Systematic literature review of insulin dose adjustments when initiating hemodialysis or peritoneal dialysis

Chronically uncontrolled hyperglycemia is the leading cause of end stage kidney disease (ESKD) necessitating dialysis. During times of transition to hemodialysis (HD) or peritoneal dialysis (PD), considerations must be given to insulin dosing adjustments for persons with diabetes (PWD) in efforts to maintain glycemic control. However, the literature is sparse with few clear and direct practical clinical recommendations for therapeutic insulin dosing adjustments in PWD and ESKD. The objective of this systematic review was to identify and report the evidence and gaps in the literature for adjustments in therapeutic insulin recommendations when initiating HD or PD in patients with ESKD and diabetes mellitus. A literature search using PubMed, CENTRAL, MEDLINE, CINAHL, Google Scholar, and ClinicalTrials.gov revealed 242 results. After removing duplicates and articles not reaching pre-specified criteria, 29 relevant articles remained for further analysis. Following the exclusion of 18 articles after full-text review due to lack of relevance or inappropriate publication type, 11 articles remained and were included in the review. The most common recommendation regarding HD was to reduce the basal insulin dose up to 25% on HD days to prevent hypoglycemia, although a lack of consensus exists on the percent reduction. Little information was found relating to insulin management with continuous ambulatory PD or automated PD. During PD, insulin may be administered subcutaneously, IP, or with the dialysis fluid. Administration of insulin with dialysate may necessitate a dose increase of up to 30% due to a loss to tubing and dilution. Furthermore, the use of dextrose-based dialysate may require additional insulin to mitigate systemic impact of dextrose absorption on BG. Overall, a gap exists in the primary literature regarding recommendations for prophylactically adjusting insulin therapy when initiating HD or PD, or when switching between the two. More research is needed to clarify ideal alterations in insulin dosing, administration techniques, and product selections for PWD and ESKD undergoing dialysis.