BLOOD-GLUCOSE CONTROL IN DIABETICS .3.

B.M. is a 58-year-old black female, who has had diabetes mellitus, Typ e I, for 25 years. She had been stabilized on insulin until 1980. Betw een 1980 and 1983, her physician noticed increased difficulty in contr olling her hypertension and a decreasing insulin requirement. In 1980, her serum creatinine was 2.5 mg/dl; by 1983, she had a serum creatini ne of 7.0 mg/dl. She was referred for treatment of renal failure. Thor ough evaluation showed only hypothyroidism, hypertension, and Type I d iabetic nephropathy. She chose treatment with CAPD. On CAPD she was in itially stabilized on a total of 70 units of a mixture of NPH and regu lar insulin given twice daily. She was switched to intraperitoneal reg ular insulin and eventually took as much as 425 units daily. For this reason, she was started on 25 units twice daily of human Ultralente (U L) insulin subcutaneously in combination with intraperitoneal regular insulin given on a sliding scale, determined by whole blood glucose va lues immediately preexchange. Her mean intraperitoneal insulin dose wa s 300 units daily. She did well until 1990 when her peritoneal solute clearance gradually declined. She was converted to hemodialysis and he r insulin regimen was changed to NPH and regular insulin therapy at 80 units daily. Since her conversion to hemodialysis she has developed b ilateral lower extremity ischemic ulcerations which have required a le ft above-knee amputation and multiple toe amputations on the right. Sh e had a steal syndrome from a left forearm access and lost two fingers on the left hand. She remains on split-mixed insulin therapy. Her tot al insulin dose has decreased to 20 units daily.