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Draft: not yet reviewed by a clinician

Use this page to prepare questions for your care team. It does not replace their advice. Your own targets and doses come from your nephrologist, diabetes team and renal dietitian.

Insulin and glucose on dialysis and after a transplant

No doses on this page

This handbook never gives insulin or medicine doses and never tells you to change one. Your prescriber sets every dose and every change, and writes down when to pause a medicine and when to restart it. A low blood glucose is always treated straight away: see Treating a low and Get help now.

In short

Dialysis and transplant medicines change your glucose from day to day. On hemodialysis, glucose often falls during a session, and most lows happen in the 24 hours after it. On peritoneal dialysis (PD), sugar from the dialysis fluid raises glucose, and one PD fluid (icodextrin) makes some meters read falsely high. After a transplant, steroids and tacrolimus push glucose up. In every case your diabetes team changes the insulin plan; your job is to check at the right times, carry fast sugar, use a safe meter, and share your readings (JBDS 2022; ADA–KDIGO 2022).

Why dialysis changes glucose

  • The kidneys normally clear insulin. With kidney failure, insulin stays active longer (ADA–KDIGO 2022).
  • Hemodialysis removes glucose from the blood. It also removes some insulin and some of the hormones that raise glucose. So a dialysis day is very different from a non-dialysis day (JBDS–Renal Association).
  • PD fluid usually contains glucose (dextrose), and your body absorbs much of it (JBDS 2022).
  • A1c is less reliable on dialysis, so your team leans on meter and CGM readings (KDIGO 2022, practice point 2.1.2; A1c).

Hemodialysis (in-center or at home)

Your numbers

When What UK guidance recommends
Before and after every session check glucose
Before the session, glucose under 126 mg/dL the unit gives 20–30 g of slow carbohydrate at the start
Low during or after a session treat with 15 g of fast carbohydrate chosen for your fluid and potassium limits; recheck in 15 minutes
The 24 hours after a session the most likely time for a low: in one study, 3 in 4 lows came within 24 hours of a session
When What UK guidance recommends
Before and after every session check glucose
Before the session, glucose under 7.0 mmol/L the unit gives 20–30 g of slow carbohydrate at the start
Low during or after a session treat with 15 g of fast carbohydrate chosen for your fluid and potassium limits; recheck in 15 minutes
The 24 hours after a session the most likely time for a low: in one study, 3 in 4 lows came within 24 hours of a session

Sources: JBDS 2022, recommendations 5A.1–5A.5; JBDS–Renal Association. US units follow their own policies, so ask yours.

What to know

  • The dialysis fluid (dialysate) should contain glucose for people who use insulin. This helps stop glucose falling during the session (JBDS–Renal Association).
  • Many people need less insulin on dialysis days. How much less is your team's decision. CGM readings from dialysis and non-dialysis days are the best guide (JBDS 2022, recommendation 3B.5). Ask for the plan in writing.
  • Keep a low treatment within reach at all times, including on the way to and from the unit (JBDS 2022, recommendation 5A.3). Glucose tablets add no fluid or potassium.
  • Home hemodialysis: the same rules apply to each session. Sessions are often more frequent or longer, so ask your team how to check around your own schedule.

Peritoneal dialysis

Sugar from the fluid. The longer fluid stays in and the stronger the bag, the more glucose you absorb. On CAPD this can be up to 100–200 g of glucose a day, about 400–800 calories (JBDS 2022). Insulin needs may rise when PD starts or when a stronger bag is added (JBDS 2022, practice point 6.10). The right plan depends on your type of PD and the glucose in your bags, so tell your diabetes team every time your PD prescription changes (JBDS 2022, practice point 6.5).

Insulin goes under the skin. UK guidance advises insulin injected under the skin only, not added to the PD bags (JBDS 2022, practice points 6.8–6.9).

Icodextrin (Extraneal) and glucose meters

Icodextrin, a PD fluid used for one long dwell a day, makes meters that use GDH-PQQ, GDO or GDH-FAD strips read falsely high. A falsely high reading can hide a real low, and extra insulin given for a false high can cause a severe low, coma or death (MHRA). Use only a glucose-specific meter your PD unit approves. False readings can last up to two weeks after the last icodextrin bag. CGM systems "may or may not be compatible", so ask before you rely on one (Extraneal label; JBDS 2022). Tell every hospital and paramedic that you use icodextrin.

UK guidance also says meters using glucose oxidase or GDH-PQQ should not be used by anyone on dialysis (JBDS 2022, recommendation 2.7). Check the strip box or ask your pharmacist which kind you have.

