Continuous Glucose Monitoring to Optimize Management of Diabetes in Patients with Advanced CKD

Abstract

Treatment of patients with diabetes and CKD includes optimizing glycemic control using lifestyle modifications and drugs that safely control glycemia and improve clinical kidney and cardiovascular disease outcomes. However, patients with advanced CKD, defined as eGFR <30 mL/min/1.73m2 or kidney disease treated with dialysis, have limitations to use of some preferred glucose-lowering medications, are often treated with insulin, and experience high rates of severe hypoglycemia. Moreover, HbA1c accuracy decreases as GFR deteriorates. Hence, there is a need for better glycemic monitoring tools. Continuous glucose monitoring (CGM) allows 24-hour glycemic monitoring to understand patterns and the impact of lifestyle and medications. Realtime CGM can be used to guide administration of insulin and non-insulin therapies. CGM can overcome the limitations of self-monitored capillary glucose testing and HbA1c and has been shown to prevent hypoglycemic excursions in some populations. More data are needed to understand whether similar benefits can be obtained for patients with diabetes and advanced CKD. This review provides an updated approach to management of glycemia in advanced CKD, focusing on the role of CGM in this high-risk population.

Continuous Glucose Monitoring and Reduced Diabetes-Related Hospitalizations in Patients with Type 2 Diabetes and CKD

“…24 Other publications support the important role that CGM can play in helping people with T2D and CKD stage 3-5 maintain glycemic control. 7,8,25 It is notable that while hospitalizations decreased a clinically meaningful and statistically significant amount, rates of hospitalization for acute dysglycemic events in this cohort of patients with CKD and T2D are still far higher than for patients with T2D, 2 underscoring the complexity of this population.…”

“…Anemia, erythropoiesis-stimulating agents, periodic blood transfusions, and the altered metabolic state associated with uremia can all contribute to erroneous A1C values. 7 , 8 Alternative measurements of glycemic control such as fructosamine and glycated albumin can be affected by albuminemia, age, body mass index, and iron levels. 8 , 9 These measurements—A1C, fructosamine, and glycated albumin—represent an average of glycemic control over 1–3 months and are, therefore, unable to detect individual episodes of problematic hypoglycemia or hyperglycemia.…”

Hyperglycaemia in people with diabetes and chronic kidney disease

“…Der foreligger ikke konsensus om insulindosis ved CKD, men ofte anbefales en reduktion af insulindosis ved CKD 3-4 (eGFR < 60 ml/min/1,73 m 2 ) svarende til 25% og en yderligere reduktion ved CKD 4-5 (eGFR < 30 ml/min/1,73 m 2 ) svarende til 50% [4,17,28]. Ved justering af behandlingen kan hyppigere BGM eller periodevis CGM vaere brugbare, fordi risikoen for hypoglykaemi er høj og validiteten af HbA 1c -niveaet kan vaere lav ved eGFR < 60 ml/min/1,73 m 2 .…”

Continuous Glucose Monitoring: A Rapidly Evolving New Tool to Understand Pathophysiology and Enhance Clinical Care in CKD

“…However, rigorous trial data quantifying these benefits and risks for people with established CKD are scant, and several substantial barriers currently limit intensive therapy. 1,2 First, severe hypoglycemia, a condition with high morbidity and mortality, is known to occur substantially more frequently with lower eGFR and to occur in the absence of diabetes among people with kidney failure (for reasons that remain incompletely understood). Second, hemoglobin A1c, a basic tool for guiding glucose-lowering therapies, loses precision at low eGFR and becomes inaccurate in kidney failure because of abnormalities in red blood cell turnover.…”

“…Continuous glucose monitoring (CGM) is a rapidly evolving new technology that has revolutionized the treatment of diabetes, particularly for patients treated with insulin. 2 CGM offers a new tool to quantify glycemia with unprecedented granularity, closely titrate therapy, and understand previously poorly characterized pathophysiology. Subcutaneous CGM sensors measure interstitial glucose concentrations that correlate well with blood glucose, with a fidelity that has progressively improved with each successive version.…”