Can peritoneal dialysis cause hyperglycemia?

Does Peritoneal Dialysis Cause Elevated Glucose?

Yes, peritoneal dialysis directly causes hyperglycemia through systemic absorption of glucose from the dialysate solution, with glucose levels rising within 1 hour of exchange and the magnitude of elevation depending on the dialysate glucose concentration used. 1

Mechanism of Hyperglycemia

• Glucose-containing peritoneal dialysate is absorbed systemically across the peritoneal membrane, leading to measurable increases in blood glucose levels 1
• Within 1 hour of exchange using glucose-containing dialysate, blood glucose levels increase, with similar glycemic excursions for 1.25% and 2.25% glucose solutions, but more prominent increments with 3.86% glucose solutions 1
• The glucose concentration of the dialysate, dwell time, and peritoneal membrane transport status all directly impact the glycemic profile 1
• Patients absorb an average of 65.7 g of glucose daily from dialysate (ranging from 19.5 to 131 g), which accounts for 13.8% of total daily energy intake 2

Clinical Significance and Prevalence

• Among non-diabetic patients starting peritoneal dialysis, 8.3% develop fasting plasma glucose >200 mg/dL (>11.1 mmol/L) and 19.0% develop glucose levels between 126-200 mg/dL (7.0-11.1 mmol/L) within the first month 3
• Patients with high peritoneal membrane transport capacity have the highest risk of hyperglycemia (50.1% morbidity) compared to low transport patients (5.4% morbidity) over 48 months of follow-up 4
• Continuous use of hypertonic (4.25%) dextrose dialysate can cause severe hyperglycemic crises with profound hypertonicity and neurological manifestations, particularly in anuric patients with volume overload 5

Risk Factors for Peritoneal Dialysis-Induced Hyperglycemia

• Fasting blood glucose levels correlate positively with glucose load from dialysate and baseline C-reactive protein levels 4
• Patient age, Charlson comorbidity score, and baseline inflammatory markers (CRP) predict hyperglycemia development 4, 3
• Contrary to common assumptions, obesity (body weight, BMI) does not increase the risk of peritoneal dialysis-induced hyperglycemia 3

Monitoring Considerations

• Continuous glucose monitoring (CGM) can detect asymptomatic glucose excursions related to hypertonic exchanges during peritoneal dialysis that would be missed by intermittent capillary testing 1
• Standard blood glucose meters using glucose dehydrogenase pyrroloquinoline quinone (GDH-PQQ) or glucose oxidase (GO) methods should not be used in peritoneal dialysis patients receiving icodextrin-based solutions, as these cause falsely elevated readings that have been associated with severe hypoglycemic events and death 1
• HbA1c underestimates mean glucose levels in dialysis patients; CGM metrics such as glucose management indicator (GMI) and time in range (TIR) provide more accurate glycemic assessment 1

Clinical Outcomes

• Even mild hyperglycemia with fasting plasma glucose >100 mg/dL (>5.6 mmol/L) is associated with worse survival in peritoneal dialysis patients 3
• At 36 months, actuarial survival rates decrease progressively with higher glucose levels: 93.7% for glucose <100 mg/dL versus 66.7% for glucose ≥200 mg/dL 3
• Better glycemic control improves survival in patients on peritoneal dialysis, even though kidney function preservation is no longer a concern 1

Management Approach

• Most patients with new-onset hyperglycemia can be managed with dietary restriction alone; only 7 of 21 patients with glucose >200 mg/dL required insulin therapy in one cohort 3
• Consider using lower glucose concentration dialysate solutions (1.25% or 2.25%) instead of 3.86% solutions when clinically feasible to minimize glucose absorption 1
• Icodextrin-based dialysate has no effect on or may reduce glucose levels compared to glucose-based solutions 1
• Partial replacement of d-glucose with alternative osmotic agents like d-allose may ameliorate both peritoneal injury and hyperglycemia without compromising dialysis efficiency 6