I often see incidents of hypoglycemia during dialysis sessions. This is a common complication of dialysis in most of the hemodialysis centers. Although hypoglycemia is one of the very common complication during haemodialysis, more often inexperienced clinicians may miss these incidents. This article is mainly focus on how to detect hypoglycemia early, how to manage hypoglycaemia and how to prevent it.
Why is the hypoglycemia very common complication during dialysis?
It is true that we often see the patient undergoing clinical and subclinical hypoglycemia during dialysis. But why the dialysis patients are more proven to get hypoglycemic attacks. Is it the dialysis which causing the hypoglycemia? Or some other cause.
Diabetes mellitus can make you hypoglycemic
We know that one of the most common cause for CKD is the diabetes. Patients with diabetes often has high blood sugar levels. This is due to the insulin insensitivity or lack of insulin. So can these patients undergo hypoglycemia during hemodialysis?
Some of these CKD patients on Metformin, some are on other oral hypoglycemic agents like Gliclacide. Even if the metformin do not cause significant hypoglycemia, some other medications can cause the hypoglycemia. In addition Insulin can cause on and off hypoglycaemic events.
Kidney disease can also cause hypoglycemia
Gluconeogenesis is the process of creating glucose inside the body. This mainly occurs when you are in a fasting state. The kidneys are the second most vital organ for this mechanism. It is second only to the liver. When you have CKD, structure of your kidney get damaged and ability of gluconeogenesis is also get reduced. As a result body fails to maintain the adequate amount of the blood sugar levels during dialysis or even at the day to day settings.
Mechanism of dialysis
Dialysis is a complicated process. There is a 15g to 20g of glucose loss during each dialysis session. This loss of plasma glucose can lead to subclnical hypoglycemia in most of the patients. However in some patients they are not fit enough to maintain this loss of glucose during dialysis. Therefore they can get a significant hypoglycemia during dialysis.
Therefore hypoglycemia during dialysis is a multifactorial complication. Although loss of glucose during dialysis do not cause significant symptoms, failure to maintain the gluconeogenesis causing the significant damage to the patient.
How to identify the hypoglycemia during dialysis?
In a usual setting an experienced healthcare professional can identify the hypoglycemic events easily. But during dialysis it is very difficult to identify the hypoglycemic events.
As an experienced clinician I have met patients with blood sugar levels of 20mg/dl but they were almost normal except few symptoms. But this is not a viable blood sugar level in a normal patient.
Therefore you need to have clear understanding about hypoglycemia during dialysis. If you are not specifically look it, you can’t identify most of the hypoglycemia during haemodialysis.
Symptoms of hypoglycemia during dialysis sessions
- Hypotensive attacks
Hypotension is the main symptom of low blood sugar levels during dialysis. If a patient develop a hypotension during dialysis, 1st thing to look is the hypoglycemia. Most of the times it is low blood sugar levels than the depletion of volume or some other cause. - Failure to maintain blood pressure with inotropes
This is a common issue with patients undergoing the urgent hemodialysis due to Acute Kidney injuries. Most of they are critically ill and on inotrope support. But if a patient do not improve with proper inotrope support, we have to look for the hypoglycemia. - Altered level of consciousness
Level of consciousness is a broad term. It include the orientation, the way of talking, level of intelligence and lot of other factors. In some instances I have met CKD patient with less than 20mg/dl blood sugar level with no significant alteration of consciousness.
Case 1. 27years old patient came to regular hemodialysis. He maintained his blood pressure levels and saturation well. No complaints too. But when I talk to him, I found some irrelevance of his sentence to each. I had some suspicion and checked the blood sugar level. It was 17mg/dl and immediate actions were taken.
Case 2. 54years old patient was in his regular haemodialysis. He was given a cup of tea while he was on dialysis. But the staff member noted that he failed to take his tea. He informed me. Then I asked for a blood sugar level. It was 27mg/dl and he was collapsed in few second. Immediate resuscitation was conducted and successfully recovered the patient.
- Sweating during dialysis
Sweating is a very common symptom of hypoglycemia. You can see it even in patients taking medication for diabetes. However surprisingly I rarely met hypoglycemic patients with sweating during dialysis. So I think you have a clear understanding on symptoms of hypoglycaemia during dialysis sessions. Then the next question is how to manage the hypoglycaemia during dialysis.
How to manage hypoglycemia during dialysis?
As I mentioned events of hypoglycemia is common and subclinical most of the times. However there are times you have to attend on events of hypoglycemia. Even if the pre dialysis and intradialysis blood sugar monitoring can be done, it is not a good and presence experience to patients. Even though the basic management of hypoglycemia is same in each complication, you have to attend the case depend on the symptoms too.
Hypoglycemia with hypotention.
Here the management of both hypoglycaemia and the hypotension should be done simultaneously.Soon as you note there is a hypotension the next action is to check the hypoglycemia.
- Start bolus of 100cc normal saline
- Give 1 vial of dextrose
- Reduce the blood flow rate and position the patient
- Repeat the blood pressure and blood sugar in 10 minutes
- If blood sugar is not enough repeat the dextrose infusion
Hypoglycemia with no response to inotropes
Inotropes are the medications to improve the blood pressure in critical patients. They have different actions. It is common that patient face significant reduction of blood pressure soon as they are connected to the dialysis machines. But it can be picked up with these medications. But if these patients do not improve the blood pressure with inotrope, it is worth to check the blood sugar level than next inotrope.
Hypoglycemia with altered level of consciousness
Hypoglycemia is not the only cause for altered level of consciousness during dialysis. There are lot of cause like electrolyte imbalance, stoke and etc. In addition there is a very important condition called Dialysis disequilibrium syndrome.
But before thinking of anything else, you should focus on hypoglycemia during dialysis. Because it is easily preventable cause for altered level of consciousness during dialysis.
Whenever a patient has a reduce level of consciousness;
- Check the blood pressure
- Check the blood sugar levels
- Look at the other neurological features
- Give bolus of dextrose irrespective of blood sugar levels unless it is too high
- Then only you can exclude other causes of altered level of consciousness.
Hypoglycemia with sweating during dialysis
Sweating is another presentation of hypoglycemia. But when someone has the sweating, it myocardial infarction should be ruled out.
- Check all vital parameters
- Give dextrose
- Check urgent ECG
How to prevent hypoglycemia during dialysis
Although hypoglycemia is commonly missed as subclinical incidents, we have to be prepared and look into it properly.
- Ask patient to have proper meal prior to dialysis
- Arrange a mid-dialysis snack or refreshment
- Monitor CBS in high risk patients
Reference:
- Vadakedath, S., & Kandi, V. (2017). Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure. Cureus, 9(8), e1603. https://doi.org/10.7759/cureus.1603
- Abe, M., & Kalantar-Zadeh, K. (2015). Haemodialysis-induced hypoglycaemia and glycaemic disarrays. Nature reviews. Nephrology, 11(5), 302–313. https://doi.org/10.1038/nrneph.2015.38