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Review
. 2023 Jan 1;18(1):130-145.
doi: 10.2215/CJN.04510422. Epub 2022 Sep 22.

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

Rodolfo J Galindo  1 , Ian H de Boer  2 , Joshua J Neumiller  3 , Katherine R Tuttle  4   5
Affiliations
Review

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

Rodolfo J Galindo et al. Clin J Am Soc Nephrol. .

Abstract

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.

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Conflict of interest statement

R.J. Galindo reports consultancy agreements with Eli Lilly, Sanofi, Pfizer, Boehringer-Ingelheim, Merck, and Weight Watchers and research support to Emory University for studies from Dexcom, Eli Lilly, and Novo Nordisk. I.H. de Boer reports consultancy agreements with AstraZeneca, Bayer, Boehringer-Ingelheim, Boehringer-Ingelheim/Lilly, Cyclerion Therapeutics, George Clinical, Gilead, Goldfinch Bio, Ironwood Pharmaceuticals, Medscape, and Otsuka; research funding from DexCom; honoraria from the National Institutes of Health; and serving as a deputy editor of CJASN, an associate editor of Contemporary Clinical Trials, and a Clinical Practice Guideline Cochair of Kidney Disease Improving Global Outcomes. J.J. Neumiller reports consultancy agreements with Bayer, Novo Nordisk, and Sanofi; honoraria from the American Diabetes Association for serving on the editorial board; an advisory or leadership role with the American Diabetes Association; and speakers bureau for Dexcom. K.R. Tuttle reports consultancy agreements with AstraZeneca, Bayer, Boehringer Ingelheim, Goldfinch Bio, Janssen, Novo Nordisk, and Travere; research funding from Bayer, Goldfinch Bio, and Travere; honoraria from Bayer, Boehringer Ingelheim, Gilead, and Novo Nordisk; other support from Gilead and Eli Lilly; personal fees and other support from AstraZeneca and Boehringer Ingelheim; grants, personal fees, and other support from Bayer AG and Novo Nordisk; grants and other support from Goldfinch Bio; and grants from Travere and is supported by National Institutes of Health research grants R01MD014712, U2CDK114886, UL1TR002319, U54DK083912, U01DK100846, OT2HL161847, and UM1AI109568 and Centers for Disease Control and Prevent project 75D301-21-P-1225.

Figures

Figure 1.
Figure 1.
Ambulatory glucose profile (AGP). CGM, continuous glucose monitoring; %CV, % coefficient of variation; DOB, date of birth; GMI, glucose management indicator; HbA1c, hemoglobin A1c; % TIR, % time in range.
<b>Figure 2</b>.
Figure 2.
AGP report from a patient with undiagnosed and asymptomatic hypoglycemia during hemodialysis using multiple daily insulin injections.
Figure 3.
Figure 3.
AGP report from a patient on hemodialysis with undiagnosed prandial-related severe hyperglycemia and inaccurate HbA1c levels. IQR, interquartile range.
Figure 4.
Figure 4.
AGP report from a patient with CKD not controlled on basal insulin and needing intensification of therapy to control prandial hyperglycemia.
See this image and copyright information in PMC

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