Letter to the Editor
Nephron 1992:61:470 471
A.H. Tzamaloukas
Pratap S. Avasthi
Hypoglycemia during Hemodialysis
VA Medical Center,
Albuquerque, N.Mex.. USA
in Diabetics Treated with Insulin
Dear Sir,
Hypoglycemia is a potentially lethal com­
plication of renal failure and dialysis [1-4],
Hemodialysis against a hath containing no
glucose may aggravate this complication.
Certain other features of the patients, such as
insulin injections and glycemic control, could
also potentially affect dialysis-induced hy­
poglycemia. We compared 16 diabetic pa­
tients who had frequent (in more than 25% of
the measurements) hypoglycemia (blood glu­
cose <3.3 mmol/l) during or immediately
after hemodialysis (group A) to another
16 diabetic patients who had infrequent (in
less than 10% of the measurements) hypogly­
cemia during or immediately after hemodial­
ysis (group B). Only I patient in group B was a
woman. Hemodialysis was performed against
a bath containing acetate as a substrate for
bicarbonate and no glucose. All patients were
receiving insulin throughout the dialysis peri­
od. No subject received drugs associated with
hypoglycemia in dialysis patients, such as ()-
adrenergic blocking agents or aspirin. Blood
glycosylated hemoglobin was measured by a
method suitable for dialysis patients [5], Sta­
tistical comparison was carried out by the
two-tailed Student’s t test for continuous var­
iables and by the %2 test for categorical var­
iables.
Table I shows the comparison of the two
groups. All parameters of glycemic control
were statistically worse in group A than in
group B. Furthermore, whereas in group A
hypoglycemia was more frequent during dial­
ysis than in routine predialysis measurements
(p <0.001), its frequency did not differ be­
tween blood samples obtained during or im­
mediately after dialysis and those obtained
A. 11. Tzamaloukas
Renal Section (IIIC), VA Medical Center
2100 Ridgecrest Dr. S t
Albuquerque. NM 87108 (USA)
before dialysis in group B. In group A. hypo­
glycemia was symptomatic during dialysis in
more than 60% of the instances requiring glu­
cose infusion. In contrast, in group B hypo­
glycemia was usually not severe and asympto­
matic, and was discovered in the course of
routine postdialysis blood measurements. A
consequence of this difference between
groups A and B was that the frequency of
blood glucose determinations during or im­
mediately after dialysis was 4 times higher in
group A than in group B. Deaths from hypo­
glycemia during or immediately after dialysis
were not noted in either group.
The development of hypoglycemia during
hemodialysis was probably facilitated by the
absence of glucose in the bath, with conse­
quent net loss of blood glucose into the dialy-
sate. and by the presence of acetate in the
bath. Acetate inhibits the release of an insu-
lin-counterregulatory hormone [6], During
the last 2 years, we have been routinely dialyz­
ing diabetics against a bath containing bicar­
bonate and glucose in a concentration of
11.1 mmol/l. Although the diabetics currently
dialyzed by this regime are different from
those included in groups A and B, the inci­
dence of symptomatic hypoglycemia has
been very low in the past 2 years, even in
diabetics with poor glycemic control, who
exhibit at times predialysis hypoglycemia.
Diabetics receiving insulin, who have
poor glycemic control, are prone to severe
hypoglycemia during hemodialysis. It ap­
pears that the use of a dialysate containing
bicarbonate and glucose prevents to a great
extent this dialysis-induced hypoglycemia.
© 1992 S. Karger AG. Basel
0028-2766/92/
0614-0470S2.75/0
 Table 1. Demographic parameters and
Group A Group B p value
glycémie control
Age, years 3 8 -6 8 3 2 -7 5
53 ± 9 58 ± 11 NS
1DDM/NIDDM 10/6 5/11 NS
Daily insulin, U 8 -6 0 8 -4 5
29+14 21 ± 11 NS
Dialysis duration, months 3 -7 8 10-126
22 ± 21 41 ±33 <0.05

CO

OC
Glucose, mmoI/la 5.4-10.0

1
II.5 ±4.2 7.5 ±1.4 <0.005

00
sC
Glycosylated hemoglobin, % 8.1-16.8

1
11.8 ±2.5 7.0 ±1.1 <0.001
Hyperglycemia, %b 0 -7 6 0 -3 3
35 ±22 9 ± 10 <0.001
Hypoglycemia, W 4 -3 8 0 -1 1
19 ± 11 3±3 <0.001
Dialysis hypoglycemia, %u 2 5 -6 8 0 -6
43 ±14 3±2 <0.001

Results on the first line are the range, on the second line, the mean ±S D .
IDDM = Insulin-dependent diabetes mellitus; NIDDM = non-insulin-dependent diabetes
mellitus.
11 Routine predialysis blood values.
b Routine predialysis blood glucose levels >11.1 mmol/!.
c Routine predialysis blood glucose levels <3.3m m ol/l.
ll Blood glucose levels <3.3 mmol/l during or immediately after hemodialysis.

References

1 Block MB, Rubenstein AH: Spontaneous hy­
poglycemia in diabetic patients with renal insuf­
ficiency. JAMA 1970:213:1863-1866.
2 White MG, Kurtzman NA: Hypoglycemia in
diabetics with renal insufficiency. JAMA 1971:
215:117.
3 Greenblatt DJ: Insulin sensitivity in renal fail­
ure. Fatal hypoglycemia following dialysis. NY
State J Med 1974:74:1040-1041.
4 Avram MM, Wolf RE, Gan A, Pahilan AN. Paik 6 Orskov H, Hansen AP, Hansen HE, Alberti
SK, Iancu M : Uremic Hypoglycemia. A preven­ KGMM, NoyGA, Nosadini R: Acetate: Inhibi­
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5 Tzamaloukas HA. Hsi 1C, Quintana BJ. Merlin doctrinol 1982;99:551-558.
TL, Avasthi PS: Glycosylated hemoglobin mea­
sured by affinity chromatography in diabetic
and non-diabetic patients on chronic dialysis.
West J Med 1989;150:415-419.

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