397-P: Insulin Dosing Adjustments in Patients with Diabetes on Peritoneal Dialysis or Hemodialysis: A Systematic Review of the Literature

Abstract

Chronically uncontrolled hyperglycemia is the leading cause of end-stage renal disease (ESRD) 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, literature is sparse with few clear and direct practical clinical recommendations for therapeutic adjustments. 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 ESRD and diabetes mellitus. A literature search using PubMed, CENTRAL, MEDLINE, CINAHL, Google Scholar, and ClinicalTrials.gov revealed 184 results. After removing duplicates and articles not reaching pre-specified criteria, 29 relevant articles remained for further analysis. 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 as to insulin management with continuous ambulatory PD (CAPD) or automated PD (APD). During PD, insulin may be administered subcutaneously, intraperitoneally, 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 blood glucose. 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. Greater research is needed to clarify ideal alterations in insulin dosing, administration techniques, and product selections for this patient population. Disclosure R. Tumlinson: None. E. Blaine: None. M. Colvin: None. T. G. Haynes: None. H. P. Whitley: None.