Prospective Cohort Study Evaluating Impact of Hemodialysis on Glycemia: BLOSSOM (Blood Sugar Sensing On Maintenance Dialysis) Cohort Findings.

KEY POINTS: Hemodialysis disrupts glucose homeostasis: Levels fall during treatment, then rebound sharply afterward, often exceeding baseline. Postdialysis glucose rebound was higher and longer in people with diabetes, especially with insulin, but also occurred in people without diabetes. Hemodialysis disrupts glucoregulatory hormonal balance, and these disruptions may impair postprandial glucose disposal.

BACKGROUND

Hemodialysis affects glycemia in a manner that remains incompletely defined.

METHODS

In a prospective cohort study, 342 participants on maintenance hemodialysis wore a Dexcom G6 Pro continuous glucose monitor (CGM) for 10 days while dialyzing with standardized 100 mg/dl glucose dialysate. We examined glycemia relative to dialysis timing and tested associations of glycemia patterns with clinical characteristics and markers of overall glycemic control. Glucoregulatory hormones were measured before and after dialysis in a subset of 20 participants.

RESULTS

Overall, CGM captured 1001 hemodialysis sessions. Among participants with treated diabetes ( n =143), with untreated diabetes ( n =78), and without diabetes ( n =121), predialysis glucose averaged 212±84, 167±65, and 120±28 mg/dl, respectively. During dialysis, glucose declined by 53±79, 29±55, and 7±32 mg/dl, respectively. After dialysis, glucose rebounded by 115±70 mg/dl (to mean peak 265±84 mg/dl), 95±60 mg/dl (227±71 mg/dl), and 61±35 mg/dl (168±37 mg/dl), respectively, with mean time to peak occurring later in treated (172 minutes after dialysis) and untreated (169 minutes) diabetes compared with no diabetes (140 minutes). Postdialytic rebound glycemia correlated with hemoglobin A1c and mean CGM glucose over the full observation period. Hypoglycemic events <70 mg/dl were uncommon ( N =259); hypoglycemic event rates were significantly higher in the postdialysis period compared with time-matched periods on nondialysis days. There were no significant differences in hypoglycemic event rates before versus after dialysis on dialysis days. In the substudy, most glucoregulatory peptides declined significantly ( P < 0.001) during dialysis, including insulin (median change: -38%), glucagon (-43%), and glucagon-like peptide-1 (-38%).

CONCLUSIONS

Hemodialysis induces intradialytic glucose declines and postdialytic rebound that link to overall glycemic control, highlighting dialysis as a physiologic stressor on glucose homeostasis.