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

Diabetes technology in people with diabetes and advanced chronic kidney disease

Diabetes is the leading cause and a common comorbidity of advanced chronic kidney disease. Glycaemic management in this population is challenging and characterised by frequent excursions of hypoglycaemia and hyperglycaemia. Current glucose monitoring tools, such as HbA1c, fructosamine and glycated albumin, have biases in this population and provide information only on mean glucose exposure. Revolutionary developments in glucose sensing and insulin delivery technology have occurred in the last decade. Newer factory-calibrated continuous glucose monitors provide real-time glucose data, with predictive alarms, allowing improved assessment of glucose excursions and preventive measures, particularly during and between dialysis sessions. Furthermore, integration of continuous glucose monitors and their predictive alerts with automated insulin delivery systems enables insulin administration to be decreased or stopped proactively, leading to improved glycaemic management and diminishing glycaemic fluctuations. While awaiting regulatory approval, emerging studies, expert real-world experience and clinical guidelines support the use of diabetes technology devices in people with diabetes and advanced chronic kidney disease.

Perspective of Continuous Glucose Monitoring-Based Interventions at the Various Stages of Type 2 Diabetes

Continuous glucose monitoring (CGM) is now advocated for the clinical management of individuals with type 1 diabetes (T1D). However, this glucose monitoring strategy is not routinely used in type 2 diabetes (T2D), given the large population, significant cost implications and relatively limited supporting evidence. T2D is a more heterogenous condition compared with T1D with various glucose lowering therapies that do not necessarily require CGM to ensure within target glucose levels. While all individuals with T2D may benefit from CGM at certain time points, the whole T2D population does not necessarily require this technology continuously, which should be prioritized based on patient benefit and cost effectiveness. In this pragmatic opinion piece, we describe the rationale and evidence for CGM use in different subgroups of individuals with T2d, divided according to the stage of the condition, glycemic therapies, presence of diabetes complications, or associated co-morbidities. We discuss a total of 16 T2D subgroups and provide a clinical view on CGM use in each, based on current evidence while also highlighting areas of knowledge gaps. This work provides health care professionals with a simple guide to CGM use in different T2D groups and gives suggestion for future studies to justify expansion of this technology.

Comparison of Point Accuracy Between Two Widely Used Continuous Glucose Monitoring Systems

BACKGROUND

Safe and effective self-management of glucose levels requires immediate access to accurate data. We assessed the point accuracy of the Dexcom G7 Continuous Glucose Monitoring System (Dexcom, Inc., San Diego, CA, USA) and FreeStyle Libre 3 (Abbott Diabetes Care, Alameda, CA, USA) sensors in a head-to-head comparison.

METHOD

Multicenter, single-arm, prospective, nonsignificant risk evaluation enrolled adults (≥ 18 years) with diagnosed type 1 diabetes (T1D) or type 2 diabetes (T2D). Accuracy was assessed by comparing sensor data to laboratory reference values Yellow Springs Instrument [YSI] and capillary blood glucose values. Outcome measures were differences in mean absolute relative difference (MARD), number and percentage of matched glucose pairs within ±20 mg/dL/±20 of reference values within glucose ranges: < 54, 54 to 69, 70 to 180, 181 to 250, > 250 mg/dL, and combined.

RESULTS

Data from 55 adults were included in the analysis. Analysis showed significantly lower MARD with the FreeStyle Libre 3 sensor vs the Dexcom G7 sensor (8.9% vs 13.6%, respectively, P < .0001) with a higher percentage of glucose values within ±20 mg/dL/±20 of reference (91.4% vs 78.6%). The MARD values for both continuous glucose monitoring (CGM) sensors were similar during the first 12 hours; however, the FreeStyle Libre 3 MARD was notably lower than the Dexcom G7 MARD during the next 12 hours (10.0% vs 15.1%, respectively, P < .0001) and throughout the study period.

CONCLUSIONS

The FreeStyle Libre 3 sensor was more accurate than the Dexcom G7 sensor in all metrics evaluated throughout the study period. This is the first head-to-head study to our knowledge that compares the flagship products currently in widespread use of the two largest CGM manufacturers.

Continuous glucose monitoring in people with diabetes and end-stage kidney disease-review of association studies and Evidence-Based discussion

Diabetic nephropathy is currently the leading cause of end-stage kidney disease. The present methods of assessing diabetes control, such as glycated hemoglobin or self-monitoring of blood glucose, have limitations. Over the past decade, the field of continuous glucose monitoring has been greatly improved and expanded. This review examines the use of continuous glucose monitoring in people with end-stage kidney disease treated with hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation. We assessed the use of both real-time continuous glucose monitoring and flash glucose monitoring technology in terms of hypoglycemia detection, glycemic variability, and efficacy, defined as an improvement in clinical outcomes and diabetes control. Overall, the use of continuous glucose monitoring in individuals with end-stage kidney disease may improve glycemic control and detection of hypoglycemia. However, most of the published studies were observational with no control group. Moreover, not all studies used the same assessment parameters. There are very few studies involving subjects on peritoneal dialysis. The small number of studies with limited numbers of participants, short follow-up period, and small number of manufacturers of continuous glucose monitoring systems are limitations of the review. More studies need to be performed to obtain more reliable results.