My patient is a woman in her 20s with long-standing type 1 diabetes who has chronic renal failure (estimated glomerular filtration rate of 20 to 30) requiring dialysis. What’s worse is she has just lost her vision.
She is a wonderful, stalwart young woman working desperately to maintain her composure; tolerate her dialysis; and try very hard to control her blood glucose to the extent possible. However, despite best intentions by her caregivers, glycemic control in the hospital is proving to be a very difficult task.
I have gone to www.UpToDate.com to learn as much as I can regarding glycemic control in patients requiring dialysis and I would recommend that section to everyone who is involved in the care of patients with diabetes requiring dialysis.
That said, particularly in type 1 diabetes, I did not find any clear guidelines to follow with the important exception that, at all costs, hypoglycemia should be avoided. Managing blood glucose in this young woman who is quite small (weight, 56 kg; height, 63 inches) was difficult in the in-patient setting, which was aggravated by her recent loss of sight. On the positive side, she is getting excellent counseling from a psychiatry colleague and is working hard to overcome this blow.
Fortunately, for now at least she has the will power to try and stay on top of things. We are getting her ready for an insulin pump and a “talking” glucose meter and something about her tells me that she will pull through this.
If any readers of this blog can let me know how they have handled something like this in the past I would be grateful.