BLOOD-GLUCOSE CONTROL IN DIABETICS .1.

A 51-year-old white male with end-stage renal disease (ESRD) secondary to diabetic glomerulosclerosis started continuous ambulatory peritoneal dialysis (CAPD) in July 1991. During the year preceding initiation of CAPD, his insulin requirements diminished by 20%, but his glycemic control remained excellent, with random blood sugars in the 100-185 mg/dl range and glycosylated hemoglobins of 7%-9%. Upon initiation of CAPD, a program consisting of divided intraperitoneal (IP) insulin was initiated. Despite a gradual increase in total insulin requirements to five times his previous total dose, his blood sugars became uncontrollable and his glycosylated hemoglobin averaged 14.8%. A sliding scale approach with larger doses of subcutaneous (SC) insulin injections was added to his IP regimen. In addition to his uncontrolled hyperglycemia, the patient developed generalized edema requiring the frequent use of 2.5% and 4.25% dextrose (D) dialysis solutions. A standard peritoneal equilibration test (PET) was obtained (Fig. 1) which demonstrated a high peritoneal solute transport rate. The patient was transferred to nocturnal peritoneal dialysis (NPD). The new regimen consisted of five, 2-1 nocturnal exchanges over 10 hr, using mostly 1.5% D solutions. IP insulin was continued, using 50% of the dose equally divided among each of the nocturnal exchanges and 50% added to 300 ml of dialysate left in the peritoneal cavity during the day. On this program, his total insulin requirements averaged 2.5 times his predialysis total dose. The patient required an occasional SC injection during the day. His average glycosylated hemoglobin dropped to 7.8%. His hydration status was markedly improved, and his estimated protein intake increased by 30% (Table 1).