Diabetes and Hemodialysis

Introduction

Patients on dialysis often require low or no antidiabetic medication. They are prone to develop hypoglycemia during dialysis. The dose of antidiabetic medications should be reduced to avoid complications.

However, other systemic complications of diabetes may continue even after a patient has reached ESRD. Glucose control and monitoring may retard or prevent other complications.

1. We recommend education of ESRD patients about diabetes management with an emphasis on how to recognize and treat hypoglycemia.

2. We recommend that all patients should have a baseline measurement of their blood sugar levels (fasting and postprandial) and glycated hemoglobin (HbA1c) at the time of initiation of dialysis therapy.

3. We recommend individualization of therapy for control of blood sugar.

4. We recommend the following targets: HbA1c ~7%, fasting blood sugar <140 mg%, and postprandial blood sugar <200 mg%.

5. We recommend the use of insulin for diabetes control over oral hypoglycemic agents (OHAs).

6. We recommend using a combination of long-acting insulin for basal requirements along with rapid acting insulin before meals two to three times daily.

7. We recommend the following starting insulin dosage:

   • a)
     Type 1 diabetes: 0.5 IU/kg
   • b)
     Type 2 diabetes: 0.25 IU/kg

8. Further adjustments to the regimen should be individualized based on the self-monitored blood glucose testing. Table 1 lists the adjustments required in Insulin dosages according to renal function.

9. The use of OHAs should be limited to repaglinide, glipizide, gliclazide, sitagliptin, saxagliptin, linagliptin, and teneligliptin with appropriate dose modifications for ESRD. Table 2 lists the adjustments required in oral antidiabetic drug dosages according to renal function.

10. We recommend that diabetic ESRD patients should follow a fixed schedule for dialysis as the blood sugars are affected by dialysis.

11. We suggest consulting an endocrinologist with expertise in managing diabetes in ESRD, in difficult-to-manage cases.

Table 1.

Insulin preparations

Insulin preparation	Onset of action	Peak action	Effective duration	Dose adjustment based on renal function
Rapid acting
Regular	30-60 min	2-3 h	8-10 h	Reduce dose by 25% when
Lispro (Humalog)	5-15 min	30-90 min	4-6 h	GFR is 10-50 ml/min and by 50%
Aspart (NovoLog)	5-15 min	30-90 min	4-6 h	When GFR <10 ml/min
Long- acting
NPH	2-4 h	4-10 h	12-18 h	Reduce dose by 25% when
Glargine (Lantus) Humalog)	2-4 h	None	20-24 h	GFR is 10-50 ml/min and by 50%
Detemir (Levemir)	3-4 h	3-14 h	6-23 (19.9) h	When GFR <10 ml/min
Premixed
70/30 human mix	30-60 min	3-12 h	12-18 h	Reduce dose by 25% when
70/30 aspart mix		30-90 min	12-18 h	10-50 ml/min and by 50%
75/25 Lispro mix	5-15 min	30-90 min	12-18 h	When GFR <10 ml/min

GFR: Glomerular filtration rate, NPH: Neutral protamin Hagedorn

Table 2.

Oral hypoglycemic agents

Drug class	Dosing change in renal failure
Sulphonylureas
Gliclazide	25 (mg)
Glipizide	No dose adjustment
DPP4 inhibitor
Sitagliptin	25 (mg) daily
Linagliptin	No dose adjustment
Thiazolidinediones
Pioglitazone	25-30 (mg) daily