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Impact of visceral adiposity on glycemic variability in patients with insulin-treated type 2 diabetes undergoing hemodialysis
Pedro Gil-Millán, Ascensión Lupiañez, Sonia Caparrós, Alicia Ribas, Shaira Martínez-Vaquera, Ángel Ortiz-Zuñiga, Cristina Hernández, Rafael Simó, Olga Simó-Servat
Pedro Gil-Millán, Ángel Ortiz-Zuñiga, Cristina Hernández, Rafael Simó, Olga Simó-Servat, Department of Endocrinology, Hospital Vall d´Hebron, Barcelona 08035, Catalonia, Spain
Pedro Gil-Millán, Department of Endocrinology, Diaverum España, Barcelona 08030, Catalonia, Spain
Pedro Gil-Millán, Department of Ciberdem, Instituto de Salud Carlos III, Madrid 28029, Spain
Ascensión Lupiañez, Department of Nutrition, Diaverum España, Barcelona 08030, Catalonia, Spain
Sonia Caparrós, Shaira Martínez-Vaquera, Department of Nephrology, Diaverum España, Barcelona 08030, Catalonia, Spain
Alicia Ribas, Department of Nurse, Diaverum España, Barcelona 08030, Catalonia, Spain
Ángel Ortiz-Zuñiga, Cristina Hernández, Rafael Simó, Olga Simó-Servat, Department of Ciberdem, Instituto Carlos III, Madrid 28029, Spain
Author contributions: Gil-Millán P was responsible for conceptualization, patient follow-up, statistical analyses, manuscript drafting, and editing; Lupiañez A was responsible for body composition assessments and supervision of multifrequency bioelectrical impedance analysis procedures; Caparrós S and Ribas A were responsible for patient follow-up and monitoring during hemodialysis sessions; Martínez-Vaquera S and Ortiz-Zuñiga A were responsible for statistical analyses and manuscript revision; Hernández C was responsible for conceptualization, supervision, manuscript editing, and funding acquisition; Simó R was responsible for conceptualization, supervision, manuscript writing, editing, and funding acquisition; Simó-Servat O was responsible for conceptualization, statistical analyses, manuscript writing, and editing; All authors read and approved the final version of the manuscript to be published.
Institutional review board statement: Approved by the Vall d’Hebron Ethics Committee, No. PR(AG)199/2024.
Clinical trial registration statement: This is a prospective study with no assigned intervention; therefore, clinical trial registration is not applicable.
Informed consent statement: All participants provided informed consent.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Data sharing statement: Data are available from the corresponding author upon reasonable request.
Corresponding author: Pedro Gil-Millán, MD, Department of Endocrinology, Hospital Vall d´Hebron, Paseo de la Vall d'Hebron, 119-129, Barcelona 08035, Catalonia, Spain.
pedroalejandro.gil@vallhebron.cat
Received: October 25, 2025
Revised: December 4, 2025
Accepted: January 28, 2026
Published online: March 15, 2026
Processing time: 138 Days and 21.3 Hours
BACKGROUND
Glycemic variability (GV) is increasingly recognized as a major metabolic risk in patients with type 2 diabetes (T2D) undergoing hemodialysis (HD); however, key contributors remain unclear.
AIM
To identify clinical predictors of GV – measured by differences in time in range (ΔTIR) – between HD and off-HD days in patients with insulin-treated T2D.
METHODS
In this prospective study, 35 patients with insulin-treated T2D on online HD were monitored using continuous glucose monitoring over 20 days. Glucometric variables included mean glucose, TIR, and glucose management indicator. Patients were stratified by ΔTIR into low (< 5%) or high (> 5%) fluctuation groups. Body composition was assessed using multifrequency bioelectrical impedance analysis, including visceral fat area (VFA), skeletal muscle index, and extracellular-to-total body water ratio.
RESULTS
Patients with ΔTIR > 5% showed higher glucose levels (HD: 187.1 ± 44.3 mg/dL; off-HD: 201.9 ± 52.3 mg/dL), reduced TIR, elevated glucose management indicator (8.02% ± 1.14%), and significantly lower VFA (63.4 ± 42.7 cm2vs 127.0 ± 49.5 cm2; P = 0.001). Skeletal muscle index and hydration parameters were not different. VFA independently predicted ΔTIR > 5% (odds ratio = 0.077; P = 0.016), and a VFA threshold of approximately 63 cm² yielded 88% sensitivity and 67% specificity (area under the curve of 0.812; P = 0.003).
CONCLUSION
VFA is a strong independent marker of GV in patients with insulin-treated T2D on HD, supporting body composition profiling in this population.
Core Tip: We conducted a prospective study using 20 days of continuous glucose monitoring to better understand glycemic instability in insulin-treated type 2 diabetes patients undergoing hemodialysis. Our results show that low visceral fat area is a strong and independent determinant of larger fluctuations in time-in-range between dialysis and non-dialysis days. Patients with low visceral adiposity had higher mean glucose, lower time-in-range, and more pronounced post-dialysis hyperglycemia. Visceral fat was the only variable that remained significant after multivariate adjustment. These findings suggest that visceral adiposity may act as a metabolic buffer, and that patients with low visceral fat area represent a fragile phenotype who may benefit from closer monitoring and more personalized diabetes management in the hemodialysis.
