The use of automated insulin delivery system in people with type 1 diabetes and end stage kidney disease on hemodialysis.

Managing patients with type 1 diabetes (T1D) with end stage kidney disease (ESKD) on hemodialysis presents unique challenges due to altered insulin kinetics and rapid glucose fluxes. We report the case of a 48-year-old female with long-standing T1D and ESKD who suffered from severe glycemic variability and recurrent hypoglycemia despite intensive insulin management. The patient was transitioned to the Medtronic MiniMed™ 780G automated insulin delivery (AID) system. Although glycemic control generally improved, she experienced frequent intradialytic hypoglycemia and hypotension. A specialized protocol was implemented to mitigate these risks: setting a temporary glucose target of 150 mg/dL (SI: 8.3 mmol/L) (reference range, 70-180 mg/dL [SI: 3.9-10 mmol/L]) two hours prior to dialysis, suspending the pump upon dialysis initiation, and resuming delivery only when sensor glucose exceeded 200 mg/dL (SI: 11.1 mmol/L). Following this adjustment, intradialytic adverse events were resolved, and the patient achieved a time in range of 69% with a glucose management indicator (GMI) of 7.0%. This case demonstrates that while standard AID algorithms are not calibrated for dialysis, they can be safely employed in ESKD patients through tailored modifications, specifically strategic pump suspension and proactive target elevation.