This is a real-world medical entrance exam question, please give the true answer based on the question and selection. Topic name: Kidney, Subject name: Medicine
What is the dose adjustment required for insulin in a patient who is diagnosed as stage IV CKD 
Select and explain. 
A. Increased insulin, B. Decreased insulin, C. No change, D. Add DPP-4 inhibitor
B: Decreased insulin
Answer: B: Decreased insulin 
Explanation: During the later phase of declining renal function, insulin requirements may fall as kidney is a site of insulin degradation. some glucose lowering agents(sulphonylureas and metformin) are contraindicated in advanced renal insufficiency Ref:Harrison 20th edition pg no 2878