Hypoglycemia in People with Type 2 Diabetes and CKD

Application and management of continuous glucose monitoring in diabetic kidney disease

Diabetic kidney disease (DKD) is a common complication of diabetes mellitus that contributes to the risk of end-stage kidney disease (ESKD). Wide glycemic var-iations, such as hypoglycemia and hyperglycemia, are broadly found in diabetic patients with DKD and especially ESKD, as a result of impaired renal metabolism. It is essential to monitor glycemia for effective management of DKD. Hemoglobin A1c (HbA1c) has long been considered as the gold standard for monitoring glycemia for > 3 months. However, assessment of HbA1c has some bias as it is susceptible to factors such as anemia and liver or kidney dysfunction. Continuous glucose monitoring (CGM) has provided new insights on glycemic assessment and management. CGM directly measures glucose level in interstitial fluid, reports real-time or retrospective glucose concentration, and provides multiple glycemic metrics. It avoids the pitfalls of HbA1c in some contexts, and may serve as a precise alternative to estimation of mean glucose and glycemic variability. Emerging studies have demonstrated the merits of CGM for precise monitoring, which allows fine-tuning of glycemic management in diabetic patients. Therefore, CGM technology has the potential for better glycemic monitoring in DKD patients. More research is needed to explore its application and management in different stages of DKD, including hemodialysis, peritoneal dialysis and kidney transplantation.

Development and Validation of an Electronic Health Record-Based Risk Assessment Tool for Hypoglycemia in Patients With Type 2 Diabetes Mellitus

BACKGROUND

The recent availability of high-quality data from clinical trials, together with machine learning (ML) techniques, presents exciting opportunities for developing prediction models for clinical outcomes.

METHODS

As a proof-of-concept, we translated a hypoglycemia risk model derived from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study into the HypoHazardScore, a risk assessment tool applicable to electronic health record (EHR) data. To assess its performance, we conducted a 16-week clinical study at the University of Minnesota where participants (N = 40) with type 2 diabetes mellitus (T2DM) had hypoglycemia assessed prospectively by continuous glucose monitoring (CGM).

RESULTS

The HypoHazardScore combines 16 risk factors commonly found within the EHR. The HypoHazardScore successfully predicted (area under the curve [AUC] = 0.723) whether participants experienced least one CGM-assessed hypoglycemic event (glucose <54 mg/dL for ≥15 minutes from two CGMs) while significantly correlating with frequency of CGM-assessed hypoglycemic events (r = 0.38) and percent time experiencing CGM-assessed hypoglycemia (r = 0.39). Compared to participants with a low HypoHazardScore (N = 19, score <4, median score of 4), participants with a high HypoHazardScore (N = 21, score ≥4) had more frequent CGM-assessed hypoglycemic events (high: 1.6 ± 2.2 events/week; low: 0.3 ± 0.5 events/week) and experienced more CGM-assessed hypoglycemia (high: 1.4% ± 2.0%; low: 0.2% ± 0.4% time) during the 16-week follow-up.

CONCLUSIONS

We demonstrated that a hypoglycemia risk model can be successfully adapted from the ACCORD data to the EHR, with validation by a prospective study using CGM-assessed hypoglycemia. The HypoHazardScore represents a significant advancement toward implementing an EHR-based decision support system that can help reduce hypoglycemia in patients with T2DM.

Frequency of Hypoglycemia Assessed by Continuous Glucose Monitoring in Advanced CKD

BACKGROUND

Hypoglycemia represents a risk for serious morbidity. We evaluated the prevalence and risk factors of hypoglycemia by continuous glucose monitoring (CGM) in patients with CKD with or without diabetes.

METHODS

In this cross-sectional study, outpatients with CKD stages G3-G5 (including hemodialysis) and type 2 diabetes without CKD were enrolled and underwent intermittently scanned CGM measurements for 7 days. The burden of CGM-measured hypoglycemia was assessed using the 7-day sum of area over the curve with glucose levels <70 mg/dl and the sum of time spent <54  mg/dl.

