Use of Continuous Glucose Monitoring in the Assessment and Management of Patients With Diabetes and Chronic Kidney Disease

Frequent hypoglycemia during hemodialysis in ESRD patients leads to higher risk of death

OBJECTIVE

With the increase of patients with end-stage renal disease (ESRD), most of are receiving hemodialysis, hypoglycemia is a frequent occurrence in ESRD patients due to alterations in glucose and insulin metabolism. The purpose of our study was to explore the correlation between hypoglycemia and long-term survival in patients with ESRD during hemodialysis.

METHODS

Using the database of Hemodialysis Center in Taizhou Second People's Hospital, 268 ESRD patients undergoing maintenance hemodialysis (MHD) for more than 3 months between January 1, 2019 and September 30, 2023 were enrolled. Basic information, laboratory tests and treatment conditions of patients were collected. We analyzed the impact of hypoglycemia during hemodialysis on survival rate, and explored whether hypoglycemia is an independent risk factor for mortality in MHD patients.

RESULTS

We found that factors such as BMI, smoking, and alcohol consumption didn't affect survival rate in ESRD patients, while all-cause mortality was higher in ESRD patients with diabetes, cardiovascular diseases, cerebrovascular disease and experienced hypoglycemia during hemodialysis (p < 0.05). We also observed that almost all ESRD patients with diabetes experienced hypoglycemia during dialysis, and 87.5% experienced ≥3 times, while this phenomenon was hardly observed in nondiabetic ESRD patients. Cox proportional hazards model analysis found that, frequent hypoglycemia (≥3 times) was associated with higher mortality risk in ESRD patients (p = 0.041), adjusted hazard ratios (95% confidence intervals) 3.998 (2.462-6.492).

CONCLUSIONS

Occurrence of hypoglycemia during dialysis was associated with a higher risk of death, frequent hypoglycemia (≥3 times) was an independent risk factor for death in MHD patients.

Assessment of accuracy, clinical validity, and analytical linearity in point-of-care glucose monitoring devices for diabetes mellitus: A systematic review and meta-analysis

Point-of-care technology (POCT) is utilized in diabetes management due to its fast turnaround time. However, the accuracy and reliability of its results are of concern. This review aims to evaluate the (i) accuracy, (ii) clinical validity and (iii) linearity of POCT for blood glucose concentration following ISO 15197. The study was conducted following the PRISMA framework. Searches with the search term "point of care test" OR "POCT" AND "Accuracy" AND "glucose" were made on Scopus, PubMed, DOAJ, and Cochrane Library. Quality assessments were performed using the QUADAS-2 tool. Proportion and Coefficient meta-analyses were used. Recent studies (2019-2023) evaluating the accuracy of POC devices in blood glucose estimation were included. 4918 participants and 56 POC brands were identified from the 30 included studies. The pooled percentage of POCT results within ±15 mg/dL (±0.83 mmol/L) for glucose concentrations <100 mg/dL (<5.6 mmol/L) was 98.83 % (95 % CI: 96.52-99.92) for professional use and 87.70 % (95 % CI: 62.65-99.65) for home-use glucometers. For glucose concentrations ≥100 mg/dL (≥5.6 mmol/L), the pooled percentages were 98.59 % (95 % CI: 95.90-99.88) and 88.79 % (95 % CI: 67.35-99.44), respectively. Measurements in zones A and B of the consensus error grid analysis were 98.06 % (95 % CI: 94.59-99.80) for professional-use and 98.70 % (95 % CI: 95.85-99.95) for home-use glucometers. The pooled correlation coefficient for professional-use glucometers was 0.988 (95 % CI: 0.980-0.993) while home-use was 0.930 (95 % CI: 0.869-0.963). While professional-use glucometers met ISO 15197 accuracy criteria but not clinical validity standards, home-use devices failed to meet both accuracy and clinical validity criteria. Professional-use glucometers demonstrated superior accuracy compared to home-use glucometers. Based on the variability in analytical performance of POC devices, it is recommended that proper care be taken when selecting POCT devices for optimal use in diabetic management.

Peritoneal dialysis and kidney transplantation: Your questions answered

Peritoneal dialysis (PD) and kidney transplantation are important therapeutic options in patients with advanced kidney disease. This article delineates the relationship between PD and kidney transplantation in several key domains, including: (1) Comparative merits and limitations of PD versus center-based hemodialysis prior to kidney transplantation, (2) Patient outcomes after kidney transplantation in individuals receiving PD prior to kidney transplantation, (3) Perioperative management strategies of patients receiving PD at the time of kidney transplantation, and (4) The relative advantages and clinical outcomes of PD use following kidney allograft failure compared to other modalities. This article aims to provide comprehensive guidance for optimizing care across the PD-kidney transplant transitions continuum.

Comprehensive assessment of antioxidant, antidiabetic, and anti-glycation properties of aqueous and methanolic extracts from Pistacia lentiscus L. leaves: a potential natural source for managing oxidative stress and diabetes-related complications

This study evaluates the phenolic and flavonoid contents, as well as the antioxidant, antidiabetic, and anti-glycation properties of aqueous and methanolic extracts from Pistacia lentiscus L. leaves. The antioxidant activity was assessed using DPPH, ABTS, FRAP, and iron-chelation assays, revealing superior activity in the aqueous extract. Both extracts exhibited potent antidiabetic effects by inhibiting the digestive enzyme alpha-amylase, with IC50 values of 2,291 ± 0.002 μg/mL (aqueous) and 2,889 ± 0.002 μg/mL (methanolic). Additionally, the extracts demonstrated significant anti-glycation activity, reducing advanced glycation end-product (AGE) formation, inhibiting fructosamine levels, and protecting thiol groups, with the aqueous extract providing greater protection. These findings underscore the potential of P. lentiscus L. as a natural source of bioactive compounds for managing oxidative stress and diabetes-related complications.

