Continuous glucose monitoring in patients with type 2 diabetes on hemodialysis

Management of hyperglycaemia in people with Type 1 diabetes on dialysis: What are the options? A case report and review of the literature

Type 1 diabetes remains an important cause of end-stage kidney disease. In this report, we describe the use of automated insulin delivery technology to assist a person living with Type 1 diabetes to manage their glucose pre-, peri- and post-renal transplantation. In addition, we review the potential options available for managing such patients, including closed-loop technology, pancreatic and islet cell transplantation.

Diabetes and Glucose Management in People on Hemodialysis

Diabetes is a major cause of end-stage kidney disease (ESKD). Glycemic management is challenging in this population, and A1C, commonly used for monitoring glycemic control, is unreliable. Continuous glucose monitoring indices can be used for glycemic monitoring in people with ESKD. Dipeptidyl peptidase 4 inhibitors, incretin mimetic agents (glucagon-like peptide 1 and glucose-dependent insulinotropic peptide receptor agonists), and insulin using an automated insulin delivery system are preferred to manage diabetes in people with ESKD on hemodialysis.

Management of diabetes in people with advanced chronic kidney disease

Diabetes is the commonest cause of end stage kidney disease globally, accounting for almost 40% of new cases requiring renal replacement therapy. Management of diabetes in people with advanced kidney disease on renal replacement therapy is challenging due to some unique aspects of assessment and treatment in this group of patients. Standard glycaemic assessment using glycated haemoglobin may not be valid in such patients due to altered red blood cell turnover or iron/erythropoietin deficiency, leading to changed red blood cell longevity. Therefore, use of continuous glucose monitoring may be beneficial to enable more focussed glycaemic assessment and improved adjustment of therapy. People with advanced kidney disease may be at higher risk of hypoglycaemia due to a number of physiological mechanisms, and in addition, therapeutic options are limited in such patients due to lack of experience or license. Insulin therapy is the basis of treatment of people with diabetes with advanced kidney disease due to many other drugs classes being contraindicated. Targets for glycaemic control should be adjusted according to co-morbidity and frailty, and continuous glucose monitoring should be used in people on dialysis to ensure low risk of hypoglycaemia. Post-transplant diabetes is common amongst people undergoing solid organ transplantation and confers a greater risk of mortality and morbidity in kidney transplant recipients. It should be actively screened for and managed in the post-transplant setting.

A new glucose monitoring system for the intermittent monitoring of interstitial glucose values in patients with diabetes mellitus

Objectives

Glucose monitoring in diabetes is changing overtime with a constant development of new devices for continuous glucose monitoring (CGM). Aim of this observational, prospective study was to evaluate the clinical performance of a novel intermittently scanned CGM system, the Glunovo Flash in a cohort of patients with type 1 diabetes.

Methods

A total of 45 patients with T1D followed at the Endocrinology Unit of the ASST-FBF-Sacco (Milan) were enrolled. All patients were habitual CGM users and were asked to wear simultaneously the Glunovo Flash system and their habitual CGM device for 14 days. A comparison of CGM glucose metrics was performed. Patients' opinions on the new device were also collected.

Results

Thirty-five patients completed the study period of two weeks (7 habitual real time CGM users, 28 habitual intermittently scanned CGM users). Mean Time In Range resulted significantly higher with the novel studied sensor respect to intermittently scanned CGM comparator. No differences were found considering other glucose metrics. A positive correlation was found between the Time In Range recorded by Glunovo Flash and intermittently scanned CGM comparators as well as for Time Above Range, Glucose Management Indicator, Time Below Range and Coefficient of Variation. No correlations were found between glucose metrics recorded by Glunovo Flash and real time CGM comparators. Patients reported a positive experience of use with the new sensor but some elements appeared improvable.

Conclusions

The CGM device Glunovo Flash for patients with diabetes shows similar performance to other intermittently scanned CGM systems.

The complexity of glucose time series is associated with short- and long-term mortality in critically ill adults: a multi-center, prospective, observational study

BACKGROUND

The wealth of data taken from continuous glucose monitoring (CGM) remains to be fully used. We aimed to evaluate the relationship between a promising new CGM metric, complexity of glucose time series index (CGI), and mortality in critically ill patients.

