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

Abstract

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.

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

“…17 Specific differences between studies include the parameters used to assess accuracy (eg, glucose ranges, varying rates of changing glucose, day of sensor wear), differences in the ages of the populations studied (eg, adult vs pediatric), 18 whether the study participants are exercising, 19 or whether they have underlying diseases that can affect the expected range of glycemia. 20 Moreover, the distribution of glucose concentrations of data points within various ranges affects the MARD of the entire cohort. As reported by Rodbard, large errors in the hypoglycemic ranges can significantly impact MARD estimates because of the strikingly nonlinear relationship with glucose level as well as the limited number of paired values in the hypoglycemic range observed in many evaluations.…”

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

“…In another review article, Bomholt et al emphasized that continuous glucose monitoring does not share the flaws of HbA1c in HD patients, and that the recommended minimum of 50% time spent in the target range (3.9–10.0 mmol/L) and less than 1% below range (< 3.9 mmol/L) seems to be a better target for the management of diabetes in HD patients [ 42 ]. In another review article, Williams et al emphasized that further studies on continuous glucose monitoring in dialysis patients are necessary because in other populations it is currently the gold standard of glycemic assessment and it is required to determine whether this technology can improve clinical outcomes in HD patients [ 43 ].…”

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

“…Moreover, this population is at risk of hypoglycemia and usually experiences large fluctuations in glucose levels due to insulin therapies and/or dialysis required for endstage renal disease [42,43]. Therefore, CGM can be particularly helpful in such patients to guide Early concerns over CGM inaccuracy in these individuals were unfounded and therefore glycemia in these individuals should be monitored using CGM [44,45].…”