Hypoglycemia in People with Chronic Kidney Disease and Diabetes

Hypoglycemia refers to low blood sugar. When your blood sugar is low, your body cannot get enough energy. Common symptoms of hypoglycemia include:¹

• Confusion about the current time, place, or situation (disorientation)
• Dizziness
• Slurred speech

Severe hypoglycemia can cause seizures or fainting.¹

Hypoglycemia is a common complication of chronic kidney disease (CKD). CKD is long-term kidney failure. People with type 2 diabetes (T2D) and CKD have an even higher risk of hypoglycemia. This is because kidney problems can cause T2D drugs to lower blood sugar too much. Hypoglycemia is linked to worse health outcomes. Talk to your doctor about how to prevent and treat it.^2,3

How are CKD and T2D linked?

T2D is a major risk factor for CKD. About 40 percent of people with T2D are diagnosed with CKD. T2D damages small blood vessels, including those in the kidneys. This can make it harder for the kidneys to clean your blood. T2D can also damage nerves involved in emptying your bladder. Pressure from your full bladder can damage the kidneys.^3-5

A mix of other factors related to T2D may increase the risk of CKD, such as:⁴

• Obesity or physical inactivity
• Aging
• High blood pressure
• The use of drugs that harm the kidneys
• Smoking or heavy drinking
• A family history of kidney disease
• Low income

Experts recommend that everyone with T2D should be screened for CKD. This includes at the time of T2D diagnosis and at least yearly after that. Early signs of diabetic kidney disease include:⁵

• Increased release in your pee of a protein called albumin
• Weight gain and ankle swelling
• Peeing more at night

How does CKD cause hypoglycemia?

People with CKD have a higher risk of hypoglycemia. About 18 percent of people with CKD have hypoglycemia. This is almost twice as high as the percentage of people without CKD who have hypoglycemia.^2,3

In CKD, the kidneys cannot clean the blood well. For people taking drugs to lower blood sugar, CKD can cause these drugs to stay in the blood longer. This increases the effects of those drugs. This means kidney problems can cause T2D drugs to lower blood sugar too much. The risk of hypoglycemia is higher in people who have had diabetes longer. A high risk of hypoglycemia also applies to people who take:^2,3,6

• Insulin
• Sulfonylureas (a class of drugs to treat T2D)
• Other drugs used to treat diabetes

In addition, kidney problems interfere with gluconeogenesis. This is the process the body uses to make sugar (glucose). These factors combined will increase the risk of low blood sugar in CKD, especially for people with T2D.³

Low hemoglobin A1c (HbA1c) is also a risk factor for hypoglycemia among people with CKD. This measures the percentage, over the past 3 months, of red blood cells (RBCs) that have glucose attached to the RBC protein called hemoglobin. A lower A1c indicates the person has lower long-term blood sugar levels. When treating T2D, your doctor may target higher HbA1c levels if you have CKD.^2,6

How does hypoglycemia affect people with T2D?

Hypoglycemia is linked to worse health outcomes for people with T2D. This is because it makes it harder to control blood sugar. Hypoglycemia can increase the risk of heart complications and death. It can also interfere with your well-being and self-care.^1,2

Hypoglycemia can be mild, moderate, or severe. The levels are defined as:^1,2

• Level 1 (mild): blood sugar above 54 mg/dL but less than 70 mg/dL
• Level 2 (moderate): blood sugar below 54 mg/dL
• Level 3 (severe): inability to function because of low blood sugar

In people with T2D and moderate to severe CKD, level-1 hypoglycemia is the most common. Episodes of hypoglycemia tend to:²

• Last about 100 minutes
• Drop blood sugar levels to around 58 mg/dL
• Happen most often in the early morning (often during sleep)
• Happen about 5 times per month

How is hypoglycemia prevented and treated?

The best way to prevent hypoglycemia is to maintain healthy blood sugar levels. Talk to your doctor about the best approach for you. Your doctor can suggest target blood-sugar levels that are right for your risk level. Prevention methods include:¹

• Eating meals and certain snacks regularly
• Monitoring blood sugar levels
• Following an exercise plan
• Taking recommended drugs

Talk to your doctor about signs of hypoglycemia. Your doctor can suggest ways to treat these symptoms when they happen. This may include taking glucose tablets or eating hard candies. Make sure family and friends know how to help.¹

Your doctor may adjust your treatment for T2D to reduce your risk of CKD and hypoglycemia. This may include changing your drug dose or target blood-sugar levels. Your doctor may also use T2D drugs that slow the progression of CKD. These include sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists.^4,6

Severe hypoglycemia is an emergency. Someone else must step in to help if it happens. You may not be able to act on your own. Treatment involves raising your blood sugar quickly with glucagon. This is a hormone that controls the levels of blood sugar. Glucagon kits are available with a prescription.¹