METHODS

A total of 293 patients admitted to mixed medical/surgical intensive care units from 5 medical centers in Shanghai were prospectively included between May 2020 and November 2021. CGI was assessed using intermittently scanned CGM, with a median monitoring period of 12.0 days. Outcome measures included short- and long-term mortality.

RESULTS

During a median follow-up period of 1.7 years, a total of 139 (47.4%) deaths were identified, of which 73 (24.9%) occurred within the first 30 days after ICU admission, and 103 (35.2%) within 90 days. The multivariable-adjusted HRs for 30-day mortality across ascending tertiles of CGI were 1.00 (reference), 0.68 (95% CI 0.38-1.22) and 0.36 (95% CI 0.19-0.70), respectively. For per 1-SD increase in CGI, the risk of 30-day mortality was decreased by 51% (HR 0.49, 95% CI 0.35-0.69). Further adjustment for HbA1c, mean glucose during hospitalization and glucose variability partially attenuated these associations, although the link between CGI and 30-day mortality remained significant (per 1-SD increase: HR 0.57, 95% CI 0.40-0.83). Similar results were observed when 90-day mortality was considered as the outcome. Furthermore, CGI was also significantly and independently associated with long-term mortality (per 1-SD increase: HR 0.77, 95% CI 0.61-0.97).

CONCLUSIONS

In critically ill patients, CGI is significantly associated with short- and long-term mortality.

Research Progress on the Application of CGM in Patients with Diabetes and Hemodialysis

Diabetes mellitus is the main cause of end-stage renal disease (ESKD), and most patients need hemodialysis (HD) treatment after they progress to uremia. Patients with diabetes and HD have obvious blood glucose fluctuation, hyperglycemia and hypoglycemia may both related to the higher mortality. Therefore, maintaining blood glucose stability is the main treatment strategy to improve the prognosis of patients. It is challenging to evaluate the blood glucose control of patients with diabetes and HD. The traditional blood glucose detection methods have certain limitations, they may be affected by many factors in HD patients. The application of continuous glucose monitoring (CGM) system is gradually recognized, CGM can monitor blood glucose real-time, timely, and predictive capabilities, there are fewer factors that are affected blood glucose in HD patients.

Asia-Pacific Perspectives on the Role of Continuous Glucose Monitoring in Optimizing Diabetes Management

Diabetes is prevalent, and it imposes a substantial public health burden globally and in the Asia-Pacific (APAC) region. The cornerstone for optimizing diabetes management and treatment outcomes is glucose monitoring, the techniques of which have evolved from self-monitoring of blood glucose (SMBG) to glycated hemoglobin (HbA1c), and to continuous glucose monitoring (CGM). Contextual differences with Western populations and limited regionally generated clinical evidence warrant regional standards of diabetes care, including glucose monitoring in APAC. Hence, the APAC Diabetes Care Advisory Board convened to gather insights into clinician-reported CGM utilization for optimized glucose monitoring and diabetes management in the region. We discuss the findings from a pre-meeting survey and an expert panel meeting regarding glucose monitoring patterns and influencing factors, patient profiles for CGM initiation and continuation, CGM benefits, and CGM optimization challenges and potential solutions in APAC. While CGM is becoming the new standard of care and a useful adjunct to HbA1c and SMBG globally, glucose monitoring type, timing, and frequency should be individualized according to local and patient-specific contexts. The results of this APAC survey guide methods for the formulation of future APAC-specific consensus guidelines for the application of CGM in people living with diabetes.

Efficacy of continuous glucose monitoring in people living with diabetes and end stage kidney disease on dialysis: a systematic review

BACKGROUND

Patients with diabetes on dialysis experience wide variations in glucose levels and an increased risk of hypoglycaemia. Due to the inaccuracies of HbA1c in dialysis patients, JBDS-IP and KDIGO recommend the use of continuous glucose monitoring (CGM). We conducted a systematic review to examine the current evidence for CGM use and its impact on clinical outcomes in patients with diabetes on dialysis.

