Management of Type 2 Diabetes in Patients on Dialysis

Pharmacological Considerations

Patients on dialysis have decreased insulin clearance and impaired gluconeogenesis, increasing the risk of hypoglycemia, and may experience "burn-out diabetes" phenomenon, requiring less medication, with 15-30% of ESKD patients affected 1
Altered drug metabolism and clearance in dialysis patients necessitate dose adjustments, according to the Kidney International guidelines 2, 3
Increased glycemic variability, particularly around dialysis sessions, is a concern in dialysis patients, as noted in Endocrine Reviews 1

The Kidney International guidelines recommend avoiding metformin in patients on dialysis due to the risk of lactic acidosis 2, 3, 4
SGLT2 inhibitors are not recommended for initiation in dialysis patients, but may be continued if started before dialysis for cardiovascular and kidney benefits, as per Kidney International 2, 3
Glyburide should be avoided in dialysis patients due to the higher risk of prolonged hypoglycemia, according to Kidney International 2

Insulin remains the mainstay treatment for dialysis patients with poor glycemic control, with dose requirements often decreasing by 40-50% compared to non-CKD patients, as noted in Endocrine Reviews and Kidney International 1, 3
GLP-1 receptor agonists, such as dulaglutide, can be used in severe CKD and dialysis patients with eGFR >15 ml/min/1.73m², and are considered for patients with cardiovascular disease, according to Kidney International 4, 5

Initial assessment should evaluate hypoglycemia risk, comorbidities, and glycemic targets, considering the "burn-out diabetes" phenomenon, as recommended by Kidney International 1, 3, 4
Medication selection should follow an algorithm, starting with DPP-4 inhibitors for mild-moderate hyperglycemia, adding or switching to insulin therapy for inadequate control, and considering GLP-1 receptor agonists for patients with high cardiovascular risk, as per Kidney International 3, 4, 5
Monitoring should include more frequent glucose monitoring, especially around dialysis sessions, watching for hypoglycemia, and adjusting medication doses based on clinical response, as noted in Endocrine Reviews and Kidney International 1, 3

The American College of Endocrinology recommends reducing the dose of Lantus (insulin glargine) by approximately 25% the day after dialysis to minimize the risk of hypoglycemia in patients with end-stage renal disease 6
Hemodialysis significantly affects glucose metabolism and insulin requirements in diabetic patients with end-stage renal disease, with a 25% reduction in basal insulin requirements needed the day after dialysis compared to the day before 6, 7
Overall, patients require approximately a 15% decrease in total daily insulin dose post-dialysis, with continuous glucose monitoring studies showing lower glucose levels during hemodialysis 6

The American Diabetes Association recommends monitoring blood glucose more frequently on dialysis days and the day after, and reducing Lantus dose by approximately 25% on the day following dialysis to minimize hypoglycemia risk 6, 7
The National Kidney Foundation advises being vigilant for signs and symptoms of hypoglycemia, which may be more common in dialysis patients, with a consideration for providing intradialytic carbohydrate-rich snacks to patients who experience hypoglycemia during dialysis 8

The American Journal of Kidney Diseases notes that HbA1c is less reliable in dialysis patients due to decreased red blood cell lifespan and anemia, and considers using alternative measures like glucose management indicator (GMI) from continuous glucose monitoring 7, 8
Tight glycemic control in dialysis patients must be balanced against the increased risk of hypoglycemia, with the American Journal of Kidney Diseases recommending careful consideration of insulin doses and glucose monitoring 8

The Endocrine Society recommends considering continuous glucose monitoring (CGM) to better understand individual glucose patterns around dialysis, with particular attention to nocturnal hypoglycemia risk 6, 7
Target fasting blood glucose levels of approximately 110-130 mg/dL rather than more aggressive targets that might increase hypoglycemia risk, as recommended by the American Journal of Kidney Diseases 8