medwireNews: A large observational study reveals a strong link between reduced kidney function and increased incidence of hypoglycemia in adults with diabetes in routine clinical practice.
“Our study underlines the need for greater provider awareness and regular monitoring of kidney function in patients with diabetes, in accordance with current ADA recommendations,” write the study authors in Diabetes, Obesity and Metabolism.
Björn Runesson (Karolinska University Hospital, Stockholm, Sweden) and co-researchers note that routine monitoring of estimated glomerular filtration rate (eGFR) is “often suboptimal.” Yet they say their findings suggest an increased hypoglycemia risk even at “mild eGFR reductions.”
The team studied 29,434 people with type 1 or 2 diabetes who accessed healthcare in the Stockholm region during 2006–2011. They were a median age of 66 years, 43% were female, and 13.4% had type 1 diabetes.
During a median 2 years of follow-up, 6.2% of the cohort had at least one documented hypoglycemic episode, with the unadjusted rate increasing across decreasing categories of eGFR, from 3.9% to 32.0% for eGFR categories of 90–104 versus less than 15 mL/min per 1.73 m2.
Compared with people in the 90–104 mL/min per 1.73 m2 eGFR category, those with even mild kidney impairment (eGFR 60–89 mL/min per 1.73 m2) had a significantly increased risk for mild hypoglycemia, at an incidence rate ratio (IRR) of 1.3 after adjustment for multiple variables including diabetes type and complications, comorbidities, medications, glycated hemoglobin level, and previous healthcare use.
For moderate or severe hypoglycemia, the risk became significantly increased at an eGFR of 45–59 mL/min per 1.73 m2, at an IRR of 1.5 versus the reference category. The IRRs for hypoglycemia in people with an eGFR below 15 mL/min per 1.73 m2 were 9.5 for mild and 4.2 for moderate or severe events.
There was also a hint of increased hypoglycemia risk (nonsignificant) in people with renal function greater than 104 mL/min per 1.73 m2, which the team suggests may reflect early renal dysfunction in the form of hyperfiltration.
Reduced kidney function was additionally associated with an increased risk for mortality within 30 days after a hypoglycemic event, although this was significant only for those with markedly reduced eGFR of less than 30 mL/min per 1.73 m2.
The researchers identified “numerous baseline predictors of hypoglycemia” besides renal function, including age, medications (insulins and sulfonylureas), and various complications and comorbidities, which they suggest may “represent a non-specific relationship between hypoglycemia and poor health.”
Indeed, they caution that, despite the existence of many plausible mechanisms by which impaired renal function could increase hypoglycemia risk, kidney disease usually occurs in the context of multiple morbidity, and so “it is also possible that the associations observed simply reflect underlying disease or duration of diabetes and insulin use.”
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