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Table of Contents
CLASSROOM READING
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 102-105

Management of hyperglycemia in dialysis patients without compromising nutritional status


Nephrologist, Lancelot Kidney and GI Centre, D1/D2, Bharat baugh, Lancelot compound, SV Road Borivali West Mumbai, India

Date of Submission27-Jun-2021
Date of Acceptance27-Jun-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Umesh Khanna
Lancelot Kidney and GI centre, D1/D2, Bharat Baugh, Lancelot Compound, SV Road Borivali West Mumbai - 400 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_12_21

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How to cite this article:
Khanna U. Management of hyperglycemia in dialysis patients without compromising nutritional status. J Renal Nutr Metab 2020;6:102-5

How to cite this URL:
Khanna U. Management of hyperglycemia in dialysis patients without compromising nutritional status. J Renal Nutr Metab [serial online] 2020 [cited 2021 Sep 26];6:102-5. Available from: http://www.jrnm.in/text.asp?2020/6/4/102/321986



The topic has two practical issues which need deliberation;

  1. Management of hyperglycemia in dialysis patients
  2. Managing them without compromising nutritional status.


Challenges of treating hyperglycemia in diabetic dialysis patients are many, chief among which are the issues of diabetes, chronic kidney disease (CKD), the process of dialysis, associated metabolic syndrome, and comorbid problems of cardiovascular (CVS) disease and diabetic complications.

Some of these issues are highlighted below:

  1. Diabetic dialysis patients have either increased insulin resistance causing hyperglycemia or increased insulin availability causing frequent attacks of hypoglycemia
  2. HbA1C measurement may not be accurate in these patients, thus making home blood glucose monitoring complicated
  3. Anti-diabetic drugs and their active metabolites may be renally excreted so you cannot use the majority of oral hypoglycemic drugs to treat DM
  4. Dialysis treatment can alter blood glucose levels, leading to YO-YO effect in monitoring blood sugar
  5. One-third of diabetic dialysis patients have normal sugars and HbA1C <6%, not requiring any treatment, the so-called “burnt out diabetes”
  6. Some patients develop spontaneous hypoglycemia during dialysis, even when not taking any antidiabetic drugs
  7. The ACCORD study has shown that more aggressive lowering of blood sugars by targeting HBA1C <6% compared to 6%–7% or even 7%–9% is harmful and should be avoided. Infarct Kidney Disease Outcomes Quality Initiative [KDOQI] and kidney disease: Improving Global Outcomes have both targeted HBA1C targets >7% in dialysis patients.



  Role of oral Hypoglycemics in Diabetic Patients Top


  1. Alpha-glucosidase inhibitors such as voglibose and acarbose are not advised as their metabolites are renally excreted and also because they cause a lot of glycemic index (GI) symptoms
  2. Sulphonylureas only short-acting is preferred, especially those which are metabolized in the liver as they are reasonably safe in early CKD. Small dose of glipizide is the safest as it is metabolized by the liver and has a very low risk of hypoglycemia
  3. Meglitinides, for example, repaglinide or nateglinides: smaller dose can be used because they are metabolized by the liver and have a lower risk of hypoglycemia but they are weaker agents
  4. Small dose of DPP4 inhibitors such as Sitagliptin and saxagliptin can be used
  5. Thiazolidinediones: Pioglitazone can cause fluid retention and CCF and hence should be avoided
  6. The new SGLT2 inhibitors: empagliflozin, etc., are cardio friendly but contraindicated in dialysis.



  Use of Insulin in Dialysis Patients Top


Thus, almost all oral hypoglycemic agents are contraindicated, and insulin is the drug of choice, with a few caveats

  1. Insulin requirement will reduce as the stage of CKD advances
  2. Dose of insulin should be reduced on dialysis day as compared to nondialysis day
  3. Long-acting insulin and insulin analogs should be avoided
  4. Peri-lunch time: Short-acting insulin is the treatment of choice
  5. Peculiarly fasting blood sugar is low and postlunch sugars are high in the majority of dialysis patients
  6. Although continuous ambulatory peritoneal dialysis (CAPD) patients can be given intraperitoneal insulin inside the CAPD bag, the standard subcutaneous insulin is still a preferred method.



  Challenges of Planning Diet and Treating Hyperglycemia in Dialysis Patients Top


  1. Dialysis patients have irregular eating timings due to irregular dialysis schedule and hence fluctuating blood sugar levels and variable insulin doses


  2. Poor appetite due to intermittent dialysis could be on one hand due to predialysis volume overload, breathlessness, liver stretching, abdominal fullness, and on the other hand, due to postdialysis tiredness, fatigue, and washout feeling which can again compromise food intake

  3. In a dialysis patient, there is a fear of hypoglycemia with diabetic drugs and poor food intake, but there is also a fear of low BP while eating due to diversion of blood flow to intestines and the fear of rebound hyperglycemia while administering glucose on dialysis
  4. Diabetic gastropathy and autonomic enteropathy make them prone to nausea, vomiting, early satiety, diarrhea, and alternating constipation
  5. Poverty, distance to travel, and nonavailability of dialysis facility can lead to underdialysis and poor intake of food
  6. Controlling fluids or water intake is a challenge in such patients as they have excessive thirst due to following reasons:


    1. Hyperglycemia and uncontrolled sugars leading to thirst
    2. Drugs such as antihypertensives, antianxiety or antidepressants, anti-itching, or antihistaminics can also cause dryness of mouth, leading to increased fluid intake
    3. Autonomic neuropathy and diabetic gastropathy cause dryness of mouth and increase thirst
    4. Sudden ultrafiltration and fluid removal during dialysis will cause excessive thirst forcing patients to drink more water and leading to fluid overload, thereby setting up a vicious cycle of increase water intake between dialysis and increased water removal on dialysis.