Cognitive impairment in chronic kidney disease: role of brain imaging, functional imaging, electroencephalography, cerebrospinal fluid biomarkers and sensors

Chronic kidney disease is associated with cognitive impairment although the underlying mechanisms are still not fully understood. Characterization and efficient monitoring of the cognitive impact of kidney disease and ensuing therapies are critical for the accurate clinical management of patients. A vast array of imaging modalities, biomarkers, and sensors have shown relevance for the assessment of cognitive impairment. Knowing the potential and limitations of these paraclinical techniques is a necessary condition to improve the understanding of this phenomenon and to design monitoring protocols and guidelines applicable to this clinical population. The goal of this review is to provide an overview of current imaging modalities and biomarker sources available to the community, for the benefit of the research and clinical community.

Scoping review protocol: The chrononutrition factors in association with glycemic outcomes in adult population

Chrononutrition, which examines the relationship between circadian rhythms and nutrition, has been associated with glycemic outcomes in adults. However, published data on delayed meal timing, increased meal frequency and frequent breakfast skipping have shown inconsistent glycemic outcomes due to variations in methodologies and populations studied. This review presents the scoping review protocol designed to map the evidence on the association between chrononutrition factors and glycemic outcomes in adults. The methodology framework from Arksey and O'Malley will be adapted for this scoping review. Relevant publications will be searched on databases including PubMed, EBSCO Host, ProQuest Central, MEDLINE & Ovid, Scopus and Web of Science. This review focuses on original articles published from January 2014 to 2024, involving participants aged 18 years and older, published in English, and encompassing experimental and observational studies. A comprehensive keyword search strategy will be developed to identify relevant articles. Two reviewers will independently screen the abstracts and titles to determine the eligibility. Subsequently, the full text of potentially eligible articles will be reviewed by additional independent reviewer for final inclusion, with full text screening being verified by two reviewers, and interrater reliability will be conducted. Data from the included articles will be extracted, collated and charted to summarize the relevant methods, outcomes and key findings. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist will be used to guide the development of protocol. This scoping review represents a novel approach to summarize the association between chrononutrition factors and glycemic outcomes among adults. We anticipate the findings of the review will provide stakeholder with crucial evidence-based information for development of effective intervention to manage glycemic outcome in adults. This protocol has been prospectively registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/PA9BU).

Nonlinear association between glycated hemoglobin levels and mortality in elderly patients with non-diabetic chronic kidney disease: a national health and nutrition examination survey analysis

Background

The relationship between glycated hemoglobin (HbA1c) levels and mortality outcomes in elderly patients with non-diabetic chronic kidney disease (CKD) has not been well characterized. This study aimed to investigate the correlation between HbA1c levels and all-cause and cardiovascular disease (CVD) mortality in elderly individuals with non-diabetic CKD.

Methods

Data from the NHANES (1999-2018) were analyzed to measure HbA1c levels in whole blood using high-performance liquid chromatography (HPLC). Information on deaths and subsequent details was collected through the National Mortality Index until December 31, 2019. Hazard ratios (HR) and 95% confidence intervals (CIs) for all-cause and CVD mortality were calculated using weighted Cox proportional hazards and restricted cubic spline models.

Results

Among the 1,931 participants (mean [SE] age, 73.2 [0.2] years; 61.9% female), over a median follow-up period of 7.6 years, a total of 1,003 deaths were observed, including 412 from CVD. HbA1c was divided into four quartiles: Quartile 1 (3.7-5.3%), Quartile 2 (5.4-5.6%), Quartile 3 (5.7-5.8%) as the reference group, and Quartile 4 (5.9-6.4%). Higher risks of all-cause mortality were noted in the lowest and highest HbA1c quartiles, with adjusted HR (95% CI) of 1.48 (1.18-1.87) and 1.31 (1.01-1.70) respectively. For CVD mortality, the lowest quartile showed a significantly increased risk (HR 1.94, 95% CI: 1.29-2.90), but the highest quartile did not significantly differ from the reference, with HR 1.14 (0.73-1.77). The RCS analysis indicated a U-shaped nonlinear relationship between HbA1c levels and all-cause mortality (P = 0.026 for nonlinearity) and a J-shaped nonlinear relationship with CVD mortality (P = 0.035 for nonlinearity).

Conclusion

This cohort study suggests that both low and high HbA1c levels are associated with an increased risk of all-cause mortality in elderly patients with non-diabetic CKD.

Trajectory Analysis in FBG and the Incidence of Chronic Kidney Disease: A Nationwide Population-Based Study

OBJECTIVES

This study aimed to classify fasting blood glucose (FBG) trajectories by sex and examine their associations with the risk of chronic kidney disease (CKD).

METHODS

Using data from the National Health Insurance Service-National Sample Cohort in Korea, participants aged 40 years and above, without CKD or diabetes mellitus (DM), were followed from 2002 to 2009. Based on their FBG trajectories, participants were categorized into two classes and stratified by sex. CKD incidence rates were analyzed according to these FBG trajectories, and the impact of additional risk factors on CKD incidence was assessed.

RESULTS

A total of 91,131 participants were analyzed. Among individuals classified in Class 1, FBG levels gradually increased from 90.7 (men) and 88.7 (women) in 2002 to 96.6 (men) and 93.2 (women) in 2009. In contrast, participants classified as Class 2 exhibited a rapid increase in FBG levels, rising from 106 (men) and 106 (women) in 2002 to 144 (men) and 132 (women) in 2009. The incidence of CKD increased over time in both men and women classified as Class 2 compared to Class 1, with respective hazard ratios (HR) of 1.35 for men and 1.53 for women. Additionally, increased age, hypertension, and body mass index (BMI) were independently associated with an elevated risk of CKD.