RESULTS

A total of 366 participants (148 participants with CKD and diabetes, 115 with CKD and without diabetes, and 103 without CKD and with diabetes) were included. Glucose levels of <54  mg/dl were observed in 41% of participants with CKD and diabetes, 48% of participants with CKD and without diabetes, and 14% of participants with diabetes and without CKD. However, only two participants reported hypoglycemic symptoms during CGM measurements, which were confirmed and documented by capillary blood glucose measurements. Between-group differences of 7-day area over the curve (<70 mg/dl) were as follows: hemodialysis group versus CKD stage G4 and G5 groups, -0.25 min·mg/dl per hour (95% confidence interval [CI], -6.40 to -0.59) P <0.001; CKD stage G4 and G5 groups versus CKD stage G3 group, -0.08 min·mg/dl per hour (95% CI, -0.0 to -0.50) P =0.15; and CKD stage G3 group versus diabetes without CKD group, -0.14 min·mg/dl per hour (95% CI, -0.0 to -0.20) P =0.01. In addition, the subgroup analysis of the diabetic or nondiabetic and at daytime or nighttime showed that the 7-day area over the curve (<70 mg/dl) and time spent (<54 mg/dl) was larger with worse kidney function.

CONCLUSIONS

The lowering level of kidney function was strongly associated with the burden of hypoglycemia in patients with CKD.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Narrative Review of glycaemic management in people with diabetes on peritoneal dialysis

There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.

The effects of glucose-free and glucose-containing dialysate during dialysis in MHD patients: a prospective cross-over study

OBJECTIVE

To investigate the effects of glucose-free and glucose-containing dialysates during dialysis in maintenance hemodialysis (MHD) patients by the prospective cross-over study, and detect glucose control methods in MHD patients.

METHODS

A total of 66 MHD 18-75 years old patients in our hospital from Nov. 2019 to Mar. 2020 were recruited. All patients underwent HD with 4 hours per time, three times per week. Glucose-free dialysate (glucose-free group) and then 5.55 mmol/L glucose-containing dialysate (glucose-5.55 group) were used alternately in dialysis. The demographics and parameters of pre- and post-dialysis were recorded.

RESULTS

A total of 60 patients were analyzed, and 28 patients among them had type 2 diabetes. Serum glucose pre and post dialysis were 8.64 ± 4.18 mmol/L versus 5.74 ± 1.82 mmol/L (p < 0.01) in glucose-free dialysate, and 9.31 ± 4.89 mmol/L versus 7.80 ± 2.59 mmol/L (p < 0.01) in glucose-5.55 dialysate. The post-dialysis blood glucose of glucose-free group was lower than glucose-5.55 group (5.74 ± 1.82 vs 7.80 ± 2.59, p < 0.01). About 18 (30.00%) patients in glucose-free group and 1 patient (1.67%) in glucose-5.55 group whose blood glucose was lower than 4.44 mmol/L (p < 0.01). About 29 patients (48.33%) in glucose-free group and 17 patients (28.33%; p = 0.02) in glucose-5.55 group have hunger feeling. Serum sodium level in the glucose-free group was higher than that in Glucose-5.55 group (137.92 ± 1.64 vs 136.70 ± 1.64, p < 0.01). Post-dialysis blood glucose had no significant differences between patients not using diabetes-related medication (13 patients) and patients using diabetes-related medication (15 patients) in glucose-free group (7.13 ± 1.78 mmol/L vs 6.08 ± 2.84 mmol/L, p = 0.23) and glucose-5.55 group (9.22 ± 2.59 mmol/L vs 9.35 ± 2.88 mmol/L, p = 0.90).

CONCLUSIONS

Glucose-free and glucose-5.55 dialysate both decrease the blood glucose post-dialysis. Dialysates containing 5.55 mmol/L glucose can reduce the incidence of hypoglycemia and lower serum sodium, but have no effect on blood pressure during dialysis. Stopping insulin and oral anti-diabetic drugs once before dialysis may not affect the control of blood glucose.

