Day-to-Day Variation of Insulin Requirements of Patients With Type 2 Diabetes and End-Stage Renal Disease Undergoing Maintenance Hemodialysis

Abstract

OBJECTIVETo evaluate day-to-day variations of insulin needs in type 2 diabetic patients with end-stage renal disease (ESRD) on maintenance hemodialysis.RESEARCH DESIGN AND METHODSWe developed a 24-h euglycemic clamp in patients who received an average of 2,200 calories in a standardized three-meal and two-snack regimen per day, adjusted to body size and sex. Intravenous insulin was adjusted every 30 min to achieve 5.5 ± 1.1 mmol/l glycemia over 24 h prehemodialysis, during hemodialysis session, and 24 h posthemodialysis in 10 type 2 diabetic patients, aged 55.7 ± 8.7 years with 11.9 ± 4.5 years diabetes duration, undergoing maintenance hemodialysis for 2.3 ± 2.3 years. Insulin requirements were derived from the dose of insulin administered to maintain euglycemia per period of time and day-to-day comparisons performed.RESULTSMean capillary glycemia was 5.5 ± 0.3 mmol/l prehemodialysis and 5.3 ± 0.2 mmol/l posthemodialysis (P = 0.39). Pre- and posthemodialysis areas under the glucose curve were comparable. This was achieved by infusing 23.6 ± 7.7 IU/24 h prehemodialysis vs. 19.9 ± 4.9 IU/24 h posthemodialysis, indicating a 15.3% decrease posthemodialysis (P = 0.09). Basal insulin needs decreased from 0.4 ± 0.1/h prehemodialysis to 0.3 ± 0.1/h posthemodialysis (P = 0.01). Total boluses were decreased by 2.2 ± 3.1 IU (P = 0.15). Changes in blood urea did not correlate with changes in insulin needs (r = 0.1, P = 0.79).CONCLUSIONSThe present study has demonstrated a significant 25% reduction in basal insulin requirements the day after dialysis compared with the day before. No significant change in boluses was observed, and overall the reduction of total insulin requirements was −15% equivalent to −4 IU/day posthemodialysis of marginal statistical significance.

The Development of Our Understanding of Uremia

“…14 Clinical studies are in agreement with the concept that uremic toxins are involved in insulin resistance in uremia. In a group of type 2 diabetic patients on maintenance hemodialysis, Sobngwi et al 15 demonstrated a 15% decrease in the daily insulin needs in the day after hemodialysis compared with the insulin needs before hemodialysis, with a significant reduction of basal hourly insulin requirement by 25%, in the face of unchanged bolus, and unchanged body-weight-indexed total insulin dose. This study confirmed earlier findings of DeFronzo et al 16 that 10 weeks of thrice-weekly hemodialysis improves insulin sensitivity in uremic patients.…”

Practical Approach to Management of Inpatient Hyperglycemia in Select Patient Populations

“…A recently published small study of patients on outpatient maintenance hemodialysis showed both pre-and post-hemodialysis variation in patient insulin requirements, as well as diurnal variation in insulin requirements. 16 The study authors found that the dose of basal insulin should be decreased by 25% on the day following hemodialysis, while nutritional bolus doses can remain unchanged. 16 In addition to adjustments in insulin dosing pre-and post-hemodialysis, patients must have close monitoring of point-of-care BG levels.…”

“…16 The study authors found that the dose of basal insulin should be decreased by 25% on the day following hemodialysis, while nutritional bolus doses can remain unchanged. 16 In addition to adjustments in insulin dosing pre-and post-hemodialysis, patients must have close monitoring of point-of-care BG levels.…”

Managing diabetes in dialysis patients

“…In addition, the act of dialysis further alters insulin requirements. Using a 24-h euglycaemic clamp in patients with T2D on HD, there is evidence that there is a significant reduction (15%) in basal insulin requirements the day following an HD session 68. Changing the mode of dialysis (eg, from CAPD to APD) requires adjustments to the insulin regime to limit extremes of glycaemia 56…”