CONCLUSIONS

The Class 2 group demonstrated a significantly higher incidence of CKD compared to the Class 1 group. This finding indicates the need for the proactive management of individuals with relatively high FBG levels featuring rapid FBG increases in order to mitigate the risk of CKD development.

Effects of PARP1 inhibitor PJ-34 on TGFα, IL-6, and IL-1β levels in diabetic nephropathy

Diabetic nephropathy is a severe chronic complication characterized by cytotoxicity, inflammation, and fibrosis, ultimately leading to renal failure. This study systematically investigated the effects of the PARP1 inhibitor PJ-34 on high glucose-induced cytotoxicity, inflammation, and fibrosis in HK-2 cells, as well as its improvement on neuropathic pain response and transforming growth factor β (TGFβ) expression in a type 1 diabetes mellitus diabetic nephropathy mouse model. Through cellular and animal experiments, we observed that PJ-34 significantly enhanced the proliferative capacity of cells damaged by high glucose, reduced apoptosis, and decreased the release of proinflammatory factors TGFα, interleukin-6, and interleukin-1β. In the type 1 diabetes mellitus nephropathy mouse model, the administration of PJ-34 substantially improved parameters of neuropathic pain, alleviated renal tissue damage, reduced indicators of renal functional impairment-inhibited renal fibrosis, and reduced the key protein expression in the epithelial-mesenchymal transition process, acting through the regulation of the TGFβ/Smads signaling pathway. This study elucidated the mechanism of action of the PARP1 inhibitor PJ-34 as a potential therapeutic agent for diabetic nephropathy, offering a novel strategy for its treatment.

Glucose control and variability assessed by continuous glucose monitoring in patients with type 1 diabetes and diabetic kidney disease

Continuous glucose monitoring (CGM) has emerged as a superior method to glycated hemoglobin (HbA1c) monitoring for glycemic control assessment in type 1 diabetes (T1D). The association between CGM parameters and diabetic kidney disease (DKD) has not been extensively researched. The aim of the present study was to compare CGM metrics between patients with stable and progressive DKD and T1D. A cross-sectional study was performed with 75 patients with T1D, of which 28 had progressive DKD, defined as an estimated glomerular filtration rate decrease of ≥3 ml/min/year or an increased albuminuria stage over the median follow-up time of 7.46 (6.50-8.16) years. FreeStyle Libre ProiQ Sensors were used for CGM. Insulin sensitivity was calculated according to the estimated glucose disposal rate (eGDR) formula. The results revealed that as compared with subjects with stable DKD, individuals with progressive DKD exhibited a higher average glucose level (P=0.03), spent more time above the target range (P=0.05), less time in time in range (TIR; P=0.03), had a higher median estimated HbA1c (P=0.02) and glucose management indicator (P=0.03), as well as a longer duration of hypoglycemic events (P=0.03). There were no differences in compliance levels and recognition of hypoglycemia between the DKD study groups. Differences in correlation patterns between CGM parameters in patients with stable and progressive DKD were observed. For example, glucose variability was significantly positively correlated with TIR in subjects with DKD (Ρ=0.390; P=0.04) but not in individuals without DKD. The progression of DKD was statistically significantly associated with several CGM parameters in multivariate logistic regression models. Collectively, associations between CGM metrics and DKD status were demonstrated in patients with T1D. The findings of the present study indicate the necessity for regular CGM in patients with progressive DKD for improvement of their glycemic control and DKD outcomes but also call for the development of a personalized approach to CGM data interpretation and establishing therapeutic targets in these subjects.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Application of Dorzagliatin in peritoneal dialysis patients with type 2 diabetes mellitus: A case report

BACKGROUND

Treating diabetes in dialysis patients remains a challenge, with many hypoglycemic drugs requiring dose adjustments or avoidance in these patients.

CASE SUMMARY

This report describes an 83-year-old female patient with a 30-year history of type 2 diabetes (T2DM) who had struggled to control her blood sugar for more than a year. She had a history of high blood pressure for 30 years, had undergone continuous ambulatory peritoneal dialysis for more than two years, was 163 cm tall, weighed 77 kg, and had a body mass index of 28.98 kg/m2. Despite intensive insulin therapy at a daily dose of 150 units, adding Dorzagliatin at a dosage of 75 mg orally twice daily led to immediate blood sugar improvement and a gradual reduction in insulin dosage. After one month of follow-up, the fasting plasma glucose was 6-8 mmol/L, and the 2-hour postprandial glucose was 8-12 mmol/L.

CONCLUSION

To our knowledge, this report is the first to use Dorzagliatin to treat type 2 diabetes peritoneal dialysis patients with challenging glucose control. Dorzagliatin, a novel glucokinase activator primarily metabolized by the liver, exhibits no pharmacokinetic differences among patients with varying degrees of chronic kidney disease. It has a high plasma protein binding rate and may not be cleared by peritoneal dialysis, potentially offering a new glycemic control option for Type 2 diabetic patients on peritoneal dialysis.

Association Between Peritoneal Glucose Absorption, Lipid Metabolism, and Cardiovascular Disease Risk in Nondiabetic Patients on Peritoneal Dialysis

BACKGROUND

Excessive sugar intake increases the energy metabolic burden and the risk of cardiovascular disease (CVD). Patients on peritoneal dialysis absorb much more glucose than the World Health Organization recommends, but the link to CVD is unclear.

OBJECTIVE

To identify the association between peritoneal glucose absorption, lipid metabolism, and CVD.

METHODS

We applied generalized additive mixed effects and mixed effects Cox proportional hazard models to evaluate the impact of peritoneal glucose absorption on lipid profiles and CVD risk. We performed subgroup analyses by using protein intake (normalized protein nitrogen appearance [nPNA] and normalized protein catabolic rate [nPCR] were used to assess protein intake) and high-sensitivity C-reactive protein (hs-CRP).

