Comparison of Glycemic Markers in Chronic Hemodialysis Using Continuous Glucose Monitoring

Abstract

Background: Glycated hemoglobin A1c (HbA1c) among diabetic hemodialysis patients continues to be the standard of care, although its limitations are well recognized. This study evaluated glycated albumin (GA) and glycated serum protein (GSP) as alternatives to HbA1c in detecting glycemic control among diabetic hemodialysis patients using continuous-glucose-monitoring (CGM)-derived glucose as reference standard. Methods: A CGM system (iPRO) was applied for 7 days in 37 diabetic hemodialysis patients to determine glycemic control. The accuracy of GA and GSP versus HbA1c in detecting a 7-day average glucose ≥184 mg/dL was evaluated via receiver-operating-characteristic (ROC) analysis. Results: CGM-derived glucose exhibited strong correlation (r = 0.970, p < 0.001) and acceptable agreement with corresponding capillary glucose measurements obtained by the patients themselves in 1,169 time-points over the 7-day-long CGM. The area under ROC curve (AUC) for GA, GSP, and HbA1c to detect poor glycemic control was 0.976 (0.862–1.000), 0.682 (0.502–0.862), and 0.776 (0.629–0.923) respectively. GA levels >20.3% had 90.9% sensitivity and 96.1% specificity in detecting a 7-day average glucose ≥184 mg/dL. The AUC for GA was significantly higher than the AUC for GSP (difference between areas: 0.294, p < 0.001) and the AUC for HbA1c (difference between areas: 0.199, p < 0.01). Conclusion: Among diabetic hemodialysis patients, GA is a stronger indicator of poor glycemic control assessed with 7-day-long CGM when compared to GSP and HbA1c.

Glycemic Control Assessment in the Dialysis Patient: Is Glycated Albumin the Answer?

“…Finally, the measurements that are most important to the patient on a day-by-day basis are the capillary blood glucose levels, which are used to determine adjustments and changes in insulin dosing. CGM is an advance in technique over the standard capillary glucose measurements, but, as this study showed [1], they are very highly correlated.…”

“…In this issue, Divani et al[1] have shown that glycated albumin (GA) correlates better than hemoglobin A1c (A1c) with one week’s worth of blood glucose levels obtained by continuous glucose monitoring (CGM) in diabetic patients on hemodialysis. It should be pointed out that both were highly correlated with the CGM-obtained average glucose values (GA r = 0.884; A1c r = 0.694).…”

“…At least with A1c, there is an international standardization of the measurement and it does not have to be done more frequently than every 3 months. However, neither GA nor HbA1c may be good indicators of an individual patient’s level of glycemic control, given the widespread values for either when plotted against the average glucose levels [1, 2, 21]. Finally, the measurements that are most important to the patient on a day-by-day basis are the capillary blood glucose levels, which are used to determine adjustments and changes in insulin dosing.…”

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

“…Indeed, the reliability of HbA1c as a marker of glycaemic control in haemodialysis patients is questionable, given the changes in red blood cell survival and erythropoietin therapy . Continuous glucose monitoring (CGM) may offer significant benefits over traditional intermittent blood glucose testing in reducing the risks of developing long‐term complications associated with type 2 diabetes …”

Briefly Noted

“…Continuous glucose monitoring in 37 diabetic HD patients over 7 days found that levels of glycated albumin correlated better with glucose levels than did hemoglobin A1C ( r = .88 vs .69) …”