Challenges in Treating Diabetes in Patients with Advanced CKD

A primary challenge was selecting an appropriate antihyperglycemic agent for a patient with advanced chronic kidney disease (CKD) and an eGFR of 26 mL/min/1.73 m². This severely limited therapeutic options, necessitating a careful review of guidelines and evidence to identify safe and effective medications for this stage of kidney disease.

Another significant challenge involved medication adherence. The patient's history of nonadherence and potential cognitive impairment (indicated by donepezil therapy) highlighted the importance of choosing a simple regimen to support consistent, long-term medication use, despite the selection of an evidence-based therapy.

The case required careful clinical judgment in balancing efficacy with safety. While insulin glargine effectively lowers blood glucose, initiating it in an older adult with advanced CKD carries a high risk of hypoglycemia due to reduced insulin clearance. A GLP-1 receptor agonist was deemed more appropriate due to its substantial A1C reduction, cardiovascular and renal benefits, and lower risk of hypoglycemia when used without insulin or sulfonylureas.

This case illustrated the complexity of integrating multiple patient-specific factors into clinical decision-making within a patient-centered approach. Reduced kidney function narrowed medication choices, requiring careful evaluation of evidence and guidelines. Simultaneously, the patient's age, cognitive status, and nonadherence history emphasized the need for a simplified, successful long-term treatment plan. The choice of a GLP-1 receptor agonist over insulin reflected the balance between glycemic efficacy, patient safety, minimized hypoglycemia risk, and additional organ protection.

This case reinforced the importance of individualized, evidence-based treatment planning. Optimal diabetes management extends beyond glycemic targets, requiring consideration of kidney function, comorbidities, medication safety, adherence barriers, and patient preferences. Clinicians must evaluate the entire clinical picture to develop effective and practical treatment plans, promoting improved outcomes, reducing adverse events, and supporting long-term management, especially in older adults with complex chronic conditions.