RESULTS

After multivariable adjustment, peritoneal glucose absorption per 10 g/d increase was associated with an increase in cholesterol of 0.145 (95% confidence interval [CI]: 0.086-0.204) mmol/L. No link with the total risk of CVD was observed; however, protein intake and hs-CRP levels affected the relationship between glucose absorption and CVD risk. Patients with values for nPNA and nPCR <1.0 g/(kg·d) were associated with a lower risk of CVD (hazard ratio [HR] 95% CI: 0.68 (0.46-0.98)) with glucose absorption per 10 g/d increase. While patients with hs-CRP levels ≥3 mg/d or values for nPNA or nPCR ≥1.0 g/(kg·d) were associated with a higher risk of CVD (HR 95% CI: 1.32 (1.07-1.63); 1.31 (1.02-1.68)) for glucose absorption per 10 g/d increase.

CONCLUSIONS

Our study found a positive correlation between peritoneal glucose absorption and lipid profiles. Increased glucose absorption was associated with a lower risk of CVD in lower protein intake patients and a higher risk of CVD in higher hs-CRP or protein intake levels in patients on peritoneal dialysis.

Consensus Report on the Use of Continuous Glucose Monitoring in Chronic Kidney Disease and Diabetes

This report represents the conclusions of 15 experts in nephrology and endocrinology, based on their knowledge of key studies and evidence in the field, on the role of continuous glucose monitors (CGMs) in patients with diabetes and chronic kidney disease (CKD), including those receiving dialysis. The experts discussed issues related to CGM accuracy, indications, education, clinical outcomes, quality of life, research gaps, and barriers to dissemination. Three main goals of management for patients with CKD and diabetes were identified: (1) greater use of CGMs for better glycemic monitoring and management, (2) further research evaluating the accuracy, feasibility, outcomes, and potential value of CGMs in patients with end-stage kidney disease (ESKD) on hemodialysis, and (3) equitable access to CGM technology for patients with CKD. The experts also developed 15 conclusions regarding the use of CGMs in this population related to CGMs' unique delivery of both real-time information that can guide monitoring and management of glycemia and continuous and predictive data in this population, which is at higher risk for hypoglycemia and hyperglycemia. The group noted three major clinical gaps: (1) CGMs are not routinely prescribed for patients with diabetes and CKD; (2) CGMs are not approved by the United States Food and Drug Administration (FDA) for patients with diabetes who are on dialysis; and (3) CGMs are not routinely available to all of those who need them because of structural barriers in the health care system. These gaps can be improved with greater stakeholder collaboration, education, and awareness brought to the use of CGM technology in CKD.

Continuous glucose monitoring among adults with type 2 diabetes receiving noninsulin or basal insulin therapy in primary care

Rates of type 2 diabetes (T2D) continue to rise in the United States, with many patients failing to achieve glycemic targets. Primary care providers often serve as the sole clinician managing diabetes. Continuous glucose monitors (CGMs) have shown promise in diabetes management, yet their adoption in primary care settings, especially among patients with T2D not using intensive insulin therapy, remains limited. We sought to evaluate the impact of CGM use on glycemic control in patients with T2D not using insulin and those using basal but not bolus insulin in a primary care setting. CGM use was associated with a significantly greater reduction in HbA1c (-0.62%, p < 0.01) compared with matched controls at 3 months (n = 182). Patients showed improvements in time in range (39.7-61.9%, p < 0.0001), time > 180 mg/dL (60.1-37.9%, p < 0.001), time > 250 mg/dL (27.6-8.5%, p < 0.001), mean estimated glucose value (212 mg/dL to 173 mg/dL, p < 0.001) and glucose management indicator (8.39-7.46%, p < 0.001). CGM use in a primary care setting compared to usual care significantly improved glycemic control in T2D patients not on bolus insulin, irrespective of treatment with non-insulin or basal insulin. This suggests potential for broader CGM integration in primary care.

Assessing the quality of CKD care using process quality indicators: A scoping review

INTRODUCTION

Assessing the quality of chronic kidney disease (CKD) management is crucial for optimal care and identifying care gaps. It is largely unknown which quality indicators have been widely used and the potential variations in the quality of CKD care. We sought to summarize process quality indicators for CKD and assess the quality of CKD care.

METHODS

We searched databases including Medline (Ovid), PubMed, Cochrane Library, Web of Science, CINAHL, and Scopus from inception to June 20, 2024. Two reviewers screened the identified records, extracted relevant data, and classified categories and themes of quality indicators.

RESULTS

We included 24 studies, extracted 30 quality indicators, and classified them into three categories with nine themes. The three categories included laboratory measures and monitoring of CKD progression and/or complications (monitoring of kidney markers, CKD mineral and bone disorder, anemia and malnutrition, electrolytes, and volume), use of guideline-recommended therapeutic agents (use of medications), and attainment of therapeutic targets (blood pressure, glycemia, and lipids). Among the frequently reported quality indicators (in five or more studies), the following have a median proportion of study participants achieving that quality indicator exceeding 50%: monitoring of kidney markers (Scr/eGFR), use of medications (ACEIs/ARBs, avoiding non-steroidal anti-inflammatory drugs (NSAIDs)), management of blood pressure (with a target of ≤140/90, or without specific targets), and monitoring for glycated hemoglobin A1c (HbA1c)). The presence of diabetes, hypertension, cardiovascular disease, or proteinuria was associated with higher achievement in indicators of monitoring of kidney markers, use of recommended medications, and management of blood pressure and glycemia.

CONCLUSION

The quality of CKD management varies with quality indicators. A more consistent and complete reporting of key quality indicators is needed for future studies assessing CKD care quality.

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.

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 .

