2 diabetes and moderate to severe CKD, hypoglycemia was common, particularly with tighter glycemic control, but not significantly different from groups with similar clinical characteristics and preserved eGFR.