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Background  Despite conventional insulin treatment being considered an effective approach for glycemic regulation during renal dysfunction, there is still a major clinical need for better insulin therapy to stabilize fluctuations in glucose levels.  Aim  The aim of this study was to assess the impact of mealtime fast-acting insulin aspart therapy on glycemic variability as compared to regular human insulin therapy in advanced chronic kidney disease (CKD) patients with type 2 diabetes (T2D).  Methods  Data from eight patients were retrospectively collected after analyzing 57 patients' data between July 2019 and October 2019. All T2D patients with stage 4 CKD were switched to mealtime fast-acting insulin aspart on account of recurrent hypoglycemic events. The continuous glucose monitoring data of the first four days were analyzed to calculate the mean amplitude of glucose excursions (MAGE) as well as five other glycemic variability indices, namely, standard deviation, mean, continuous overall net glycemic action, average daily risk range, and J index.  Results  The primary endpoint of 24-h MAGE significantly decreased from 7.01 ± 2.59 to 4.19 ± 1.06 mg/dL (p = 0.012) when short-acting regular human insulin (RHI) therapy was replaced with mealtime fast-acting insulin aspart therapy. However, no significant change was observed in 24-h mean glucose levels and other indices of glucose variability. Significant reduction in 24-h and night-time hypoglycemic events was reported in patients after therapy switch during the four-day follow-up period.  Conclusions  The present study demonstrated an improvement in glycemic variability with the administration of fast-acting insulin aspart as compared to RHI, suggesting that modern bolus insulin replacement might prove to be a useful therapeutic strategy in type 2 diabetes patients with advanced CKD. Further clinical studies will be required to confirm the benefits of this therapeutic approach.  Relevance for patients  The safety and effectiveness of fast-acting insulin aspart in CKD patients have not yet been established. The clinical effectiveness and better safety profile of newer mealtime insulin therapy may prompt a reconsideration of its use in patients with an advanced stage of renal dysfunction, leading to better adherence and improved quality of life.

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Switch-over Study with Fast-acting Insulin Aspart Showing Lower Glycemic Variability in Type 2 Diabetics with Stage 4 Chronic Kidney Disease: A Case Series