Dialysis meets devices: the use of automated insulin delivery in end stage kidney disease and haemodialysis

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INTRODUCTION: Diabetes management in end-stage kidney disease (ESKD) presents unique challenges due to perturbations in renal physiology. ESKD influences the pharmacokinetics of insulin and glucose metabolism, while hemodialysis (HD) adds further complexity. There is an unmet need for adaptable therapies to help glucose management in ESKD. Automated insulin delivery (AID) may provide a solution to the dynamic, complex physiology of diabetes in ESKD on HD. AREAS COVERED: We provide a narrative review of the pathophysiology of diabetes in ESKD on HD and the role of AID in this setting. Literature search included PubMed/MEDLINE and Scopus. We included manuscripts published between 2000 and 2025 focussed on the pathophysiology of diabetes in people with ESKD on HD and 2015 to 2025 for AID use in the setting of ESKD on HD. EXPERT OPINION: Our review of the pathophysiology of diabetes in ESKD on HD and the utilization of AID in this setting highlights the need for further research to establish the evidence base for this technology in this high-risk population. The available data support the use of AID systems as they provide greater flexibility in insulin delivery, increase time within target range (3.9-10 mmol/L), and reduce glycemic variability and hypoglycemia, thus emerging as a promising treatment modality in people with insulin-treated diabetes and ESKD on HD.

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