Dialysis-associated hyperglycemia: manifestations and treatment

Sun, Yijuan; Roumelioti, Maria‐Eleni; Ganta, Kavitha; Glew, Robert H.; Gibb, James; Vigil, Darlene; Do, Catherine; Servilla, Karen S.; Wagner, Brent; Owen, Jonathan; Rohrscheib, Mark; Dorin, Richard I.; Murata, Glen H.; Tzamaloukas, Antonios H.

doi:10.1007/s11255-019-02373-1

Cited by 13 publications

(8 citation statements)

References 97 publications

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“…The risk of hemodialysis-induced hypoglycemia is higher with the use of glucose-free dialysate solutions, but hypoglycemic episodes may also occur even with a standard glucose-containing dialysate of 5.5 mmol/L [ 37 ]. The removal of plasma insulin by the dialyzer and compensatory release of other hormones in response to hypoglycemia represent the main mechanisms involved in pathogenesis of inappropriate postprandial rise in blood glucose levels after the completion of hemodialysis, a phenomenon known as “hemodialysis-related hyperglycemia” [ 38 ]. Thus, administration of intradialytic meals could be a preventive measure against hemodialysis-induced hypoglycemia, normalizing also the glycemic profile over the entire hemodialysis treatment day.…”

Section: Malnutritionmentioning

confidence: 99%

Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

et al. 2020

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Historically, eating during the hemodialysis treatment has been associated with increased risk for adverse intradialytic symptoms and events, risks that have resulted in the implementation of restrictive in-center nutrition policies. Recent studies, however, have recorded a shift in clinical practice with a higher proportion of physicians following the view that administration of intradialytic meals and supplements represents a simple and effective approach to enhance caloric intake and improve nutritional status among patients on hemodialysis. This shift towards less restrictive in-center nutrition practices is mainly supported by evidence from observational studies associating intradialytic nutritional supplementation with improvements in protein-energy wasting, inflammatory state, and health-related quality of life. In sharp contrast, earlier and recent interventional studies have documented that feeding during the hemodialysis treatment provokes a rapid postprandial decline in blood pressure and raises the incidence of symptomatic intradialytic hypotension. Furthermore, other studies have shown that postprandial redistribution in intravascular volume and enhanced blood supply to the gastrointestinal circulation may interfere with the adequacy of the delivered hemodialysis. Those who defend the position that intradialytic nutritional support is beneficial do not dispute the physiology of postprandial hemodynamic response, but they argue against its clinical significance. In this article, we provide an overview of studies that explored the effect of eating during the hemodialysis treatment on intradialytic hemodynamic stability and adequacy of the delivered hemodialysis. We reason that these risks have important clinical implications that are not counteracted by anticipated benefits of this strategy on caloric intake and nutritional status.

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Section: Malnutritionmentioning

confidence: 99%

Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

et al. 2020

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“…The low reliability of HbA1c poses difficulties in the assessment of glycemic control among diabetic hemodialysis patients [ 4 , 7 ]. The measurement of GA is proposed as an alternative glycemic biomarker in this high-risk population [ 15 , 16 ].…”

Section: Discussionmentioning

confidence: 99%

“…Notably, the reliability of HbA1c is even lower among end-stage-kidney-disease (ESKD) patients on hemodialysis [ 3 ]. In these patients, certain conditions and pathophysiological processes, such as the formation of carbamylated hemoglobin within the context of uremia and metabolic acidosis, the presence of anemia and the use of erythropoietin-stimulating agents or intravenous iron supplements, have long been recognized as factors that limit the accuracy and precision of HbA1c [ 4 ]. Alternative glycemic biomarkers, such as glycated albumin (GA), have been proposed, but their adoption for use in daily clinical practice remains low, mainly due to the lack of solid evidence to demonstrate their superiority over HbA1c in assessing glycemic control and in prognosticating the long-term risk for diabetes-related complications and adverse clinical outcomes [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Assessment of Hyperglycemia, Hypoglycemia and Inter-Day Glucose Variability Using Continuous Glucose Monitoring among Diabetic Patients on Chronic Hemodialysis

Divani

Georgianos

Didangelos

et al. 2021

JCM

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Continuous glucose monitoring (CGM) facilitates the assessment of short-term glucose variability and identification of acute excursions of hyper- and hypo-glycemia. Among 37 diabetic hemodialysis patients who underwent 7-day CGM with the iPRO2 device (Medtronic Diabetes, Northridge, CA, USA), we explored the accuracy of glycated albumin (GA) and hemoglobin A1c (HbA1c) in assessing glycemic control, using CGM-derived metrics as the reference standard. In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) in diagnosing a time in the target glucose range of 70–180 mg/dL (TIR70–180) in <50% of readings was higher for GA (AUC: 0.878; 95% confidence interval (CI): 0.728–0.962) as compared to HbA1c (AUC: 0.682; 95% CI: 0.508–0.825) (p < 0.01). The accuracy of GA (AUC: 0.939; 95% CI: 0.808–0.991) in detecting a time above the target glucose range > 250 mg/dL (TAR>250) in >10% of readings did not differ from that of HbA1c (AUC: 0.854; 95% CI: 0.699–0.948) (p = 0.16). GA (AUC: 0.712; 95% CI: 0.539–0.848) and HbA1c (AUC: 0.740; 95% CI: 0.570–0.870) had a similarly lower efficiency in detecting a time below target glucose range < 70 mg/dL (TBR<70) in >1% of readings (p = 0.71). Although the mean glucose levels were similar, the coefficient of variation of glucose recordings (39.2 ± 17.3% vs. 32.0 ± 7.8%, p < 0.001) and TBR<70 (median (range): 5.6% (0, 25.8) vs. 2.8% (0, 17.9)) were higher during the dialysis-on than during the dialysis-off day. In conclusion, the present study shows that among diabetic hemodialysis patients, GA had higher accuracy than HbA1c in detecting a 7-day CGM-derived TIR70–180 < 50%. However, both biomarkers provided an imprecise reflection of acute excursions of hypoglycemia and inter-day glucose variability.

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“…Hyperglycemia in patients with advanced renal failure allows study of the theoretical predictions in a closed system because it can be treated with insulin infusion and with no or minimal changes in the external balance of sodium, potassium and water (45,46). One report analyzed 43 episodes of severe hyperglycemia ([Glu] > 33.3 mmol/L or 600 mg/dL), treated with insulin and no other interventions, in patients on chronic dialysis with no or minimal fluid intake and urine loss and no change in body weight during treatment (47).…”

Section: Closed System Of Hyperglycemia: Clinical Observationsmentioning

confidence: 99%

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

et al. 2020

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In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.

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Dialysis-associated hyperglycemia: manifestations and treatment

Cited by 13 publications

References 97 publications

Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

Assessment of Hyperglycemia, Hypoglycemia and Inter-Day Glucose Variability Using Continuous Glucose Monitoring among Diabetic Patients on Chronic Hemodialysis

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

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