Blood Glucose Management in Dialysis Patients
Dec 29, 2022
Uremia belongs to the late stage of various chronic kidney diseases, and uremia patients often need hemodialysis treatment to prolong their survival time. In recent years, the number of patients with diabetic nephropathy undergoing hemodialysis has increased day by day. The complications and mortality of diabetic patients with maintenance hemodialysis are higher than those of non-diabetic patients. Hypoglycemia is more common during hemodialysis, and its harm is even greater. Serious; however, some diabetic patients on hemodialysis did not seriously implement the hypoglycemia plan because they were afraid of hypoglycemia during dialysis, resulting in severe hyperglycemia.
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Therefore, how effectively manage blood sugar in diabetic hemodialysis patients is a dialysis-related problem that needs to be solved urgently.
For diabetic patients receiving hemodialysis, the setting of hypoglycemic goals should be based on the specific conditions of the patients and follow the principle of individualization, which varies from person to person. The most basic principle is to pay attention to safety. "Sugar reduction is valuable, and the price of safety is higher." On the one hand, hypoglycemia should be prevented, and on the other hand, acute metabolic disorders, infections, and other complications caused by obvious hyperglycemia should be avoided.
The 2019 edition of the "Clinical Guidelines for the Prevention and Treatment of Diabetic Kidney Diseases in China" proposes blood sugar control goals: HbA1c should not exceed 7%, and HbA1c should not exceed 8% for diabetic nephropathy patients with eGFR<60ml·min-1·1.73m2. For elderly patients, the HbA1c control target can be appropriately relaxed to 8.5%. The 2020 edition of the "Expert Consensus on HbA1c Control Targets and Strategies for Adults with Type 2 Diabetes" in China recommends that HbA1c be controlled at 7.0% to 9.0%. However, since patients undergoing hemodialysis are often accompanied by anemia, the life span of red blood cells is shortened, which reduces the measured value of HbA1c. Therefore, the measured value of HbA1c in these patients should be interpreted cautiously and can be combined with glycated albumin and blood glucose monitoring results (fasting blood glucose, Postprandial blood glucose) to comprehensively evaluate blood glucose control status.
Diabetic patients undergoing hemodialysis should be reminded to strengthen self-monitoring of blood sugar, grasp the situation of blood sugar control, detect hypoglycemia in time, and adjust treatment strategies in time. Especially during dialysis, blood sugar fluctuations and asymptomatic hypoglycemia often occur. The reasons mainly include the following aspects: On the one hand, because the molecular weight of glucose is small during dialysis, it can freely pass through the dialysis membrane. On the other hand, insulin is a large molecule, which is not easy to be leaked out during dialysis, and when renal failure occurs, the degradation of insulin by the kidney is significantly reduced, and its metabolic clearance of insulin will also be significantly reduced, which may easily cause insulin to accumulate in the body, In addition, hemodialysis can reduce insulin resistance and improve insulin sensitivity, so hypoglycemia is more likely to occur during dialysis.
Diabetes Diet Guidance for Hemodialysis Patients
Reasonable intake of carbohydrates, and control of protein, water, and sodium intake are particularly important for dialysis results.
Patients with diabetes on dialysis choose foods with low sugar content, put snacks between meals, and make correct food distribution to control blood sugar levels. At present, there are no relevant clinical guidelines advocating the control range of fasting blood glucose and 2-hour postprandial blood glucose in hemodialysis patients. In terms of protein intake, if the patient has sufficient dialysis, the protein intake can reach 1.2-1.4g/(kg·d), of which high-quality protein rich in essential amino acids accounts for more than 1/2 (such as chicken, beef, eggs, etc.).
In terms of water and sodium intake, patients with hyperglycemia have a strong sense of thirst, and are prone to drinking too much water, and diabetic patients are prone to edema. The weight gain rate of dialysis patients should be controlled at 3% to 5% of the standard body weight. If the patient's dry weight is 50 kg, the weight gain of the patient on dialysis every other day should not exceed 1.5 kg, and the weight gain should not exceed 2.5 kg every two days.