Diabetes technology in people with diabetes and advanced chronic kidney disease

Diabetes is the leading cause and a common comorbidity of advanced chronic kidney disease. Glycaemic management in this population is challenging and characterised by frequent excursions of hypoglycaemia and hyperglycaemia. Current glucose monitoring tools, such as HbA1c, fructosamine and glycated albumin, have biases in this population and provide information only on mean glucose exposure. Revolutionary developments in glucose sensing and insulin delivery technology have occurred in the last decade. Newer factory-calibrated continuous glucose monitors provide real-time glucose data, with predictive alarms, allowing improved assessment of glucose excursions and preventive measures, particularly during and between dialysis sessions. Furthermore, integration of continuous glucose monitors and their predictive alerts with automated insulin delivery systems enables insulin administration to be decreased or stopped proactively, leading to improved glycaemic management and diminishing glycaemic fluctuations. While awaiting regulatory approval, emerging studies, expert real-world experience and clinical guidelines support the use of diabetes technology devices in people with diabetes and advanced chronic kidney disease.

Glucagon-like peptide receptor-1 receptor agonists: The emerging fourth pillar in type 2 diabetes and chronic kidney disease?

Previously, no randomized controlled trials investigated the renoprotective effects of glucagon-like peptide-1 receptor agonists (GLP-1RA) as the primary endpoint in patients with diabetes and chronic kidney disease. In the FLOW trial, Perkovic et al. showed that once-weekly semaglutide reduced kidney failure, kidney-related death, and cardiovascular death by 24% as compared with placebo in patients with type 2 diabetes at high risk of renal progression.1.

Scoping review: Exploring the relationship between chrononutrition and glycemic responses in the adult population

Chrononutrition, an emerging body of evidence on the relationship between biological rhythms and metabolism, has been established to be associated with glycemic responses. However, the available evidence is inconsistent, due to protocol variations. Therefore, this review aims to summarize the findings on chrononutrition characteristics and their association with glycemic responses among adults. Systematic searches were conducted across six databases (PubMed, EBSCO Host, ProQuest Central, MEDLINE & Ovid, Scopus and Web of Science) to identify all relevant studies published from January 2012. Two reviewers independently screened the abstracts and full-text articles based on the inclusion and exclusion criteria. Details about population characteristics, study methods and key findings were extracted following the PRISMA-ScR guideline. The quality of selected studies was evaluated using the mixed methods appraisal tool. The searchers identified 49 studies eligible for analysis. The results showed that meal timing, particularly night-time eating and snacking were associated with glycemic responses. Regarding meal regularity, skipping breakfast may affect glycemic responses, but no clear conclusion was drawn about its effect on insulin. The association between meal frequency and glycemic responses was inconclusive. Night fasting duration and restricted eating window are potentially associated with glycemic responses. The current review extensively investigates the association between chrononutrition factors and glycemic responses in adults. However, more prospective cohort and interventional studies are needed to better understand this causal-effect relationship.

Box A of HMGB1 Maintains the DNA Gap and Prevents DDR-induced Kidney Injury in D-galactose Induction Rats

BACKGROUND/AIM

Disability and mortality rates for renal failure are still increasing. DNA damage and oxidative stress intoxication from body metabolism, high blood glucose, or the environment cause significant kidney damage. Recently, we reported that Box A of HMGB1 (Box A) acts as molecular scissors, producing DNA gaps that prevent DNA damage in kidney cell lines and ultimately reverse aging phenotypes in aging rat models. The present study aimed to demonstrate the potency of Box A in preventing D-galactose (D-gal)-induced kidney injury.

MATERIALS AND METHODS

A Box A expression plasmid was constructed and administered to a rat model. D-gal was injected subcutaneously for eight weeks. Serum was collected to study renal function, and white blood cells were collected for DNA gap measurement. Kidney tissue was also collected for γ-H2AX and NF-κB immunostaining; Senescence-associated (SA)-beta-gal staining; and analysis of the mRNA expression of p16INK4A, TNF-α, and IL-6. Moreover, histopathology analysis was performed using hematoxylin & eosin and Masson trichome staining.

RESULTS

Pretreatment with Box A administration prevented the reduction of DNA gaps and the consequences of the DNA damage response, which include elevated serum creatinine; high serum BUN; an increased positive SA-beta-gal staining area; overexpression of p16INK4A, NF-κB and senescence-associated secretory phenotype molecules, including IL-6, TNF-α; and histological alterations, including tubular dilation and collagen accumulation.

CONCLUSION

Box A effectively prevents DNA gap reduction and all D-gal-induced kidney pathological changes at the molecular, histological, and physiological levels. Therefore, Box A administration is a promising novel therapeutic strategy to prevent DNA-damaging agent-induced kidney failure.

Proactive Identification of Patients with Diabetes at Risk of Uncontrolled Outcomes during a Diabetes Management Program: Conceptualization and Development Study Using Machine Learning

BACKGROUND

The growth in the capabilities of telehealth have made it possible to identify individuals with a higher risk of uncontrolled diabetes and provide them with targeted support and resources to help them manage their condition. Thus, predictive modeling has emerged as a valuable tool for the advancement of diabetes management.

OBJECTIVE

This study aimed to conceptualize and develop a novel machine learning (ML) approach to proactively identify participants enrolled in a remote diabetes monitoring program (RDMP) who were at risk of uncontrolled diabetes at 12 months in the program.

METHODS

Registry data from the Livongo for Diabetes RDMP were used to design separate dynamic predictive ML models to predict participant outcomes at each monthly checkpoint of the participants' program journey (month-n models) from the first day of onboarding (month-0 model) up to the 11th month (month-11 model). A participant's program journey began upon onboarding into the RDMP and monitoring their own blood glucose (BG) levels through the RDMP-provided BG meter. Each participant passed through 12 predicative models through their first year enrolled in the RDMP. Four categories of participant attributes (ie, survey data, BG data, medication fills, and health signals) were used for feature construction. The models were trained using the light gradient boosting machine and underwent hyperparameter tuning. The performance of the models was evaluated using standard metrics, including precision, recall, specificity, the area under the curve, the F1-score, and accuracy.

