What is the appropriate dosing of insulin in patients with End-Stage Renal Disease (ESRD) undergoing dialysis?

From the Guidelines

Insulin dosing for patients with End-Stage Renal Disease (ESRD) undergoing dialysis should be carefully adjusted to prevent hypoglycemia, with a typical reduction of 25-50% on dialysis days, and consideration of using intermediate-acting insulins like NPH rather than long-acting analogs. For hemodialysis patients, the greatest reduction is often needed for long-acting insulins like glargine or detemir 1. Patients on peritoneal dialysis may require a 25% overall reduction in insulin requirements due to glucose absorption from dialysate. Regular monitoring of blood glucose before, during, and after dialysis sessions is essential, with target glucose levels of 140-180 mg/dL during dialysis 1.

Some key considerations for insulin dosing in ESRD patients include:

• The use of rapid-acting insulins (lispro, aspart, glulisine) for meal coverage with minimal adjustment 1
• The potential need to lower the basal dose by 4 units per day or 10% of basal dose if A1C is below goal 1
• The importance of educating patients about recognizing hypoglycemia symptoms and carrying fast-acting carbohydrates during and after dialysis sessions 1

The most recent and highest quality study, published in 2020 in Endocrine Reviews, provides guidance on glycemic monitoring and management in advanced chronic kidney disease, including the importance of adjusting insulin doses in patients with ESRD undergoing dialysis 1. While other studies, such as those published in 2023 and 2025 in Diabetes Care, provide additional guidance on pharmacologic approaches to glycemic treatment, the 2020 study in Endocrine Reviews is the most relevant and highest quality study for informing insulin dosing decisions in ESRD patients undergoing dialysis 1.

From the Research

Insulin Dosing in ESRD Patients Undergoing Dialysis

• The appropriate dosing of insulin in patients with End-Stage Renal Disease (ESRD) undergoing dialysis is crucial to prevent hypoglycemia and hyperglycemia 2.
• A randomized crossover study found that a 25% decrease in daily insulin needed on the day after hemodialysis was associated with sustained glycemic efficacy and fewer hypoglycemic symptoms in type 2 diabetes patients with ESRD 2.
• The study suggests that adjusting insulin doses based on the patient's glucose levels and dialysis schedule can help improve glycemic control and reduce the risk of hypoglycemia 2.
• Another study highlights the importance of adequate glycemic monitoring and control in diabetic kidney disease management, noting that existing glycemic metrics have limitations in accuracy, convenience, and accessibility in ESRD patients 3.
• Noninsulin glucose-lowering agents can also be used safely in patients undergoing dialysis, but insulin therapy is often necessary to achieve adequate glycemic control 4.
• A review of the literature provides practical recommendations for managing diabetes in hemodialysis patients, including observations on the challenges of glycemic control in this population 5.

Key Considerations

• ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, making adequate glycemic monitoring and control essential 3.
• Insulin requirements may vary depending on the patient's glucose levels, dialysis schedule, and other factors, highlighting the need for individualized insulin dosing 2.
• The use of continuous glucose monitoring (CGM) can provide automated, less invasive glucose measurements and more comprehensive glycemic data, potentially improving metabolic outcomes and quality of life in ESRD patients with diabetes 3.