Three days later, she returns to the doctor's office for a review of her blood-glucose readings and a measurement of her fasting blood-glucose level, which is found to be 95 mg/dl. Most of her glucose readings during the day have been in the low- to mid-100 range. Her glucose levels before supper, however, are in the upper 200s.

How might you adjust Cindy's insulin-dosing schedule to bring her pre-supper glucose levels down?

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3. Cindy returns to her pediatrician three months later for a re-check, and is found to have a glycosylated hemoglobin level (Hb A1C) of 9.5%.

A. What is glycolsylated hemoglobin? What is the normal range for glycosylated hemoglobin?

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B. What does Cindy's Hb A1C level indicate that a one-time direct measurement of blood glucose doesn't indicate?

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4. The years progress, and Cindy has considerable difficulty controlling her diabetes. She has been told that she has "brittle" diabetes, a form of the disease marked by wide swings in blood-glucose levels despite the best efforts at control. Cindy is advised by her physician that she is at risk for developing certain complications of diabetes.

A. What are the possible long-term complications of her disease?

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B. Cindy is advised that she must take very good care of her feet, never walking barefoot. Why is this important?

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5. In her mid-forties, Cindy began to show early signs of diabetic nephropathy (kidney disease), consisting of persistent proteinuria, hypertension, and gradually decreasing renal function as measured by chemical tests. She nonetheless felt fairly healthy over the next 10 years. At age 55, however, she has noticed becoming increasingly fatigued upon mild physical exertion and requiring more sleep than previously. In addition, she has generally felt nauseated most of the time, and in the past two weeks, has vomited on several occasions. She has increased swelling in her ankles, and is short of breath. She has also become less responsive over the past day or so. Laboratory tests reveal that her kidney disease is now progressing at a much faster rate:

BUN (blood urea nitrogen) = 56 mg / dl (normal = 10 - 20 mg / dl)
Urinary output = 25 cc / hour (normal = 50-60 cc / hour)

Cindy is advised by her physician that her kidneys are failing. She is informed about treatment options: hemodialysis vs. continuous ambulatory peritoneal dialysis (CAPD) vs. kidney transplant. In consultation with her physician, Cindy chooses to undergo hemodialysis. A checkup two weeks after beginning dialysis reveals the BUN has decreased to 35 mg / dl.

Although hemodialysis is fairly effective, it is not fool-proof. For example, patients with chronic renal failure, despite a regular schedule of hemodialysis, will experience disruptions in calcium and phosphate balance.

A. Failing kidneys have a harder time excreting phosphate, and thus blood-phosphate levels tend to rise. What effect will rising blood-phosphate levels have on blood calcium levels?

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B. What danger is presented to soft tissues when blood-phosphate levels are too high?

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C. How might the endocrine system compensate for the change in blood calcium levels?

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D. What effect will the compensatory mechanism have on the skeletal system (i.e. the bones)? What is "renal osteodystrophy" (which, in children with chronic renal failure, is sometimes called "renal rickets")?

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