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
Dr. Umesh Khanna
Lancelot Kidney and GI centre, D1/D2, Bharat Baugh, Lancelot Compound, SV Road Borivali West Mumbai - 400 092
|How to cite this article:|
Khanna U. Management of hyperglycemia in dialysis patients without compromising nutritional status.J Renal Nutr Metab 2020;6:102-105
|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 2022 Dec 5 ];6:102-105
Available from: http://www.jrnm.in/text.asp?2020/6/4/102/321986
The topic has two practical issues which need deliberation;
Management of hyperglycemia in dialysis patientsManaging 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:
Diabetic dialysis patients have either increased insulin resistance causing hyperglycemia or increased insulin availability causing frequent attacks of hypoglycemiaHbA1C measurement may not be accurate in these patients, thus making home blood glucose monitoring complicatedAnti-diabetic drugs and their active metabolites may be renally excreted so you cannot use the majority of oral hypoglycemic drugs to treat DMDialysis treatment can alter blood glucose levels, leading to YO-YO effect in monitoring blood sugarOne-third of diabetic dialysis patients have normal sugars and HbA1C <6%, not requiring any treatment, the so-called “burnt out diabetes”Some patients develop spontaneous hypoglycemia during dialysis, even when not taking any antidiabetic drugsThe 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
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) symptomsSulphonylureas 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 hypoglycemiaMeglitinides, 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 agentsSmall dose of DPP4 inhibitors such as Sitagliptin and saxagliptin can be usedThiazolidinediones: Pioglitazone can cause fluid retention and CCF and hence should be avoidedThe new SGLT2 inhibitors: empagliflozin, etc., are cardio friendly but contraindicated in dialysis.
Use of Insulin in Dialysis Patients
Thus, almost all oral hypoglycemic agents are contraindicated, and insulin is the drug of choice, with a few caveats
Insulin requirement will reduce as the stage of CKD advancesDose of insulin should be reduced on dialysis day as compared to nondialysis dayLong-acting insulin and insulin analogs should be avoidedPeri-lunch time: Short-acting insulin is the treatment of choicePeculiarly fasting blood sugar is low and postlunch sugars are high in the majority of dialysis patientsAlthough 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
Dialysis patients have irregular eating timings due to irregular dialysis schedule and hence fluctuating blood sugar levels and variable insulin doses
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
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 dialysisDiabetic gastropathy and autonomic enteropathy make them prone to nausea, vomiting, early satiety, diarrhea, and alternating constipationPoverty, distance to travel, and nonavailability of dialysis facility can lead to underdialysis and poor intake of foodControlling fluids or water intake is a challenge in such patients as they have excessive thirst due to following reasons:
Hyperglycemia and uncontrolled sugars leading to thirstDrugs such as antihypertensives, antianxiety or antidepressants, anti-itching, or antihistaminics can also cause dryness of mouth, leading to increased fluid intakeAutonomic neuropathy and diabetic gastropathy cause dryness of mouth and increase thirstSudden 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.
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 fruitsChallenges 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 importanceLimiting the role of saturated fats, transfats to reduce the risk of cardiovascular diseaseProviding 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
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). 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.
KDOQI guidelines mention an energy intake of 35 Kcal/kg body weight to achieve neutral nitrogen balance in stable diabetic dialysis patients. 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.
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.
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.
Poor glycemic control can lead to a vicious cycle of thirst and polydipsia, increasing problems with fluid management. Therefore, a patient with poorly controlled diabetes will continue to be at risk of a higher interdialytic weight gain (IDWG). The European Best Practice Guidelines recommend maximum IDWG of 2–2.5 kg (4%–4.5% of dry weight). 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.
K+ is found mainly in fruits, vegetables, pulses, legumes, nuts, milk, and milk products. 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 and form part of healthy eating guidelines. 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. 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.
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. 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
Conflicts of interest
There are no conflicts of interest.
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