Comparison of Glycemic Markers in Chronic Hemodialysis Using Continuous Glucose Monitoring

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

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 per 1.73 m2 or kidney disease treated with dialysis, have limitations to the use of some preferred glucose-lowering medications, are often treated with insulin, and experience high rates of severe hypoglycemia. Moreover, hemoglobin A1c accuracy decreases as GFR deteriorates. Hence, there is a need for better glycemic monitoring tools. Continuous glucose monitoring allows for 24-hour glycemic monitoring to understand patterns and the effects of lifestyle and medications. Real-time continuous glucose monitoring can be used to guide the administration of insulin and noninsulin therapies. Continuous glucose monitoring can overcome the limitations of self-monitored capillary glucose testing and hemoglobin A1c 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 continuous glucose monitoring in this high-risk population.

Usefulness of continuous glucose monitoring of blood glucose control in patients with diabetes undergoing hemodialysis: A pilot study

Background

Blood glucose stability has recently been considered important in the treatment of diabetes. Both hypoglycemia and hyperglycemia can frequently occur in patients with diabetes undergoing hemodialysis. This study aimed to determine the usefulness of continuous glucose monitoring (CGM) for glycemic control and glycemic variability stabilization in patients with diabetes undergoing hemodialysis.

Materials and methods

Eighteen patients aged ≥18 years with type 1 or 2 diabetes and ≥3 months on hemodialysis at the Eulji Medical Center, Daejeon, Republic of Korea between November 2021 and May 2022 were included. Patients underwent 7 days CGM twice: the baseline study period (T0) and the follow-up study period (T1), at a 12 weeks interval. Physicians modified the treatment strategy according to the T0 results, and then patients conducted T1. As indicators of glycemic control, the mean glucose levels, glycated hemoglobin A1c (HbA1c), and time in range were measured. As indicators of glycemic variability, standard deviation (SD) and % coefficient variation (%CV) were measured.

Results

Data from 18 patients were analyzed. The mean glucose levels, HbA1c, SD, and %CV improved in T1 compared to T0 (P < 0.05). During T0, the mean glucose level was significantly lower on a day with hemodialysis than on a day without (P < 0.05), and SD and %CV were significantly higher on a day with hemodialysis than on a day without (P < 0.05). After the physicians modified the treatment according to the T0 results, there were no differences in the mean glucose levels, SD, and %CV between days with and without hemodialysis during T1.

Conclusion

Continuous glucose monitoring could be a promising tool for individualizing treatment strategies in patients with diabetes undergoing hemodialysis.

Making sense of glucose sensors in end-stage kidney disease: A review

Diabetes mellitus remains the leading cause of end-stage kidney disease worldwide. Inadequate glucose monitoring has been identified as one of the gaps in care for hemodialysis patients with diabetes, and lack of reliable methods to assess glycemia has contributed to uncertainty regarding the benefit of glycemic control in these individuals. Hemoglobin A1c, the standard metric to evaluate glycemic control, is inaccurate in patients with kidney failure, and does not capture the full range of glucose values for patients with diabetes. Recent advances in continuous glucose monitoring have established this technology as the new gold standard for glucose management in diabetes. Glucose fluctuations are uniquely challenging in patients dependent on intermittent hemodialysis, and lead to clinically significant glycemic variability. This review evaluates continuous glucose monitoring technology, its validity in the setting of kidney failure, and interpretation of glucose monitoring results for the nephrologist. Continuous glucose monitoring targets for patients on dialysis have yet to be established. While continuous glucose monitoring provides a more complete picture of the glycemic profile than hemoglobin A1c and can mitigate high-risk hypoglycemia and hyperglycemia in the context of the hemodialysis procedure itself, whether the technology can improve clinical outcomes merits further investigation.

Flash glucose monitoring system in special situations

The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.

Managing Acute Ankle and Hindfoot Fracture in Diabetic Patients

The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes.

Glycated hemoglobin levels and risk of all-cause and cause-specific mortality in hemodialysis patients with diabetes

AIM

Adequate glycemic control is fundamental for improving clinical outcomes in hemodialysis patients with diabetes. However, the target for glycated hemoglobin (HbA1c) level and whether cause-specific mortality differs based on HbA1c levels remain unclear.

