From the Guidelines
The best test to follow diabetes mellitus in patients with end-stage renal disease is Continuous Glucose Monitoring (CGM), as it provides a more accurate reflection of glycemic control and can help minimize glucose fluctuations and hypoglycemia. This is based on the most recent evidence from the study published in Diabetologia in 2024 1, which highlights the limitations of traditional HbA1c measurements in ESRD patients and recommends the use of CGM-derived metrics such as Time in Range (TIR) and Time Below Range (TBR) to define glycaemic targets.
The study suggests that TIR >50% and TBR <1% are recommended targets for individuals with advanced CKD or ESKD on dialysis 1. Additionally, the study mentions that the Glucose Management Indicator (GMI), which is derived from CGM data, can be used to monitor glycaemic management in individuals whose HbA1c is discordant with directly measured blood glucose levels.
Other studies, such as those published in Endocrine Reviews in 2020 1, also discuss the limitations of HbA1c measurements in ESRD patients and the potential benefits of alternative glycemic biomarkers, such as glycated albumin or fructosamine. However, these studies are less recent and of lower quality compared to the Diabetologia study, and therefore, their recommendations are not prioritized.
Key points to consider when using CGM in ESRD patients include:
- Monitoring frequency of hypoglycaemic events
- Targeting a TIR >50% and TBR <1%
- Using GMI to monitor glycaemic management
- Minimizing glycaemic variability to avoid glucose fluctuations and hypoglycemia
- Considering the use of alternative glycemic biomarkers, such as glycated albumin or fructosamine, in certain situations.
From the Research
Monitoring Diabetes Mellitus in End-Stage Renal Disease
To monitor diabetes mellitus (DM) in patients with end-stage renal disease (ESRD), several tests can be utilized, each with its own advantages and limitations. The choice of test depends on various factors including the patient's renal function, the presence of other comorbidities, and the goal of treatment.
- Hemoglobin A1c (HbA1c): Considered the standard measure of long-term glycemic control, HbA1c levels are strongly associated with complications of diabetes 2. However, it does not provide real-time information about individual hyperglycemic or hypoglycemic excursions.
- Self-Monitoring of Blood Glucose (SMBG): Provides real-time blood glucose data, complementing HbA1c by offering insights into the effects of diet, exercise, and medications on day-to-day glycemic control 2, 3. SMBG is recommended for all patients as part of an overall diabetes management plan.
- Retrospective Continuous Glucose Monitoring (CGM): Offers detailed information about glucose levels over time, helping to identify patterns of hyperglycemia and hypoglycemia 3. A study found that both CGM and SMBG were equally effective in improving glycemic control in patients with diabetic kidney disease.
Glycemic Control Targets
For patients with ESRD, glycemic control targets are crucial to prevent damage to other organs. The recommended targets include:
- Fasting blood sugar less than 140 mg/dL
- 1-h postprandial blood glucose less than 200 mg/dL
- HbA1c levels between 6-7% for patients with type 1 diabetes and 7-8% for patients with type 2 diabetes 4
Considerations for Patients with ESRD
In patients with reduced glomerular filtration rate (GFR), it is necessary to adjust the dosage of certain anti-diabetic medications to avoid accumulation and potential side effects such as hypoglycemia or lactic acidosis 5, 6. The choice of medication should consider the patient's renal function and the presence of other comorbidities. Sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists are examples of medications with proven cardio-renal benefits in patients with advanced diabetic kidney disease 6.