Continuous Glucose Monitoring to Optimize Management of Diabetes in Patients with Advanced CKD

Treatment of patients with diabetes and CKD includes optimizing glycemic control using lifestyle modifications and drugs that safely control glycemia and improve clinical kidney and cardiovascular disease outcomes. However, patients with advanced CKD, defined as eGFR <30 ml/min per 1.73 m2 or kidney disease treated with dialysis, have limitations to the use of some preferred glucose-lowering medications, are often treated with insulin, and experience high rates of severe hypoglycemia. Moreover, hemoglobin A1c accuracy decreases as GFR deteriorates. Hence, there is a need for better glycemic monitoring tools. Continuous glucose monitoring allows for 24-hour glycemic monitoring to understand patterns and the effects of lifestyle and medications. Real-time continuous glucose monitoring can be used to guide the administration of insulin and noninsulin therapies. Continuous glucose monitoring can overcome the limitations of self-monitored capillary glucose testing and hemoglobin A1c and has been shown to prevent hypoglycemic excursions in some populations. More data are needed to understand whether similar benefits can be obtained for patients with diabetes and advanced CKD. This review provides an updated approach to management of glycemia in advanced CKD, focusing on the role of continuous glucose monitoring in this high-risk population.

Frequency of adrenal insufficiency in patients with hypoglycemia in an emergency department: A cross-sectional study

Context

In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.

Objective

We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.

Methods

In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level &lt;70 mg/dL [3.9 mmol/L]) between April 1, 2016, and March 31, 2021, using a rapid adrenocorticotropic hormone (ACTH) test.

Results

There were 528 cases with hypoglycemia included (52.1% male; median age 62 years [range 19 to 92]). The majority (389 [73.7%]) of patients were using anti-diabetes drugs. Additionally, 33 (6.3%) consumed alcohol, 17 (3.2%) suffered from malnutrition, 13 (2.5%) liver dysfunction, 12 (2.3%) severe infectious disease, 11 (2.1%) malignancy, 9 (1.7%) heart failure, 4 (0.8%) insulin autoimmune syndrome, 3 (0.6%) insulinoma, 2 (0.4%) were using hypoglycemia-relevant drugs, and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs. 139 mEq/L, P&lt;0.01), eosinophil counts were higher (14 vs. 8%, P&lt;0.01), and systolic blood pressure was lower (120 vs. 128 mmHg, P&lt;0.05) at baseline than in patients with the other etiologies, respectively.

Conclusion

The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.

Insulin use in chronic kidney disease and the risk of hypoglycemic events

BACKGROUND

We examined in persons with type 2 diabetes (T2D) whether the use of insulin and the risk of serious hypoglycemic events with insulin is higher in persons with more advanced CKD.

METHODS

In a national cohort of 855,133 veterans with T2D seen at Veteran Affairs clinics between Jan 1, 2008 and December 31, 2010 with at least two serum creatinine measurements, we defined insulin use from pharmacy records and serious hypoglycemic events by ICD-9/10 codes from emergency room visits or hospitalizations that occurred until December 31, 2016.

RESULTS

Mean age was 66 ± 11 years and 97% were men. Mean baseline eGFR was 73 ± 22 ml/min/1.73 m². In a multivariable Cox regression model of those without insulin use at baseline (N = 653,200), compared to eGFR ≥90 group, eGFR < 30 group had higher hazard (HR 1.80, 95% CI 1.74 to 1.88) of subsequent insulin use. In a multivariable Cox model with propensity score matching for baseline insulin use (N = 305,570), both insulin use (HR 2.34, 95% CI 2.24 to 2.44) and advanced CKD (HR 2.28, 95% CI 2.07 to 2.51 for comparison of eGFR < 30 to eGFR ≥90 ml/min/1.73 m² groups) were associated with increased risk of subsequent serious hypoglycemic events.

CONCLUSIONS AND RELEVANCE

In T2D, more advanced CKD was associated with greater insulin use. Both insulin use and advanced CKD were risk factors for serious hypoglycemic events. The safety of insulin compared to newer glycemic agents in more advanced CKD needs further study.

Evaluation of risk factors and correlation in large sample from the perspective of hypoglycemia

