Rates of hypoglycemic, hyperglycemic crises high in patients with diabetes and ESKD

The results of a retrospective study of U.S. data in patients with both diabetes and end-stage kidney disease (ESKD) indicate that current glycemic monitoring and treatment in this population are suboptimal, the authors said.

Patients with diabetes and end-stage kidney disease (ESKD) are vulnerable to hyperglycemic and hypoglycemic crises, and hypoglycemic crises were especially common in patients who were Black, female, or younger, according to a recent study.

Researchers used data from the U.S. Renal Data System Registry between 2013 to 2017 to perform a retrospective study of adults with diabetes and ESKD and determine annual trends of severe hypoglycemic and hyperglycemic crises. Included patients were required to have an established diabetes diagnosis as of the index date and to have been receiving dialysis for at least three months. The primary outcome was annual rates of ED visits or hospitalizations for these events, with adjustment for patient age, sex, race/ethnicity, type of dialysis, comorbid conditions, treatment regimen, and U.S. region. The study results were published Nov. 5 by Diabetes Care.

Overall, 521,789 adults with diabetes and ESKD were included in the study. The median age was 65 years, 56.1% were men, and 46% were White, with 43% from the Southern U.S. The overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. Older patients had lower risk of both hypoglycemic and hyperglycemic crises; the incidence rate ratios (IRRs) in patients ages 75 years and older versus those ages 18 to 44 years were 0.35 (95% CI, 0.33 to 0.37) and 0.03 (95% CI, 0.02 to 0.03), respectively.

Risk for both hypoglycemic or hyperglycemic crises was increased in several other subgroups, with respective IRRs of 1.09 (95% CI, 1.06 to 1.12) and 1.44 (95% CI, 1.35 to 1.54) in women, 1.36 (95% CI, 1.28 to 1.43) and 1.71 (95% CI, 1.53 to 1.91) in patients who smoked, 1.27 (95% CI, 1.15 to 1.42) and 1.53 (95% CI, 1.23 to 1.9) in patients with substance misuse, and 1.10 (95% CI, 1.06 to 1.15) and 1.36 (95% CI, 1.26 to 1.47) in patients with retinopathy. Risk for hypoglycemic crises was increased among Black patients (IRR, 1.11; 95% CI, 1.08 to 1.15) and those with a history of amputation (IRR, 1.20; 95% CI, 1.13 to 1.27).

The researchers noted that the study was retrospective, that they did not have access to data on social determinants of health, and that they could not differentiate between diabetes type or method of dialysis. They concluded that rates of hypoglycemic and hyperglycemic crises were high in this population, with younger patients, women, and non-Hispanic Black patients experiencing the highest rates of the former and young patients and women particularly affected by the latter. These results suggest that current glycemic monitoring and treatment in patients with diabetes and ESKD are suboptimal, the authors said.

“For patients already bearing high morbidity, mortality, and health care use burdens, these data represent a call for action for innovative and personalized strategies that can decrease these preventable—and in many cases iatrogenic—acute diabetes complications in this population,” they wrote. “A multidisciplinary management team, including endocrinologists/diabetologists, pharmacists, and [certified diabetes care and education specialists], and use of [continuous glucose monitoring] should be incorporated in dialysis centers to help prevent these avoidable acute glycemic complications.”