What is the recommended insulin sliding‑scale regimen, including basal insulin dosing, for an adult with end‑stage renal disease on chronic dialysis (CKD 5‑D) who requires insulin?

Insulin Sliding‑Scale Regimen for Adults with End‑Stage Renal Disease on Chronic Dialysis (CKD 5‑D)

Sliding‑scale insulin as monotherapy is explicitly condemned and should be immediately discontinued in favor of a scheduled basal‑bolus regimen with correction doses as an adjunct only.

Major diabetes guideline societies—including the American Diabetes Association—explicitly condemn sliding‑scale insulin (SSI) used as the sole regimen because it reacts to hyperglycemia after it occurs rather than preventing it, leading to dangerous glucose fluctuations and poor outcomes. 1 Only approximately 38 % of patients achieve mean glucose < 140 mg/dL with SSI alone, versus 68 % with a scheduled basal‑bolus approach. 1 In dialysis patients, SSI monotherapy is particularly hazardous because hypoglycemia during and after dialysis is extremely common (occurring in 46–52 % of ambulatory diabetic patients on maintenance hemodialysis) and is associated with increased mortality. 2

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Pathophysiology of Insulin Requirements in Dialysis

• Dialysis patients require substantially less insulin than those with earlier‑stage CKD because the kidney normally clears 30–80 % of insulin; reduced kidney function leads to decreased insulin clearance, prolonged insulin action, and decreased gluconeogenesis. 2
• Several mechanisms contribute to hypoglycemia risk: impaired insulin clearance and degradation, increased erythrocyte glucose uptake during hemodialysis, impaired counterregulatory hormone responses, and nutritional deprivation common in dialysis patients. 2
• 15–30 % of patients with end‑stage kidney disease may experience "burn‑out diabetes," requiring minimal or no insulin therapy. 2

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Specific Insulin Dose Adjustments for Dialysis Patients

Type 1 Diabetes on Dialysis

• Reduce total daily insulin dose by 35–40 % from pre‑dialysis requirements. 2
• On pre‑hemodialysis days, reduce basal insulin dose by an additional 25 % to prevent intradialytic hypoglycemia. 2

Type 2 Diabetes on Dialysis

• Reduce total daily insulin dose by approximately 50 % from pre‑dialysis requirements. 2
• For patients already on higher insulin doses (≥ 0.6 units/kg/day), reduce the total daily dose by 20 % when hospitalized. 2

Insulin‑Naïve Dialysis Patients

• For insulin‑naïve dialysis patients or those on low doses, start with 0.3–0.5 units/kg/day total daily dose, split 50 % basal and 50 % prandial. 2

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Recommended Insulin Regimen Structure

Basal‑Plus‑Correction Approach (Preferred for Dialysis Patients)

• Use a basal‑plus approach rather than full basal‑bolus regimens to minimize hypoglycemia risk in dialysis patients. 2
• Administer long‑acting basal insulin once daily (e.g., insulin glargine, detemir, or degludec) to suppress hepatic glucose production. 1
• Add correction doses only when pre‑meal glucose exceeds predefined thresholds, using rapid‑acting insulin (lispro, aspart, or glulisine). 1

Correction Insulin Protocol (Adjunct to Basal Insulin)

• Add 2 units of rapid‑acting insulin for pre‑meal glucose > 250 mg/dL. 1
• Add 4 units for pre‑meal glucose > 350 mg/dL. 1
• Correction doses must supplement—not replace—scheduled basal insulin. 1

Full Basal‑Bolus Regimen (If Needed for Severe Hyperglycemia)

• If basal‑plus approach is insufficient, initiate scheduled prandial insulin at 4 units before each of the three largest meals (or ≈ 10 % of the current basal dose). 1
• Administer prandial insulin 0–15 minutes before meals for optimal post‑prandial control. 1
• Never use rapid‑acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 1

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Basal Insulin Titration Protocol

• Increase basal insulin by 2 units every 3 days if fasting glucose is 140–179 mg/dL. 1
• Increase basal insulin by 4 units every 3 days if fasting glucose is ≥ 180 mg/dL. 1
• Target fasting glucose: 110–130 mg/dL (more moderate than the standard 80–130 mg/dL target) to reduce hypoglycemia risk in dialysis patients. 2
• If any unexplained hypoglycemia (< 70 mg/dL) occurs, reduce the implicated insulin dose by 10–20 % immediately. 1

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Prandial Insulin Titration (If Full Basal‑Bolus Regimen Is Used)

• Adjust each meal dose by 1–2 units (≈ 10–15 %) every 3 days based on 2‑hour post‑prandial glucose. 1
• Target post‑prandial glucose: < 180 mg/dL. 1
• Stop basal insulin escalation when the dose approaches 0.5–1.0 units/kg/day without achieving targets; add or intensify prandial insulin instead to prevent "over‑basalization." 1

