Type 2 Diabetes and Hemodialysis: Metabolic Challenges and the Role of Intradialytic Exercise

Background and Aims: Type 2 diabetes mellitus (T2DM) is the leading global cause of end-stage kidney disease (ESRD). Patients receiving hemodialysis often have a high cardiometabolic risk profile, including insulin resistance, glycemic variability, chronic inflammation, sarcopenia, and altered mineral metabolism. In this setting, standard glycemic markers are often unreliable, supporting the use of additional non-pharmacological strategies, particularly structured physical activity, alongside standard treatment. This narrative review synthesizes current evidence on metabolic dysregulation in hemodialysis patients with T2DM and evaluates the potential role of intradialytic exercise as a multi-target intervention. Methods: A focused narrative search was conducted in PubMed, Scopus and Web of Science (2014-2025). Randomized trials, observational studies, clinical guidelines and narrative reviews addressing key metabolic and musculoskeletal complications, CKD-MBD, and intradialytic exercise in advanced kidney disease were considered. Conclusions: Intradialytic exercise represents a feasible adjunct strategy targeting interconnected metabolic pathways in patients with T2DM and ESRD. Further large-scale prospective studies are warranted to define the optimal intensity, modality and timing of intradialytic exercise and to clarify its long-term cardiometabolic and clinical benefits.

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