METHODS

A search of MEDLINE(R) ALL, Ovid Emcare, Journals@Ovid Full Text and Embase databases were conducted. Clinical or observational trials in adults with Type 1(T1D) or Type 2 (T2D) diabetes on dialysis and CGM intervention reporting on glycaemic outcomes were included.

RESULTS

Of the 936 citations identified, 49 duplicates were removed. 887 citations were screened by title and abstract. 9 full texts were reviewed and a further 7 excluded due to duplications or failure to meet to selection criteria. Data was extracted for 2 studies, both prospective before-and-after interventional studies with no control group. Joubert et al. (2015) showed results for 15 participants with T1D. Mean CGM glucose level decreased from 8.37mmol/L at baseline to 7.7mmol/L at the end of the CGM period (p < 0.05) while HbA1c decreased from 6.9 to 6.5% (p < 0.05) during the same period. Mean CGM was lower on dialysis days (7.68mmol/L vs. 7.8mmol/L, p < 0.05). Képénékian et al. (2014) reported on data from 29 T2D patients. Following a 3 month CGM-adapted insulin regimen, HbA1c decreased from 8.4% at baseline to 7.6% (p < 0.01) by the end of study. Mean CGM values decreased from 9.9mmol/L to 8.9mmol/L (p = 0.05) and the frequency of glucose values > 10mmol/L decreased from 41 to 30% (p < 0.05), without a significant increase in hypoglycaemia frequency. Both studies were deemed to be of 'good' quality.

CONCLUSION

Evidence demonstrating the benefits of CGM in patients with diabetes receiving dialysis is lacking. There is a need for well-designed randomised controlled trials to ascertain the benefits of this technology in this patient group.

TRAIL REGISTRATION

PROSPERO registration number: CRD42023371635, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=371635 .

The use of technology in type 2 diabetes and prediabetes: a narrative review

The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern. Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes (defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%] and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrating evidence-based technology into care for people living with type 2 diabetes and prediabetes.

Clinical application of real-time continuous glucose monitoring system during postoperative enteral nutrition therapy in esophageal cancer patients

BACKGROUND

Enteral nutrition (EN) support therapy increases the risk of abnormal blood glucose (BG). The aim of this study is to evaluate the clinical value of a real-time continuous glucose monitoring (rt-CGM) system in BG monitoring during postoperative EN support therapy in patients with esophageal cancer.

METHODS

Patients without diabetes mellitus (DM) with esophageal cancer who planned to receive postoperative EN were enrolled. With the self-monitoring of BG value as the reference BG, the accuracy of rt-CGM was evaluated by the mean absolute relative difference (MARD) value, correlation efficient, agreement analysis, and Parkes and Clarke error grid plot. Finally, paired t tests were used to compare the differences in glucose fluctuations between EN and non-EN days and slow and fast days.

RESULTS

The total MARD value of the rt-CGM system was 13.53%. There was a high correlation between interstitial glucose and fingertip capillary BG (consistency correlation efficient = 0.884 [95% confidence interval, 0.874-0.894]). Results of 15/15%, 20/20%, 30/30% agreement analysis were 58.51%, 84.71%, and 99.65%, respectively. The Parkes and Clarke error grid showed that the proportion of the A and B regions were 100% and 99.94%, respectively. The glucose fluctuations on EN days vs non-EN days and on fast days vs slow days were large, and the difference was statistically significant (P < 0.001).

CONCLUSION

The rt-CGM system achieved clinical accuracy and can be used as a new option for glucose monitoring during postoperative EN therapy. The magnitude of glucose fluctuation during EN therapy remains large, even in the postoperative population without DM.

Factors associated with nocturnal and diurnal glycemic variability in patients with type 2 diabetes: a cross-sectional study

PURPOSE

There is little information on factors that influence the glycemic variability (GV) during the nocturnal and diurnal periods. We aimed to examine the relationship between clinical factors and GV during these two periods.

