Diabetes, Insulin and Hyperkalemia in Chronic Kidney Disease

Mrs. Bilodeau, 61, is admitted to the medical unit for community-acquired pneumonia. She has lived with type 2 diabetes for fifteen years and with chronic kidney disease. Her usual regimen includes NPH insulin morning and evening plus a rapid-acting analogue before meals. This morning the NPH was given at 07:30, but the breakfast tray arrived late and Mrs. Bilodeau, short of breath and without appetite, took only a few bites. Laboratory results drawn at 08:00 show a potassium of 6.2 mmol/L, a creatinine higher than her baseline and a reduced glomerular filtration rate. In the early afternoon the nurse finds her pale, clammy and trembling; she answers questions, but slowly, and remains able to swallow.