To further clarify the correlation between glucose and other biochemical indicators, to search the risk factors of hypoglycemia through a cross-sectional study. Data were obtained from subjects who underwent health examination in the Health Promotion Center from July 2018 to June 2019. Hypoglycemia is defined as fasting blood glucose less than 4.2 mmol/L. All data were analyzed using Windows R software. A total of 23,935 subjects were included. There were significant differences in age, BMI, waist circumference, blood pressure, glucose, lipid, thyroid function, liver function, and kidney function between men and women (p < .05). The occurrence of hypoglycemia was affected by gender and nondiabetic patients (p < .001). In nondiabetic patients, hypoglycemia was affected by age (p < .05). For each year of age increase, the risk of hypoglycemia was reduced by 2.6%; the risk of hypoglycemia decreased by 3.7% when the waist circumference increased by 1 cm; the risk of hypoglycemia increased by 30.3% with each unit of TG increased; the risk of hypoglycemia decreased by 66.1% for each unit increased by TC; the risk of hypoglycemia increased by 1.715 times for each increased unit of HDLC; the risk of hypoglycemia increased by 1.185 times for each unit of LDLC. Women and nondiabetic people are more likely to have hypoglycemia. Among the group without diabetes, diastolic blood pressure, triglyceride, HDLC, and LDLC are risk factors of hypoglycemia.

Glucagon as a Therapeutic Approach to Severe Hypoglycemia: After 100 Years, Is It Still the Antidote of Insulin?

Hypoglycemia represents a dark and tormented side of diabetes mellitus therapy. Patients treated with insulin or drug inducing hypoglycemia, consider hypoglycemia as a harmful element, which leads to their resistance and lack of acceptance of the pathology and relative therapies. Severe hypoglycemia, in itself, is a risk for patients and relatives. The possibility to have novel strategies and scientific knowledge concerning hypoglycemia could represent an enormous benefit. Novel available glucagon formulations, even now, allow clinicians to deal with hypoglycemia differently with respect to past years. Novel scientific evidence leads to advances concerning physiopathological mechanisms that regulated glycemic homeostasis. In this review, we will try to show some of the important aspects of this field.

Maternal risk factors and pregnancy complications associated with low birth weight neonates in preterm birth

AIM

To explore the association between common pregnancy complications and low birth weight (LBW) neonates in preterm birth.

METHODS

The study included 1764 pregnant women who experienced a single birth prematurely at a city hospital in Guangzhou, China between January 1, 2017 and December 31, 2019. A total of 874 normal birth weight neonates and 890 LBW neonates were included. Multivariate logistic regression analysis was conducted to identify and measure risk factors; two-tailed test was applied, with a p ≤ 0.05 considered statistically significant.

RESULTS

Hypertension was the primary risk factor of LBW in preterm neonates, odds ratio (OR) = 2.912 (p < 0.001; 95% confidence interval [CI], 2.044-4.149), followed by hypothyroidism, OR = 1.807 (p = 0.046; 95% CI, 1.012-3.226), placental abruption, OR = 1.759 (p = 0.049; 95% CI, 1.002-3.087), reproductive tract infection, OR = 1.746 (p < 0.001; 95% CI, 1.325-2.301), abnormal amniotic fluid volume, OR = 1.737 (p = 0.003; 95% CI, 1.202-2.501), and fetal distress OR = 1.690 (p = 0.012; 95% CI, 1.120-2.551).

CONCLUSION

Preventing risk factors, such as hypertension, hypothyroidism, and reproductive tract infections, during pregnancy may reduce the incidence of LBW neonates.

Sexual dimorphism in the progression of type 2 diabetic kidney disease in T2DN rats

Diabetic kidney disease (DKD) is a common complication of diabetes, which frequently leads to end-stage renal failure and increases cardiovascular disease risk. Hyperglycemia promotes renal pathologies such as glomerulosclerosis, tubular hypertrophy, microalbuminuria, and a decline in glomerular filtration rate. Importantly, recent clinical data have demonstrated distinct sexual dimorphism in the pathogenesis of DKD in people with diabetes, which impacts both severity- and age-related risk factors. This study aimed to define sexual dimorphism and renal function in a nonobese type 2 diabetes model with the spontaneous development of advanced diabetic nephropathy (T2DN rats). T2DN rats at 12- and over 48-wk old were used to define disease progression and kidney injury development. We found impaired glucose tolerance and glomerular hyperfiltration in T2DN rats to compare with nondiabetic Wistar control. The T2DN rat displays a significant sexual dimorphism in insulin resistance, plasma cholesterol, renal and glomerular injury, urinary nephrin shedding, and albumin handling. Our results indicate that both male and female T2DN rats developed nonobese type 2 DKD phenotype, where the females had significant protection from the development of severe forms of DKD. Our findings provide further evidence for the T2DN rat strain's effectiveness for studying the multiple facets of DKD.

