From the Research
For dialysis patients with hyperglycemia, a regimen of long-acting insulin (such as insulin glargine) once daily combined with rapid-acting insulin (like insulin lispro, aspart, or glulisine) before meals is typically recommended, as supported by the most recent study 1 which showed that insulin glargine improves glycemic control and quality of life in type 2 diabetic patients on hemodialysis. The starting dose should be conservative, often 0.3 units/kg/day total insulin, with approximately 50% as basal insulin and 50% as prandial insulin divided among meals. Some key points to consider when managing hyperglycemia in dialysis patients include:
- Insulin is preferred over oral agents because it's metabolized independently of kidney function and can be adjusted regardless of dialysis schedule, as noted in 2.
- Dosing should occur after dialysis on treatment days to prevent inadvertent removal of insulin during the procedure.
- Blood glucose monitoring is crucial before and after dialysis sessions, as glucose levels can fluctuate significantly.
- Insulin requirements often decrease in end-stage renal disease due to decreased insulin clearance and reduced renal gluconeogenesis.
- Hypoglycemia risk is elevated in these patients, so conservative initial dosing with frequent monitoring and gradual titration is essential, as discussed in 3 and 4.
- Target A1c goals may be slightly higher (7-8%) than in the general population to minimize hypoglycemia risk while still providing glycemic control, although the optimal target may vary depending on individual patient factors and the specific clinical context, as considered in 5.