  7. Challenges of hyperkalemia: Diabetic patients have Type IV renal tubular acidosis which makes them prone to hyperkalemia. This can turn severe and life-threatening sometimes, especially if they are on some drugs such as ACEI/ARBS/spironolactone/B-blockers/heparin. Hyperkalemia can also occur due to diet containing vegetables, complex carbohydrates, legumes, and fruits
  8. Challenges of salt restriction: Salt is described as a white poison for many of these patients as dialysis patients carry a very high risk of hypertension, volume overload, and CVS disease. In fact, the most common cause of mortality is sudden cardiac death. Hence, salt restriction is of paramount importance
  9. Limiting the role of saturated fats, transfats to reduce the risk of cardiovascular disease
  10. Providing appropriate calories to avoid malnutrition and malnutrition, inflammation, and atherosclerosis (MIA) syndrome and at the same time avoiding obesity considering their restricted level of physical activity is a big challenge.



  How to Plan A Diabetic Dialysis Diet Top


Protein energy wasting

Approximately 40% of dialysis patients exhibit some degree of protein and energy malnutrition and this is associated with low albumin, increased risk of morbidity and mortality, and MIA syndrome.

A change of mindset from low-protein diet before dialysis to high-protein on dialysis must be swiftly achieved with more emphasis on high biological value proteins. Protein intake should be planned up to 1.2 gm/kg for HD patients and at least 1.3 gm/kg in CAPD patients (KDOQI guidelines).[1] Good protein sources include dairy products, egg whites, lean meat, pulses, and soy protein. Protein supplements can be added to diet if the patient is malnourished or having poor appetite.

Energy

KDOQI guidelines mention an energy intake of 35 Kcal/kg body weight to achieve neutral nitrogen balance in stable diabetic dialysis patients.[1] Patients with CAPD receive part of their energy requirements from glucose in CAPD fluid.

For HD patients giving supplements on the day of dialysis helps as shown by Shah et al. in JAPI and for CAPD patients, they should be encouraged to eat after fluid drain out and to wait for 20–30 min before commencing the next dialysate bag. Avoiding fluid at mealtimes can also improve appetite by minimizing stomach distension. If energy requirements are not achieved despite improving dietary intake, nutritional supplements should be considered.[2]

Carbohydrates

Since strict maintenance of HBA1C <6% is not required, we can be liberal in giving carbohydrates in dialysis patients. It is recommended to take 20–30 g of carbohydrates just before dialysis and 10–20 g of a low glycemic index carbohydrate is recommended in the second hour of hemodialysis for patients who develop hypoglycemia during dialysis.[2]

Salt and fluid

In end-stage renal disease on dialysis, sodium intake is directly correlated to interdialytic weight gain in maintenance dialysis patients. Fluid retention over time in any stage of CKD increases the risk for comorbidities such as uncontrolled hypertension, left ventricular hypertrophy, pulmonary edema, and cardiovascular disease. Salt intake should be limited to 6 g salt/day. It should be restricted to much <6 g/day and liquid <1 L/day, if there is anuria. Residual urinary excretion is maintained for longer periods of time in PD patients than in HD; hence, fluid and sodium intake can initially be little more liberal in PD patients.[3]

Poor glycemic control can lead to a vicious cycle of thirst and polydipsia, increasing problems with fluid management.[4] Therefore, a patient with poorly controlled diabetes will continue to be at risk of a higher interdialytic weight gain (IDWG).[5] The European Best Practice Guidelines recommend maximum IDWG of 2–2.5 kg (4%–4.5% of dry weight).[6] Salt restricted diet may be less palatable to most patients. Salt seasonings such as amchur, vinegar, kokum, spices, ginger, garlic, and lemon (in moderation) can be added in food to increase the palatability.

