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

Consensus Report on the Use of Continuous Glucose Monitoring in Chronic Kidney Disease and Diabetes

This report represents the conclusions of 15 experts in nephrology and endocrinology, based on their knowledge of key studies and evidence in the field, on the role of continuous glucose monitors (CGMs) in patients with diabetes and chronic kidney disease (CKD), including those receiving dialysis. The experts discussed issues related to CGM accuracy, indications, education, clinical outcomes, quality of life, research gaps, and barriers to dissemination. Three main goals of management for patients with CKD and diabetes were identified: (1) greater use of CGMs for better glycemic monitoring and management, (2) further research evaluating the accuracy, feasibility, outcomes, and potential value of CGMs in patients with end-stage kidney disease (ESKD) on hemodialysis, and (3) equitable access to CGM technology for patients with CKD. The experts also developed 15 conclusions regarding the use of CGMs in this population related to CGMs' unique delivery of both real-time information that can guide monitoring and management of glycemia and continuous and predictive data in this population, which is at higher risk for hypoglycemia and hyperglycemia. The group noted three major clinical gaps: (1) CGMs are not routinely prescribed for patients with diabetes and CKD; (2) CGMs are not approved by the United States Food and Drug Administration (FDA) for patients with diabetes who are on dialysis; and (3) CGMs are not routinely available to all of those who need them because of structural barriers in the health care system. These gaps can be improved with greater stakeholder collaboration, education, and awareness brought to the use of CGM technology in CKD.

Treatment of Type 2 Diabetes Mellitus in Advanced Chronic Kidney Disease for the Primary Care Physician

Diabetes mellitus (DM) is a common cause of chronic kidney disease (CKD), leading to the need for renal replacement therapy (RRT). RRT includes hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation (KT), and medical management. As CKD advances, the management of DM may change as medication clearance, effectiveness, and side effects can be altered due to decreasing renal clearance. Medications like metformin that were safe to use early in CKD may build up toxic levels of metabolites in advanced CKD. Other medications, like sodium-glucose co-transporter 2 inhibitors, which work by excreting glucose in the urine, may not be able to work effectively in advanced CKD due to fewer working nephrons. Insulin breakdown may take longer, and both formulation and dosing may need to be changed to avoid hypoglycemia. While DM control contributes to CKD progression, effective DM control continues to be important even after patients have been placed on RRT. Patients on RRT are frequently taken care of by a team of providers, including the primary care physician, both in and outside the hospital. Non-nephrologists who are involved with the care of a patient treated with RRT need to be adept at managing DM in this population. This paper aims to outline the management of type 2 DM in advanced CKD.

Application and management of continuous glucose monitoring in diabetic kidney disease

Diabetic kidney disease (DKD) is a common complication of diabetes mellitus that contributes to the risk of end-stage kidney disease (ESKD). Wide glycemic var-iations, such as hypoglycemia and hyperglycemia, are broadly found in diabetic patients with DKD and especially ESKD, as a result of impaired renal metabolism. It is essential to monitor glycemia for effective management of DKD. Hemoglobin A1c (HbA1c) has long been considered as the gold standard for monitoring glycemia for > 3 months. However, assessment of HbA1c has some bias as it is susceptible to factors such as anemia and liver or kidney dysfunction. Continuous glucose monitoring (CGM) has provided new insights on glycemic assessment and management. CGM directly measures glucose level in interstitial fluid, reports real-time or retrospective glucose concentration, and provides multiple glycemic metrics. It avoids the pitfalls of HbA1c in some contexts, and may serve as a precise alternative to estimation of mean glucose and glycemic variability. Emerging studies have demonstrated the merits of CGM for precise monitoring, which allows fine-tuning of glycemic management in diabetic patients. Therefore, CGM technology has the potential for better glycemic monitoring in DKD patients. More research is needed to explore its application and management in different stages of DKD, including hemodialysis, peritoneal dialysis and kidney transplantation.

Fructosamine as a predictor of incident diabetic microvascular disease in a population with high prevalence of red cell disorders: A cohort study

AIMS

Fructosamine can be used to estimate glycaemia in individuals in whom HbA1c may be unreliable. We aimed to establish clinically useful fructosamine treatment targets in a population with a high prevalence of conditions affecting erythrocyte survival, including variant haemoglobin and G6PD deficiency.

METHODS

Fructosamine was measured on a clinical basis in individuals in whom HbA1c was suspected to be unreliable by their primary physician. Study endpoints were incident retinopathy and albuminuria in individuals with Prediabetes (n = 60), Type 1 (n = 161) or Type 2 diabetes (n = 1350) during follow up of 4.4 ± 2.3 years.

RESULTS

Fructosamine ≥ 250 umol/L was significantly associated with incident retinopathy, and fructosamine ≥ 300 umol/L with incident microalbuminuria, in univariate analysis and adjusted for established risk factors. Fructosamine ≥ 250 umol/L was also significantly associated with incident retinopathy in individuals with HbA1c < 7.0% (53 mmol/mol) at inclusion.

CONCLUSIONS

In this patient population, a single measurement of fructosamine significantly and independently predicts incident retinopathy in individuals with HbA1c < 7.0% (53 mmol/mol). Routine measurement of fructosamine on at least one occasion is recommended as part of assessment of prediabetes or diabetes mellitus in populations with a high prevalence of conditions affecting erythrocyte lifespan.

Narrative Review of glycaemic management in people with diabetes on peritoneal dialysis

There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.

Toward Revision of the ‘Best Practice for Diabetic Patients on Hemodialysis 2012’

Diabetic nephropathy is the leading cause of dialysis therapy worldwide. The number of diabetes patients on dialysis in clinical settings has been increasing in Japan. In 2013, the Japanese Society for Dialysis Therapy (JSDT) published the “Best Practice for Diabetic Patients on Hemodialysis 2012”. While glycated hemoglobin (HbA1c) is used mainly as a glycemic control index for dialysis patients overseas, Japan is the first country in the world to use glycated albumin (GA) for assessment. According to a survey conducted by the JSDT in 2018, the number of facilities measuring only HbA1c has decreased compared with 2013, while the number of facilities measuring GA or both has significantly increased. Ten years have passed since the publication of the first edition of the guidelines, and several clinical studies regarding the GA value and mortality of dialysis patients have been reported. In addition, novel antidiabetic agents have appeared, and continuous glucose monitoring of dialysis patients has been adopted. On the other hand, Japanese dialysis patients are rapidly aging, and the proportion of patients with malnutrition is increasing. Therefore, there is great variation among diabetes patients on dialysis with respect to their backgrounds and characteristics. This review covers the indices and targets of glycemic control, the treatment of hyperglycemia, and diet recommendations for dialysis patients with diabetes.

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.