Insulin Requirements the Day After Hemodialysis
No, insulin requirements are LOWER the day after hemodialysis, not higher. Specifically, basal insulin needs decrease by approximately 25% the day following dialysis compared to the day before, with an overall reduction in total daily insulin requirements of approximately 15% post-hemodialysis. 1, 2
Physiologic Mechanisms Explaining Reduced Insulin Needs Post-HD
The reduction in insulin requirements after hemodialysis occurs through several interconnected mechanisms:
Decreased insulin clearance: The damaged kidneys in ESKD patients normally clear 30-80% of insulin, and this impairment persists post-dialysis, leading to prolonged insulin action 3, 1
Reduced gluconeogenesis: Hemodialysis further impairs the kidney's ability to produce glucose, which normally accounts for 20-25% of blood glucose during fasting states 3
Insulin removal during dialysis: Plasma insulin levels decrease significantly as blood passes through the dialyzer, with both glucose and insulin concentrations dropping during the HD session itself 4, 5
Improved insulin sensitivity: Post-dialysis removal of uremic toxins temporarily reduces insulin resistance, though this effect is modest 3
Specific Dosing Recommendations for Post-HD Days
Reduce basal insulin by 25% on the day following hemodialysis to prevent hypoglycemia, as recommended by the Endocrine Society. 1, 6
For context on overall insulin needs in dialysis patients:
- Type 1 diabetes patients: Reduce total daily insulin dose by 35-40% compared to pre-ESKD requirements 1
- Type 2 diabetes patients: Reduce total daily insulin dose by approximately 50% compared to pre-ESKD requirements 1
The basal insulin reduction is more pronounced than bolus insulin changes—the research demonstrates a statistically significant 25% decrease in basal requirements post-HD, while bolus insulin changes are minimal and not statistically significant. 2
Timing of Hypoglycemia Risk
The highest risk period for hypoglycemia is actually the 24 hours BEFORE hemodialysis, not after. A majority (61%) of all hypoglycemic episodes occur in the 24 hours prior to an HD session, though vigilance is required throughout the dialysis cycle. 7
During the actual hemodialysis session:
- Glucose levels drop progressively, reaching their lowest point at the end of dialysis 1
- This is followed by a glycemic peak approximately 2.5 hours after dialysis ends 1
- Post-dialysis hyperglycemia is common due to relative insulin deficiency after insulin removal during HD 5
Critical Monitoring Considerations
Implement continuous glucose monitoring (CGM) rather than relying on point-of-care testing alone, as traditional monitoring misses most hypoglycemic episodes in dialysis patients. 1
Important monitoring caveats:
- HbA1c is unreliable in dialysis patients due to decreased red blood cell lifespan, anemia, and erythropoietin use—it typically underestimates mean glucose levels 3, 1, 6
- Use CGM metrics (mean glucose, GMI, time-in-range) as more accurate glycemic indicators 1
- Monitor blood glucose more frequently on dialysis days and the day after 1, 6
Practical Algorithm for Insulin Adjustment Around HD
Day before HD:
- Use standard insulin doses (or consider 25% reduction in basal if recurrent hypoglycemia) 1
- Monitor closely as this is the highest-risk period for hypoglycemia 7
Day of HD:
- Expect glucose to drop during dialysis session 1, 4
- Anticipate post-dialysis hyperglycemia 2-3 hours after session ends 1, 5
Day after HD:
- Reduce basal insulin by 25% 1, 6, 2
- Overall total daily insulin needs decrease by approximately 15% 2
- Bolus insulin typically requires minimal adjustment 2
Common Pitfalls to Avoid
Do not use aggressive glycemic targets (HbA1c <7%) in dialysis patients, as very low HbA1c levels are associated with increased mortality, creating a U-shaped mortality curve. Target HbA1c of 7-8% instead, or fasting glucose of 110-130 mg/dL. 1
Avoid relying on total daily insulin doses exceeding 0.23 units/kg/day in hospitalized hemodialysis patients, as nearly 65% of hypoglycemic episodes occur with doses >0.20 units/kg/day. 7
Do not assume insulin needs remain constant throughout the dialysis cycle—the 25% reduction in basal insulin the day after HD is physiologically driven and clinically significant. 2