Hemodialysis-Related Glycemic Disarray Proven by Continuous Glucose Monitoring: Glycemic Markers and Hypoglycemia

Abstract

<b>OBJECTIVE</b> <p>There is a high risk of asymptomatic hypoglycemia associated with hemodialysis (HD) using glucose-free dialysate; therefore, the inclusion of glucose in the dialysate is believed to prevent intradialytic hypoglycemia. However, the exact glycemic fluctuation profiles and frequency of asymptomatic hypoglycemia using dialysates containing >100 mg/dL glucose have not been determined.</p> <p><b>RESEARCH DESIGN AND METHODS</b></p> <p>We evaluated the glycemic profiles of 98 type 2 diabetes patients undergoing HD (68 men, HbA1c 6.4±1.2%, glycated albumin 20.8±6.8%) with a dialysate containing 100, 125, or 150 mg/dL glucose using continuous glucose monitoring.</p> <p><b>RESULTS</b></p> <p>Sensor glucose level (SGL) showed a sustained decrease during HD, irrespective of the dialysate glucose concentration, and reached a nadir that was lower than the dialysate glucose concentration in 49 participants (50%). Twenty-one participants (21%) presented with HD-related hypoglycemia, defined by an SGL <70 mg/dL during HD and/or between the end of HD and their next meal. All these hypoglycemic episodes were asymptomatic. Measures of glycemic variability calculated using the SGL data (standard deviation, coefficient of variation, and range of SGL) were higher and time below range (<70 mg/dL) was lower in participants who experienced HD-related hypoglycemia than in those who did not, whereas time in range between 70 and 180 mg/dL, time above range (>180 mg/dL), HbA1c and GA of the two groups were similar.</p> <p><b>CONCLUSIONS</b></p> <p>Despite the use of dialysate containing 100–150 mg/dL glucose, diabetic HD patients experienced HD-related hypoglycemia unawareness frequently. SGL may fall well below the dialysate glucose concentration toward the end of HD.<br> </p>

Peri‐dialytic hypoglycemia with hemodialysis and online post‐dilutional hemodiafiltration

“…As such, we cannot answer the key question of whether providing patients a sandwich whilst attending for dialysis reduced the risk of peri‐dialytic hypoglycemia or ending dialysis with a blood sugar below that of the dialysate, or conversely increased the risk of post‐prandial reactive hypoglycemia. However, a recent study from Japan reported around 50% of patients having a blood sugar below that of that of the dialysate during dialysis, when patients were not permitted to eat until after dialysis [33]. The sandwiches supplied to our patients were of relatively low carbohydrate and contained minimal amounts of refined simple carbohydrates.…”

Evaluation of the relationship between hemodialysis-related glycemic variability and hormonal profiles in patients with type 2 diabetes on hemodialysis: a pilot study

“…However, in clinical situation, plasma glucose levels fall below the dialysate glucose levels during and after HD session, and some patients complain of hypoglycemic symptoms. Our previous study in diabetic patients undergoing HD showed that about 20% of them presented with hypoglycemia after HD and all of them revealed asymptomatic [29,30]. The cause of this HD-related hypoglycemia has suggested abnormal response of insulin secretion and the reaction disorder of insulin-counter hormones such as glucagon, ACTH, and cortisol, but there was not sufficient evidence.…”

Continuous Glucose Monitoring to Optimize Management of Diabetes in Patients with Advanced CKD

“…The higher risk of hypoglycemia in CKD is attributed to several factors, including diminished kidney gluconeogenesis, impaired insulin clearance by the kidney, defective insulin degradation due to uremia, increased erythrocyte glucose uptake during hemodialysis, impaired counter-regulatory hormone responses, nutritional deprivation, variability of exposure to oral glucose-lowering agents and exogenous insulin, and effects of dialysis treatment (13,18,32). Moreover, because insulin secretion may be stimulated by glucose from the dialysate, patients who have maintained even moderate levels of b cell function have a higher risk of hypoglycemia with hemodialysis, particularly after experiencing large hyperglycemic excursions (33).…”