Using automated insulin delivery to address the clinical challenges of glycemic management in people with type 1 diabetes and kidney failure on maintenance hemodialysis

Diabetes management in end-stage kidney disease (ESKD) is complicated by altered insulin pharmacokinetics and glucose metabolism, particularly in the context of hemodialysis (HD). Automated insulin delivery (AID) systems offer dynamic insulin adjustment and may help address these challenges. We present real-world data from nine individuals (five females) with type 1 diabetes and ESKD on HD, median age 38 years (range 33-50). Over a median follow-up of 7 months (range 1.5-25), AID use led to significant improvements in glucose time in range (3.9-10 mmol/l) which increased from 39.7% to 59.8% (P = 0.001), glucose variability decreased from 39.8% to 33.8% (P = 0.01), and HbA1c improved from 78.6 to 56.1 mmol/mol (P = 0.003). Time below range fell from 4.0% to 1.4%, but this was not significant (P = 0.1). AID was well tolerated and implemented with multidisciplinary support. Our findings highlight the potential of AID to improve glycemic control in this high-risk population and the need for further studies in this area.