Management of Type 2 Diabetes in Patients Undergoing Dialysis
For patients with type 2 diabetes undergoing dialysis, insulin therapy is the preferred treatment approach due to decreased renal clearance of insulin and contraindications for many oral agents.1
Glycemic Monitoring and Targets
- HbA1c measurements have low reliability in dialysis patients due to anemia, decreased red blood cell lifespan, and uremic toxins 2
- Continuous glucose monitoring (CGM) or frequent self-monitoring of blood glucose (SMBG) is recommended as the preferred method for glycemic assessment in dialysis patients 2
- A glucose management indicator (GMI) derived from CGM data can be used when HbA1c is not concordant with directly measured blood glucose levels 2
- Glycemic targets should be less stringent for dialysis patients, with HbA1c targets of 7-8% being appropriate to reduce hypoglycemia risk 2
Medication Management
Insulin Therapy
- Standard starting insulin dose should be reduced to 0.5 units/kg/day due to decreased renal clearance 1
- Divide total daily insulin dose as 50% basal and 50% bolus (rapid-acting) insulin 1
- Analog insulins are preferred over human insulin as they are associated with:
Oral Antidiabetic Agents
- Metformin is contraindicated in patients on dialysis 2
- SGLT2 inhibitors should be discontinued in patients on dialysis 2
- DPP-4 inhibitors (particularly sitagliptin 25mg daily) can be used safely in dialysis patients 4
- GLP-1 receptor agonists may be considered in select patients on dialysis, particularly for those with atherosclerotic cardiovascular disease 2
Nutritional Management
- Patients on hemodialysis should consume 1.0-1.2 g protein/kg/day 2
- Patients on peritoneal dialysis should consume slightly higher protein intake (1.2-1.3 g/kg/day) due to protein losses in dialysate 2
- Sodium intake should be limited to <2 g per day 2, 5
- Diet should be high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages 2
Physical Activity
- Patients should undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 2
- Patients should be advised to avoid sedentary behavior 2
- For patients at higher risk of falls, consider recommending low to moderate intensity exercises 2
Hypoglycemia Prevention and Management
- Hypoglycemia risk is increased in dialysis patients due to decreased insulin clearance, impaired gluconeogenesis, and malnutrition 2, 1
- Immediate treatment for hypoglycemia should include 15-20g of glucose for conscious patients 2
- For patients with cognitive impairment, administer 20-40 ml of 50% glucose solution intravenously or glucagon 0.5-1.0 mg intramuscularly 2
- Monitor blood glucose every 15 minutes after treatment until normalized 2
Special Considerations
- Peritoneal dialysis patients may experience glucose absorption from dialysate, making glycemic control more challenging 6
- Automated insulin delivery (AID) systems have shown promise in improving glycemic control in dialysis patients, with studies showing significantly higher time in range (69.0% vs 31.5%) compared to conventional insulin therapy 2
- Continuous glucose monitoring can be affected by uremic toxins in dialysis patients, which may interfere with sensor accuracy 2
Multidisciplinary Approach
- Involve registered dietitians, diabetes educators, and nephrologists in the care team 2
- Consider cultural differences, food intolerances, resource variations, and comorbidities when developing treatment plans 2
- Regular monitoring for cardiovascular complications is essential as dialysis patients with diabetes have high cardiovascular risk 2, 7
By following these guidelines, clinicians can optimize the management of type 2 diabetes in patients undergoing dialysis, with the goal of reducing complications and improving quality of life.