Why do the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) recommend concurrent use of Glycated Hemoglobin (HbA1c), Continuous Glucose Monitoring (CGM), and Self-Monitoring of Blood Glucose (SMBG) for monitoring glycemic control in patients with Chronic Kidney Disease (CKD) and Type 2 Diabetes Mellitus (T2D)?

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Last updated: May 2, 2025 • View editorial policy

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From the Guidelines

The ADA and KDIGO recommend the concurrent use of HbA1c, CGM, and SMBG for monitoring glycemic control in patients with CKD and T2D because of the limited accuracy and precision of HbA1c in this population. In patients with CKD, several factors can affect HbA1c measurements, including reduced red blood cell lifespan, recent transfusions, erythropoietin therapy, iron deficiency, and metabolic acidosis, as noted in the consensus report by the ADA and KDIGO 1. These factors can lead to falsely low or high HbA1c readings that don't accurately reflect true glycemic control. By using multiple monitoring methods concurrently, clinicians can obtain a more comprehensive and accurate assessment of glycemic status. CGM provides real-time glucose data and patterns, while SMBG offers point-in-time measurements that can validate CGM readings and provide information during times when CGM may be unavailable.

The use of CGM in advanced CKD has been assessed in several studies, with newer factory-calibrated CGMs showing promising results 1. However, the current evidence on the accuracy of CGMs in individuals with advanced CKD is limited, and more research is needed to fully understand their effectiveness in this population. Despite these limitations, the ADA and KDIGO guidelines emphasize the importance of using multiple monitoring methods, including HbA1c, CGM, and SMBG, to overcome the limitations of any single technique and enable more appropriate treatment adjustments for patients with both CKD and T2D.

Some key points to consider when using CGM in patients with CKD include:

  • The potential for inaccurate readings due to factors such as reduced red blood cell lifespan and erythropoietin therapy
  • The need for frequent calibration and validation of CGM readings using SMBG
  • The importance of considering the glucose concentration of the dialysate, dwell time, and status of membrane transport when using CGM in patients on peritoneal dialysis
  • The potential benefits of using CGM to detect asymptomatic glucose excursions and aid in the detection of hypoglycemic events.

Overall, the concurrent use of HbA1c, CGM, and SMBG is recommended for monitoring glycemic control in patients with CKD and T2D, as it provides a more comprehensive and accurate assessment of glycemic status and enables more appropriate treatment adjustments.

From the Research

Limitations of Glycemic Control Metrics

The American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) recommend the concurrent use of glycated hemoglobin (HbA1c), continuous glucose monitoring (CGM), and self-monitoring of blood glucose (SMBG) for monitoring glycemic control in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2D) due to the limitations of each metric. The limitations include:

  • The limited accuracy and precision of HbA1c in patients with CKD, as it may underestimate average glucose levels 2, 3
  • The potential for HbA1c to be biased by factors such as age, BMI, serum iron concentration, transferrin saturation, and albuminuria 3
  • The limited accuracy and precision of CGM, although it provides automated and less invasive glucose measurements, and more comprehensive glycemic data versus conventional metrics 4, 5
  • The potential for poor patient compliance with SMBG, although this is not directly addressed in the provided studies

Comparison of Glycemic Control Metrics

Studies have compared the accuracy and precision of different glycemic control metrics, including:

  • HbA1c, which has been found to underestimate average glucose levels in patients with CKD 2
  • CGM, which has been found to be more accurate and easier to use than HbA1c in detecting glucose abnormalities in patients with CKD 2, 5
  • Glucose time in range (TIR), which has been found to be associated with diabetic peripheral neuropathy (DPN) symptoms in patients with CKD 6
  • Glucose management indicator (GMI), which has been found to have a strong correlation with TIR and to be a more appropriate glucose control marker than HbA1c in patients with CKD 2

Clinical Implications

The limitations and comparisons of glycemic control metrics have important clinical implications, including:

  • The need for healthcare providers to consider the limitations of each metric when interpreting results and making treatment decisions
  • The potential for CGM to be a useful tool for monitoring glycemic control in patients with CKD, particularly those with T2D
  • The importance of considering multiple metrics, including HbA1c, CGM, and SMBG, when evaluating glycemic control in patients with CKD and T2D 4, 2, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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