METHODS

A total of 24,243 HD patients with diabetes were enrolled from a multicenter, nationwide registry. We examined the association between HbA1c levels and the risk of all-cause and cause-specific mortality.

RESULTS

Compared to patients with HbA1c 6.5%-7.5%, patients with HbA_1c 8.5-9.5% and ≥9.5% were associated with a 1.26-fold (95% CI, 1.12-1.42) and 1.56-fold (95% CI, 1.37-1.77) risk for all-cause mortality. The risk of all-cause mortality did not increase in patients with HbA1c < 5.5%. In cause-specific mortality, the risk of cardiovascular deaths significantly increased from small increase of HbA1c levels. However, the risk of other causes of death increased only in patients with HbA1c > 9.5%. The slope of HR increase with increasing HbA1c levels was significantly faster for cardiovascular causes than for other causes.

CONCLUSIONS

There was a linear relationship between HbA1c levels and risk of all-cause mortality in hemodialysis patients, and the risk of cardiovascular death increased earlier and more rapidly, with increasing HbA1c levels, compared with other causes of death.

Association of type 2 diabetes with periodontitis and tooth loss in patients undergoing hemodialysis

BACKGROUND

Limited evidence are available regarding the influence of diabetes on periodontitis in hemodialysis patients, although the association between diabetes and periodontal disease is well-known.

OBJECTIVE

This study aimed to investigate the influence of type 2 diabetes mellitus (T2D) and its control level on periodontal disease and the number of missing teeth in patients undergoing hemodialysis.

SUBJECTS AND METHODS

A single-center cross-sectional study was conducted on 246 Japanese patients with end-stage renal disease undergoing hemodialysis. Comprehensive medical and dental examinations were performed. The association between severity of periodontitis and T2D was examined by multiple ordered logistic regression analysis. A multiple linear regression model was fitted to assess the association of periodontal probing depth (PPD) ≥4 mm and the number of missing teeth with T2D (n = 125). A subgroup analysis involving only the patients with T2D was performed to investigate the factors associated with missing teeth among them.

RESULTS

After adjusting for confounders, the classification of periodontitis severity was significantly advanced in patients with T2D (odds ratio: 1.64, 95% confidence interval [CI]: 1.02-2.65, p = 0.04). The proportion of PPD≥4 mm sites and the number of missing teeth was significantly associated with T2D (coefficient: 4.1 and 5.7, 95% CI: 0.2-8.0 and 3.4-8.0, p = 0.04 and <0.001, respectively). Subgroup analysis of T2D patients revealed that glycoalbumin levels (coefficient: 0.4, 95% CI: 0.03-0.80, p = 0.03), but not hemoglobin A1c levels (coefficient: 0.8, 95% CI: -1.0-2.7, p = 0.37), were significantly associated with the number of missing teeth.

CONCLUSION

T2D was significantly associated with periodontitis and the number of missing teeth in hemodialysis patients. Moreover, it is first documented that poor glycemic control, as determined by glycoalbumin levels, was significantly associated with the number of missing teeth in hemodialysis patients with T2D.

Assessment of glycemia in chronic kidney disease

Reliable assessment of glycemia is central to the management of diabetes. The kidneys play a vital role in maintaining glucose homeostasis through glucose filtration, reabsorption, consumption, and generation. This review article highlights the role of the kidneys in glucose metabolism and discusses the benefits, pitfalls, and evidence behind the glycemic markers in patients with chronic kidney disease. We specifically highlight the role of continuous glucose monitoring as an emerging minimally invasive technique for glycemic assessment.