RESULTS

The ML models exhibited strong performance, accurately identifying observable at-risk participants, with recall ranging from 70% to 94% and precision from 40% to 88% across the 12-month program journey. Unobservable at-risk participants also showed promising performance, with recall ranging from 61% to 82% and precision from 42% to 61%. Overall, model performance improved as participants progressed through their program journey, demonstrating the importance of engagement data in predicting long-term clinical outcomes.

CONCLUSIONS

This study explored the Livongo for Diabetes RDMP participants' temporal and static attributes, identification of diabetes management patterns and characteristics, and their relationship to predict diabetes management outcomes. Proactive targeting ML models accurately identified participants at risk of uncontrolled diabetes with a high level of precision that was generalizable through future years within the RDMP. The ability to identify participants who are at risk at various time points throughout the program journey allows for personalized interventions to improve outcomes. This approach offers significant advancements in the feasibility of large-scale implementation in remote monitoring programs and can help prevent uncontrolled glycemic levels and diabetes-related complications. Future research should include the impact of significant changes that can affect a participant's diabetes management.

Development and validation of a clinical prediction model for ischemic stroke recurrence after successful stent implantation in symptomatic intracranial atherosclerotic stenosis

OBJECTIVE

This study aimed to analyze the risk factors for recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (ICAS) who underwent successful stent placement and to establish a nomogram prediction model.

METHODS

We utilized data from a prospective collection of 430 consecutive patients at Jining NO.1 People's Hospital from November 2021 to November 2022, conducting further analysis on the subset of 400 patients who met the inclusion criteria. They were further divided into training (n=321) and validation (n=79) groups. In the training group, we used univariate and multivariate COX regression to find independent risk factors for recurrent stroke and then created a nomogram. The assessment of the nomogram's discrimination and calibration was performed through the examination of various measures including the Consistency index (C-index), the area under the receiver operating characteristic (ROC) curves (AUC), and the calibration plots. Decision curve analysis (DCA) was used to evaluate the clinical utility of the nomogram by quantifying the net benefit to the patient under different threshold probabilities.

RESULTS

The nomogram for predicting recurrent ischemic stroke in symptomatic ICAS patients after stent placement utilizes six variables: coronary heart disease (CHD), smoking, multiple ICAS, systolic blood pressure (SBP), in-stent restenosis (ISR), and fasting plasma glucose. The C-index (0.884 for the training cohort and 0.87 for the validation cohort) and the time-dependent AUC (>0.7) indicated satisfactory discriminative ability of the nomogram. Furthermore, DCA indicated a clinical net benefit from the nomogram.

CONCLUSIONS

The predictive model constructed includes six predictive factors: CHD, smoking, multiple ICAS, SBP, ISR and fasting blood glucose. The model demonstrates good predictive ability and can be utilized to predict ischemic stroke recurrence in patients with symptomatic ICAS after successful stent placement.

Continuous Glucose Monitoring and Reduced Diabetes-Related Hospitalizations in Patients with Type 2 Diabetes and CKD

Key Points

Patients with diabetes and CKD have a heightened risk of glycemic variability, which can lead to severe hypoglycemic or hyperglycemic events, potentially resulting in hospitalization. This study describes the results of a retrospective claims analysis of people with insulin-requiring type 2 diabetes and stage 3–5 CKD who initiated continuous glucose monitoring. Continuous glucose monitoring could help patients with type 2 diabetes and CKD control their glucose and avoid potentially dangerous glycemic events.

Background

There is a heightened risk of glycemic variability in patients with diabetes and CKD. This glycemic variability could lead to hypoglycemic or hyperglycemic crises. We hypothesized that initiation of continuous glucose monitoring (CGM), which provides a glucose measurement every 1–5 minutes, could reduce the incidence of hospitalizations for patients with type 2 diabetes (T2D) and CKD.

Methods

A retrospective analysis of US administrative claims data from the Optum Clinformatics database was conducted. People with T2D, using insulin, not receiving dialysis, and living with stage 3–5 CKD who initiated CGM between January 1, 2016, and March 31, 2022, were identified. National Drug Codes and Healthcare Common Coding Procedure System codes were used to identify CGM device use, and International Classification of Diseases 10th revision codes were used to identify CKD diagnosis and categorize health care encounters. Rates of diabetes-related hospitalizations were obtained, and multivariable logistic regression analyses revealed predictors of hypoglycemic and hyperglycemic encounters.

Results

A total of 8,959 insulin-using patients with T2D and CKD were identified. Most were White (72.3%), had Medicare insurance coverage (82.2%), were using intensive insulin (91.3%), and had stage 3 CKD (86.0%). After CGM initiation, rates of hospitalizations for hyperglycemia or hypoglycemia decreased by 18.2% and 17.0%, respectively (P < 0.0001 for both). The proportion hospitalized with at least one hypoglycemic or hyperglycemic event also significantly decreased after CGM initiation. Significant predictors of both hypoglycemic and hyperglycemic encounters included a previous encounter of that type, age 30–59 years and depression (for hypoglycemia), and age 30–49 years and neuropathy (for hyperglycemia). Use of CGM or glucagon-like peptide-1 receptor agonists was significantly protective against hypoglycemic encounters.

Conclusions

Initiation of CGM was associated with significant reductions in diabetes-related hospitalizations among insulin-using individuals with T2D and moderate-to-severe CKD. CGM could help patients with T2D and CKD control their glucose and avoid potentially dangerous glycemic events.

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Assessment of Glycemic Control by Continuous Glucose Monitoring, Hemoglobin A1c, Fructosamine, and Glycated Albumin in Patients With End-Stage Kidney Disease and Burnt-Out Diabetes

OBJECTIVE

Patients with diabetes and end-stage kidney disease (ESKD) may experience "burnt-out diabetes," defined as having an HbA1c value <6.5% without antidiabetic therapy for >6 months. We aim to assess glycemic control by continuous glucose monitoring (Dexcom G6 CGM) metrics and glycemic markers in ESKD patients on hemodialysis with burnt-out diabetes.

