Prospective Cohort Study Evaluating Impact of Hemodialysis on Glycemia
Yoshio N. Hall, Leila R. Zelnick, Irl B. Hirsch, Andrew N. Hoofnagle, Simon Hsu, Matthew B. Rivara, Ian H. de BoerBackground:
Hemodialysis affects glycemia in a manner that remains incompletely defined.
Methods:
In a prospective cohort study, 342 participants on maintenance hemodialysis wore a Dexcom G6 Pro continuous glucose monitor (CGM) for 10 days while dialyzing with standardized 100 mg/dL glucose dialysate. We examined glycemia relative to dialysis timing and tested associations of glycemia patterns with clinical characteristics and markers of overall glycemic control. Glucoregulatory hormones were measured pre- and post-dialysis in a subset of 20 participants.
Results:
Overall, CGM captured 1,001 hemodialysis sessions. Among participants with treated diabetes (n=143), untreated diabetes (n=78), and without diabetes (n=121), pre-dialysis glucose averaged 212 ± 84 mg/dL, 167 ± 65 mg/dL, and 120 ± 28 mg/dL, respectively. During dialysis, glucose declined by 53 ± 79 mg/dL, 29 ± 55 mg/dL, and 7 ± 32 mg/dL, respectively. Post-dialysis, glucose rebounded by 115 ± 70 mg/dL (to mean peak 265 ± 84 mg/dL), 95 ± 60 mg/dL (227 ± 71 mg/dL) and 61 ± 35 mg/dL (168 ± 37 mg/dL), respectively, with mean time to peak occurring later in treated (172 minutes post-dialysis) and untreated (169 min) diabetes compared with no diabetes (140 min). Post-dialytic rebound glycemia correlated with hemoglobin A1c and mean CGM glucose over the full observation period. Hypoglycemic events <70 mg/dL were uncommon (N=259); hypoglycemic event rates were significantly higher in the post-dialysis period compared with time-matched periods on non-dialysis days. There were no significant differences in hypoglycemic event rates pre- versus post-dialysis on dialysis days. In the substudy, most glucoregulatory peptides declined significantly (p<0.001) during dialysis including insulin (median change: -38%), glucagon (-43%), and glucagon-like peptide-1 (-38%).
Conclusions:
Hemodialysis induces intradialytic glucose declines and post-dialytic rebound that link to overall glycemic control, highlighting dialysis as a physiologic stressor on glucose homeostasis.