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

Abstract

<b><i>Introduction:</i></b> Shortened erythrocyte life span and erythropoietin-stimulating agents may affect hemoglobin A<sub>1c</sub> (HbA<sub>1c</sub>) levels in patients receiving peritoneal dialysis (PD). We compared HbA<sub>1c</sub> with interstitial glucose measured by continuous glucose monitoring (CGM) in patients with type 2 diabetes receiving PD. <b><i>Methods:</i></b> 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 m<sup>2</sup>. Patients were matched on gender and age (±5 years). HbA<sub>1c</sub> (mmol/mol), its derived estimate of mean plasma glucose (eMPG<sub>A1c</sub>) (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. <b><i>Results:</i></b> In the PD group, mean sensor glucose was 0.98 (95% con­fidence interval (CI): 0.43–1.54) mmol/L higher than the eMPG<sub>A1c</sub> compared with the control group (<i>p</i> = 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 (<i>p</i> = 0.89) or y-intercepts (<i>p</i> = 0.28). <b><i>Discussion/Conclusion:</i></b> HbA<sub>1c</sub> 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 HbA<sub>1c</sub> to increase the accuracy of glycemic monitoring in the PD population.

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“…Evidence has confirmed that HbA1c value is a well-established metric to predict the progression of diabetes complications, including DR or diabetic nephropathy and cardiovascular events [22] . However, contrary to expectation, in a few studies limitations of the measurement of HbA1c for lack of accuracy affected with many factors including anaemia, pregnancy, hemoglobinopathy ethnicity were observed [23][24] . For the record, research has increased in recent years as CGM has become more popular to assess overall glycemic control.…”

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“…As a matter of fact, it has been reported that poorly controlled DM patients are an important risk factor for many dental surgeries and various dental complications may occur [15]. However, many studies have reported that the role of the relationship between HbA1c and glucose levels in the diagnosis of DM disease cannot be fully explained [17].…”

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“…The adjustment of diabetes medications together with use of CGM was associated with improvements in glycemic control but not in blood-glucose monitoring by finger prick [55]. It has been reported that plasma glucose concentrations in dialysis patients tend to be underestimated when inferred from HbA1c levels rather than CGM, GA, or fructosamine [56][57][58]. Furthermore, the results of the meta-analysis revealed that there was a significant correlation between CGM and the self-monitoring of blood-glucose levels [59].…”