I am 32 with T1D and CKD. How can I manage the insulin dose?

Question

Hello doctor,

I am a 32-year-old male living with type 1 diabetes since I was 12. Over the past year, my blood sugar control has been difficult despite using a continuous glucose monitor (CGM) and an insulin pump. My HbA1c is currently 8.6%, and I have been experiencing more frequent hypoglycemic episodes, especially at night.

Recently, my nephrologist diagnosed me with stage 3 chronic kidney disease, my eGFR is down to 42 mL/min/1.73 m², and my creatinine is 1.8 mg/dL. I also have persistent proteinuria, with a urine albumin-to-creatinine ratio of 720 mg/g. I am worried about the long-term implications of having both these conditions, especially since I have been noticing swelling in my legs and more fatigue than usual.

I am on Lisinopril for kidney protection, but my potassium level was 5.5 mmol/L last week, so my doctor is considering stopping it. How should I manage my insulin dosing now that my kidney function is declining? Are there safer alternatives to ACE inhibitors in diabetic kidney disease? Also, does CKD change how I should be monitoring my blood sugars or adjusting my diet?

I am really concerned about needing dialysis in the next few years. What can I do to slow this progression?

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

You are dealing with a challenging combination of type 1 diabetes and stage 3 chronic kidney disease (CKD), and your concerns about the future are completely valid.

As kidney function declines, insulin is cleared more slowly because the kidneys normally break down a significant portion of circulating insulin. This means your current doses may last longer and act more strongly, especially overnight, increasing the risk of hypoglycemia. Stage 3 CKD (eGFR ~42) is often when insulin requirements begin to drop.

Work with your endocrinologist to gradually reduce basal insulin (pump basal rate or long-acting dose), often by 10 to 20 percent initially, though this must be individualized. Pay close attention to overnight trends on your CGM (continuous glucose monitoring), as low blood sugars during sleep can be particularly dangerous.

Lisinopril is kidney-protective because it reduces intraglomerular pressure and proteinuria. However, hyperkalemia is a common side effect in CKD. Before stopping it completely, your doctor may consider lowering the dose or adding a potassium binder. Dietary potassium restriction (limiting high-potassium foods such as bananas, oranges, potatoes, tomatoes, and dried fruits) may also help.

If Lisinopril must be discontinued, an ARB (angiotensin receptor blocker) such as Losartan can be considered, as it offers similar benefits with similar potassium-related risks, so potassium will still need to be monitored.

SGLT2 (sodium-glucose co-transporter 2) inhibitors such as Empagliflozin or Dapagliflozin now have evidence for slowing kidney decline even in type 1 diabetes, though they are off-label for this use and carry a risk of ketoacidosis. If considered, they should be used only under careful specialist supervision.

To avoid hypoglycemia, set your low alarm a bit higher to catch drops early.

More frequent post-meal checks are helpful because digestion and insulin clearance can be slower. Aim for A1C (glycated hemoglobin) around seven percent or slightly higher if hypoglycemia is frequent.

Diet adjustments for stage 3 CKD diabetes:

Your diet now has to balance blood sugar control, kidney protection, and potassium management.

Protein: 0.8 grams per day is enough to maintain muscle, but avoid excess (high protein can accelerate CKD).
Salt: Strictly limit to less than two grams of sodium per day to help control blood pressure and swelling.
Carbohydrates: Prefer low carbohydrates to reduce glucose spikes.
Fluids: No restriction yet unless advised, but avoid overhydration.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.