To the Editor:
In their recent article, Alicic et al.1 discuss the use of glucose-lowering agents for persons with diabetes and chronic kidney disease. Notably, in the section about insulin treatment, Table 3 shows total daily doses of insulin in units/kg/d according to type of diabetes and estimated glomerular filtration rate.1 This table reference comes from a consensus statement on insulin therapy in chronic kidney disease by Rajput et al.2 published in Diabetes Research and Clinical Practice in 2017. The table recommends doses of 1 unit/kg/d for an individual with type 1 diabetes (T1D) and an estimated glomerular filtration rate >60 ml/min per 1.73 m2, and 0.5 units/kg/d in persons with type 2 diabetes.These doses are listed as “expert group recommendation” in the reference by Rajput et al.2 Interestingly, in the chapter cited in the paper directly above Table 3, the authors recommend calculating the total daily dose in T1D and type 2 diabetes using 0.3 to 0.5 units/kg/d and 0.3 to 0.7 units/kg/d respectively. The authors in this chapter add that, often patients with type 2 diabetes may exhibit more insulin resistance and require more than 1 unit/kg/d.3
According to the 2023 American Diabetes Association Standards of Medical Care for Pharmacologic Therapy for Adults that also references the American Diabetes Association/Juvenile Diabetes Research Foundation Type 1 Diabetes Sourcebook, the starting total daily doses of insulin for persons with T1D is 0.5 units/kg/d and the final dose is 0.4 to 1.0 units/kg/d for persons with normal kidney function, significantly lower than Table 3 from Alicic et al.1 suggests.4 Furthermore, the American Association of Clinical Endocrinologists Clinical Practice Guideline from 2022 indicates that starting total daily doses doses for persons with T1D are based on weight, ranging from 0.4 to 0.5 units/kg/d but lower doses of 0.2 to 0.3 units/kg/d for older adults, those with renal failure, malnutrition, or low body mass index.5
We bring this to the attention of Kidney International Report readers to clarify the recommended starting doses and usual insulin doses for persons with T1D and type 2 diabetes to avoid potential overdose and hypoglycemia. We disagree with the recommendations from the paper by Rajput et al.,2 and the reprinting of this table by the noted authors of the otherwise excellent paper, “Use of Glucose-Lowering Agents in Diabetes and CKD.”1
References
- 1.Alicic R.Z., Neumiller J.J., Galindo R.J., Tuttle K.R. Use of glucose-lowering agents in diabetes and CKD. Kidney Int Rep. 2022;7:2589–2607. doi: 10.1016/j.ekir.2022.09.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rajput R., Sinha B., Majumdar S., Shunmugavelu M., Bajaj S. Consensus statement on insulin therapy in chronic kidney disease. Diabetes Res Clin Pract. 2017;127:10–20. doi: 10.1016/j.diabres.2017.02.032. [DOI] [PubMed] [Google Scholar]
- 3.Barnard K., Batch B., Lien L. In: Glycemic Control in the Hospitalized Patient. Lien L.F., Cox M.E., Feinglos M.N., Corsino L., editors. Springer; 2010. Subcutaneous insulin: a guide for dosing regimens in the hospital; pp. 7–16. [Google Scholar]
- 4.ElSayed N.A., Aleppo G., Aroda V.R., et al. Pharmacologic approaches to glycemic treatment: standards of Care in diabetes-2023. Diabetes Care. 2022;46(Suppl 1):S140–S157. doi: 10.2337/dc23-S009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Blonde L., Umpierrez G.E., Reddy S.S., et al. American association of clinical endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan-2022 update. Endocr Pract. 2022;28:923–1049. doi: 10.1016/j.eprac.2022.08.002. [DOI] [PMC free article] [PubMed] [Google Scholar]