Throwaway comment in a specialist visit or harbinger of bad news to come?

In My Humble Opinion
1

(Medical advice question)

Okay, background: kaylasmom was diagnosed with Type II diabetes in 1994. Except for during her 1995-1996 pregnancy, she has attempted to maintain her blood sugars using oral meds. Some have been more effective than others, and some have had side effects that required abandonment.

It may be relevant to note that she is blind from birth (not diabetes-related), and has been told that she is not a good candidate for an insulin pump on account of that. It may also be relevant to note that, in terms of being a compliant patient, her record could be characterized as “spotty.”

Anyways, down through the years, her HbA1c has been sometimes better, sometimes worse. Her latest one was one of the worse ones, and her PCP decided to insist that she get back to an endocrinologist, to see if there’s another oral medication she can try.

So (after blowing off and rescheduling her initial appointment in June), she went to see him two weeks ago. He had her immediate blood sugar tested (very high, in excess of 450 mg/dl), took a non-fasting blood draw for a test of some kind, and turned her over to his diabetic educator (NB: “his” diabetic educator is actually employed by Roche, according to her business card).

The diabetic educator put her on a regimen with a new meter, which allows you to tell it how many grams of carbohydrates your next meal will contain, and tells you how many units of fast-acting insulin you should take. If your blood sugar is low, it will also tell you how many grams of carbs to ingest right now. During the past two weeks, her blood sugars have been dramatically improving (compliance can be REALLY effective, right? ;)).

SO: Today, she went for a follow-up visit to the endocrinologist. The gist of his interaction with her was that he told her that the results of her blood test showed a reduced kidney function, which indicated that she was no longer a good candidate for oral meds. He also suggested that she ask the diabetic educator to evaluate her for fitting with an insulin pump.

Having had a few hours for this to sink in, kaylasmom is beginning to freak out that “reduced kidney function” means that she should be preparing herself emotionally for life as a dialysis patient. About which she has stated (and is currently stating) she would prefer to die.

Now, I recognize that we should have asked for more information at the time, but we didn’t (but we will. Just, it might be a while before we get the chance). The fact that he dropped the “kidney function” line without any numbers, but just as an indicator that she shouldn’t count on oral meds for glucose control, suggests to me that he does NOT see her as a candidate for dialysis (and she could have either of my kidneys for the asking – if we were a match), just not a good candidate for glucose control by oral meds. Am I wrong to have that impression?

Anyway, how does a kidney function result suggest anything about the efficacy of any non-kidney-disease-related medication? If he had mentioned a liver function result, I might be inclined to think differently about it.

Also, the doctor said that the initiation of an insulin pump doesn’t involve any surgical procedures, which is contrary to the impression we’ve always had about insulin pumps. Has insulin pump technology advanced to the stage there it can be used entirely non-invasively?

2

As a CKD (aka “Kidney Failure”) patient, all I can say is:
about every other sentence in Kidney Care has an asterisk - unless you are diabetic.

Hoping to get a “one size fits all” discussion about the dozen or so variables you are asking about is going to be impossible.

Get the results of the “Blood Tests” (they have names, and each is important) and start getting really good with google.
The main “Kidney Number” is eGFR, found in the Metabolic Panels. Note that the numbers vary between black and non-black.
google away

3

Thanks. I’ll call the endocrinologist’s office tomorrow and ask them to share the test results with us and her primary doctor.

4

Way too many variables here. I’ve also had Type II since the mid-90s, and am currently on two different types of insulin, three times a day. I also have “reduced kidney function,” but am a long, long way from dialysis. (There are five stages to kidney disease. I’ve been Stage 3 for about ten years; stage 5 is dialysis.) Ask the doctor about your wife’s blood pressure. That’s a very important correlation with kidney function. Controlling blood pressure is pretty much controlling kidney function. But the main thing is, of course, compliance. Good luck.

