At what capillary blood glucose (CBG) level and what dose of 50% dextrose solution (D50%) should be administered during hemodialysis (HD)?

D50 Administration During Hemodialysis for Hypoglycemia

For hypoglycemic patients during hemodialysis, administer 10-25 grams of 50% dextrose (20-50 mL of D50) intravenously when capillary blood glucose (CBG) falls below 70 mg/dL, with a strong preference for titrated dosing using 5-gram aliquots to avoid overcorrection. 1, 2

Blood Glucose Threshold for Treatment

• Treat when CBG drops below 70 mg/dL (3.9 mmol/L) during hemodialysis, as this represents the standard threshold for hypoglycemia requiring intervention 2, 3
• Patients with pre-dialysis glucose levels below 140 mg/dL are at particularly high risk for intradialytic hypoglycemia and warrant closer monitoring 4
• Hypoglycemia during hemodialysis is frequently asymptomatic, occurring in up to 21% of diabetic patients on dialysis even with glucose-containing dialysate (100-150 mg/dL), making routine glucose monitoring essential 3

Dosing Strategy for D50

Initial Dose

• Administer 10-25 grams of dextrose as 50% solution (20-50 mL of D50) for insulin-induced or dialysis-related hypoglycemia 1
• The FDA-approved dosing for hypoglycemia treatment is 10-25 grams of dextrose given as 20-50 mL of 50% dextrose solution 1

Preferred Titrated Approach

• Use 5-gram aliquots (10 mL of D50) administered over 1 minute, repeated every minute as needed rather than giving the full 25-gram dose at once 2, 5
• This titrated approach corrects blood glucose into target range in 98% of patients within 30 minutes while avoiding overcorrection 2
• Median time to recovery of consciousness (GCS 15) is approximately 6-8 minutes regardless of concentration used 6, 5
• Titrated dosing with 5-gram aliquots results in lower total dextrose administration (median 10 grams vs 25 grams) and more appropriate post-treatment glucose levels 5

Maximum Dose

• Do not exceed 25 grams total in the initial treatment phase 1, 5
• Repeated doses and supportive treatment may be required in severe or refractory cases 1

Administration Technique

• Administer slowly via intravenous push to minimize complications 1
• Rapid administration of concentrated D50 has been associated with cardiac arrest and hyperkalemia 2
• Obtain blood glucose measurement before treatment when possible, but do not delay treatment in emergencies awaiting laboratory results 1

Monitoring Requirements

• Recheck CBG 15 minutes after each dose and repeat treatment if glucose remains below 70 mg/dL 2
• Continue monitoring every 15 minutes until blood glucose stabilizes above 70 mg/dL 2
• For patients on insulin infusions during dialysis, monitor glucose every 1-2 hours until stable, then every 4 hours 2

Hemodialysis-Specific Considerations

Risk Factors for Intradialytic Hypoglycemia

• Pre-dialysis glucose <140 mg/dL significantly increases hypoglycemia risk 4
• Use of glucose-free or low-glucose dialysate (<100 mg/dL) 4, 7
• Patients on insulin or sulfonylureas 2
• Impaired gluconeogenesis and reduced insulin clearance in advanced CKD 2
• Increased erythrocyte glucose uptake during hemodialysis 2

Prevention Strategies

• Patients with pre-dialysis glucose ≤100 mg/dL should be dialyzed with dialysate containing at least 100 mg/dL glucose 7
• Despite glucose-containing dialysate (100-150 mg/dL), sensor glucose may still fall below the dialysate concentration in 50% of patients 3
• Ensure patients do not skip meals before or during dialysis 7

Common Pitfalls to Avoid

• Avoid administering the full 25-gram dose as a single bolus, as this leads to excessive post-treatment hyperglycemia (median 169 mg/dL vs 112 mg/dL with titrated dosing) 2
• Do not rely on symptoms alone to detect hypoglycemia during hemodialysis—all hypoglycemic episodes may be asymptomatic due to blunted counterregulatory responses 7, 3
• Do not use point-of-care capillary glucose measurements without caution in dialysis patients; arterial blood glucose is preferred if arterial access is available 2
• Avoid using hypotonic solutions like D5W for volume replacement during dialysis, as these can worsen cerebral edema 2

Alternative Considerations

• While 10% dextrose in 5-gram aliquots (50 mL doses) is equally effective and results in lower post-treatment glucose levels, D50 remains the standard in most clinical settings due to smaller volume requirements 6, 5
• Glucagon is not recommended for dialysis patients due to delayed response (140 minutes to peak effect) and unpredictable efficacy in the setting of depleted glycogen stores 2