Content area
Full Text
REVIEWS
Haemodialysis-induced hypoglycaemia andglycaemic disarrays
Masanori Abe and Kamyar Kalantar-Zadeh
Abstract | In patients with diabetes receiving chronic haemodialysis, both very high and low glucose levelsare associated with poor outcomes, including mortality. Conditions that are associated with an increased risk of hypoglycaemia in these patients include decreased gluconeogenesis in the remnant kidneys, deranged metabolic pathways, inadequate nutrition, decreased insulin clearance, glucose loss to the dialysate and diffusion of glucose into erythrocytes during haemodialysis. Haemodialysisinduced hypoglycaemia is common during treatments with glucosefree dialysate, which engenders a catabolic status similar to fasting; this state can also occur with 5.55 mmol/l glucosecontaining dialysate. Haemodialysisinduced hypoglycaemia occurs more frequently in patients with diabetes than in those without. Insulin therapy and oral hypoglycaemic agents should, therefore, be used with caution in patients on dialysis. Several hours after completion of haemodialysis treatment a paradoxical rebound hyperglycaemia may occur via a similar mechanism as the Somogyi effect, together with insulin resistance. Appropriate glycaemic control tailored for patients on haemodialysis is needed to avoid haemodialysisinduced hypoglycaemia and other glycaemic disarrays. In this Review we summarize the pathophysiology and current management of glycaemic disarrays in patients on haemodialysis.
Abe, M. & KalantarZadeh, K. Nat. Rev. Nephrol. 11, 302313 (2015); published online 7 April 2015; corrected online 27 April 2015; http://www.nature.com/doifinder/10.1038/nrneph.2015.38
Web End =doi:10.1038/nrneph.2015.38
Introduction
Type2 diabetes mellitus (T2DM) is one of the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in developed and developing countries.1 In the USA, New Zealand, Japan and some other Asian countries, T2DM accounts for nearly 50% of patients on incident dialysis.2,3 The disease has been described as a condition of dysglycaemia, which occurs mostly in the form of hyperglycaemia. However, two other components of dysglycaemiahypoglycaemia and glucose variabilityare now also considered to be clinically relevant as they each contribute to the overall risk of adverse diabetes-related outcomes.4 Hypoglycaemic events can be exceptionally serious, even life-
threatening, and can make glycaemic control of diabetic patients challenging. Hence, whereas hyperglycaemia was traditionally the main focus of attention, contemporary medicine considers the occurrence of hypoglycaemia an even more substantial challenge in the management of T2DM.
Optimum glycaemic control of diabetic patients with CKD is a topic of considerable uncertainty and confusion.5 In diabetic patients with ESRD receiving...