RESEARCH DESIGN AND METHODS

In this pilot prospective study, glycemic control was assessed by continuous glucose monitoring (CGM), HbA1c measures, and glycated albumin and fructosamine measurements in patients with burnt-out diabetes (n = 20) and without a history of diabetes (n = 20).

RESULTS

Patients with burnt-out diabetes had higher CGM-measured daily glucose levels, lower percent time in the range 70-180 mg/dL, higher percent time above range (>250 mg/dL), and longer duration of hyperglycemia >180 mg/dL (hours/day) compared with patients without diabetes (all P < 0.01). HbA1c and fructosamine levels were similar; however, patients with burnt-out diabetes had higher levels of glycated albumin than did patients without diabetes.

CONCLUSIONS

The use of CGM demonstrated that patients with burnt-out diabetes have significant undiagnosed hyperglycemia. CGM and glycated albumin provide better assessment of glycemic control than do values of HbA1c and fructosamine in patients with ESKD.

Supporting Type 1 and Type 2 Diabetes Care in the Hemodialysis Unit: A Quality-improvement Initiative Throughout the COVID-19 Pandemic

OBJECTIVE

People living with diabetes mellitus (DM) and chronic kidney disease can have difficulty attending multiple appointments to receive DM care. We developed and studied the utility of a DM outreach program to offer in the hemodialysis (HD) unit.

METHODS

We conducted a quality improvement project in a satellite HD unit in London, Ontario, Canada, between August 1, 2019, and July 31, 2022. We assessed for baseline gaps in DM care among those with DM, performed root-cause analysis with key stakeholders to identify critical drivers of gaps, and conceptualized a certified diabetes educator-led outreach program to offer in the HD unit. We aimed to improve DM self-monitoring, hypo- and hyperglycemia, and DM-related screening. We used run and control charts to track outcome measures over time and modified our outreach program iteratively.

RESULTS

Fifty-eight persons with DM receiving HD participated in our program. Support spanned multiple waves of the COVID-19 pandemic. With 4 tests of change, we observed improvement in DM self-monitoring with a modest decline in self-reported hyperglycemia. There were no adverse consequences, and satisfaction with our program was high.

CONCLUSIONS

Although we did not meet all measures of success during the pandemic, outreach DM support in the HD unit appeared to improve self-monitoring and self-reported hyperglycemia. Similar programs could be modified and implemented in other centres.

Risk prediction of the progression of chronic kidney disease stage 1 based on peripheral blood samples: construction and internal validation of a nomogram

Patients with chronic kidney disease (CKD) have high morbidity and mortality, and the disease progression has a significant impact on their survival and living standards. This research aims to analyze risk factors for CKD stage 1 and provide a reference for clinical decision making. The clinical data and peripheral blood samples of 300 patients with CKD stage 1 were collected retrospectively. Patients were randomly assigned into a training set (n = 210) and a validation set (n = 90). Patients' baseline characteristic levels were subjected to statistical tests for difference. Univariate and multivariate Cox regression analyses were utilized to identify risk factors influencing disease progression. Subsequently, a prediction model for disease progression was developed using a nomogram, and the model's accuracy was assessed using the C-index and calibration curve. The results revealed that hypertension, diabetes, and urinary albumin were essential factors in the progression of CKD stage 1. The nomogram was constructed and then the C-index was calculated. The calibration curve was utilized to assess the risk model. The C-index of the training set was 0.75, and the C-index of the validation set was 0.73, suggesting a good predictive ability of the model. The risk model accurately predicted the progression of CKD stage 1, which is of great significance to developing personalized treatment for patients in clinical practice.

Association between serum complements and kidney function in patients with diabetic kidney disease

Objective

We aimed to explore the association between serum complements and kidney function of diabetic kidney disease (DKD) in Chinese patients.

Methods

This is a retrospective study involving 2,441 participants. DKD was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) categories. Participants were classified as stages G1-G5 by KDIGO glomerular filtration rate (GFR) categories. Effect sizes are expressed as odds ratio (OR) with 95% confidence interval (CI).

Results

After balancing age, gender, systolic blood pressure (SBP), hemoglobin A1c (HbA1C), serum triglyceride (TG), and urinary albumin-to-creatinine ratio (UACR) between the G2-G5 and control groups, per 0.1 g/L increment in serum complement C3 was significantly associated with a 27.8% reduced risk of DKD at G5 stage (OR, 95% CI, P: 0.722, 0.616-0.847, <0.001) relative to the G1 stage. Conversely, per 0.1 g/L increment in serum complement C4 was associated with an 83.0-177.6% increased risk of G2-G5 stage (P<0.001). Serum complement C1q was not statistically significant compared to controls at all stages prior to or after propensity score matching.

Conclusions

Our results indicate that high concentrations of serum C4 were associated with the significantly elevated risk of kidney function deterioration across all stages, and reduced serum C3 levels with an increased risk of DKD stage G5.

Epidermal Wearable Biosensors for the Continuous Monitoring of Biomarkers of Chronic Disease in Interstitial Fluid

Healthcare technology has allowed individuals to monitor and track various physiological and biological parameters. With the growing trend of the use of the internet of things and big data, wearable biosensors have shown great potential in gaining access to the human body, and providing additional functionality to analyze physiological and biochemical information, which has led to a better personalized and more efficient healthcare. In this review, we summarize the biomarkers in interstitial fluid, introduce and explain the extraction methods for interstitial fluid, and discuss the application of epidermal wearable biosensors for the continuous monitoring of markers in clinical biology. In addition, the current needs, development prospects and challenges are briefly discussed.

