title: Haemodialysis-induced hypoglycaemia and glycaemic disarrays.
abstract: In patients with diabetes receiving chronic haemodialysis, both very high and low glucose levels are 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. Haemodialysis-induced hypoglycaemia is common during treatments with glucose-free dialysate, which engenders a catabolic status similar to fasting; this state can also occur with 5.55 mmol/l glucose-containing dialysate. Haemodialysis-induced 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 haemodialysis-induced hypoglycaemia and other glycaemic disarrays. In this Review we summarize the pathophysiology and current management of glycaemic disarrays in patients on haemodialysis.
authors.affiliation: Divisions of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-chou, Itabashi-ku, Tokyo 173-8610, Japan.
authors.forename: Masanori
authors.initials: M
authors.lastname: Abe
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
mesh_terms: D001786:Blood Glucose / Q000032:analysis*; D003928:Diabetic Nephropathies / Q000503:physiopathology*; D005943:Gluconeogenesis; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology / Q000503:physiopathology*; D007004:Hypoglycemic Agents / Q000494:pharmacology; D007333:Insulin Resistance / Q000502:physiology; D010809:Physical Fitness; D006435:Renal Dialysis / Q000009:adverse effects
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents
references.citation: N Engl J Med. 2013 Jul 25;369(4):374-82
references.pmid: 23841704
references.citation: Clin Nephrol. 2007 Nov;68(5):287-94
references.pmid: 18044260
references.citation: N Engl J Med. 1993 Sep 30;329(14):977-86
references.pmid: 8366922
references.citation: Clin J Am Soc Nephrol. 2011 May;6(5):1041-8
references.pmid: 21511838
references.citation: Clin J Am Soc Nephrol. 2011 Jul;6(7):1520-2
references.pmid: 21734081
references.citation: Kidney Int. 1980 Dec;18(6):754-61
references.pmid: 7206459
references.citation: Clin Nephrol. 2000 Jul;54(1):30-4
references.pmid: 10939754
references.citation: Am J Physiol. 1998 May;274(5):E817-26
references.pmid: 9612239
references.citation: Am J Kidney Dis. 2012 Nov;60(5):850-86
references.pmid: 23067652
references.citation: Int J Artif Organs. 2011 Jan;34(1):16-25
references.pmid: 21298620
references.citation: J Am Soc Nephrol. 2011 Mar;22(3):437-42
references.pmid: 21310819
references.citation: Semin Dial. 2000 Jan-Feb;13(1):4-8
references.pmid: 10740665
references.citation: Clin Nephrol. 2008 May;69(5):354-60
references.pmid: 18538098
references.citation: Diabetes. 2012 Mar;61(3):708-15
references.pmid: 22315308
references.citation: Diabetes. 1991 Feb;40(2):223-6
references.pmid: 1991573
references.citation: Diabetes Care. 2007 May;30(5):1049-55
references.pmid: 17337501
references.citation: Clin Nephrol. 2010 Jun;73(6):431-8
references.pmid: 20497755
references.citation: Semin Dial. 2010 Mar-Apr;23(2):148-56
references.pmid: 20374552
references.citation: Clin J Am Soc Nephrol. 2012 Jul;7(7):1155-62
references.pmid: 22554719
references.citation: J Clin Invest. 1981 Feb;67(2):563-8
references.pmid: 7007440
references.citation: Am J Kidney Dis. 2012 Nov;60(5):747-69
references.pmid: 22999165
references.citation: J Am Soc Nephrol. 2005 Mar;16 Suppl 1:S7-10
