Endocrine Abstracts

Achieving optimal glycaemic management in children with diabetes and end stage renal disease (ESRD) on dialysis is challenging. Specific factors include dietary and fluid restrictions and variable insulin requirements owing to idiosyncratic glucose disposal during dialysis. We present a case where a hybrid closed loop system was trialled to enable tighter glycaemic management and improve quality of life. An 8-year-old female with microcephalic osteodysplastic primordial dwarfism, global developmental delay and chronic kidney disease presented to GOSH in 2021 with acute kidney injury. Peritoneal dialysis was complicated by episodes of acute pancreatitis with hyperglycaemia requiring insulin therapy. She was switched to haemodialysis (HD) and commenced on a flash glucose monitoring sensor (Libre 2). Over 2 months her HbA1c increased from 33 mmol/mol to 56 mmol/mol. GAD antibodies were positive. Glycaemic management was challenging with changing restrictions in the nature and volume of feeds, and variations in insulin requirements on HD vs non-HD days. Optimising long-acting insulin increased the risk of hypoglycaemia. Managing glucose excursions with rapid acting insulin for carbohydrate intake and corrections was a significant burden for the child and carer. Inaccuracies in the Libre 2 sensor prompted a move to continuous glucose monitoring (Dexcom G6). To make insulin delivery more effective, an off-licence trial of a hybrid closed loop (HCL) system (Tandem T-Slim pump) was initiated. This led to significant improvement in glycaemic management. Time in range increased from 40% - 83% with a reduction in average glucose from 10.4 mmol/l to 7.4 mmol/l and standard deviation from 5.3 mmol/l to 2.8 mmol/l. The family also reported substantial improvement in quality of life. Oral feeds were changed to improve palatability which provided higher fat and lower carbohydrate content. The delayed glucose spike likely caused by the higher fat load was tackled using the extended bolus feature. Pump settings were regularly reviewed and adjusted in line with glucose variability, noting variance in feed times on HD and non-HD days.

Conclusion: The use of a HCL system and dietary modifications in a child with diabetes and ESRD on dialysis led to significant improvement in glycaemic management and quality of life reported by her family.