Thread by @KIReports

🚨 Tweetorial Alert 🚨

T1. Diabetes mellitus is commonly encountered in our CKD clinics and so proper monitoring is paramount. We’ll discuss limitations of glucose monitoring in CKD…but first let’s start with a quiz!

T2. Are CKD patients prone to hypoglycemia?

T3. CKD patients are prone to hypoglycemia due to the following reasons:

🍬 high insulin use
🍬 long disease duration
🍬 impaired renal gluconeogenesis
🍬 decreased insulin clearance

T4. KDIGO guideline recommends measuring HbA1c biannually… but A1c is a poor marker especially in advanced CKD due to:
🍬 altered red cell survival
🍬 use of iron and ESAs
🍬 blood transfusions

T5. All of the above result in decreased A1c and give a false sense of “improvement in DM” when in fact, it is a reflection of worsening kidney function, not improving DM!

T6. Other markers like fructosamine and glycated albumin aren’t that great markers for glycemic control either & are poorly understood

T7.
pubmed.ncbi.nlm.nih.gov/20202728/
demonstrates fructosamine may underestimate the mean glucose values.

karger.com/Article/FullTe…
glycated albumin there hasn’t been much data to understand its utility in improving glycemic control

Basing management on such testing could be harmful

T8. So what can we use?

T9. The current study explores the utility of continuous glucose monitoring (CGM) to assess glycemic control in patients with CKD and DM.

kireports.org/article/S2468-…

T10. Check out the awesome #visual abstract by @sophia_kidney!

T11. CGMs measure the minute-to-minute interstitial glucose and give insight on daily variability of blood glucose levels that may occur and there can be as much as 20% or more variation from plasma levels especially during rapidly falling/rising values.

T12. The 2020 KDIGO guidelines support the use of a continuous glucose monitoring index (GMI), which is compiled from the mean CGM, as a way to examine HBA1c reliability in later stage CKD.

kdigo.org/wp-content/upl…

T13. The study aim was to understand the relation between the CGM metrics in advanced CKD (stages 3b, 4, and non dialysis 5) and hypoglycemia/hyperglycemia events.

T14. It's a prospective, single center trial for adults (age 18-75) with type 1 or type 2 DM and CKD G3b-5. The study compared a 7-day avg CGM blood sugar with HbA1c.

T15.
Characteristics of the participants:
💎90 participants, with majority being G4 stage
💎Majority were males (63%)
💎Patients were well matched across CKD stages other than proteinuria being higher in advanced stages of CKD

T16.
Age, BMI, length of DM, Hgb, and urine albumin to creatinine were not significantly associated with differences between HBA1c and GMI groups.

T17.
As the stage of CKD advanced, the study patients were increasingly hyperglycemic (>10 mmol/l, 180 mg/dL) and time in range (TIR: 3.9-10 mmol/l, 70-180 mg/dL) decreased. This was true regardless of HbA1C %.

T18.
Over a period of 4 months, when repeating the GMI and HBA1c measurements, there was moderate correlation.This suggests that use of GMI over an extended period of time to monitor DM status in advanced CKD may be useful.

T19. Limitations
💎Small study, n=90
💎Short duration of study (7 days in comparison HbA1C typically looks at 90 days of glycemic control).
💎Exclusion of dialysis patients or those on ESA/iron therapies.

T20. Conclusion
💎There may be benefits of using HbA1c and GMI values in monitoring glucose control in patients with moderate to advanced CKD.
💎Larger, long-term studies are still needed before this becomes a standard of care!

T21. Thanks for tuning into this tweetorial. This is @SaiAchi1 with @KIReports signing off!