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Background: Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States, accounting for 47% of individuals who began dialysis treatment in 2019. Managing glucose levels in persons with diabetes undergoing hemodialysis (HD) can be challenging due to altered glucose and insulin metabolism and uremia. This often leads to difficulties in establishing optimal insulin dosing regimens and concerns about hypoglycemia.
Purpose/Objective: Current recommendations for insulin dose adjustment for persons with diabetes undergoing HD are poorly established and vary across clinical settings. To address this issue, we conducted a systematic review to synthesize evidence from existing clinical studies, including randomized controlled trials (RCT)s and quasi-experimental studies that examined insulin adjustment for this population on HD days. The primary outcome was the percent of insulin dose decrease on HD days; other outcomes of interest were glycemic range and rates of hypoglycemia.
Following an a priori protocol published in Prospero and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched four databases: PubMed, Embase, CINAHL, and Web of Science. Studies were included if the population studied were people with diabetes requiring insulin for glycemic management receiving HD in inpatient and/or outpatient settings. Studies were excluded if individuals were on peritoneal dialysis, treated exclusively with oral or other injectable antihyperglycemic agents with chronic kidney disease stage 1-5, pre-dialysis, or hospitalized in critical care units. Two independent reviewers screened studies, performed data extraction, and assessed study quality using the Downs and Black Checklist.
Of 351 records, five studies (2 RCTs, 1 RCT post-hoc analysis, 2 quasi-experimental) were included (N=137). Three studies (n=87) utilized either automated insulin delivery (closed loop system) with continuous glucose monitoring (CGM) or an insulin intravenous drip, on which insulin dose was adjusted based on concurrent glucose values. Intervention participants achieved optimal glucose goal range for longer periods (52-69%) than controls (32-37%) with no significant hypoglycemia. Insulin requirement on HD days was 15.7% to 19.4% lower than non-HD days. Two studies employed a preset insulin dose reduction and/or carbohydrate snacks during HD. These interventions resulted in a decrease in hypoglycemia episodes by 79-85%. The mean glucose range during HD in these groups ranged from 127.9 to 154.2mg/dL.
Individualized insulin dosing, considering nutritional status, residual renal function, and dialysis schedule, is crucial for achieving optimal glycemic goals in persons with diabetes undergoing HD. CGM or frequent glucose checks, along with a decreased insulin dose by 15%-20%, appears to be effective in achieving these outcomes while minimizing hypoglycemia risk. These findings provide insight into potential strategies for optimizing glucose management in this population. Future research should focus on large-scale prospective studies to determine optimal insulin regimens and target glucose ranges for individuals with diabetes undergoing HD.
“This research was previously presented at the International Diabetes Federation Virtual Congress 2023, highlighting its relevance and contribution to the scientific community." I also declare that re-submitting the abstract is permitted by the organizers of the original meeting(s).