Predictive value of the glycated albumin versus glycosylated hemoglobin in follow-up of glucose homeostasis in hemodialysis-maintained type-2 diabetic patients

Objectives. Markers for glucose control in hemodialysis patients (HDP) are debated. Glycosylated hemoglobin (HbA1c%) relies on the stable red blood cell survival. Albumin turnover is faster than hemoglobin. Glycated albumin (GA%) may be used as an index of short-term glycemic control. The predictive value of GA% versus HbA1c% in monitoring the glucose homeostasis in type-2 diabetic HDP is studied. Methods. Forty type-2 diabetic HDP and 20 healthy non diabetic subjects matched age and sex as a control group were included. Calculation of body mass index and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and urea reduction ratio were done. Glycosylated hemoglobin, glycated albumin, fasting blood glucose, insulin, total lipid, kidney and liver functions tests, hepatitis markers, electrolytes, complete blood count, and international normalized ratio were performed. Patients were followed up after 6 months. Results. The study showed that GA% is more sensitive than HbA1c%, but less specific in the follow-up of the glucose homeostasis in type-2 diabetic HDP. Diagnostic accuracy is higher in HbA1c% than in GA%. HOMA-IR is superior regarding the sensitivity and the diagnostic accuracy. Conclusion. The present data show that GA% is more sensitive than HbA1c% and has more diagnostic accuracy in the follow-up of the glucose homeostasis in type-2 diabetic HDP.

Simplified, Low-Cost Method on Glucose Tolerance Testing in High-Risk Group of Diabetes, Explored by Simulation of Diagnosis

Objective: Explore the distribution of basic characteristics of high-risk groups of diabetes; verify the practical significance and diagnostic value of the “three-point method”; layered analysis of glycated hemoglobin and glycated serum albumin, and study its value and significance in the diagnosis of diabetes mellitus, Type II and pre-diabetes mellitus, Type II.Methods: 1304 high-risk individuals with T2D in Shanghai, 529 males and 841 females with an average of (50.5 ± 15.2) years old, were examined by oral glucose tolerance test (OGTT), HbA1c and GA were determined. Process the data by Python and GraphPad; judge the diagnostic value of HbA1C, GA by ROC.Results: (1) The numbers of DM, NGT, HOG, IFG, Mild–IGT and Mid–IGT in the objects were 647, 141, 70, 4, 208 and 234 respectively. In the 43-49 age group with a higher incidence, the proportion of selected high-risk groups is low. (2) The sensitivity and specificity about “three-point method” used to determine NGT is 100% and 90.11%; to determine IGR is 75.11% and 97.32%; to determine HOG is 97.14% and 100%; to determine DM is 94.67% and 100%. (3) According to ROC judgment, it is found that these 2 did not have the function of separate diagnoses, the optimal critical point of HbA1C related to DM status is 5.95%, (P<.01); HbA1C related to IGR status is 5.75% (P<.01); of GA related to DM status is 15.25% (P<.01); GA related to IGR status is 14.95% (P<.01).

Hemoglobin A1c and Fructosamine Evaluated in Patients with Type 2 Diabetes Receiving Peritoneal Dialysis Using Long-Term Continuous Glucose Monitoring

INTRODUCTION

Shortened erythrocyte life span and erythropoietin-stimulating agents may affect hemoglobin A1c (HbA1c) levels in patients receiving peritoneal dialysis (PD). We compared HbA1c with interstitial glucose measured by continuous glucose monitoring (CGM) in patients with type 2 diabetes receiving PD.

METHODS

Fourteen days of CGM (Ipro2, Medtronic) were performed in 23 patients with type 2 diabetes receiving PD and in 23 controls with type 2 diabetes and an estimated glomerular filtration rate over 60 mL/min/1.73 m2. Patients were matched on gender and age (±5 years). HbA1c (mmol/mol), its derived estimate of mean plasma glucose (eMPGA1c) (mmol/L), and fructosamine (µmol/L) were measured at the end of the CGM period and compared with the mean sensor glucose (mmol/L) from CGM.

RESULTS

In the PD group, mean sensor glucose was 0.98 (95% con-fidence interval (CI): 0.43-1.54) mmol/L higher than the eMPGA1c compared with the control group (p = 0.002) where glucose levels were nearly identical (-0.05 (95% CI: -0.35-0.25) mmol/L). A significant association was found between fructosamine and mean sensor glucose using linear regression with no difference between slopes (p = 0.89) or y-intercepts (p = 0.28).

DISCUSSION/CONCLUSION

HbA1c underestimates mean plasma glucose levels in patients with type 2 diabetes receiving PD. However, the clinical significance of this finding is undetermined. Fructosamine seems to more accurately reflect glycemic status. CGM or fructosamine could complement HbA1c to increase the accuracy of glycemic monitoring in the PD population.

