Effect of Dialysis on Hypo/Hyperglycemia  (Continued)

And we have had the familiar chronic hypoglycemic that looks at you once the issue is resolved and ask if you brought the “refusal” in with you. A recent study may alter the way EMS generally deals with issues like this for many patients.

Many diabetics end up with End-Stage Kidney Disease (ESKD), especially those that are hypertensive. Many of those end up on hemodialysis. A nationwide retrospective study involving 571,789 dialyzed diabetics over a four-year period illustrates that scenarios like the one above are more dangerous than most realize. This includes the patient, the medics, the patient’s PCP, and many times the ED physician. Rodolfo Galindo, MD, associate professor of medicine, Emory University School of Medicine, in Atlanta was lead author on the study stated, "Our results confirmed that patients with diabetes/ESKD are vulnerable to large glycemic excursions and that the current standard of care for glycemic monitoring and treatment for this population is far from optimal."

These are high-risk, potentially life-threatening episodes which patients can easily die from. Galindo states these are not just low blood sugars, these are the most extreme cases that require external help to resolve the event. The report is considered critically important, as it raises awareness about how common severe glycemic disorders, both hypo- and hyperglycemia are, among hemodialysis patients.

Of great concern are the number of patients that neither call EMS nor seek emergency department care.  A substantial concern for EMS is considering the glycemic episode in the context of the patient’s dialysis history, as non-dialyzed patients have a low incidence of this occurring.  Dialyzed patients experience this crisis on a 3-5 times greater level than do non-dialyzed renal patients. Higher incidence rates are seen in younger (18-44 years), female, and black patients.

From an EMS standpoint we obviously cannot violate a patient’s civil rights, and it is within their legal ability, once cognitive, to refuse transport, but we need to be making every effort to fully inform them, sharing this information with them. This is especially important if it is their first glycemic episode, or they routinely take insulin. Insulin therapy patients have a 34% increased risk for hypoglycemia, compared to non-insulin dependent patients. Interestingly, insulin therapy also increases the risk of hyperglycemia by over 70%, compared to those using other antidiabetic medications. One would ostensibly expect this may be, at least partially, in response to hypoglycemic episodes that are overcorrected.  If EMS runs on a patient that is insulin dependent and on dialysis, a suggestion that they speak with their PCP, endocrinologist, or nephrologist about Constant Glucose Monitoring (CGM) could reduce the number of crises they experience because of its predictive function.

Originally published online in Diabetes Care, November 5, 2021. Excerpted from Life-Threatening Swings Common in Patients on Dialysis-Medscape-Nov. 19, 2021