The impact of haemodialysis on glycaemia

Haemodialysis disrupts glucose homeostasis through rapid changes in circulating glucose and the clearance of key glucoregulatory hormones, including insulin, glucagon and incretin peptides. Despite advances in continuous glucose monitoring (CGM) and diabetes therapies, the impact of haemodialysis on glycaemia remains incompletely understood,  particularly regarding how alterations in glucoregulatory hormone dynamics contribute to glycaemic variability.

In the prospective BLOSSOM cohort study, 361 participants with treated diabetes, untreated diabetes or no diabetes who were undergoing thrice-weekly maintenance haemodialysis using a standardised 100 mg/dL (5.6 mmol/L) glucose dialysate wore a Dexcom G6 Pro CGM device for 10 days. CGM data from 342 participants with valid data from at least one haemodialysis session were analysed in relation to dialysis timing. 

In a subset of 20 individuals, blood concentrations of glucoregulatory hormones were measured at four time points: the start and end of the first haemodialysis session, and the start and end of a second haemodialysis session. 

CGM captured data from 1001 haemodialysis sessions. At treatment start, mean blood glucose concentrations were highest among participants with treated diabetes (n=143), intermediate among those with untreated diabetes (n=78) and lowest among those without diabetes (n=121) (212±84, 167±65 and 120±28 mg/dL, respectively). During haemodialysis, glucose concentrations declined across all groups, with the greatest reduction observed in the treated diabetes group. 

After dialysis, glucose rebounded sharply by 115±70 mg/dL (to a mean peak of 265±84 mg/dL), 95±60 mg/dL (227±71 mg/dL) and 61±35 mg/dL (168±37 mg/dL) in participants with treated diabetes, untreated diabetes and no diabetes, respectively. Peaks occurred later in participants with treated or untreated diabetes (~170 min) than in no diabetes (~140 min). The magnitude of post-dialytic rebound glycaemia correlated with HbA_1c and mean CGM glucose measurements over the full observation period.

Hypoglycaemic events (<70 mg/dL) were uncommon (n=259) but occurred significantly more frequently during the post-dialysis period than during time-matched periods on non-dialysis days. On dialysis days, however, hypoglycaemic event rates did not differ significantly between the pre-dialysis and post-dialysis periods.

In the sub-study, most glucoregulatory hormone concentrations, including insulin (median change, –38%), Glucagon (−43%) and glucagon-like peptide-1 (−38%) declined during haemodialysis. Glucose-dependent insulinotropic polypeptide was an exception.

The association of intradialytic glucose declines and post-dialytic rebounds with overall glycaemic control highlights the substantial disruption of glucose homeostasis during dialysis. Further studies are needed to determine whether mitigating dialysis-associated glucose disturbances can meaningfully improve metabolic or clinical outcomes.

The full article can be read here.