Category: Diabetes/Prediabetes/Hypoglycemia

Hypoglycemia in Hospitalized, Insulin-Requiring Diabetic Patients Receiving Hemodialysis

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Inpatient glycemic control significantly impacts outcomes. Hemodialysis (HD) dependent diabetic patients are at risk of hypoglycemia and no evidence-based recommendations for insulin dosing are available for this population. We evaluated the incidence and risk factors for hypoglycemia in these patients with a focus on insulin dose.


Methods :

Retrospective chart review of 118 hospital encounters of patients receiving HD and insulin was performed. Encounters were divided into hypoglycemia and non-hypoglycemia groups. Baseline characteristics and glucometrics were collected and compared.


Results :

At least 1 episode of hypoglycemia (<70 mg/dl) was observed in 45% encounters, of which 33% had an episode of severe hypoglycemia (<40 mg/dl) and 50% had multiple episodes of hypoglycemia. Although not statistically significant, the hypoglycemia group had longer hospital stays (8 vs 6 days) and higher 30-day readmission rates (35% vs 30%). A greater incidence of hypoglycemia was noted among females (OR 1.51) and patients with sepsis/acute infections (OR 1.52). Hypoglycemia group patients received a lower mean total daily dose (TDD) of insulin (0.29 vs 0.33 units/kg) and had lower mean blood glucose (BG) values (151 vs 176 mg/dl). Considerable fluctuation in BG values and TDD of insulin was observed in this group. Interestingly, mean insulin received in 24 hours preceding hypoglycemic episodes was 0.35 u/kg with 60% occurring at >0.3 u/kg and 20% at <0.2 u/kg. Almost 60% of episodes occurred in pre-dialysis period (non-dialysis days and morning of HD day), and 35% of episodes occurred in the morning (3-8am). At least 30% of episodes occurred when patients ate <50% of the meal.


Discussion :

Despite receiving a lower mean TDD of insulin, the hypoglycemia group still had frequent episodes of hypoglycemia suggestive of greater insulin sensitivity with impaired counter-regulatory mechanisms and hypoglycemia unawareness. As expected, these patients were at an increased risk of hypoglycemia when receiving greater insulin doses (especially >0.3 u/kg). Aside from insulin dose, factors such as acute infection, variation in diet and timing of HD also contributed to hypoglycemic episodes. Due to these confounding variables, this study cannot recommend a TDD of insulin that can be generalized for this population as hypoglycemia occurred at a wide range of insulin doses.


Conclusion :

Glycemic control in hospitalized, diabetic hemodialysis-dependent patients is challenging and often requires daily modification of insulin dose. Total daily dose of insulin must be individualized based on a patient’s insulin sensitivity, history of hypoglycemia, dietary intake, infection status and timing of HD.

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Hisham Farhan

Resident
Wellspan York Hospital
York, Pennsylvania

I am an internal medicine resident at York Hospital. I am planning to pursue Endocrinology fellowship. I like to travel and take pictures.

Chalak Muhammad

Diabetologist
Wellspan

I am working as diabetes specialist at wellspan endocrinology.

Frederick Shrimp

Resident
Wellspan

2nd year internal medicine resident. Interested in hematology-oncology

Elham Rabiei-flori

Resident
Wellspan York Hospital

3rd year internal medicine resident, interested in endocrinology

Ali Akram

Resident
Wellspan York Hospital

1ST year internal medicine resident

Junaid Mir

Resident
Wellspan York Hospital

1st year resident, pursuing endocrinology fellowship

Pramod Tripathi

Resident
Wellspan York Hospital

3rd year resident pursuing endocrinology fellowship