5

Kaylasdad, how I understand it (For my bonafides, I used to be a dialysis nurse - though I do disclose that was about 10 years ago) is that it is not that decreased renal function makes the oral meds less effective; but rather that several of the oral meds can worsen already dicey renal function.

6

Thanks very much for the responses thus far.

Can anyone furnish us with information about how insulin pumps are deployed? Is a surgical installation of the monitoring/control device necessary?

7

Absolutely not - there is no surgery involved with a pump. Not sure where you got that idea, but it’s absolutely untrue.

Insulin pumps simply use a small cannula that is inserted right under the skin using a special inserter, or, in some cases, automatically when you press a button. They typically only go in a few millimeters, and are generally painless.

Most pumps have some flexible plastic tubing that attach the cannula to the pump itself, which looks sort of like a pager, and is worn on your belt. The pump pumps a set amount of insulin every few minutes to cover basal insulin needs, and when you eat, you tell it how many carbs you ate, and it’ll give you the insulin to cover them.

The pump I personally use is a little different - the Omnipod doesn’t use tubing to connect with a pump. Instead, it’s a self-contained unit that sticks to your skin, and communicates wirelessly with a controller. Other than that, it delivers insulin per what I described above.

No surgery needed, very easy to use, and no more insulin shots!

Edit: if you want more info, feel free to ask. Also, there are dozens of videos on YouTube that show in great detail how all the various insulin pumps work. The most common brands nowadays are Omnipod, Minimed, T-Slim, and Animas. Google any of those and you’ll find tons of info.

8

Another thing - have you looked into continuous glucose monitoring devices, like the Dexcom? I know she’s blind, but the latest version interacts with a cell phone, and you could monitor it. Also, it has vibrate/audio alerts that would tell her if she was going too low or high.

I personally rely on my CGM as much as my pump. It gives you a LOT of insight about how various food & activity affect your blood sugar, and has helped immensely with a lot of people’s A1c numbers. Plus, peace of mind, especially with a pump, since it’ll tell you when you’re trending low or high before things get dangerous.

Once again, no surgery is needed, it’s just a cannula that goes under the skin and communicates wirelessly with a controller or phone. Super cool technology.

9

As a CDE and an RN, insulin pumps are attached using a temporary infusion set with a catheter that is inserted with a needle. An infusion set is good for about 3-5 days. (The technology on these is getting better). There is no surgery necessary. It’s a little like an IV you would get in a hospital, but it does not go into a vein. The most common site to have the pump is the tissue on the stomach.

There are many different pumps with different capabilities available. The first factor to consider is what will the insurance company pay for? There is an approval process for pumps, which includes special labwork to determine if the patient is making any of their own insulin - if their pancreas is still functioning. It’s called a C Peptide test, and it can tell the difference between insulin someone injects, and the insulin made by the human body. The approval criteria include other factors, too. The doctor’s office will have more information on this.

There is information on the net about insulin pumps and what’s involved with them. A good place to start is The American Diabetes Association’s website. Look on THIS PAGE for information about insulin and links to their sections on pumps (over on the right of the page). It’ll tell you a lot of the basics!

I doubt - though it’s very hard to say without knowing all the ins and outs - that your relative is facing dialysis any time soon. As noted by other posters, there are stages to kidney disease. The thing is, catching it early and getting the problem under control with the best tools available, which are usually insulin and appropriate blood pressure medication. Doctors test their diabetic patients kidney function frequently to keep an eye on this. As also noted, some of the oral diabetes medications should not be taken by people who have developed kidney damage because they can damage the kidneys further.

I hope everything goes well, and please feel free to ask me if you have any questions!

10

Also - about the links to the ADA website I just posted? One of the reasons I love that website is almost every page on it has an audio version that you can sit and listen to. Just look over to the right side and click where it says ‘listen’. It will read the page to you. This way, your wife can have access to the information, too. I hope it’s helpful. They have lots of other info out there on the site that might be helpful for her.