Can hyperglycemia be caused by missed dialysis in a patient with diabetes type 2 (diabetes mellitus type 2) and end-stage renal disease (ESRD) who has missed dialysis for one week and now presents with elevated blood glucose levels and confusion?

Hyperglycemia from Missed Dialysis in Type 2 Diabetes with ESRD

Yes, missed dialysis can directly cause hyperglycemia in patients with type 2 diabetes and ESRD, and this is likely the primary cause of your patient's elevated blood glucose and confusion. 1, 2

Why Missed Dialysis Causes Hyperglycemia

When dialysis is missed for a week, several metabolic derangements occur that drive blood glucose upward:

• Accumulation of uremic toxins creates a persistent inflammatory state that worsens insulin resistance, directly elevating blood glucose levels 3, 4
• Metabolic acidosis from missed dialysis sessions impairs insulin action and glucose metabolism 4
• Volume overload and electrolyte disturbances from one week without dialysis trigger counterregulatory hormone release (cortisol, catecholamines) that raise blood glucose 3
• The stress response from uremia itself acts like an acute illness, releasing hormones that antagonize insulin and increase glucose production 3

The Paradox: Good Control Before vs. High Glucose Now

Your patient had good glycemic control while receiving regular dialysis, which makes sense because:

• Regular hemodialysis partially reverses the insulin resistance seen in advanced CKD 4
• Dialysis removes some uremic toxins that impair glucose metabolism 4
• However, missing dialysis for one week allows these protective effects to disappear, causing a rapid deterioration in glucose control 1, 2

Critical Clinical Considerations

The confusion is concerning and requires immediate attention:

• Confusion could represent hyperglycemic hyperosmolar state, uremic encephalopathy, or both 5
• Check serum osmolality, electrolytes, and blood urea nitrogen immediately 5
• This patient needs urgent dialysis to address both the hyperglycemia and the underlying uremic state 1, 2

Do not aggressively treat the hyperglycemia with insulin before dialysis:

• Once dialysis resumes, insulin requirements will drop dramatically (by approximately 50% in type 2 diabetes patients) 1, 2
• Aggressive insulin dosing now could lead to severe hypoglycemia during and after the first dialysis session 1, 2
• If you must give insulin before dialysis, reduce the usual dose by at least 25-50% 1, 2

Management Algorithm

Immediate actions:

1. Arrange urgent hemodialysis within hours, not days 1, 2
2. Check capillary glucose, serum osmolality, electrolytes, BUN, and creatinine 5
3. If glucose >400 mg/dL with osmolality >320 mOsm/kg, treat as hyperglycemic hyperosmolar state with cautious IV fluids 5
4. Hold or significantly reduce (by 50%) any scheduled insulin doses until after dialysis 1, 2

During the first dialysis session:

• Monitor glucose hourly during dialysis, as levels will drop progressively and reach their nadir at the end of the session 5, 1, 2
• Expect glucose to decline by 50-100 mg/dL during the 3-4 hour dialysis session 5, 2
• Have glucose tablets or D50 immediately available for hypoglycemia treatment 5, 1

After resuming regular dialysis:

• Reduce total daily insulin dose by approximately 50% from pre-ESRD requirements 1, 2
• On hemodialysis days specifically, reduce basal insulin by an additional 25% 1, 2
• Target fasting glucose of 110-130 mg/dL rather than aggressive control, as very low HbA1c creates a U-shaped mortality curve in hemodialysis patients 1, 2
• Implement continuous glucose monitoring if possible, as it detects the frequent asymptomatic hypoglycemia that occurs during and after dialysis 1, 2, 6

Common Pitfalls to Avoid

Do not rely on HbA1c for glycemic assessment in dialysis patients—it underestimates mean glucose due to anemia, erythropoietin use, and reduced red blood cell lifespan 5, 1, 2

Do not use glucose meters with GDH-PQQ or glucose oxidase methodology in dialysis patients, as they produce falsely elevated readings; use meters with HK, GDH-NAD, or GDH-FAD methodology instead 5, 1

Do not assume the patient needs more insulin long-term—once dialysis resumes regularly, insulin requirements typically decrease substantially, and 15-30% of ESRD patients experience "burnt-out diabetes" requiring minimal or no insulin 1, 7