METHODS

This cross-sectional study included 134 patients with type 2 diabetes. 24-h changes in blood glucose were recorded by a continuous glucose monitoring system. Nocturnal and diurnal GV were assessed by standard deviation of blood glucose (SDBG), coefficient of variation (CV), and mean amplitude of glycemic excursions (MAGE), respectively. Robust regression analyses were performed to identify the factors associated with GV. Restricted cubic splines were used to determine dose-response relationship.

RESULTS

During the nocturnal period, age and glycemic level at 12:00 A.M. were positively associated with GV, whereas alanine aminotransferase was negatively associated with GV. During the diurnal period, homeostatic model assessment 2-insulin sensitivity (HOMA2-S) was positively associated with GV, whereas insulin secretion-sensitivity index-2 (ISSI2) was negatively associated with GV. Additionally, we found a J-shape association between the glycemic level at 12:00 A.M. and MAGE, with 9.0 mmol/L blood glucose level as a cutoff point. Similar nonlinear associations were found between ISSI2 and SDBG, and between ISSI2 and MAGE, with ISSI2 value of 175 as a cutoff point.

CONCLUSION

Factors associated with GV were different between nocturnal and diurnal periods. The cutoff points we found in this study may provide the therapeutic targets for beta-cell function and pre-sleep glycemic level in clinical practice.

Daytime hypoglycemic episodes during the use of an advanced hybrid closed loop system

AIMS

The use of advanced hybrid closed loop systems is spreading due to the beneficial effects on glycometabolic control obtained in patients with type 1 diabetes. However, hypoglycemic episodes can be sometimes a matter of concern. We aim to compare the hypoglycemic risk of an advanced hybrid closed loop system and a predictive low glucose suspend sensor augmented pump.

METHODS

In this retrospective three months observational study, we included 30 patients using Medtronic Minimed™ 780G advanced hybrid closed loop system and 30 patients using a Medtronic Minimed™ predictive low glucose suspend sensor augmented pump.

RESULTS

The advanced hybrid closed loop system reduced the time spent above 180 mg/dL threshold and increased the time in range as compared to the predictive low glucose suspend. No severe hypoglycemia occurred in both groups and no differences were observed in the percentage of time spent below 70 mg/dl and 54 mg/dl glucose threshold. Nevertheless, more hypoglycemic episodes were recorded during daytime, but not in nighttime, with the use of the advanced hybrid closed loop system.

CONCLUSIONS

Our results confirmed the general improvement of glycemic outcomes obtained with the advanced hybrid closed loop system; however more hypoglycemic episodes during daytime were evident.

Effectiveness of Non-Contact Dietary Coaching in Adults with Diabetes or Prediabetes Using a Continuous Glucose Monitoring Device: A Randomized Controlled Trial

We aimed to evaluate the effectiveness of dietary coaching and continuous glucose monitoring (CGM) in patients with diabetes or prediabetes to improve their behavioral skills and health outcomes. A randomized controlled study with pre- and post-testing was conducted. Data were collected between November 2020 and April 2021. Forty-five patients with diabetes or prediabetes who used a CGM device were enrolled and analyzed. Dietary education, individual coaching and group coaching were provided to participants in the experimental group for 4 weeks. After the intervention, the thigh circumference in men significantly differed between the two groups (z = -2.02, p = 0.044). For women, participants in the experimental group showed greater improvement in eating self-efficacy compared with those in the control group (z = -2.66, p = 0.008). Insomnia was negatively related to the change in eating self-efficacy (r = -0.35, p = 0.018) and increase in thigh circumference (r = -0.35, p = 0.017). Even if used within a short intervention period, non-contact dietary coaching programs can help enhance behavioral skills, such as eating self-efficacy and health outcomes, such as thigh circumference. Moreover, the changed variables can indirectly improve other health outcomes in patients with diabetes or prediabetes.

Blood Glucose Fluctuation in Older Adults with Diabetes Mellitus and End-Stage Renal Disease on Maintenance Hemodialysis: An Observational Study

INTRODUCTION

Patients with diabetes mellitus and end-stage renal disease are at a high risk of developing coronary, cerebrovascular, and peripheral vascular diseases. This study aimed to characterize hypoglycemia and blood glucose fluctuations associated with maintenance hemodialysis in older adult patients with diabetes mellitus and end-stage renal disease using a continuous glucose monitoring system.

