Evaluation and management of diabetic and non-diabetic hypoglycemia in end-stage renal disease.

Patients with end-stage renal disease (ESRD) regardless of diabetes status are at increased risk of hypoglycemia with a resultant array of adverse clinical outcomes. Therefore, hypoglycemia should be thoroughly evaluated in ESRD patients. In diabetic dialysis patients, hypoglycemic agents and nutritional alterations can trigger hypoglycemia in the background of diminished gluconeogenesis, reduced insulin clearance by the kidney and improved insulin sensitivity following initiation of renal replacement therapy. Detailed evaluation of antidiabetic regimen and nutritional patterns, patient education on self-monitoring of blood glucose and/or referral to a diabetes specialist may reduce risk of subsequent hypoglycemia. In certain situations, it is important to recognize the possibility of non-diabetic causes of hypoglycemia in patients with diabetes and to avoid treating pseudo-hyperglycemia caused by glucose- non-specific glucometers in patients utilizing icodextrin-based solutions for peritoneal dialysis. Adrenal insufficiency, certain medications, malnutrition and/or infection are among the most common causes of hypoglycemia in non-diabetic ESRD patients, and they should be suspected after exclusion of inadvertent use of hypoglycemic agents. The goal of this review article is to summarize approaches and recommendations for the work up and treatment of hypoglycemia in ESRD.