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Glycemic Targets for Dialysis Patients

• Target fasting glucose: 110–130 mg/dL rather than aggressive targets (< 100 mg/dL), as very low HbA1c levels are associated with increased mortality in hemodialysis patients, creating a U‑shaped mortality curve. 2
• Target HbA1c: 7–8 % in dialysis patients with high comorbidity burden or hypoglycemia risk, rather than the standard < 7 % target. 2
• HbA1c is less reliable in dialysis patients due to decreased red blood cell lifespan, anemia, and erythropoietin use; it underestimates mean glucose levels and correlates poorly with actual glycemic control. 2

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Glucose Monitoring Strategy

Continuous Glucose Monitoring (Preferred)

• Implement continuous glucose monitoring (CGM) as the primary method to detect asymptomatic and nocturnal hypoglycemia during and after dialysis sessions, as traditional monitoring misses most episodes. 2
• Base therapeutic decisions on CGM‑derived metrics (mean glucose, glucose management indicator, time‑in‑range) rather than HbA1c. 2

Point‑of‑Care Glucose Monitoring

• Use glucose meters with HK, GDH‑NAD, or GDH‑FAD methodology instead of GDH‑PQQ or glucose oxidase (GO) methodology in dialysis patients, as they produce falsely elevated readings with peritoneal dialysis solutions containing icodextrin. 2
• Low hematocrit (< 35 %) may result in falsely high glucose readings with GO‑based meters. 2

Monitoring Frequency

• Monitor blood glucose more frequently on dialysis days and the day after to detect hypoglycemia. 2
• For patients eating regular meals, check glucose before each meal and at bedtime (minimum 4 times daily). 1
• For patients with poor oral intake or NPO, check glucose every 4–6 hours. 1

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Timing Considerations Around Dialysis

• Total daily insulin requirements may decrease by 15 % post‑dialysis, with a 25 % reduction in basal insulin needs the day after dialysis compared to the day before. 2
• Glucose levels drop progressively during hemodialysis, reaching their lowest point at the end of the dialysis session, followed by a glycemic peak approximately 2.5 hours after dialysis ends. 2
• On pre‑hemodialysis days, reduce basal insulin dose by 25 % to prevent intradialytic hypoglycemia. 2

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Hypoglycemia Management Protocol

Immediate Treatment

• Administer glucose immediately when blood glucose falls below 60 mg/dL (3.3 mmol/L), even if the patient is asymptomatic, because dialysis patients often experience silent but potentially life‑threatening hypoglycemia. 2
• Give oral glucose (15–20 g) as first‑line therapy in conscious patients who can safely swallow. 2
• Provide intravenous dextrose promptly to unconscious patients or those unable to swallow, then switch to oral glucose once consciousness is regained. 2

Post‑Treatment Management

• After the acute episode, reduce insulin doses by 35–50 % to lower the risk of recurrent hypoglycemia. 2
• Once the patient can swallow, offer oral carbohydrate snacks to replenish liver glycogen and help prevent recurrence, acknowledging the impaired gluconeogenesis in end‑stage renal disease. 2

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Critical Pitfalls to Avoid

• Never use sliding‑scale insulin as monotherapy in dialysis patients; it is condemned by all major diabetes guidelines and leads to dangerous glucose fluctuations. 1
• Never rely solely on HbA1c for glycemic management in dialysis patients, as it underestimates mean glucose levels and correlates poorly with actual glycemic control. 2
• Avoid aggressive glycemic targets (fasting glucose < 100 mg/dL or HbA1c < 6.5 %) that increase hypoglycemia risk without mortality benefit in this population. 2
• Never give rapid‑acting insulin at bedtime as a sole correction dose, as this markedly increases nocturnal hypoglycemia risk. 1
• Do not delay dose reduction when hypoglycemia occurs; studies show 75 % of hospitalized patients with hypoglycemia receive no basal insulin dose adjustment before the next dose. 1
• Hypoglycemia‑related hospitalizations before dialysis initiation strongly predict higher mortality after starting dialysis. 2

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Expected Clinical Outcomes

• With a properly implemented basal‑plus‑correction regimen (not SSI monotherapy), ≈ 68 % of patients achieve mean glucose < 140 mg/dL, compared with ≈ 38 % on sliding‑scale alone. 1
• Properly adjusted insulin regimens do not increase hypoglycemia incidence when titrated according to protocol, unlike inadequate or sliding‑scale regimens. 1
• In dialysis patients, hypoglycemia during dialysis is extremely common (46–52 %) and is associated with increased mortality, making prevention critical. 2