The association between serum uric acid and diabetic complications in patients with type 2 diabetes mellitus by gender: a cross-sectional study

BACKGROUND

The relationship between serum uric acid (SUA) and several diabetic complications or co-morbidities remains a matter of debate. The study aims to explore the association between SUA levels and the prevalence of non-alcoholic fatty liver disease (NAFLD), diabetic retinopathy (DR), diabetic nephropathy (DN) and diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 2,809 participants (1,784 males and 1,025 females) were included in this cross-sectional study. Clinical characteristics and the prevalence of each of the four diseases were analyzed based on gender-specific quartiles of SUA levels. The Pearson correlation analysis and linear-regression analysis were used to access the correlation between SUA levels and clinical characteristics. Furthermore, a binary logistic regression analysis was carried out to determine whether SUA was an independent risk factor for each of the four complications.

RESULTS

SUA levels were positively correlated to BMI, BUN, Scr and TG, but negatively associated with eGFR, HDL, FBG, 2h-PG and HbA1c% for the patients with T2DM. The prevalence of NAFLD and DN, but not DR or DPN, were increased with SUA levels from the first to the fourth quartile. Binary logistic regression further disclosed that SUA was an independent risk factor for NAFLD (ORs Male = 1.002, ∗ P = 0.0013; ORs Female = 1.002, ∗ P = 0.015) and DN (ORs Male = 1.006, ∗ P < 0.001; ORs Female = 1.005, ∗ P < 0.001), but not for DR and DPN. After adjustment for the confounders, SUA levels were significantly associated with NAFLD within the 3rd (ORs = 1.829, P = 0.004) and 4th quartile (ORs = 2.064, P = 0.001) for women, but not independently associated with SUA for man. On the other hand, our results revealed increased prevalence of DN for SUA quartile 2 (ORs = 3.643, P = 0.039), quartile 3 (ORs = 3.967, P = 0.024) and quartile 4 (ORs = 9.133, P < 0.001) in men; however, SUA quartiles were significantly associated with DN only for quartile 4 (ORs = 4.083, P = 0.042) in women.

CONCLUSION

For patients with T2DM, elevated SUA concentration is an independent risk factor for the prevalence of NAFLD and DN after adjustment for other indicators, but not DR or DPN.

Assessment of the accuracy of an intermittent-scanning continuous glucose monitoring device in patients with type 2 diabetes mellitus undergoing hemodialysis (AIDT2H) study

FreeStyle Libre has been approved for use in patients undergoing hemodialysis (HD) in Japan, unlike Europe and the United States; however, evidence regarding its accuracy in such patients is sparse. Forty‐one participants with type 2 diabetes undergoing HD were recruited. The overall mean absolute relative difference and mean absolute difference were 23.4% and 33.9 mg/dL, respectively. Sensor glucose levels and capillary glucose levels were significantly correlated (r = 0.858, P < .01), although the sensor glucose levels were significantly lower than the capillary glucose levels. The accuracy of FreeStyle Libre in patients undergoing HD became deteriorated with the days of usage. The percentage of sensor results in Zones A and B in the consensus error grid analysis and in the Clarke error grid analysis were 99.7% and 99.0%, respectively. Its insufficient accuracy necessitates adjunct usage of FreeStyle Libre with self‐monitoring of blood glucose in patients undergoing HD.

Retinal Capillary Nonperfusion on OCT-Angiography and Its Relationship to Kidney Function in Patients with Diabetes

Background

Diabetic retinopathy and kidney disease share underlying mechanisms of microvascular damage and are often comorbid in people with diabetes. We evaluated whether there is a relationship between retinal capillary perfusion as measured by swept-source optical coherence tomography angiography and estimated glomerular filtration rate (eGFR) and albuminuria in patients with diabetes and chronic kidney disease (CKD).

Method

A cross-sectional pilot study was conducted at the University of Washington among a subset of participants with diabetes and CKD participating in a larger cohort study. Participants were excluded if they were known to have kidney disease from conditions other than diabetes. Ten participants (11 eyes) were included. Retinal nonperfusion (RNP) and vessel density (VD) were measured by swept-source optical coherence tomography angiography in 30° and 60° field of view (FOV) regions centered at the fovea. Correlations of RNP and VD with eGFR and albuminuria were analyzed.

