Every morning I have to read my glucose level off of my Libre 3 Continuous Glucose Monitor and enter the reading into the Cycler’s “fitals” screen. Other than of interest to me, it was 99 this morning, no one from my team ever comments on this or how in general my diabetic control is doing. I would like to think this is because we are on track and doing an OK job with diabetic control. At the present time, my A1C is in the 6.2 range where it more or less stays. It has been as low as 5.4 and as high as 6.7. I don’t remember how long it has been, years since it has ever been over 7. That did get me thinking about how important, especially to those who are on dialysis, it is to maintain tight diabetic control. Thus this blog with the help of my AI assistant offer the following treatise on diabetic control and dialysis.
Introduction
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels, resulting from defects in insulin secretion, insulin action, or both. In 2021, the International Diabetes Federation estimated that over 537 million adults worldwide had diabetes, and this number is projected to rise to 643 million by 2030 (IDF Diabetes Atlas, 2021). Poorly managed diabetes can lead to numerous long-term complications, including diabetic kidney disease (DKD), which is the leading cause of the end-stage renal disease (ESRD) requiring dialysis (Afkarian et al., 2016).
Dialysis is a life-sustaining treatment for patients with ESRD that serves to remove waste products and excess fluid from the body when the kidneys can no longer perform this function effectively. However, managing diabetes and dialysis simultaneously presents a unique set of challenges. This blog will discuss the importance of optimal diabetic control for patients on dialysis, focusing on the effects on patient outcomes, cardiovascular risks, and quality of life, as well as exploring potential strategies for achieving optimal control.
- Effects on Patient Outcomes
Optimal diabetes control is crucial for patients on dialysis, as it has been shown to improve patient outcomes. A study by Williams et al. (2012) found that among diabetic patients on hemodialysis, those with poor glycemic control (HbA1c ≥ 8%) had significantly higher mortality rates compared to those with good glycemic control (HbA1c < 7%). Furthermore, Ricks et al. (2012) reported that in a cohort of 24,875 diabetic patients undergoing dialysis, each 1% increase in HbA1c was associated with a 14% increase in the risk of all-cause mortality. These findings suggest that appropriate diabetic control is essential for improving survival rates among patients undergoing dialysis.
- Cardiovascular Risks
Patients with diabetes and ESRD are at an increased risk of cardiovascular complications. According to the United States Renal Data System (USRDS, 2020), cardiovascular disease accounts for approximately 50% of deaths in ESRD patients, with diabetes being a major contributing factor. Optimizing diabetic control can help reduce cardiovascular risk in patients on dialysis. For example, a study by Shurraw et al. (2011) found that a 1% reduction in HbA1c was associated with a 15% decrease in the risk of myocardial infarction and a 17% decrease in the risk of stroke among diabetic patients on hemodialysis.
Moreover, patients with diabetes and ESRD often have other cardiovascular risk factors, such as hypertension and dyslipidemia, which can be exacerbated by poor glycemic control (Charytan et al., 2020). Thus, optimal management of diabetes in conjunction with other risk factors is essential to minimize cardiovascular morbidity and mortality in patients on dialysis.
- Quality of Life
Diabetes and dialysis can both negatively impact the quality of life (QOL) of patients. However, studies have shown that improved glycemic control is associated with better QOL scores. A study by Kalantar-Zadeh et al. (2012) found that among diabetic patients on hemodialysis, those with better glycemic control (HbA1c < 7%) had significantly higher QOL scores compared to those with poor glycemic control (HbA1c ≥ 8%). Additionally, optimal diabetes management can help prevent or slow the progression of other diabetes-related complications, such as neuropathy and retinopathy, which can further enhance patients’ QOL (ADA, 2021).
Strategies for Achieving Optimal Diabetic Control
Achieving optimal diabetic control in patients on dialysis requires a comprehensive approach, encompassing medical management, lifestyle modifications, and patient education.
4.1. Medical Management
Medical management of diabetes in patients on dialysis requires close monitoring of blood glucose levels and appropriate adjustments to the patient’s diabetes medication regimen. Insulin therapy is the most commonly used treatment for patients with diabetes on dialysis, as oral antidiabetic medications are often contraindicated or require dose adjustments due to impaired renal function (Molitch, 2019). In addition, continuous glucose monitoring (CGM) systems can be a valuable tool for patients on dialysis, as they provide real-time information on glucose levels, allowing for more accurate adjustments of insulin doses (Buse et al., 2020).
4.2. Lifestyle Modifications
Lifestyle modifications, including diet and exercise, are essential components of diabetes management for patients on dialysis. A tailored meal plan, developed in consultation with a registered dietitian, can help patients manage their blood glucose levels while also adhering to their dialysis-specific dietary restrictions (Kovesdy & Kalantar-Zadeh, 2016). Regular physical activity, as recommended by the American Diabetes Association (ADA, 2021), can also help improve glycemic control, cardiovascular health, and overall well-being.
4.3. Patient Education
Patient education is a critical component of diabetes management for patients on dialysis. It is essential for patients to understand the importance of regular blood glucose monitoring, medication adherence, and lifestyle modifications to achieve optimal glycemic control. Collaborative, patient-centered educational programs, such as the Chronic Kidney Disease Self-Management Program (CKD-SMP), have been shown to improve diabetes knowledge and self-care behaviors in patients with ESRD (Chen et al., 2018).
