eGFR is………………………………..

Patient profile: 80-Year-old female. Symptoms: thirst and polyuria. Signs: obesity,
diabetes mellitus type 2 (DMT2) by blood test, serum creatinine 150 μmol /l but no
ketonuria and electrolytes are normal.
What interventions can be taken to improve outcomes for this patient?
Address the following issues: Obesity, raised HbA1c, hypertension, atherosclerotic
CVD, poor diet, poor renal function. Patient is mobile with good balance and gait.
A serum creatinine of 150 μmol/l is high. To establish a treatment plan we need to
calculate her GFR. The National Kidney Foundation Calculator
(https://www.Kidney.org/professionals/kdoqi/gfr_calculator )
gave the following results:
CKD-EPI creatine equation (2009) = 28 ml/min/1.73m2
CKD classification = G4/A1
Risk of progression = very high
Treatment plan.
Discuss diagnosis with patient. Reassure patient that there are different treatment
options for diabetes and that we will develop, as a joint effort, a plan to suit her
needs.
Lifestyle changes are central for treatment of DMT2(Tuomilehto 2001). The main
pillars are weight loss (Table 1)(Grüßer 2016) , diet (Coppel 2010) and exercise
(Table 2) (Coldberg 2010). It is now established that DMT2 is in principal a
reversable disease (Lean 2018).
Table 1 The success of weight loss depends on the total amount of calories per day.
In 1 gram Water are 0 calories
In 1 gram Protein are 4 calories
In 1 gram carbohydrates are 4 calories
In 1 gram alcohol are 7 calories
In 1 gram fat are 9 calories
(Grüßer 2016)
Table 2. Recommendations Physical Activity in DMT2
Type Frequency Intensity Duration
Aerobic 3 Moderate, At least 150 min/week, in
exercise days/week, approximately bouts of a minimal 10
training max. 2 40-60% of VO2max. minutes.
days in e.g. brisk walking. To lose weight through
between. Vigorous, exercise one should
approximately exercise at least one hour
>60% of VO2max a day total 7 hours a week.
(extra benefits).

Resistance At twice a Moderate, Each training session

exercise week with approximately should minimally include 5-
training at least 1 50% of 1 repetition 10 exercises involving
day in Maximum (1-RM). major muscle groups
between, 3 Vigorous 75 -80% of (upper body, lower body
times 1-RM and core)
weekly is Is better.
 better.
Flexibility This training e.g. Yoga may be included but should not replace
training aerobic and resistance training.
(Colberg 2010)
We also know that advising patients about lifestyle change on its own is insufficient.
Structured education by a trained educator in groups of 4 to 10 patients with similar
functionality is the most cost-effective way to introduce these changes and equally
efficient as individual education (Patti et al. 2002). The goal of patient education is
empowerment and self-management of their diabetes (Table 3).
Table 3. Strategies for self-management through education.
Consider the individual`s needs
Teach skills that match functional ability in order to
optimize outcomes
Facilitate behavioural change
Provide emotional support
(Fisher 2005)
Goals of treatment.
It is agreed with the patient to set a HbA1C target of about 8%. If this is not
achieved with lifestyle changes (three months), we need to commence drug
treatment. To reduce her cardiovascular risk and stabilise her renal function we need
to treat her BP to < 130/80 mmHg (target) with an ACE- inhibitor or an angiotensin-2-
receptor antagonist. This will improve cardiovascular and microvascular outcomes,
for example, her kidney function (Berl 2003;Heart-Outcome-Prevention-Evaluation-
Study Investigators 2000).In diabetes statins show a reduced atherosclerotic CVD
risk and total mortality up to the age of 85 years (Ramos 2018).
If the HbA1C target is not reached through lifestyle changes we need to commence
drug treatment.
The first line of treatment in DMT2 is metformin. However, with a GFR below 30
ml/min/1.73m2 metformin is contraindicated. So too are GLP-1-Receptor agonists,
SGLT2-inhibitors and Sulphonureas (Daikeler 2016).
DPP-4 inhibitors can be used as a monotherapy in patients with chronic kidney
disease who should not gain weight and are at risk of hypoglycaemia (Dungan
2017).
Normally these patients are started, for example, on Linagliptin 5mg once daily.
Linagliptin is not excreted by the kidney and does not need a dose adjustment for
renal function (Giorda;2014).
If after 3 months the treatment goal of HbA1C < 8% is still not achieved, a basal
insulin should be added. Insulin Glargine 300U/ml (Toujeo) is a relatively new
formulation of glargine Riddle et al. (2014) demonstrated less nocturnal
hypoglycaemia compared to glargine 100U/ml. We start an 80 kg patient on 16 U
daily with careful titration until the treatment goal is reached.
The combination of DDP-4 inhibitor and glargine has the advantage that weight gain
and risk of hypoglycaemia are minimal. At the same time postprandial and fasting
plasma glucose concentrations are reduced (Mathieu 2015; Gomez-Peralta 2018).

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