Results

Participants had a mean age of 72 years, hemoglobin A1c of 8.1%, eGFR of 45 mL/min/1.73 m², and urine albumin-to-creatinine ratio of 162 mg/g. Mean (SD) RNP was 6.6% (4.2%) and 16.9% (7.7%) in 30° and 60° FOV regions, respectively. eGFR was negatively correlated to RNP in both the 30° and 60° FOV regions (R = −0.69, p=0.004, and R = −0.46, p=0.057, respectively), and correlations were stronger among a subset of 7 participants with evidence of diabetic retinopathy on exam and fundus photos. The estimated GFR was not significantly correlated with vessel density. Urine albumin-to-creatinine ratio was not significantly correlated with RNP or VD.

Conclusions

Our proof-of-concept study showed that lower eGFR was significantly correlated with retinal nonperfusion in participants with diabetes and CKD. Advanced retinal imaging may enhance the noninvasive evaluation of kidney function in diabetes.

Continuous Glucose Monitoring and Use of Alternative Markers To Assess Glycemia in Chronic Kidney Disease

OBJECTIVE

In chronic kidney disease, glycated albumin and fructosamine have been postulated to be better biomarkers of glycemic control than HbA_1c. We evaluated the accuracy, variability, and covariate bias of three biomarkers (HbA_1c, glycated albumin, and fructosamine) compared with continuous glucose monitoring (CGM)-derived measurement of glycemia across estimated glomerular filtration rate (eGFR) in type 2 diabetes.

RESEARCH DESIGN AND METHODS

A prospective cohort study was conducted of 104 participants with type 2 diabetes, 80 with eGFR <60 mL/min/1.73 m² (not treated with dialysis) and 24 frequency-matched control subjects with eGFR ≥60 mL/min/1.73 m². Participants wore a blinded CGM for two 6-day periods separated by 2 weeks, with blood and urine collected at the end of each CGM period. HbA_1c, glycated albumin, and fructosamine were measured by high-performance liquid chromatographic, enzymatic, and colorimetric nitroblue tetrazolium methods, respectively.

RESULTS

Within-person biomarker values were strongly correlated between the two CGM periods (r = 0.92-0.95), although no marker fully captured the within-person variability of mean CGM glucose. All markers were similarly correlated with mean CGM glucose (r = 0.71-77). Compared with mean CGM glucose, glycated albumin and fructosamine were significantly biased by age, BMI, serum iron concentration, transferrin saturation, and albuminuria; HbA_1c was underestimated in those with albuminuria.

CONCLUSIONS

Glycated albumin and fructosamine were not less variable than HbA_1c at a given mean CGM glucose level, with several additional sources of bias. These results support measuring HbA_1c to monitor trends in glycemia among patients with eGFR <60 mL/min/1.73 m². Direct measurements of glucose are necessary to capture short-term variability.

Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Prospective Observational Study

BACKGROUND

Glycemic management in patients with type 2 diabetes mellitus (T2DM) and CKD can become complicated. One factor that may affect treatment is hypoglycemia. Hypoglycemia risk may be increased by several biologic processes in CKD. The objective of this study was to determine the frequency, severity, and risk factors for hypoglycemia in patients with T2DM and CKD.

METHODS

The design was a prospective observational study. A continuous glucose monitor (CGM) was worn by 80 patients for up to 14 days; glucose was measured every 15 minutes. Patients with T2DM and eGFR <45 ml/min were enrolled. Patients on dialysis were excluded. The primary outcome was to assess the frequency of hypoglycemic episodes during the study period. Hypoglycemic episodes were defined as a reduced glucose concentration (<70 mg/dl) lasting ≥15 minutes. Secondary outcomes included assessment of severity of hypoglycemia and risk factors for its development.

RESULTS

A total of 80 patients wore the CGM for a mean of 12.7±2.9 days. Hypoglycemic events occurred in 61 of 80 patients (76%) with glucose <70 mg/dl, and 49 of 80 (61%) with glucose <60 mg/dl. Prolonged hypoglycemic events (CGM glucose <54 mg/dl for ≥120 consecutive minutes) occurred in 31 patients (39%) with 118 total events. Most hypoglycemic episodes occurred overnight, from 1:00 am to 9:00 am. By multivariate analysis, lower hemoglobin A1c and treatment with insulin were two modifiable risk factors for hypoglycemic events.