references.pmid: 15938025
references.citation: J Ren Nutr. 2011 Jan;21(1):2-6
references.pmid: 21195908
references.citation: Nephrol Dial Transplant. 2002;17 Suppl 11:28-31
references.pmid: 12386254
references.citation: J Clin Endocrinol Metab. 2009 Jul;94(7):2299-305
references.pmid: 19401377
references.citation: Nephrol Dial Transplant. 2010 Jul;25(7):2044-7
references.pmid: 20388630
references.citation: Diabetes. 1988 Jul;37(7):901-7
references.pmid: 3290007
references.citation: J Ren Nutr. 2011 Mar;21(2):149-59
references.pmid: 20580251
references.citation: Am J Physiol Endocrinol Metab. 2004 Apr;286(4):E589-97
references.pmid: 14678952
references.citation: Arch Ophthalmol. 1998 Jul;116(7):874-86
references.pmid: 9682700
references.citation: Int J Artif Organs. 2001 Dec;24(12):863-9
references.pmid: 11831591
references.citation: J Am Soc Nephrol. 2002 Jan;13(1):134-141
references.pmid: 11752030
references.citation: Nephron. 1977;19(3):131-9
references.pmid: 19712
references.citation: Ther Apher Dial. 2013 Dec;17(6):567-611
references.pmid: 24330555
references.citation: Ther Apher Dial. 2007 Aug;11(4):280-7
references.pmid: 17661834
references.citation: Endocrinol Metab Clin North Am. 1989 Mar;18(1):103-21
references.pmid: 2645122
references.citation: Clin Nephrol. 2009 May;71(5):514-20
references.pmid: 19473611
references.citation: Curr Drug Metab. 2011 Jan;12(1):57-69
references.pmid: 21303332
references.citation: J Clin Invest. 1988 Aug;82(2):436-44
references.pmid: 3403713
references.citation: Am J Clin Nutr. 1997 Jan;65(1):128-35
references.pmid: 8988924
references.citation: Diabetes Obes Metab. 2000 Dec;2(6):345-50
references.pmid: 11225963
references.citation: Semin Dial. 2010 Jul-Aug;23(4):378-82
references.pmid: 20701717
references.citation: Ther Apher Dial. 2007 Aug;11(4):288-95
references.pmid: 17661835
references.citation: Ther Apher Dial. 2014 Oct;18(5):434-42
references.pmid: 24251784
references.citation: Nephrology (Carlton). 2008 Jun;13(4):278-83
references.pmid: 18476915
references.citation: Kidney Int. 2005 Apr;67(4):1216-33
references.pmid: 15780075
references.citation: Am J Physiol Endocrinol Metab. 2004 Dec;287(6):E1049-56
references.pmid: 15304374
references.citation: Am J Clin Nutr. 2004 Aug;80(2):299-307
references.pmid: 15277149
references.citation: Clin J Am Soc Nephrol. 2010 Sep;5(9):1595-601
references.pmid: 20671217
references.citation: JAMA. 1999 Apr 14;281(14):1275-81
references.pmid: 10208142
references.citation: Am J Physiol. 1991 Jul;261(1 Pt 1):E41-8
references.pmid: 1858873
references.citation: Curr Diab Rep. 2012 Aug;12(4):432-9
references.pmid: 22638938
references.citation: Kidney Int. 1994 Sep;46(3):814-22
references.pmid: 7996803
references.citation: Am J Clin Nutr. 1978 Oct;31(10):1870-5
references.pmid: 707341
references.citation: Artif Organs. 2011 Apr;35(4):398-403
references.pmid: 21314833
references.citation: Nephron Clin Pract. 2007;106(3):c125-35
references.pmid: 17522475
references.citation: J Am Soc Nephrol. 2007 Mar;18(3):896-903
references.pmid: 17267743
references.citation: Kidney Int Suppl. 2011 Mar;(120):S1-6
references.pmid: 21358696
references.citation: Am J Kidney Dis. 2010 Jan;55(1 Suppl 1):S1-420, A6-7
references.pmid: 20082919