Accuracy of Continuous Glucose Monitoring in an Insulin-Treated Population Requiring Haemodialysis

BACKGROUND

Continuous glucose monitoring (CGM) is revolutionizing diabetes care by giving both patients and the healthcare professionals unprecedented insights into glucose variability and patterns. It is established in National Institute for Health and Care Excellence (NICE) guidance as a standard of care for type 1 diabetes and diabetes in pregnancy under certain conditions. Diabetes mellitus (DM) is recognized as an important risk factor for chronic kidney disease (CKD). Around a third of patients receiving in-center haemodialysis as renal replacement therapy (RRT) have diabetes, either as a direct cause of renal failure or as an additional co-morbidity. Evidence of poor compliance with the current standard of care (self-monitoring of blood glucose [SMBG]) and overall greater morbidity and mortality, suggests this patient population as an ideal target group for CGM. However, there exists no strong published evidence showing the validity of CGM devices in insulin-treated diabetes patients requiring haemodialysis.

METHODS

We applied a Freestyle Libre Pro sensor to 69 insulin-treated diabetes haemodialysis (HD) patients on a dialysis day. Interstitial glucose levels were obtained, and time matched within 7 minutes to capillary blood glucose testing and any plasma blood glucose levels sent. Data cleansing techniques were applied to account for rapidly correcting hypoglycaemia and poor SMBG technique.

RESULTS

Clarke-error grid analysis showed 97.9% of glucose values in an acceptable range of agreement (97.3% on dialysis days and 99.1% on non-dialysis days).

CONCLUSIONS

We conclude that the Freestyle Libre sensor is accurate in measuring glucose levels when compared to glucose as measured by capillary SMBG testing and laboratory obtained serum glucose in patients on HD.

Transcriptomic analysis identifies novel candidates in cardiorenal pathology mediated by chronic peritoneal dialysis

Peritoneal dialysis (PD) is associated with increased cardiovascular (CV) risk. Studies of PD-related CV pathology in animal models are lacking despite the clinical importance. Here we introduce the phenotypic evaluation of a rat model of cardiorenal syndrome in response to chronic PD, complemented by a rich transcriptomic dataset detailing chronic PD-induced changes in left ventricle (LV) and kidney tissues. This study aims to determine how PD alters CV parameters and risk factors while identifying pathways for potential therapeutic targets. Sprague Dawley rats underwent Sham or 5/6 nephrectomy (5/6Nx) at 10 weeks of age. Six weeks later an abdominal dialysis catheter was placed in all rats before random assignment to Control or PD (3 daily 1-h exchanges) groups for 8 days. Renal and LV pathology and transcriptomic analysis was performed. The PD regimen reduced circulating levels of BUN in 5/6Nx, indicating dialysis efficacy. PD did not alter blood pressure or cardiovascular function in Sham or 5/6Nx rats, though it attenuated cardiac hypertrophy. Importantly PD increased serum triglycerides in 5/6Nx rats. Furthermore, transcriptomic analysis revealed that PD induced numerous changed transcripts involved with inflammatory pathways, including neutrophil activation and atherosclerosis signaling. We have adapted a uremic rat model of chronic PD. Chronic PD induced transcriptomic changes related to inflammatory signaling that occur independent of 5/6Nx and augmented circulating triglycerides and predicted atherosclerosis signaling in 5/6Nx LV tissues. The changes are indicative of increased CV risk due to PD and highlight several pathways for potential therapeutic targets.

Comprehensive analysis of endoplasmic reticulum stress-related mechanisms in type 2 diabetes mellitus

BACKGROUND

The endoplasmic reticulum (ER) is closely related to a wide range of cellular functions and is a key component to maintain and restore metabolic health. Type 2 diabetes mellitus (T2DM) is a serious threat to human health, but the ER stress (ERS)-related mechanisms in T2DM have not been fully elucidated.

AIM

To identify potential ERS-related mechanisms and crucial biomarkers in T2DM.

METHODS

We conducted gene set enrichment analysis (GSEA) and gene set variation analysis (GSVA) in myoblast and myotube form GSE166502, and obtained the differentially expressed genes (DEGs). After intersecting with ERS-related genes, we obtained ERS-related DEGs. Finally, functional analyses, immune infiltration, and several networks were established.

RESULTS

Through GSEA and GSVA, we identified several metabolic and immune-related pathways. We obtained 227 ERS-related DEGs and constructed several important networks that help to understand the mechanisms and treatment of T2DM. Finally, memory CD4⁺ T cells accounted for the largest proportion of immune cells.

CONCLUSION

This study revealed ERS-related mechanisms in T2DM, which might contribute to new ideas and insights into the mechanisms and treatment of T2DM.

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.

Applications of continuous glucose monitoring across settings and populations: Report from the 23rd Hong Kong diabetes and cardiovascular risk factors-East meets west symposium

Continuous glucose monitoring (CGM) is now an integral part of glycaemic management in people with type 1 diabetes and those with insulin-treated type 2 diabetes. Immediate access to information on CGM glucose levels and trends helps to inform food choices, titration and timing of insulin doses and prompts corrective actions in the event of impending hypo- or hyperglycaemia. Although glycated haemoglobin (HbA1c) remains an important measure of the average of glucose, CGM metrics including time-in-range (TIR) and other metrics on glycaemic variability and hypoglycaemia are strongly endorsed by people with diabetes as impacting their daily lives. There is growing consensus on definitions and targets of CGM metrics with an increasing number of studies demonstrating correlations between CGM metrics and incident complications of diabetes. Implementation of new technologies needs to take into consideration factors such as cost-effectiveness, accessibility as well as acceptability of the person with diabetes and healthcare professional. The United Kingdom is one of the few countries that have developed clinical pathways for integrating CGM into the routine care of people with type 1 diabetes. Besides type 1 diabetes, special groups such as people with impaired kidney function and women during pregnancy may derive additional benefits from CGM.