Use of continuous glucose monitoring system in patients with type 2 mellitus diabetic during hemodialysis treatment

BACKGROUND

Studies highlight the inaccuracy of glycated hemoglobin (HbA1c) for the assessment of glycemic control in dialysis diabetics and suggest the use of continuous glucose monitoring (CGM) as an alternative. Of the CGMs, FreeStyle Libre^® is the most used in worldwide, but there is still no consensus on its use in dialysis.

METHOD

A 3-week prospective study was performed with 12 patients comparing capillary and interstitial glucose during dialysis.

RESULTS

Comparing capillary and interstitial measurements, similar values were observed in pre-dialysis in the 1st week (184.1 ± 69.5 mg/dl and 173.1 ± 78.9 mg/dl, respectively, p = 0.303), in patients with body mass index less than 24.9 kg/m² (214.2 ± 72.2 mg/dl and 201.3 ± 77.0 mg/dl respectively, p = 0.466), in those dialysis fluid loss less than 2 l (185.5 ± 82.6 mg/dl and 183.1 ± 94.0 mg/dl respectively and p = 0.805) and in those with hemoglobin greater than 12 g/dl (152.0 ± 35, 5 mg/dl and 129.5 ± 47.4 mg/dl respectively, p = 0.016). In the correlation of the capillary measurement with the interstitial sensor, it was observed that the proportions in the Clarke Error Grid of zone A, zone B, zone C, zone D and zone E were 62.5%, 27.1%, 0.0%, 10.4% and 0.0% respectively and in the Parkes error grid in zone A, zone B, zone C, zone D and zone E were 80.6%, 9.7%, 9.7% 0.0% and 0.0%, respectively.

CONCLUSION

The mean absolute relative difference in dialysis patients is higher than the general population without end-stage renal disease. However, clinical decision-making based on the values measured by the system can be made with a good margin based on the correlation between interstitial and capillary measurements.

Assessment of Hyperglycemia, Hypoglycemia and Inter-Day Glucose Variability Using Continuous Glucose Monitoring among Diabetic Patients on Chronic Hemodialysis

Continuous glucose monitoring (CGM) facilitates the assessment of short-term glucose variability and identification of acute excursions of hyper- and hypo-glycemia. Among 37 diabetic hemodialysis patients who underwent 7-day CGM with the iPRO2 device (Medtronic Diabetes, Northridge, CA, USA), we explored the accuracy of glycated albumin (GA) and hemoglobin A1c (HbA1c) in assessing glycemic control, using CGM-derived metrics as the reference standard. In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) in diagnosing a time in the target glucose range of 70–180 mg/dL (TIR^70–180) in <50% of readings was higher for GA (AUC: 0.878; 95% confidence interval (CI): 0.728–0.962) as compared to HbA1c (AUC: 0.682; 95% CI: 0.508–0.825) (p < 0.01). The accuracy of GA (AUC: 0.939; 95% CI: 0.808–0.991) in detecting a time above the target glucose range > 250 mg/dL (TAR^>250) in >10% of readings did not differ from that of HbA1c (AUC: 0.854; 95% CI: 0.699–0.948) (p = 0.16). GA (AUC: 0.712; 95% CI: 0.539–0.848) and HbA1c (AUC: 0.740; 95% CI: 0.570–0.870) had a similarly lower efficiency in detecting a time below target glucose range < 70 mg/dL (TBR^<70) in >1% of readings (p = 0.71). Although the mean glucose levels were similar, the coefficient of variation of glucose recordings (39.2 ± 17.3% vs. 32.0 ± 7.8%, p < 0.001) and TBR^<70 (median (range): 5.6% (0, 25.8) vs. 2.8% (0, 17.9)) were higher during the dialysis-on than during the dialysis-off day. In conclusion, the present study shows that among diabetic hemodialysis patients, GA had higher accuracy than HbA1c in detecting a 7-day CGM-derived TIR^70–180 < 50%. However, both biomarkers provided an imprecise reflection of acute excursions of hypoglycemia and inter-day glucose variability.