references.citation: Am J Kidney Dis. 1982 Nov;2(3):349-53
references.pmid: 7148826
references.citation: Kidney Int. 2006 Oct;70(8):1503-9
references.pmid: 16941022
references.citation: Diabetes Care. 2011 Dec;34(12):2536-41
references.pmid: 21994430
references.citation: Diabetes Res Clin Pract. 2008 Oct;82(1):e17-9
references.pmid: 18774617
references.citation: Eur J Clin Pharmacol. 2003 Jun;59(2):91-7
references.pmid: 12698302
references.citation: Clin J Am Soc Nephrol. 2013 Dec;8(12):2174-82
references.pmid: 23970134
references.citation: Am J Kidney Dis. 2003 Nov;42(5):864-81
references.pmid: 14582032
references.citation: Clin Nephrol. 1999 Apr;51(4):242-7
references.pmid: 10230557
references.citation: Kidney Int. 1999 Feb;55(2):648-58
references.pmid: 9987089
references.citation: Ren Fail. 2000 Mar;22(2):219-23
references.pmid: 10803766
references.citation: Nat Rev Nephrol. 2013 Mar;9(3):147-53
references.pmid: 23358424
references.citation: Semin Dial. 2014 Mar;27(2):135-45
references.pmid: 24588802
references.citation: Blood Purif. 2006;24(4):335-41
references.pmid: 16557022
references.citation: Int Urol Nephrol. 2013 Aug;45(4):1079-90
references.pmid: 22684796
references.citation: J Am Soc Nephrol. 2002 Jul;13(7):1894-900
references.pmid: 12089386
references.citation: J Diabetes Investig. 2012 Jun 6;3(3):298-301
references.pmid: 24843580
references.citation: Pediatr Nephrol. 2008 Aug;23(8):1211-21
references.pmid: 18324423
references.citation: Kidney Int. 2013 Dec;84(6):1096-107
references.pmid: 23698226
references.citation: Circulation. 2009 Dec 15;120(24):2421-8
references.pmid: 19948978
references.citation: J Am Soc Nephrol. 2012 Jul;23(7):1258-70
references.pmid: 22626821
references.citation: Nephron Clin Pract. 2003;95(1):c31-6
references.pmid: 14520019
references.citation: Am J Physiol. 1996 May;270(5 Pt 2):F839-44
references.pmid: 8928846
references.citation: Nat Clin Pract Nephrol. 2008 Sep;4(9):482-3
references.pmid: 18628741
references.citation: Nephrol Dial Transplant. 2012 Apr;27(4):1559-68
references.pmid: 21940484
references.citation: Diabetologia. 2007 Jun;50(6):1170-7
references.pmid: 17393134
references.citation: Clin Nephrol. 2011 Jan;75(1):49-58
references.pmid: 21176750
references.citation: Nephrol Dial Transplant. 2011 Dec;26(12):4095-103
references.pmid: 21750157
references.citation: Am J Physiol Endocrinol Metab. 2002 Feb;282(2):E428-34
references.pmid: 11788376
references.citation: Clin Nephrol. 2004 Nov;62(5):362-8
references.pmid: 15571181
references.citation: Atherosclerosis. 2000 Nov;153(1):257-8
references.pmid: 11184631
references.citation: Nephron. 1993;65(1):108-10
references.pmid: 8413768
references.citation: Am J Physiol. 1986 Oct;251(4 Pt 1):E442-7
references.pmid: 3532819
references.citation: J Clin Invest. 1985 Feb;75(2):391-6
references.pmid: 3882760
references.citation: Ren Fail. 2005;27(3):305-8
references.pmid: 15957547
references.citation: Kidney Int. 1987 Jul;32(1):129-35
references.pmid: 3306095
references.citation: Kidney Int Suppl. 2009 Dec;(114):S12-9
references.pmid: 19946322
references.citation: Endocr J. 2011;58(11):979-87
references.pmid: 21921362
references.citation: Am J Kidney Dis. 2001 Oct;38(4 Suppl 1):S195-9
references.pmid: 11576954
references.citation: J Ren Nutr. 2009 Jan;19(1):33-7