CONCLUSIONS

Patients with T2DM and CKD have frequent periods of hypoglycemia that can be severe and prolonged. Hemoglobin A1c does not portray the full scope of hypoglycemia risk. This study illustrates the need for careful monitoring of glucose levels in patients with T2DM and CKD.

Association between reduced kidney function and incident hypoglycaemia in people with diabetes: The Stockholm Creatinine Measurements (SCREAM) project

AIM

To evaluate possible associations between estimated glomerular filtration rate (eGFR) and hypoglycaemia in adults with diabetes.

METHODS

We conducted an observational study in adults with diabetes from the Stockholm Creatinine Measurement (SCREAM) project, a Swedish healthcare utilization cohort during 2007 to 2011. We evaluated diagnoses and outpatient glucose tests for incidence rate ratios (IRRs) of hypoglycaemia (overall and by severity) in outpatient care by eGFR strata using zero-inflated negative binomial regression. We identified clinical predictors through ordinal logistic regression and assessed 7-day and 30-day mortality from hypoglycaemia in relation to eGFR with Cox proportional hazard models.

RESULTS

We identified 29 434 people with diabetes (13% with type 1 diabetes). Their mean age was 66 years, 43% were women and the median eGFR was 80 mL/min/1.73 m² . During 2 years of follow-up, 1812 patients (6.2%) had hypoglycaemia registered at least once. The risk of hypoglycaemia increased linearly with lower eGFR, with an IRR of 1.2 (95% confidence interval [CI] 1.0-1.4) for eGFR 60-89 mL/min/1.73 m² and 5.8 (95% CI 3.8-9.0) for eGFR <15 mL/min/1.73 m² compared to eGFR 90 to 104 mL/min/1.73 m² . This trend was observed for both mild and severe hypoglycaemia. Both 7-day and 30-day post-hypoglycaemia mortality increased with lower eGFR, peaking in those with eGFR <15 mL/min/1.73 m² (hazard ratio 21.2, 95% CI 5.1-87.9) as compared to those with eGFR 90 to 104 mL/min/1.73 m² . Lower eGFR categories, type 1 diabetes, previous hypoglycaemia, liver disease, presence of diabetic complications and use of insulin and sulphonylureas increased the odds of hypoglycaemia.

CONCLUSION

In this large, observational study, low eGFR was strongly associated with the occurrence, severity and fatality of hypoglycaemia in people with diabetes.

Efficacy of Intermittently Scanned Continuous Glucose Monitoring in the Prevention of Recurrent Severe Hypoglycemia

Background: People with diabetes experiencing hypoglycemia are at increased risk of recurrence because of attenuated autonomic warning. We assessed the efficacy of intermittently scanned continuous glucose monitoring (isCGM; FreeStyle Libre™, Abbott) compared with usual-care self-monitoring of blood glucose (SMBG) in reducing this risk in type 1 and insulin-treated type 2 diabetes. Methods: Insulin-treated adults with diabetes and an episode of clinically significant biochemical hypoglycemia (blood glucose [BG] <3.0 mM) or symptomatic hypoglycemia and BG <4.0 mM were randomized to 6 months of isCGM (intensive group) or SMBG (control group) against a background of usual care. The primary outcome was hypoglycemia requiring second-party assistance for recovery. Prespecified secondary outcomes included other hypoglycemic episodes (self-reported, and BG <3.0, 3.0-3.9, <4.0 mM) and change in HbA_1c at 24 weeks. Results: Of 59 participants (mean age 53.6 years, 44.1% males, median HbA_1c 61.8 mmol/mol or 7.8%), 30 were allocated to isCGM and 29 to SMBG. The incidence of severe hypoglycemia was not significantly different between the two groups (incident rate ratio [95% confidence interval]: 1.49 [0.46-5.56], P = 0.47). The incidence of other recorded hypoglycemic episodes in the intervention group was double that in the control group (P < 0.001). There was no difference in the change in HbA_1c between the two groups (P = 0.74). There were seven serious adverse events and none was considered related to the intervention. Conclusions: Although isCGM is safe, it does not appear to have a role in preventing recurrent severe hypoglycemia in at-risk individuals with diabetes.

