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For educational use only — The physician’s written order and the unit protocol always govern
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Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N16 — Glucose, HbA1c, and CGM

Glucose review, symptoms during treatment, or an HbA1c that disagrees with the patient.
Andrew Bland, MD, FACP, FAAP Updated September 2026 Prints on one sheet, front and back
N16 — Glucose, HbA1c, and CGM FRONT
Front · at the chair

When: Glucose review, symptoms during treatment, or an HbA1c that disagrees with the patient.

Do this

  1. Compare HbA1c with capillary glucose or CGM patterns and symptoms. Include treatment days and days off dialysis [1].
  2. Record recent ESA or iron changes, transfusion, blood loss, and anemia. These can change HbA1c without an equivalent change in glucose [1].
  3. For suspected hypoglycemia, check glucose promptly and use the unit treatment and recheck protocol. Confirm a discordant sensor reading with the approved meter method.
  4. Bring recurrent lows, high readings, poor intake, and missed meals to the diabetes prescriber; document timing relative to dialysis and medicines.

Call / escalate

  • Altered consciousness, seizure, inability to swallow, or persistent symptoms: activate emergency assessment and the unit hypoglycemia protocol.
  • Repeated low readings, marked hyperglycemia with illness, or a mismatch between HbA1c and measured glucose: contact the responsible clinician promptly.

Don't

  • Do not call diabetes resolved because HbA1c is low. Dialysis, anemia, and treatment can make HbA1c misleading [1].
  • Do not independently change insulin or apply a single HbA1c target to every dialysis patient.
N16 — Glucose, HbA1c, and CGM BACK
Back · why, and the evidence

Why

  • HbA1c remains useful for follow-up, but its reliability decreases in advanced CKD and is particularly limited during dialysis [1].
  • KDIGO supports CGM-derived glucose management indicator when HbA1c disagrees with measured glucose or symptoms. Direct glucose data help detect variability and hypoglycemia [1].
  • The KDIGO HbA1c target range of below 6.5% to below 8% was written for people not treated with dialysis; it should not be copied into a universal dialysis order [1].

Bring this to the review

Symptoms and timing; glucose or CGM values and confirmation; treatment-day pattern; food intake; diabetes medicines; recent ESA, iron, transfusion, or blood loss; action and recheck.

Go deeper

References

  1. KDIGO 2022 Diabetes in CKD guideline, chapter 2 (glycemic monitoring).

Adapted from the linked Clinical Mastery reviews; updated September 27, 2026. For education; the physician's written order and the unit protocol always govern.