Potassium

K+ is found mainly in fruits, vegetables, pulses, legumes, nuts, milk, and milk products.[7] Consumption of these foods is generally encouraged in the management of diabetes with normal kidney function as they mostly have a low-to-moderate GI[8] and form part of healthy eating guidelines.[9] However, in dialysis patients, dietary freedom with fruits and vegetables is feasible only and only if low K+, carbohydrate options (pasta, rice, noodles, and bread) are encouraged in place of potatoes and other starchy root vegetables. Combining low K+ carbohydrates, fruit or vegetable options with appropriate cooking methods should allow even the dialysis patient to achieve healthy eating guidelines.[9] Other causes of hyperkalemia such as medications, dialysis inadequacy, recirculation, acidosis, constipation, and spurious results should be investigated and corrected before advising on low potassium dietary advice. Commercial salt substitutes, for example, Lona salt and rock salt are too high in potassium and hence to be restricted.[10]

Phosphorus

High-protein diet would mean a higher phosphate load and hence you need the services of a renal dietitian to guide HD patients. Foods containing phosphate additives should not be allowed. Low phosphate dietary advice should be provided to maintain serum phosphate 2.7–4.5 mg/dl.[11] Low phosphate dietary advice means the reduction of dairy foods, eggs, seafood, and nuts. These foods, however, are also sources of high biological protein and may be an essential part of the diet for this population. Education on the management of diabetes may have already included reducing the amount of biscuits, cakes, desserts, processed meats and meat products, cake mixes, and fizzy drinks, which can be high in phosphate additives. Although whole-grain products are high in phosphate, phosphate is unlikely to be absorbed due to the phytate content, so they should not be avoided. These products could in fact be encouraged and may help diabetes control due to their low GI.

  • Acidosis correction: acidosis can lead to mineral bone disease worsening. Hence, correcting acidosis is helpful. However, vegetables and some fruits which help in correcting acidosis have a limited role in dialysis patients.
  • Replacing mineral and vitamins: Dialysis can wash away the vitamins; hence, these patients require vitamin supplements challenges facing a renal dietitian.


The planning and execution of a healthy and nutritious diet and balancing the contradictory and complementary needs in these patients is a tight rope walk and a fine balancing act, especially in India.

The dietician has to remember that “Taste, convenience, and cost are the driving factors in food selection all over the world and so also in the dialysis patients.”

Dieticians need to keep in mind before planning diet, a patient's food preferences, culture, religion, fasting habits, lifestyle, socioeconomic status, workforce shortages, and facilities to cook and most important poverty and hence inability to eat, nutritious expensive diets, and protein supplements.

They have to struggle to change the mindset of patients who are stuck in the predialysis mode of low-protein diet and convert him to high-protein, high-energy mode and they have to struggle with planning a tasty diet with minimum salt and tackling poor appetite due to gastropathy, dysgeusia, medicine-related constipation, inadequate dialysis and uremia, inflammatory state of dialysis, and changing dialysis schedules.

The least we can do as nephrologists is to convince our dialysis unit to invest in services of qualified renal nutritionists and the nephrology community should train more dietitians and hold more workshops and seminars to inculcate the nuances of renal nutrition in dieticians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kidney Disease Outcomes Quality Initiative. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease (2007): Guideline 5; Nutritional Management in Diabetes and Chronic Kidney Disease. Available from: http://www2.kidney.org/professionals/KDOQI/guideline_diabetes. [Last accessed on 2016 Feb 20].  Back to cited text no. 1
    
2.
Frankel A, Kazempour-Ardebili As, Bedi Ra, Chowdhury Ta, Parijat De, El-Sherbini N, et al. Management of Adults with Diabetes on the Haemodialysis Unit April 2016 Joint British Diabetes Societies for Inpatient Care. 2016;16:69-77.  Back to cited text no. 2
    
3.
Faidon Magkos, Mary Yannakoulia, Jean L. Chan, and Christos S. Annu Rev Nutr. 2009;29:223-56.  Back to cited text no. 3
    
4.
O'Toole SM, Fan SL, Yaqoob MM, Chowdhury TA. Managing diabetes in dialysis patients. Postgrad Med J 2012;88:160-6.  Back to cited text no. 4
    
5.
Davenport A. Intradialytic weight gain in diabetic haemodialysis patients and diabetic control as assessed by glycated haemoglobin. Nephron Clin Pract 2009;113:C33-7.  Back to cited text no. 5
    
6.
Fouque D, Vennegoor M, Ter Wee P, Wanner C, Basci A, Canaud B, et al. European best practice guideline on nutrition. Nephrol Dial Transplant 2007;22 Suppl 2:ii45-87.  Back to cited text no. 6
    
7.
McCance, R.A. and Widdowson, E.M. McCance, Widdowson's. The Composition of Foods. 6th ed. royal society of Chemistry/Glycaemic Index (GI).  Back to cited text no. 7
    
8.
Diabetes UK. Glycaemic Index. Available from: https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/GlycaemicIndex-GI. [Last accessed on 2016 Feb 15].  Back to cited text no. 8
    
9.
NHS Choices; 2011. The Eatwell Plate. Available from: http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx. [Last accessed on 2016 Feb 12].  Back to cited text no. 9
    
10.
Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ 2009;339:b4114.  Back to cited text no. 10
    
11.
National Institute for Health and Care Excellence. Chronic Kidney Disease (Stage 4 or 5): Management of Hyperphosphatemia: NICE Clinical Guideline 157; 2013. Available from: https://www.nice.org.uk/guidance/cg157. [Last accessed on 2013 Feb 15].  Back to cited text no. 11
    




 

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Role of oral Hyp...
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