Before a colonoscopy or gynecology procedure, tell your PD unit: ISPD suggests antibiotics first, and draining your PD fluid so your belly is empty for the procedure (ISPD 2022). Plan your insulin for the fasting day with your diabetes team.

After a kidney transplant

  • Glucose usually rises. Steroids and tacrolimus raise glucose, most of all in the first weeks and after treatment for rejection (KDIGO 2009 transplant, chapter 15; Prograf label). Expect your insulin plan to change several times.
  • Lows can still happen, because your insulin plan keeps changing. Keep glucose tablets with you, and keep your glucagon: ADA advises it for everyone who uses insulin (ADA 2026 §6, recommendation 6.16).
  • Pancreas-kidney transplant: a working pancreas can bring glucose back to normal, and insulin may stop. Only your transplant team decides that, and you keep checking glucose (ADA 2026 §9).
  • Anti-rejection medicines are taken every day, on time. Never stop them because glucose or appetite changes (After a transplant).

CGM on dialysis: what to trust

Point What it means for you
Dexcom (G7) and Abbott (Libre 3 Plus, 2 Plus) say not to use their systems if you are on dialysis, because they have not been tested in people on dialysis and readings may be wrong (Dexcom G7 user guide; Abbott) UK guidance still suggests offering CGM on dialysis in some cases (below), so use one only with your team's agreement. Check with a meter when a reading does not match how you feel
CGM trails blood glucose, and the lag is longer with kidney failure (JBDS–Renal Association) A CGM can be late to show a fast fall during or after dialysis
Start a new sensor on a non-dialysis day (JBDS–Renal Association) Avoids the big glucose swings of a session. The 2016 advice was written when sensors needed fingerstick calibration; ask whether it still applies to yours
Some medicines and supplements disturb sensors and make readings look higher than they are: hydroxyurea; acetaminophen (paracetamol) above the label's daily maximum with Dexcom, or at any amount with the Medtronic Guardian 4; high-dose vitamin C with Libre; and mannitol or sorbitol, given into a vein or in a PD fluid, with the Eversense 365 (ADA 2026 §7, recommendation 7.20 and Table 7.4; Dexcom G7 user guide; Abbott) Tell your team about every medicine and supplement
UK guidance suggests real-time CGM for people on dialysis who have repeated lows or do not feel them (JBDS 2022, recommendation 2.9) Ask about one if that is you

More on reading the reports: CGM reports.

What to do

  • Check glucose before and after every hemodialysis session, and treat any low straight away.
  • Pack a dialysis bag: glucose tablets, your meter or CGM reader, and a snack your unit allows.
  • Ask your team for a written insulin plan for dialysis days and non-dialysis days.
  • On PD: check that your meter and strips are glucose-specific, and tell your diabetes team about every change of bag strength.
  • After a transplant: expect insulin changes, and report highs and lows.
  • Log what you eat on dialysis days and your low treatments in the app. Mark your dialysis days in your profile so the app can show them (Dialysis days; First setup).

Examples

  • Low on the bus home. Ken's CGM alarms at 65 mg/dL (3.6 mmol/L) an hour after hemodialysis. He takes 4 glucose tablets, rechecks after 15 minutes (95 mg/dL, 5.3 mmol/L) and tells the nurse at his next session. His team looks at two weeks of CGM data and changes his dialysis-day plan.
  • A new night bag on PD. Grace starts icodextrin for her long night dwell. Her pharmacist checks her meter: it uses GDH-PQQ strips, so she switches to a glucose-specific meter that day.
  • Steroids after a transplant. In the first weeks after his transplant, Luis runs high every afternoon. He sends his readings to the transplant team every few days, and they adjust his insulin plan as the steroid dose falls.

Ask your care team

  1. How should my insulin change on dialysis days? Can I have it in writing?
  2. Does our unit use dialysate with glucose? Do you give a snack if I am low before a session?
  3. Is my meter safe with my PD fluid? Is my CGM?
  4. Should I have a real-time CGM with alarms?
  5. After my transplant, who adjusts my insulin: the transplant team or my diabetes team?

Get help now if…

  • A low the person cannot treat themselves: give glucagon and call 911 (or your local emergency number).
  • Blood ketones 3.0 mmol/L or more, or ketones with vomiting (Sick days).
  • On PD: cloudy fluid or belly pain, call your PD unit the same day and keep the bag (ISPD 2022). After a transplant: fever over 100 °F (37.8 °C), call your transplant center right away (NIDDK; After a transplant). See Get help now.

Sources

Not yet reviewed by a clinician. Facts and sources last checked 2026-10-06.