Continuous glucose monitoring in patients with type 2 diabetes on hemodialysis

Diabetic kidney disease is the leading cause of end-stage kidney disease in high-income countries. The strict control of glycemic oscillations is the principal therapeutic target, but this could be hard to achieve in uremic patients due to their unpredictable insulin sensitivity. Currently, the evaluation of the glycemic profile relies on serum markers (glycated hemoglobin HbA1c, glycated albumin, and fructosamine), capillary glucose blood control (self-monitoring of blood glucose), and interstitial glucose control (continue glucose monitoring). We conducted a systematic review of published articles on continue glucose monitoring in hemodialysis patients with type 2 diabetes, which included 12 major articles. Four studies found significant fluctuations in glucose levels during hemodialysis sessions. All studies reported a higher mean amplitude of glucose variations on the hemodialysis day. Three studies agreed that continue glucose monitoring is better than glycated hemoglobin in detecting these abnormalities. Moreover, continue glucose monitoring was more accurate and perceived as easier to use by patients and their caregivers. In patients with type 2 diabetes on hemodialysis, glucose levels show different variation patterns than the patients on hemodialysis without diabetes. Considering manageability, accuracy, and cost-effectiveness, continue glucose monitoring could be the ideal diagnostic tool for the patient with diabetes on hemodialysis.

Quantitation of glycated albumin by isotope dilution mass spectrometry

BACKGROUND

Glycated albumin is considered an alternative glycemic indicator in certain situations where HbA1c does not accurately reflect glycemic status. These patient cases are usually associated with decreased erythrocyte lifespan, gestational diabetes, or end-stage renal disease. The aim of our study was to develop an assay for absolute quantitation of glycated albumin based on isotope dilution liquid chromatography-mass spectrometry.

METHODS

The plasma samples were reduced/alkylated, spiked with isotope-labeled standards RQIKKQTALV(D₈)E and RQIKK(fructosyl)QTALV(D₈)E and enzymatically digested by Glu-C. The samples were analyzed on an LC-MS system. Two MRM transitions (M³⁺ → (b₉-3H₂O)²⁺ and M³⁺ → (b₁₀-3H₂O)²⁺ or M³⁺ → b₉²⁺ and M³⁺ → b₁₀²⁺) were used for each peptide, then the percentage of glycation (MS GA%) was calculated.

RESULTS

The comparison study demonstrated a good linear correlation between our LC-MS/MS and Lucica method with r² = 0.95. The intra-day CV for the low HbA1c sample was 2.2%, while CV for the high HbA1c sample was 0.64%. Inter-day CV for low HbA1c sample was 5.6%, while the CV for the high HbA1c sample was 5.7%. We found the LLOQ to be 0.12 nmol/ml for the non-glycated and glycated peptide. No interference from hemoglobin was observed up to 500 mg/dL concentration.

CONCLUSIONS

This is the first implementation of isotope dilution LC-MS assay for glycated albumin with simultaneously quantitation of glycated and non-glycated peptides. The method includes a simple sample preparation and has demonstrated a good analytical performance.

Comparison of Premixed Human Insulin 30/70 to Biphasic Aspart 30 in Well-Controlled Patients with Type 2 Diabetes Using Continuous Glucose Monitoring

AIM

To compare in terms of glycemic variability two premixed insulins, Premixed Human Insulin 30/70 (PHI) and Biphasic Aspart 30 (BiAsp30), using Continuous Glucose Monitoring (CGM) and to estimate the correlation of Glycated Albumin (GA) and Fructosamine (FA) with CGM data. Patients-Data: A total of 36 well-controlled patients with type 2 Diabetes Mellitus (T2DM) underwent 7-day CGM with PHI and subsequently with BiAsp30. GA and FA were measured at the first and last day of each week of CGM.

