“The perfect storm” is an event where a combination of circumstances will aggravate a situation drastically.
In the UK we have an established and ever increasing population of people living with diabetes who, by definition, fall into a risk group for developing acute kidney injury (AKI). These people are aged 65 or older and have a pill box full of ACEI, statins and metformin, and are likely to have a degree of chronic kidney disease. To add insult to injury if their IFCC value is greater than 64 mmol/mol (a venous blood sample that measures a mean glucose over 8-12 weeks) hyperglycaemic or symptoms of poor glucose control may be apparent, such as passing more urine and increased thirst leading to dehydration and a risk of infection.
Ask anyone with diabetes what they fear most about the condition and the answer will be “a hypo”. Hypoglycaemia is a serious and potentially life changing complication for people with diabetes who take insulin and/or oral hypoglycaemic agents. When glucose values fall below 4mmol/L people with diabetes may experience symptoms which can include disorientation, confusion, aggression, increased perspiration and unconsciousness. The causes of hypoglycaemia are commonly considered by health professionals to be caused by either an excess of insulin and /or tablets or a period of patient starvation.
Infections and dehydration are very common causes of hospital admissions and are primarily linked to AKI. However they can be experienced during a patient’s stay, particularly in the elderly. Continuing to receive insulin or anti-diabetes agents typically excreted by our kidneys with impaired kidney function is all too often overlooked as a primary trigger for hypoglycaemia.
It is also recognised that recurrent episodes of hypoglycaemia lead to a lack of awareness and diminished symptoms experienced by the patient leading ultimately to additional health risks such as falls and fractures and dealing with the complexity of driving a motor vehicle when well.
So get to the point I hear you say!
Hospitals have high bed occupancy for people with diabetes and GP surgeries and diabetes centres are overwhelmed with diabetic reviews trying to pursue tight glycaemic targets to improve long term vascular outcomes. Patient education regarding sick day rules and the risk of hypoglycaemia in association with AKI is rarely discussed.
Vulnerable adults requiring third party assistance and residents in nursing homes where glucose values are infrequently measured may be suffering from undiagnosed, untreated hypoglycaemia when they become septic and dehydrated.
Before this storm hits land, education and therapy guidance to prescribers of diabetes drugs – and anyone looking after people with diabetes – is vital to reduce the potential hazards and risks of hypoglycaemia with AKI. Prescribers should be aware of suitable alternative therapies with shorter action times to reduce hypoglycaemia, and patient awareness needs to be addressed wherever and whenever therapy reviews take place. We also need to reconsider the benefits of tight control over risks in patients with diabetes who have an AKI risk.
Stephen Trowbridge
Steve works at the Royal Bournemouth Hospital in Dorset where he has been a Diabetes Nurse Specialist since 1997, working as a community, in patient outreach and out-patient lead. In 2014 Steve was asked to develop a new Acute Kidney Injury Service for the trust involving daily ward outreach services and project development. Steve qualified as a nurse in 1986 working in CCU/ITU and medicine before setting up a treatment and investigation unit. His three children have now left home and he and his wife keep busy mountain biking, dog walking , gardening and karate which he has taught for 20 years.