Is there a role for intensive insulin therapy in patients with kidney disease?

There is increasing evidence for the benefit of intensive insulin therapy in maintaining near-normoglycemia in patients without diabetes with severe acute illness. Morbidity and mortality have both improved, with decreased episodes of sepsis, acute kidney injury, transfusion requirements, and post-intensive care complications. The metabolic mayhem of severe acute illness has many parallels with those induced by kidney failure itself, and patients with kidney failure are at increased risk from many of the complications potentially improved by insulin therapy. We reviewed the potential benefits of intensive insulin therapy and examined the published trials for data directly applicable to patients with kidney failure. There are no trials directly answering the question and no specific analysis of patients with kidney disease in published studies. We extracted pertinent data regarding patients with impaired renal function from the reported trials, identified parallels between patients with kidney injury and other severe illnesses, and suggest possible future studies. We hypothesize that intensive insulin therapy has a role outside the intensive care setting and, in particular, a role for patients with severe acute illness and kidney failure, whether acute or chronic.