A 30-Year-Old Man Is Brought to the ER Because He

A 30-year-old man is brought to the ER because he lost his consciousness. An IV fluid, thiamin and dextrose are given to him. Vital sings and physical examinations are normal. He has a long-term type I diabetes and states that he has a recurrent hypoglycemic episode. He previously had difficulty controlling his high blood glucose levels, but over the past several weeks his blood glucose has intermittently dropped to <50 mg/dL with accompanying symptoms of tremulousness and headache. He has same diet and activity level as before. On further history, the patient has chronic kidney disease from diabetic nephropathy. His estimated glomerular filtration rate has declined to 20 mL/min in recent months, and he is under consideration for initiation of hemodialysis. Which of the following is most likely contributing to this patient's current glycemic disturbances?

A) Decreased hepatic glucose production
B) Decreased renal insulin clearance
C) Increased pancreatic insulin secretion
D) Increased renal glucose excretion
E) Increased tissue insulin sensitivity