A 68 year old woman diagnosed with Type2 DM and BMI 33. Laboratory investigations: GFR 29, urea 13, creatinine 390mmol/L. what is the next appropriate management?

The key is C. insulin. [Insulin is devoid of significant side effect than Glitazones (like fluid retention).

In renal failure there is reduced GFR and some fluid retention. It is not desirable that glitazone to cause

more fluid retention by causing oedema. The oral agents that are thought to be relatively safe in

patients with nondialysis CKD include short-acting sulfonylureas (eg, glipizide) and repaglinide. If an oral

agent is used, the short-acting sulfonylurea, glipizide, is the preferred agent among nondialysis CKD

patients who have an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73. The dose for

glipizide is 2.5 to 10 mg/day. Glyburide and other long-acting sulfonylureas are generally not

recommended in any CKD patient with type 2 diabetes, because of the risk of hypoglycemia. Some

clinicians recommend the use of the meglitinide repaglinide (starting with a dose of 0.5 mg) for

nondialysis CKD patients since these agents are not renally cleared. Nondialysis CKD patients with type 2

diabetes may be treated with an oral agent, although many patients end up on insulin therapy because

it is more effective. So it may be that we can go for insulin as the answer!!].