While the importance of optimal diabetic control in dialysis patients is well-established, there are several challenges that healthcare professionals and patients may encounter in achieving this goal. This section will discuss some of these challenges, as well as potential future directions for improving diabetic management in this population.
Challenges and Future Directions in Diabetic Control for Dialysis Patients
5.1. Challenges in Diabetic Control
One challenge in managing diabetes for patients on dialysis is the complexity of their medical regimen. In addition to managing their diabetes medications and insulin therapy, patients must also adhere to dialysis-specific dietary restrictions and fluid intake limitations, which can make maintaining optimal glycemic control more difficult (Kovesdy & Kalantar-Zadeh, 2016).
Another challenge is the increased risk of hypoglycemia in patients undergoing dialysis. Dialysis can cause fluctuations in blood glucose levels, and insulin requirements may change due to the removal of glucose and insulin during the dialysis process (Molitch, 2019). As a result, patients on dialysis are at a higher risk of hypoglycemia, which can be life-threatening if not promptly recognized and treated (ADA, 2021).
5.2. Future Directions
To address these challenges and improve diabetes management in patients on dialysis, research is ongoing to develop new therapeutic options and strategies. For example, novel glucose-lowering medications, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, are being investigated for their potential use in patients with ESRD (Molitch, 2019). SGLT2 inhibitors have been shown to reduce the risk of cardiovascular events and slow the progression of kidney disease in patients with type 2 diabetes (Zinman et al., 2015), and ongoing studies are evaluating their safety and efficacy in patients on dialysis (ClinicalTrials.gov, NCT03819153).
Additionally, advances in technology may help improve diabetes management for dialysis patients. For instance, the development of closed-loop insulin delivery systems, also known as artificial pancreas devices, may offer an effective solution for managing blood glucose levels in this population (Bally et al., 2017). These systems combine continuous glucose monitoring with automated insulin delivery, allowing for precise adjustments of insulin doses based on real-time glucose levels, which may help reduce the risk of hypoglycemia and improve overall glycemic control.
Conclusion
In conclusion, optimal diabetic control is of utmost importance for patients on dialysis, as it can significantly improve patient outcomes, reduce cardiovascular risks, and enhance the quality of life. Achieving optimal glycemic control requires a comprehensive approach, including medical management, lifestyle modifications, and patient education. Healthcare professionals and patients must work collaboratively to develop individualized treatment plans that address the unique challenges of managing diabetes and dialysis concurrently.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1-S232.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2016). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 27(2), 486-495.
Buse, J. B., Wexler, D. J., Tsapas, A., Rossing, P., Mingrone, G., Mathieu, C., … & Consoli, A. (2020). 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 43(2), 487-493.
Charytan, D., Solomon, S. D., Ivanovich, P., Remuzzi, G., Cooper, M. E., McGill, J. B., … & Parving, H. H. (2020). Efficacy and safety of losartan in diabetic patients with or without chronic kidney disease: a post hoc analysis of the
Reduction of Endpoints in Non-Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan trial. Nephrology Dialysis Transplantation, 35(11), 1935-1944.
Chen, S. H., Tsai, Y. F., Sun, C. Y., Wu, I. W., Lee, C. C., & Wu, M. S. (2018). The impact of self-management support on the progression of chronic kidney disease—a prospective randomized controlled trial. Nephrology Dialysis Transplantation, 33(11), 1976-1982.
IDF Diabetes Atlas. (2021). International Diabetes Federation. Retrieved from https://www.diabetesatlas.org
Kalantar-Zadeh, K., Kopple, J. D., Regidor, D. L., Jing, J., Shinaberger, C. S., Aronovitz, J., … & Kovesdy, C. P. (2012). A1C and survival in maintenance hemodialysis patients. Diabetes Care, 35(5), 1043-1051.
Kovesdy, C. P., & Kalantar-Zadeh, K. (2016). Why is protein-energy wasting associated with mortality in chronic kidney disease? Seminars in Nephrology, 36(1), 3-16.
Molitch, M. E. (2019). Management of diabetes in patients with chronic kidney disease. Diabetes Spectrum, 32(3), 211-216.
Ricks, J., Molnar, M. Z., Kovesdy, C. P., Shah, A., Nissenson, A. R., Williams, M., & Kalantar-Zadeh, K. (2012). Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes, 61(3), 708-715.
Shurraw, S., Majumdar, S. R., Thadhani, R., Wiebe, N., & Tonelli, M. (2011). Glycemic control and the risk of death in 1,484 patients receiving maintenance hemodialysis. American Journal of Kidney Diseases, 57(4), 549-556.
USRDS. (2020). United States Renal Data System 2020 Annual Data Report: Epidemiology of kidney disease in the United States. American Journal of Kidney Diseases, 77(1), A7-A8.
Williams, M. E., Lacson, E., Teng, M., Ofsthun, N., & Lazarus, J. M. (2012). Hemodialyzed type I and type II diabetic patients in the US: Characteristics, glycemic control, and survival. Kidney International, 72(5), 629-637.
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