Glycemic management in patients with diabetes and end-stage renal disease (ESRD) is challenging. There is limited evidence about the incidence of severe hypoglycemia and hyperglycemia in this population. Here, we examine rates of emergency department visits and hospitalizations for severe hypoglycemia and hyperglycemia (ascertained using validated ICD-9/10 codes) in a national cohort of adults with diabetes and incident ESRD, included in the United States Renal Data System, between 2010-2015. We then examine risk factors for these events using logistic regression. Among 678,376 patients with ESRD, 59.5% (n=403,490) had diabetes (63.6±13.0 years, 56.4% male, 26.8% Black, and 18.0% Hispanic). Rates of severe hypoglycemia and hyperglycemia were 126.2 and 35.5 per 1000 person-years, respectively. Strongest risk factors for hypoglycemia were insulin therapy (OR 4.5 [95% CI, 4.4-4.6] vs. no medications) and non-insulin diabetes medications (OR 3.7 [3.6-3.8]); Black race (OR 1.3 [1.3-1.4] vs. Caucasian); older age: 65-74 years (OR 1.2 [1.1-1.3] and ≥75 years OR 1.1 [1.1-1.1] vs. 18-44 years); and history of amputation (OR 1.4 [1.4-1.5]) or retinopathy (OR 1.2 [1.2-1.3]). Strongest risk factors for hyperglycemia were insulin (OR 7.7 [7.4-8.2]) and non-insulin diabetes medication use (OR 2.8 [2.6-3.1]) and retinopathy (OR 1.5 [1.4-1.5]). Older age was protective for hyperglycemia (OR 0.1 [0.1-0.1] for age ≥75 and 0.2 [0.2-0.2] for age 65-74 vs. 18-44 years). Patients on peritoneal dialysis had a lower risk (OR 0.8 [0.8-0.9]) of hypoglycemia, but no difference in odds of hyperglycemia, compared to patients on hemodialysis.
Hypoglycemia requiring ED/hospital care was 3.6-fold more prevalent than severe hyperglycemia, greatly exceeding rates previously reported for older adults and those with non-end stage chronic kidney disease. There is a critical need for proactive interventions to reduce hypoglycemia and related ED/hospital use in this high-risk population.
R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. M.K. Ali: Research Support; Self; Merck & Co., Inc. N. Shah: None. S. Funni: None. G.E. Umpierrez: None. R.G. McCoy: None.
National Institute of Diabetes and Digestive and Kidney Diseases (P30DK111024)