End-stage renal disease (ESRD) patients with or without diabetes on renal replacement therapy are at high risk for hypoglycemia, highlight the authors of a new clinical article in Nephrology Dialysis Transplantation.

Aidar R. Gosmanov, MD, Elvira O. Gosmanova, MD, and Csaba P. Kovesdy, MD, of the University of Tennessee Health Science Center in Memphis, detailed approaches to hypoglycemia evaluation and management in ESRD patients.

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For ESRD patients with diabetes, clinicians should prescribe antidiabetic medications with low hypoglycemic potential or reduce the dose of secretagogues to reduce the chances of hypoglycemia. Match meal plans to medication and educate patients about glucose self-monitoring.

Recognize pseudo-hyperglycemia caused by glucose non-specific glucometers (which measure maltose) in patients using icodextrin-based solutions for peritoneal dialysis. If hypoglycemia persists, consider other causes such as adrenal insufficiency, infection, and/or other medications. Refer to a diabetes specialist when necessary.   


Several factors can combine and lead to hypoglycemia in ESRD patients without diabetes. The authors recommended following guidelines from the Endocrine Society, including identification of Whipple’s triad, but with caveats.

“Screening for adrenal insufficiency and evaluation for malnutrition and infections are central in evaluation in non-diabetic patients,” they stated. Measure insulin and C-peptide levels to determine whether medications have raised insulin levels. Other common causes of hypoglycemia include alcohol abuse and organ failure. Emerging evidence also shows that antimicrobial therapy may result in hypoglycemia.

The authors provided details for the work up and treatment of hypoglycemia in ESRD. A single treatment may not reverse hypoglycemia, they emphasized. Re-test in 15 minutes after therapy, and repeat treatment if blood glucose remains low. 


  1. Gosmanov AR, Gosmanova EO, and Kovesdy CP. Evaluation and Management of Diabetic and Non-Diabetic Hypoglycemia in End-stage Renal Disease. Nephrol Dial Transplant 31:8-15. doi:10.1093/ndt/gfv258.