No, Short-Acting Insulin is NOT Given to Increase Blood Glucose During Hemodialysis
Short-acting insulin like Humalog (insulin lispro) is never administered to increase capillary blood glucose levels during hemodialysis—insulin lowers glucose, not raises it. This appears to be a fundamental misunderstanding of insulin's mechanism of action. 1, 2
Understanding the Actual Problem: Hypoglycemia During Hemodialysis
Why Hypoglycemia Occurs During Dialysis
Hemodialysis patients face multiple mechanisms that drive blood glucose down, not up:
- Decreased kidney gluconeogenesis eliminates 20-40% of normal glucose production, which can increase two- to threefold during fasting 3
- Impaired insulin clearance occurs because kidneys normally clear 30-80% of insulin, leading to prolonged insulin action in dialysis patients 4, 3
- Increased erythrocyte glucose uptake during hemodialysis creates an additional glucose sink that depletes plasma glucose 3
- Plasma insulin is actively removed by the dialyzer itself, but this removal is insufficient to prevent hypoglycemia given the other mechanisms 5
- Impaired counterregulatory hormone responses result in blunted hormonal responses to falling glucose 6, 3
The Correct Approach: Reduce Insulin, Don't Add More
For patients already on insulin therapy during hemodialysis, the evidence-based approach is to substantially reduce insulin doses, not increase them:
- Type 1 diabetes patients on dialysis should have their total daily insulin dose reduced by 35-40%, according to the American College of Endocrinology 4
- Type 2 diabetes patients on dialysis should have their total daily insulin dose reduced by approximately 50%, according to the American Diabetes Association 4
- On pre-hemodialysis days specifically, the Endocrine Society recommends reducing basal insulin dose by an additional 25% 4
What Actually Increases Blood Glucose During Hemodialysis
Dialysate Glucose Concentration
The primary intervention to prevent hypoglycemia and maintain adequate glucose levels during hemodialysis is adjusting the dialysate glucose concentration, not administering insulin:
- Dialysate glucose concentration is the main determinant of plasma glucose levels after hemodialysis, with glucose-free or low-glucose dialysate significantly increasing hypoglycemia risk 3
- Using dialysate with glucose (100 mg/dL) results in higher blood glucose levels (125 ± 25 mg/dL) compared to glucose-free dialysate (110 ± 26 mg/dL) 7
- In poorly-controlled diabetic patients, glucose-free dialysate results in significant evening hyperglycemia, while glucose-containing dialysate prevents both acute hypoglycemia and rebound hyperglycemia 5
Nutritional Support
- Providing carbohydrate-rich snacks during dialysis can help prevent hypoglycemia, particularly in patients with pre-dialysis glucose ≤100 mg/dL, reducing hypoglycemia recurrence from 46.5% to 15% in subsequent sessions 4, 8
Monitoring Strategy
Continuous glucose monitoring (CGM) is strongly recommended as the preferred method to detect asymptomatic hypoglycemia during and after dialysis sessions, as traditional point-of-care monitoring misses most episodes 6, 4, 8
Critical Pitfall to Avoid
Never administer insulin to "increase" blood glucose—this is pharmacologically impossible and dangerous. Insulin's mechanism of action is to facilitate cellular glucose uptake and lower blood glucose levels. 1, 2 If hypoglycemia occurs during dialysis, the appropriate interventions are oral glucose/carbohydrates for conscious patients or intravenous dextrose for severe cases—never additional insulin.