Insulin degludec allows for better glycaemic control with a lower risk of hypoglycaemia in patients with chronic kidney disease and type 2 diabetes

We conducted a retrospective observational study to demonstrate that switching to insulin degludec from other long-acting insulins reduces the risk of hypoglycaemia events and improves glycaemic control in patients with type 2 diabetes and stage 2-3B chronic kidney disease.

Glucose time in range and peripheral neuropathy in type 2 diabetes mellitus and chronic kidney disease

​OBJECTIVE: Compared with hemoglobin A1c (HbA1c), continuous glucose monitoring (CGM) may better capture risk of diabetes complications in patients with chronic kidney disease (CKD), including diabetic peripheral neuropathy (DPN). We hypothesized that glucose time in range (TIR), measured by CGM, is associated with DPN symptoms among participants with type 2 diabetes mellitus (type 2 DM) and moderate-to-severe CKD. ​RESEARCH DESIGN AND METHODS: We enrolled 105 people with type 2 DM treated with insulin or sulfonylurea, 81 participants with CKD (estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m²) and 24 matched control participants with eGFR ≥60 mL/min/1.73 m². Each participant wore a CGM for two 6-day periods. Calculated glycemic measures included TIR (glucose 70-180 mg/dL) and glucose management indicator (GMI). DPN symptoms were assessed using the Michigan Neuropathy Screening Instrument (MNSI) questionnaire, with a positive MNSI score defined as ≥2 symptoms. ​RESULTS: Participants with CKD had a mean age of 68 years, diabetes duration 20 years, eGFR 38 mL/min/1.73 m² and HbA1c 7.8%, 61 mmol/mol. Sixty-two participants reported ≥2 DPN symptoms, 51 (63%) with CKD and 11 (46%) controls. Less TIR and higher GMI were associated with higher risk of MNSI questionnaire score ≥2 (OR 1.25 (95% CI 1.02 to 1.52) per 10% lower TIR, and OR 1.79 (95% CI 1.05 to 3.04) per 1% higher GMI, adjusting for age, gender and race). Similar results were observed when analyses were restricted to participants with CKD. In contrast, there was no significant association of HbA1c with DPN symptoms. ​CONCLUSIONS: Symptoms of DPN were common among participants with long-standing type 2 DM and CKD. Lower TIR and higher GMI were associated with DPN symptoms.

A Retrospective Observational Study of Insulin Glargine in Type 2 Diabetic Patients with Advanced Chronic Kidney Disease

Background

The majority of type 2 diabetes mellitus (T2DM) subjects are on multiple oral antidiabetic drugs (OADs) but as kidney dysfunction progresses, many of them become inappropriate. Basal insulin, such as glargine, is generally recommended as first-line insulin therapy by most guidelines. However, there is limited data on the safety and efficacy of the use of glargine in diabetic kidney disease (DKD).

Objectives

To evaluate the efficacy and safety of insulin glargine in T2 DM patients with Stage 3 or 4 chronic kidney disease (CKD).

Material and methods

This single-centered, retrospective, observational study evaluates the efficacy and safety of insulin glargine in DKD with estimated glomerular filtration rate (eGFR) 60 and below. Non-pregnant T2DM patients with DKD receiving insulin glargine for 24 weeks and beyond were included for analysis. Data relating to anthropometric measurements, blood pressure, renal parameters, and glycemic control were analyzed. Sixty patients were in CKD Stage 3 (group A) and 35 patients were in CKD Stage 4 (group B). Glargine was started at an initial dose of 10 units daily as per the standard of care followed by the institute and up-titrated or down-titrated using a prespecified algorithm to maintain fasting plasma glucose between 90 mg/dl and 130 mg/dl.

Results

The study achieves (1.2%) (13.2 mmol/mol) of glycosylated hemoglobin (HbA1C) reduction in both groups (Group A and Group B) and a significant reduction in fasting and postprandial glucose values without a significant weight change over the study period. Out of 95 patients, 32 (33.68%) had documented hypoglycemia; out of them, 9 (28.2%) had severe hypoglycemia, and 8 (25%) had nocturnal hypoglycemia (either mild or severe). No change in weight, blood pressure, or eGFR was observed during the study period.

Conclusions

Treatment with glargine-based basal insulin therapy in diabetes with Stage 3 or Stage 4 CKD was efficacious in reducing glycemic parameters and was safe without significant changes in weight and hypoglycemia.