RESULTS

BiAsp30 was associated with lower Average Blood Glucose (ABG) during the 23:00-03:00 period (PHI: 135.08 ± 28.94 mg/dL, BiAsp30: 117.75 ± 21.24 mg/dL, p < 0.001) and the 00:00-06:00 period (PHI: 120.42 ± 23.13 mg/dL, BiAsp30: 111.17 ± 14.74 mg/dL, p = 0.008), as well as with more time below range (<70 mg/dL) (TBR) during the 23:00-03:00 period in the week (PHI: 3.65 ± 5.93%, BiAsp30: 11.12 ± 16.07%, p = 0.005). PHI was associated with lower ABG before breakfast (PHI: 111.75 ± 23.9 mg/dL, BiAsp30: 128.25 ± 35.9 mg/dL, p = 0.013). There were no differences between the two groups in ABG, Time In Range and Time Below Range during the entire 24-h period for 7 days, p = 0.502, p = 0.534, and p = 0.258 respectively, and in TBR for the 00:00-06:00 period p = 0.253. Total daily insulin requirements were higher for BiAsp30 (PHI: 47.92 ± 12.18 IU, BiAsp30: 49.58 ± 14.12 IU, p = 0.001). GA and FA correlated significantly with ABG (GA: r = 0.512, p = 0.011, FA: r = 0.555, p = 0.005).

CONCLUSIONS

In well-controlled patients with T2DM, BiAsp30 is an equally effective alternative to PHI.

Glycated albumin and hemoglobin A1c levels and cause-specific mortality by patients' conditions among hemodialysis patients with diabetes: a 3-year nationwide cohort study

INTRODUCTION

Differences in mortality and cause-specific mortality rates according to glycated albumin (GA) and hemoglobin A1c (HbA1c) levels among dialysis patients with diabetes based on hypoglycemic agent use and malnutrition status remain unclear. Here, we examine these associations using a nationwide cohort.

RESEARCH DESIGN AND METHODS

We examined 40 417 dialysis patients with diabetes who met our inclusion criteria (female, 30.8%; mean age, 67.3±11.2 years; mean dialysis duration, 5.4±4.6 years). The Global Leadership Initiative on Malnutrition criteria were used to assess malnutrition. Adjusted HRs and 95% confidence limits were calculated for 3-year mortality after adjustment for 18 potential confounders. HRs and subdistribution HRs were used to explore cause-specific mortality.

RESULTS

We found a linear association between 3-year mortality and GA levels only in patients with GA ≥18% and not in patients with low GA levels, with a U-shaped association between HbA1c levels and the lowest morality at an HbA1c 6.0%-6.3%. This association differed based on patient conditions and hypoglycemic agent use. If patients using hypoglycemic agents were malnourished, mortality was increased with GA ≥24% and HbA1c ≥8%. In addition, patients with GA ≥22% and HbA1c ≥7.6% had significantly higher infectious or cardiovascular mortality rates. On the other hand, an inverse association was found between GA or HbA1c levels and cancer mortality. Patients with GA ≤15.8% had a higher risk of cancer mortality, especially those not using hypoglycemic agents (HR 1.63 (1.00-2.66)).

CONCLUSIONS

Target GA and HbA1c levels in dialysis patients may differ according to hypoglycemic agent use, nutritional status, and the presence of cancer. The levels may be higher in malnourished patients than in other patients, and a very low GA level in dialysis patients not taking hypoglycemic agents may be associated with a risk of cancer.

TRIAL REGISTRATION NUMBER

UMIN000018641.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Effect of adding vildagliptin to insulin in haemodialysed patients with type 2 diabetes: The VILDDIAL study, a randomized, multicentre, prospective study

AIM

To evaluate the effect of adding the dipeptidyl-peptidase-4 inhibitor vildagliptin to insulin on the glycaemic control of patients with type 2 diabetes undergoing haemodialysis.

METHODS

Overall, 65 insulin-treated patients with type 2 diabetes undergoing haemodialysis (HbA1c: 7.3% ± 1.1%; age: 70.5 ± 8.5 years) were randomized (1:1) either to receive vildagliptin 50 mg/day in addition to insulin (vildagliptin-insulin group) or to pursue their usual insulin regimen (insulin-only group). Continuous glucose monitoring (CGM) was performed for 48 ± 6 hours at baseline and at week 12. The primary study endpoint was change from baseline in mean interstitial glucose using CGM. The secondary endpoints included other CGM variables and glucose control markers.

