Table 3.

Inpatient Treatment Considerations

Clinical Scenario	Concerns	Treatment Considerations	Potential Problems
Immediate post-transplant	High-dose immunosuppression, pain, and stress are common	Frequently require iv insulin infusion protocol	Requires diligent monitoring of blood glucose
	Often under observation in intensive care unit or require critical care	Hourly blood glucose monitoring initially	Frequent adjustment of insulin dose based on algorithm and/or anticipated dose changes to cover corticosteroids or other changes
First week post-transplant	Increased nutritional intake	High-dose immunosuppression common	Insulin requirements may change daily due to renal function changes, increased nutritional intake
	Steroid doses weaning	Transition to sc insulin when stable and/or starting oral intake
	Rapid improvement in renal function (after kidney transplant)	Calculate sc insulin dose from last 8–24 h iv insulin requirement
		Monitor blood glucose at least 4 times daily
Acute steroid bolus (eg, for acute rejection)	Increased insulin requirements	Consider NPH insulin for steroid bolus or, if very high-dose steroid, temporary iv insulin	If blood glucose rises significantly when on sc insulin, consider temporary iv insulin
	Fluctuations in renal function, particularly, after kidney transplant	Transition back to previous insulin regimen once steroid complete, noting any changes in renal function
TPN or enteral feeding	Increased insulin requirements	Consider iv insulin as drip and/or in TPN bag	Adjust insulin dose for changes in TPN/tube feed rate or dextrose concentration
		Once iv requirements are established and stable, switch to NPH insulin every 8 h plus fast-acting correction insulin every 4 to 6 h	Long-acting insulin held or decreased significantly if TPN or tube feeds stopped.

Contributing factors and considerations to management of glucose during initial hospitalization.