METHODS

Seven patients were enrolled in this study, and 13 pairs of continuous glucose monitoring system data were collected. Each pair included data of 1 dialysis-on day and 1 dialysis-off day. Information on basic patient characteristics, including age, diabetes mellitus duration, hemodialysis duration, and proportions of hemoglobin A1c and glycated albumin, were collected. Differences in blood glucose fluctuation were compared between dialysis-on days and dialysis-off days.

RESULTS

The mean blood glucose on dialysis-on days (6.96 ± 2.57 mmol/L) was significantly lower than that on dialysis-off days (7.68 ± 2.31 mmol/L; P < 0.05). In contrast, the following parameters had significantly higher values (all P < 0.05) on dialysis-on days compared to dialysis-off days: large amplitude of glycemic excursion level (5.82 ± 2.86 mmol/L versus 4.21 ± 1.71 mmol/L), large amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (3.6 ± 1.74 mmol/L versus 2.8 ± 1.33 mmol/L), mean amplitude of glycemic excursion level (4.78 ± 1.68 mmol/L versus 3.89 ± 1.67 mmol/L), mean amplitude of glycemic excursion level from 8 a.m. to 2 p.m. (4.01 ± 1.03 mmol/L versus 3.12. ± 0.97 mmol/L), standard deviation of blood glucose (1.55 ± 0.89 mmol/L versus 1.03 ± 0.4 mmol/L), and time below a target glucose range of less than 3.9 mmol/L (8.27% versus 4.25%).

CONCLUSION

Fluctuations in blood glucose levels were larger on dialysis-on days, particularly from the start of hemodialysis to 2 h post-hemodialysis, than on dialysis-off days. Hypoglycemia, as indicated by the time below a target glucose range of less than 3.9 mmol/L, occurred more frequently on dialysis-on days than on dialysis-off days.

Assessment of Hyperglycemia, Hypoglycemia and Inter-Day Glucose Variability Using Continuous Glucose Monitoring among Diabetic Patients on Chronic Hemodialysis

Continuous glucose monitoring (CGM) facilitates the assessment of short-term glucose variability and identification of acute excursions of hyper- and hypo-glycemia. Among 37 diabetic hemodialysis patients who underwent 7-day CGM with the iPRO2 device (Medtronic Diabetes, Northridge, CA, USA), we explored the accuracy of glycated albumin (GA) and hemoglobin A1c (HbA1c) in assessing glycemic control, using CGM-derived metrics as the reference standard. In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) in diagnosing a time in the target glucose range of 70–180 mg/dL (TIR^70–180) in <50% of readings was higher for GA (AUC: 0.878; 95% confidence interval (CI): 0.728–0.962) as compared to HbA1c (AUC: 0.682; 95% CI: 0.508–0.825) (p < 0.01). The accuracy of GA (AUC: 0.939; 95% CI: 0.808–0.991) in detecting a time above the target glucose range > 250 mg/dL (TAR^>250) in >10% of readings did not differ from that of HbA1c (AUC: 0.854; 95% CI: 0.699–0.948) (p = 0.16). GA (AUC: 0.712; 95% CI: 0.539–0.848) and HbA1c (AUC: 0.740; 95% CI: 0.570–0.870) had a similarly lower efficiency in detecting a time below target glucose range < 70 mg/dL (TBR^<70) in >1% of readings (p = 0.71). Although the mean glucose levels were similar, the coefficient of variation of glucose recordings (39.2 ± 17.3% vs. 32.0 ± 7.8%, p < 0.001) and TBR^<70 (median (range): 5.6% (0, 25.8) vs. 2.8% (0, 17.9)) were higher during the dialysis-on than during the dialysis-off day. In conclusion, the present study shows that among diabetic hemodialysis patients, GA had higher accuracy than HbA1c in detecting a 7-day CGM-derived TIR^70–180 < 50%. However, both biomarkers provided an imprecise reflection of acute excursions of hypoglycemia and inter-day glucose variability.