HbA1c overestimates the glucose management indicator: a pilot study in patients with diabetes, chronic kidney disease not on dialysis, and anemia using isCGM

Abstract

Introduction: There are multiple mechanisms by which HbA1c values can be altered in chronic kidney disease (CKD), which limits its usefulness as a strategy to assess glycemic control in this population.

Methods: Concordance and agreement study between two diagnostic tests: HbA1c and glucose management indicator (GMI) measured by intermittently scanned continuous glucose monitoring (isCGM), based in a prospective cohort of patients with diabetes, CKD (glomerular filtration rate between 15 and 60 ml/min/1.73 m²), and anemia. The isCGM was performed for 3 months, and the GMI was compared with the HbA1c levels taken at the end of isCGM. Agreement was evaluated using Bland-Altman graph analysis and Lin's concordance correlation coefficient (CCC). The concordance of the measures with good glycemic control (<7%) was also evaluated.

Results: A total of 74 patients were enrolled (median age 68.5 years, 51.3% female, 64.9% with CKD stage 3, hemoglobin 11.1 ± 1.2 g/l). The Bland-Altman analysis shows a mean difference between GMI and HbA1c of 0.757 ± 0.687% (95% limits of agreement: -0.590 and 2.105). Difference was greater as the values of GMI and HbA1c increased. The agreement was poor [CCC 0.477; 95% confidence interval (CI): 0.360-0.594], as well as the concordance of values with good glycemic control according to GMI versus HbA1c (67.5% versus 29.7%, p < 0.001) (Kappa 0.2430; 95% CI: 0.16-0.32).

Conclusion: The HbA1c overestimates the GMI values with highly variable ranges of difference, which prevents a precise correction factor. isCGM probably is a safer option for monitoring and decision-making in this population, especially in patients treated with insulin where the risk of hypoglycemia is greater.

Keywords: anemia; chronic kidney disease; continuous glucose monitoring; diabetes; glucose management indicator; glycated hemoglobin.

Figure 1.

(a) Correlation between HbA1c and GMI in adults with chronic kidney disease and anemia. (b) Bland–Altman analysis (agreement) between HbA1c and GMI. Mean of HbA1c_3 and GMI: 3-month glycated hemoglobin and GMI average. Difference of HbA1c_3 and GMI: difference of 3-month HbA1c and GMI. GMI, glucose management indicator; HbA1c, glycated hemoglobin.

Figure 2.

Subgroup analysis. (a) Correlation between HbA1c and GMI in adults with chronic kidney disease (G4) and anemia. (b) Bland–Altman analysis (agreement) between HbA1c and GMI in chronic kidney disease (G4). (c) Correlation between HbA1c and GMI in adults with chronic kidney disease (G3) and anemia. (d) Bland–Altman analysis (agreement) between HbA1c and GMI in chronic kidney disease (G3). (e) Correlation between HbA1c and GMI in adults with chronic kidney disease and anemia (Hb <10 g/dl). (f) Bland–Altman analysis (agreement) between HbA1c and GMI in chronic kidney disease and anemia (Hb <10 g/dl). (g) Correlation between HbA1c and GMI in adults with chronic kidney disease and anemia (Hb >10 g/dl). (h) Bland–Altman analysis (agreement) between HbA1c and GMI in chronic kidney disease and anemia (Hb >10 g/dl). Mean of HbA1c_3 and GMI: 3-month glycated hemoglobin and GMI average. Difference of HbA1c_3 and GMI: difference of 3-month HbA1c and GMI. GMI, glucose management indicator; HbA1c, glycated hemoglobin.