Hypoglycemic and Hyperglycemic Crises Among U.S. Adults With Diabetes and End-stage Kidney Disease: Population-Based Study, 2013–2017

Abstract

OBJECTIVE We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD). RESEARCH DESIGN AND METHODS This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United States Renal Data System registry, between 2013 and 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 person-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen, and U.S. region. RESULTS Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 57–73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (≥75 vs. 18–44 years old: incidence rate ratio 0.35, 95% CI 0.33–0.37, and 0.03, 0.02–0.03), women (1.09, 1.06–1.12, and 1.44, 1.35–1.54), and those with smoking (1.36, 1.28–1.43, and 1.71, 1.53–1.91), substance abuse (1.27, 1.15–1.42, and 1.53, 1.23–1.9), retinopathy (1.10, 1.06–1.15, and 1.36, 1.26–1.47), and insulin therapy (vs. no therapy; 0.60, 0.59–0.63, and 0.44, 0.39–0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08–1.15) and amputation history (1.20, 1.13–1.27). CONCLUSIONS In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected.

Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults With Diabetes

“…We captured all glucose-lowering medications filled during each calendar year (eTable 2 in Supplement 1), the baseline count of diabetes complications ascertained using the Diabetes Complications Severity Index, and the baseline year individual deductible amount. These covariates were selected based on their clinical relevance and association with severe dysglycemia …”

“…These covariates were selected based on their clinical relevance and association with severe dysglycemia. 18,19,23 Outcomes ED visits and hospitalizations for severe hypoglycemia and hyperglycemia were identified using…”

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

“…Control of hyperglycemia may help reduce these complications. In a recent nationwide study, Galindo et al (24) demonstrated that severe hypoglycemic crises are common among patients with diabetes and kidney failure treated by hemodialysis, three-fold more frequent than hyperglycemic crises, and greatly exceeding prior reports in patients with CKD not on dialysis. Notably, insulin therapy was a strong risk factor for both hypoglycemic and hyperglycemic crises, and it was used in 64% of patients, indicating a need for better therapies in this population (24).…”

“…For years, insulin therapy was considered a safe therapy for patients with CKD, particularly in advanced CKD, because many older medications were contraindicated or had significant precautions. Consequently, the majority of patients with kidney failure on hemodialysis who require glucose-lowering drug therapy are treated with insulin, up to >60% in the United States (24). However, this study also associated insulin use with a higher risk of severe hypoglycemia.…”

“…However, this study also associated insulin use with a higher risk of severe hypoglycemia. Interestingly, insulin therapy was also associated with emergency department visits or hospitalizations for diabetic ketoacidosis or hyperosmolar state in a nationwide study in the United States (24), suggesting a high risk of complications if not maintaining full adherence. Although there is a need for prospective studies assessing safer interventions in patients receiving hemodialysis, clinicians should avoid overinsulinization, particularly using complex regimens, such as basal bolus with MDIs or mixed insulin.…”