references.pmid: 19121768
references.citation: Semin Dial. 2010 Mar-Apr;23(2):163-8
references.pmid: 20210915
references.citation: Diabetes Technol Ther. 2011 Aug;13(8):813-8
references.pmid: 21561372
references.citation: Clin Nephrol. 2012 Oct;78(4):273-80
references.pmid: 22541674
references.citation: Kidney Int. 2008 May;73(9):1062-8
references.pmid: 18288102
references.citation: Clin Sci (Lond). 1991 Jul;81(1):1-9
references.pmid: 1649714
references.citation: Hemodial Int. 2008 Apr;12(2):221-6
references.pmid: 18394054
references.citation: Nephrol Dial Transplant. 2007 Apr;22(4):1184-9
references.pmid: 17272314
references.citation: Expert Opin Pharmacother. 2013 Feb;14(3):259-67
references.pmid: 23289982
references.citation: Diabetes Metab. 2000 Jul;26 Suppl 4:73-85
references.pmid: 10922977
references.citation: Diabetes Care. 2001 May;24(5):909-13
references.pmid: 11347753
references.citation: Diabetes Res Clin Pract. 1995 May;28(2):103-17
references.pmid: 7587918
references.citation: Am J Kidney Dis. 2006 Apr;47(4):636-43
references.pmid: 16564941
references.citation: Diabetes Care. 2006 Jul;29(7):1496-500
references.pmid: 16801568
references.citation: Kidney Int. 2008 Feb;73(4):391-8
references.pmid: 18094682
references.citation: Am J Kidney Dis. 2014 Jan;63(1):84-94
references.pmid: 23958400
references.citation: Trans Am Soc Artif Intern Organs. 1976;22:412-9
references.pmid: 951859
references.citation: Diabetes Care. 2012 Dec;35(12):2527-32
references.pmid: 22912431
references.citation: J Am Soc Nephrol. 2010 Feb;21(2):353-61
references.pmid: 20007751
references.citation: Am J Clin Nutr. 1979 Dec;32(12):2443-9
references.pmid: 506968
references.citation: Blood Purif. 2005;23(3):219-25
references.pmid: 15809505
references.citation: Clin Nephrol. 2011 Nov;76(5):401-6
references.pmid: 22000561
references.citation: Am J Kidney Dis. 2014 Oct;64(4):510-33
references.pmid: 25257325
references.citation: Semin Dial. 2004 Sep-Oct;17(5):365-70
references.pmid: 15461745
references.citation: Kidney Int. 1978 Nov;14(5):491-500
references.pmid: 750694
references.citation: Ann Intern Med. 2008 Apr 1;148(7):563
references.pmid: 18378956
references.citation: Am J Kidney Dis. 2007 Feb;49(2):257-66
references.pmid: 17261428
references.citation: J Investig Med. 2004 Sep;52(6):375-8
references.pmid: 15612450
references.citation: J Clin Invest. 1976 Jun;57(6):1403-11
references.pmid: 932188
references.citation: Hemodial Int. 2006 Jan;10(1):15-28
references.pmid: 16441823
references.citation: J Am Soc Nephrol. 2013 Feb;24(3):337-51
references.pmid: 23264684
references.citation: Intern Med. 2007;46(12):807-14
references.pmid: 17575371
references.citation: Diabetologia. 1995 Dec;38(12):1412-8
references.pmid: 8786014
references.citation: Diabetes Care. 2001 Feb;24(2):382-91
references.pmid: 11213896
references.citation: Nephrol Dial Transplant. 2000 Jul;15(7):953-60
references.pmid: 10862630
references.citation: Diabetologia. 1995 May;38(5):565-72
references.pmid: 7489839
references.citation: Nephrol Dial Transplant. 2009 Feb;24(2):338-41
references.pmid: 19015168
references.citation: Intern Med. 1998 Oct;37(10):826-30
references.pmid: 9840702
references.citation: Am J Kidney Dis. 2009 Apr;53(4):606-16
references.pmid: 19216016