RESULTS

After 12 weeks, a greater reduction in mean CGM glucose from baseline was observed in the vildagliptin-insulin group compared with the insulin-only group, although the between-treatment difference was not statistically significant (mean difference [CI 95%]: -0.96 mmol/L [-2.09; 0.18] vs. -0.29 mmol/L [-1.29; 0.76], P = 0.32). However, a significant decrease from baseline in HbA1c, glycated albumin and insulin daily doses was observed in the vildagliptin-insulin group versus the insulin-only group (-0.6% [-1.19; -0.1], P < 0.01), in the vildagliptin-insulin group versus no change in the insulin-only group (-130.6 μmol/L [-271; 10.7] vs. +36.2 μmol/L [-164.4; 236.9], P = 0.04 and - 5.9 IU/day [-1.8; 7.1] vs. +1.1 IU/day [-14.5; 16.6], P = 0.01, respectively). There was no significant difference in the percentage of time spent in hypoglycaemia using CGM, occurrence of severe hypoglycaemia or number of adverse events.

CONCLUSION

In this study, vildagliptin added to insulin improved glycaemic control with an associated insulin-sparing effect in patients with type 2 diabetes undergoing haemodialysis and was well tolerated.

When ESKD complicates the management of diabetes mellitus

Given the increased incidence and prevalence of ESKD (end-stage kidney disease) attributed to diabetes mellitus, it is important to consider the physiological and global sociodemographic factors that give rise to unique challenges in providing excellent care to this population. The individual with diabetes and ESKD faces alterations of glucose homeostasis that require close therapeutic attention, as well as the consideration of safe and effective means of maintaining glycemic control. Implementation of routine monitoring of blood glucose and thoughtful alteration of the individual's hypoglycemic drug regimen must be employed to reduce the risk of neurological, cardiovascular, and diabetes-specific complications that may arise as a result of ESKD. Titration of insulin therapy may become quite challenging, as kidney replacement therapy often significantly impacts insulin requirements. New medications have significantly improved the ability of the clinician to provide effective therapies for the management of diabetes, but have also raised an equal amount of uncertainty with respect to their safety and efficacy in the ESKD population. Additionally, the clinician must consider the challenges related to the delivery of kidney replacement therapy, and how inter-modality differences may impact glycemic control, diabetes, and ESKD-related complications, and issues surrounding dialysis vascular access creation.

Dialysis-associated hyperglycemia: manifestations and treatment

PURPOSE

Dialysis-associated hyperglycemia (DAH), is associated with a distinct fluid and electrolyte pathophysiology. The purpose of this report was to review the pathophysiology and provide treatment guidelines for DAH.

METHODS

Review of published reports on DAH. Synthesis of guidelines based on these reports.

RESULTS

The following fluid and solute abnormalities have been identified in DAH: (a) hypoglycemia: this is a frequent complication of insulin treatment and its prevention requires special attention. (b) Elevated serum tonicity. The degree of hypertonicity in DAH is lower than in similar levels of hyperglycemia in patients with preserved renal function. Typically, correction of hyperglycemia with insulin corrects the hypertonicity of DAH. (c) Extracellular volume abnormalities ranging from pulmonary edema associated with osmotic fluid shift from the intracellular into the extracellular compartment as a consequence of gain in extracellular solute (glucose) to hypovolemia from osmotic diuresis in patients with residual renal function or from fluid losses through extrarenal routes. Correction of DAH by insulin infusion reverses the osmotic fluid transfer between the intracellular and extracellular compartments and corrects the pulmonary edema, but can worsen the manifestations of hypovolemia, which require saline infusion. (d) A variety of acid-base disorders including ketoacidosis correctable with insulin infusion and no other interventions. (e) Hyperkalemia, which is frequent in DAH and is more severe when ketoacidosis is also present. Insulin infusion corrects the hyperkalemia. Extreme hyperkalemia at presentation or hypokalemia developing during insulin infusion require additional measures.

CONCLUSIONS

In DAH, insulin infusion is the primary management strategy and corrects the fluid and electrolyte abnormalities. Patients treated for DAH should be monitored for the development of hypoglycemia or fluid and electrolyte abnormalities that may require additional treatments.