Systematic literature review of insulin dose adjustments when initiating hemodialysis or peritoneal dialysis

Abstract

Chronically uncontrolled hyperglycemia is the leading cause of end stage kidney disease (ESKD) necessitating dialysis. During times of transition to hemodialysis (HD) or peritoneal dialysis (PD), considerations must be given to insulin dosing adjustments for persons with diabetes (PWD) in efforts to maintain glycemic control. However, the literature is sparse with few clear and direct practical clinical recommendations for therapeutic insulin dosing adjustments in PWD and ESKD. The objective of this systematic review was to identify and report the evidence and gaps in the literature for adjustments in therapeutic insulin recommendations when initiating HD or PD in patients with ESKD and diabetes mellitus. A literature search using PubMed, CENTRAL, MEDLINE, CINAHL, Google Scholar, and ClinicalTrials.gov revealed 242 results. After removing duplicates and articles not reaching pre-specified criteria, 29 relevant articles remained for further analysis. Following the exclusion of 18 articles after full-text review due to lack of relevance or inappropriate publication type, 11 articles remained and were included in the review. The most common recommendation regarding HD was to reduce the basal insulin dose up to 25% on HD days to prevent hypoglycemia, although a lack of consensus exists on the percent reduction. Little information was found relating to insulin management with continuous ambulatory PD or automated PD. During PD, insulin may be administered subcutaneously, IP, or with the dialysis fluid. Administration of insulin with dialysate may necessitate a dose increase of up to 30% due to a loss to tubing and dilution. Furthermore, the use of dextrose-based dialysate may require additional insulin to mitigate systemic impact of dextrose absorption on BG. Overall, a gap exists in the primary literature regarding recommendations for prophylactically adjusting insulin therapy when initiating HD or PD, or when switching between the two. More research is needed to clarify ideal alterations in insulin dosing, administration techniques, and product selections for PWD and ESKD undergoing dialysis.

The Fascinating Interplay between Growth Hormone, Insulin-Like Growth Factor-1, and Insulin

“…During times of transition to hemodialysis or peritoneal dialysis, consideration must be given to insulin dosing adjustments for subjects with T1DM in efforts to maintain glycemic control. In a recent review by Blaine et al [ 15 ], it was concluded that during peritoneal dialysis, insulin may be administered subcutaneously, intraperitoneally, or with the dialysis fluid. Administration of insulin with dialysate may necessitate a dose increase of up to 30% [ 15 ].…”

“…In a recent review by Blaine et al [ 15 ], it was concluded that during peritoneal dialysis, insulin may be administered subcutaneously, intraperitoneally, or with the dialysis fluid. Administration of insulin with dialysate may necessitate a dose increase of up to 30% [ 15 ]. Providing the liver with insulin in the dialysate will restore the GHR expression in the liver.…”

A Practical Approach to the Initiation, Titration and Intensification of Insulin Therapy in Adults with Diabetes in the Indian Context: Recommendations by Association of Clinical Endocrinologists Consensus Group

“…People on dialysis are at an increased risk considering glucose fluctuations. It may be required to lower the basal insulin dosage by up to 25% on days of hemodialysis (HD) to avoid hypoglycemia [90]. People undergoing HD are usually advised to avoid short-acting insulins during and immediately before HD [91].…”

“…During peritoneal dialysis (PD), insulin may be administered SC, or along with the dialysis fluid. If insulin is administered along with dialysate, an increase of up to 30% may be necessary to minimize the effects of dextrose absorption for the PD fluids and for the loss of tubing and dilution [90]. Hence, the lowest possible dialysate dextrose concentration should be used as a PD fluid as much as possible [92].…”

Complications of Peritoneal Dialysis Part II

“…88 However, insulin requirements are reduced in some patients because insulin resistance is ameliorated with PD initiation. 89,90 We note that continuous glucose measurement devices are presently not approved for dialysis patients. In addition, the use of icodextrin may interfere with certain incompatible glucose measurement or continuous glucose monitoring devices where the metabolites will be misread as glucose.…”