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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　March 19, 2010 — 根據一項線上發表於3月9日糖尿病照護（Diabetes Care）期刊的研究結果，第二型糖尿病患者在維持性透析後那天基礎胰島素需求較低。
　　
　　喀麥隆Yaounde Yaounde大學Eugene Sobngwi博士與其同事們寫到，透析對於透析前後胰島素需求的潛在效應仍然未知。確實，目前並沒有糖尿病患透析後胰島素調整之證據為基礎的建議。這項研究是要確認透析前24小時、透析時、透析後24小時，罹患慢性腎臟病第二型糖尿病患者接受維持性透析，以維持血糖值正常所需要的胰島素量。
　　
　　研究者對10位每天接受標準3餐與2次點心療程的第二型糖尿病患者，研發出24小時正常血糖夾鉗技術。這些病患的平均年齡為55.7 ± 8.7歲，平均糖尿病罹病時間為11.9 ± 4.5年，接受維持性透析平均時間為2.3 ± 2.3年。每日平均熱量為2200大卡，校正體型大小與性別。
　　
　　在透析前24小時、透析時、透析後24小時，每30分鐘調整一次靜脈注射胰島素劑量，使其血糖值達到5.5 ± 1.1-mmol/L。研究者們比較每天不同的胰島素需求量，決定每個階段維持正常血糖所須胰島素量。
　　
　　透析前的平均微血管血糖為5.5 ± 0.3 mmol/L，透析後為5.3 ± 0.2 mmol/L（P=0.39），而透析前後曲線下血糖面積是相當的。這些結果在透析前的胰島素流速為23.6 ± 7.7 IU/24小時，透析後則是19.9 ± 4.9 IU/24小時，或是透析後降低了15.3%（P=0.09）。
　　
　　基礎胰島素需求從透析前的0.4 ± 0.1/小時到透析後的0.3 ± 0.1/小時（P=0.01），然而，整體速注胰島素需求量下降了2.2 ± 3.1 IU（P=0.15）。尿素濃度變化與胰島素需求量並沒有關係（r=0.1；P=0.79）。
　　
　　研究作者表示，目前這項研究顯示，透析完那天，相較於透析前，基礎胰島素需求量顯著下降了25%。速注胰島素需求量則沒有太大變化，且整體胰島素需求量在透析後下降了15%，相當於4 IU/天，有些微統計上差異。
　　
　　這項研究的限制包括樣本數目較小；靜脈輸注胰島素，使得這項發現無法應用到皮下投予胰島素。
　　
　　研究作者們的結論是，這些結果因此支持了接受透析的第二型糖尿病患者，在透析後的那天，基礎體外胰島素需求量全身性地下降了25%。
　　
　　The North East Diabetes Trust、英國Newcastle upon Tyne公司，提供血糖夾鉗。研究作者們表示已無相關資金上的往來。


Basal Insulin Requirements May Be Less on the Day After Dialysis

By Laurie Barclay, MD
Medscape Medical News

March 19, 2010 — Basal insulin requirements may be less on the day after maintenance hemodialysis in type 2 diabetic patients with end-stage renal disease, according to the results of a study reported online in the March 9 issue of Diabetes Care.

"It is uncertain whether dialysis has a potential effect on pre to post dialysis days exogenous insulin requirements," write Eugene Sobngwi, MD, PhD, from University of Yaounde in Yaounde, Cameroon, and colleagues. "Indeed, there is currently no evidence base recommendation for the adjustment of insulin dose post hemodialysis in diabetic patients. This study was undertaken to determine the insulin requirements necessary to achieve euglycemia over 24 hours pre-hemodialysis, during hemodialysis, and 24 hours post-hemodialysis in type 2 diabetic patients with chronic kidney disease on maintenance hemodialysis."

The investigators developed a 24-hour euglycemic clamp in ten type 2 diabetic patients receiving a standardized 3-meal and 2-snack regimen per day. Mean age was 55.7 ± 8.7 years, mean diabetes duration was 11.9 ± 4.5 years, and mean duration of maintenance hemodialysis was 2.3 ± 2.3 years. Average daily intake was 2200 calories, with adjustments for body size and sex.

Intravenous insulin was adjusted every 30 minutes to achieve 5.5 ± 1.1-mmol/L glycemia during the 24-hour period preceding hemodialysis, during the hemodialysis session, and during the 24-hour period after hemodialysis. The investigators compared day-to-day insulin requirements, which were determined from the dose of insulin given to maintain euglycemia during each period.

Mean capillary glycemia was 5.5 ± 0.3 mmol/L before hemodialysis and 5.3 ± 0.2 mmol/L after hemodialysis (P = .39), and areas under the glucose curve before and after hemodialysis were comparable. These results were obtained by insulin infusion of 23.6 ± 7.7 IU/24 hours before hemodialysis vs 19.9 ± 4.9 IU/24 hours after hemodialysis, or a 15.3% decrease after hemodialysis (P = .09).

Basal insulin requirements decreased from 0.4 ± 0.1/hour before hemodialysis to 0.3 ± 0.1/hour after hemodialysis (P = .01), whereas total boluses were decreased by 2.2 ± 3.1 IU (P = .15). Changes in serum urea concentration were not associated with changes in insulin requirements (r = 0.1; P = .79).

"The present study has demonstrated a significant 25% reduction in basal insulin requirements the day after dialysis compared to the day before," the study authors write. "No significant change in boluses was observed, and overall the reduction of total insulin requirements was –15% equivalent to –4IU/day post hemodialysis of marginal statistical significance."

Limitations of this study include small sample size; and intravenous administration of insulin, preventing generalization of the findings to subcutaneous administration of insulin.

"These results therefore support a systematic reduction of basal exogenous insulin administration by 25% in type 2 diabetic patients undergoing hemodialysis the day after dialysis," the study authors conclude.

The North East Diabetes Trust, Newcastle upon Tyne, United Kingdom, provided equipments for the clamp. The study authors have disclosed no relevant financial relationships.

Diabetes Care. Published online March 9, 2010.