Nursing care of hypoglycemic drugs in hemodialysis patients
The interaction between renal failure and hypoglycemic drugs will increase the complexity of stable blood sugar control, and the metabolism of hypoglycemic drugs in hemodialysis patients will also change. Therefore, hemodialysis patients should make appropriate adjustments when using hypoglycemic drugs. Adjustment.
In 2016, the "Guidelines for the Management of Adult Diabetic Patients on Hemodialysis" issued by the Joint Inpatient Treatment Group (JBDS-IP) of the British Diabetes Society clearly stated that most oral hypoglycemic agents should be used with caution or banned in hemodialysis patients.
For example, metformin may increase the risk of lactic acidosis and should be used with caution in patients with diabetic nephropathy, should be avoided in patients with CKD (stage 3b-5), and should not be used in patients with maintenance hemodialysis; sulfonylureas can increase the incidence of hypoglycemia, patients with maintenance hemodialysis should be banned; acarbose CKD (stage 4-5) should be avoided, and it has not been approved for use in patients with maintenance hemodialysis. SGLT-2 inhibitors can be used in early chronic kidney disease (CKD stage 1-3a) without dose adjustment but should be avoided in moderate to severe CKD (stage 3b-5). For injection, the current experience with GLP-1RA in maintenance hemodialysis patients is insufficient, so its use is not recommended. Guidelines for the prevention and treatment of diabetic nephropathy suggest that severe CKD (stages 4-5) should be avoided.
To improve the quality of life and avoid the occurrence of severe hyperglycemia or hypoglycemia, diabetic patients undergoing maintenance hemodialysis should receive insulin therapy, and for diabetic patients receiving insulin therapy, the use of glucose-containing dialysate should be avoided during dialysis. The latest version of my country's "Expert Consensus on Oral Hypoglycemic Drugs for Type 2 Diabetic Patients with Chronic Kidney Disease" also recommends that patients with CKD stage 3b-5 should be treated with insulin.
Precautions for insulin therapy
Precautions for insulin therapy include:
1) Insulin dosage forms are different, attention should be paid to the injection dosage to avoid adverse reactions caused by inaccurate dosage;
2) The interval between medium and long-acting insulin and meals can be less strict, but quick-acting preparations need to be applied 30 minutes before meals;
3) The injection site should be selected appropriately. The commonly used sites are the gluteus maximus, abdomen, and lateral thigh, and should be injected in turn;
4) Pay attention to the storage of insulin, generally stored in a refrigerator at 5°C, the long-term storage time can reach 3 years, but generally, it can only be stored for 3 months;
5) Application strategy of hypoglycemic drugs on hemodialysis day:
The insulin specification plan, it can be divided into 3 categories:
① Inject short-acting or ultra-short-acting insulin before meals, and stop using the meal before hemodialysis; ② Inject short-acting or ultra-short-acting + intermediate-acting or long-acting insulin before going to bed, and stop using the meal before hemodialysis; Inject mixed insulin before dinner, reduce the dose by 1/3 before breakfast, or reduce insulin dosage according to the patient's fasting blood sugar and dietary status. However, some studies have suggested that suspending insulin will lead to transient hyperglycemia in patients, which will bring a series of adverse reactions, and the intervention effect is not the same when the dose of different types of insulin is also halved. Therefore, it is necessary to consider the type of insulin and the patient's condition to formulate an individualized insulin reduction plan for the patient to achieve more ideal results.
Relevant studies have shown that the first 2-3 hours of hemodialysis belong to the period of the high incidence of hypoglycemia. Therefore, the prevention and treatment of hypoglycemia during hemodialysis can be set at 2-3 hours of hemodialysis, and blood glucose monitoring can be carried out at this time. During the dialysis period, the patient was instructed to eat properly. According to the patient's condition, those who could eat were required to eat first. If they were unable to eat, a 50% glucose injection was injected intravenously, and the dose was determined according to the blood sugar level. If there is hypoglycemia during hemodialysis, measure blood sugar in time, inject 40-60 mL of 50% glucose intravenously, measure blood sugar after 15 minutes, and closely observe the condition.
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