How to adjust insulin regimen for a type 1 diabetes patient with severe renal impairment starting dialysis?

Insulin Management for Type 1 Diabetes Patient Starting Dialysis with Severe Renal Impairment

For this 57-year-old male with type 1 diabetes (60 kg, creatinine 5.04, GFR 15) starting dialysis today with overnight blood glucose of 83 mg/dL on Lantus 6 units, the total daily insulin dose should be reduced by 35-40% from the current regimen to prevent hypoglycemia during and after dialysis.1

Current Assessment

• Patient is on Lantus 6 units with 1:18 carbohydrate ratio and insulin sensitivity factor (ISF) of 75
• Severe renal impairment (GFR 15 mL/min/1.73m²) requiring dialysis initiation
• Blood glucose overnight was 83 mg/dL, suggesting potential risk for hypoglycemia

Insulin Adjustment Recommendations

Basal Insulin Adjustment

• Reduce basal insulin (Lantus) by 35-40% from current dose of 6 units to approximately 3.6-3.9 units (rounded to 3.5-4 units) 1
• Consider further reducing basal insulin dose by 25% on pre-dialysis days to prevent hypoglycemia 2, 1
• The kidney normally clears 30-80% of insulin, so decreased kidney function leads to reduced insulin clearance and prolonged insulin action 1

Bolus Insulin Adjustment

• Adjust carbohydrate ratio from current 1:18 to approximately 1:25-30 (less insulin per carb) 2, 1
• Maintain or slightly increase insulin sensitivity factor from 75 to 85-90 to account for increased insulin sensitivity in ESRD 1

Monitoring Recommendations

• Monitor blood glucose more frequently on dialysis days and the day after 1
• Check blood glucose before, during (at hourly intervals), and after dialysis sessions 3
• Consider continuous glucose monitoring to detect asymptomatic and nocturnal hypoglycemia, which is common in dialysis patients 2, 1
• Be aware that HbA1c is less reliable in dialysis patients due to decreased red blood cell lifespan and anemia 1

Hypoglycemia Prevention During Dialysis

• Provide carbohydrate-rich snacks during dialysis sessions if blood glucose drops below 100 mg/dL 3
• Consider stopping parenteral nutrition 30-45 minutes before dialysis if applicable 4
• Be vigilant for signs of hypoglycemia, which may be more common and dangerous in dialysis patients 1

Pathophysiological Considerations

• Several mechanisms contribute to hypoglycemia risk in dialysis patients: 1
  • Decreased renal gluconeogenesis
  • Impaired insulin clearance and reduced insulin degradation
  • Increased erythrocyte glucose uptake during hemodialysis
  • Impaired counterregulatory hormone responses

Long-term Management

• Target more moderate fasting blood glucose levels (110-130 mg/dL) rather than aggressive targets 1
• Consider using a basal-plus approach rather than full basal-bolus insulin regimen to minimize hypoglycemia risk 1
• Some patients (15-30%) with ESRD may experience "burn-out diabetes," requiring minimal or no insulin therapy over time 1
• Reassess insulin requirements regularly as they may continue to change with ongoing dialysis treatment 5

Common Pitfalls and Caveats

• Avoid maintaining pre-dialysis insulin doses, which significantly increases hypoglycemia risk 3
• Do not rely solely on HbA1c for glycemic monitoring in dialysis patients 2
• Be aware that insulin requirements may fluctuate significantly based on dialysis schedule 1
• Recognize that hypoglycemia symptoms may be masked by uremic symptoms in patients with severe renal impairment 5