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.

Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease in the world. It is known that maintaining optimal glycemic control can slow the progression of CKD. However, the failing kidney impacts glucose and insulin metabolism and contributes to increased glucose variability. Conventional methods of insulin delivery are not well equipped to adapt to this increased glycemic lability. Automated insulin delivery (AID) has been established as an effective treatment in patients with type 1 diabetes mellitus, and there is emerging evidence for their use in type 2 diabetes mellitus. However, few studies have examined their role in diabetes with concurrent advanced CKD. We discuss the potential benefits and challenges of AID use in patients with diabetes and advanced CKD, including those on dialysis.

Hemoglobin A1c (HbA1c) is widely used to estimate glycemia, yet it is less reliable in patients with chronic kidney disease (CKD). There is growing interest in the complementary use of glycated albumin (GA) to improve glycemic monitoring and risk stratification. However, whether GA associates with clinical outcomes in a non-dialysis-dependent CKD population remains unknown.

Prospective cohort study.

3,110 participants with CKD from the Chronic Renal Insufficiency Cohort study.

Baseline GA levels.

Incident end-stage kidney disease (ESKD), cardiovascular disease (CVD) events, and all-cause mortality.

Cox proportional hazards regression.

Participant characteristics included mean age 59.0±10.8 SD years; 1,357 (43.6%) female; and 1,550 (49.8%) with diabetes. The median GA was 18.7% (IQR, 15.8%-23.3%). During an average 7.9-year follow-up, there were 980 ESKD events, 968 CVD events, and 1,084 deaths. Higher GA levels were associated with greater risks of all outcomes, regardless of diabetes status: hazard ratios for ESKD, CVD, and death among participants with the highest quartile compared with quartile 2 (reference) were 1.42 (95% CI, 1.19-1.69), 1.67 (95% CI, 1.39-2.01), and 1.63 (95% CI, 1.37-1.94), respectively. The associations with CVD and death appeared J-shaped, with increased risk also seen at the lowest GA levels. Among patients with coexisting CKD and diabetes, the associations of GA with outcomes remained significant even after adjusting for HbA1c. For each outcome, we observed a significant increase in the fraction of new prognostic information when both GA and HbA1c were added to models.

Lack of longitudinal GA measurements; and HbA1c measurements were largely unavailable in participants without diabetes.

Among patients with CKD, GA levels were independently associated with risks of ESKD, CVD, and mortality, regardless of diabetes status. GA added prognostic value to HbA1c among patients with coexisting CKD and diabetes.

Hemoglobin A1c (HbA1c) is widely used to estimate glycemia, yet it is less reliable in patients with chronic kidney disease (CKD). There is growing interest in the complementary use of glycated albumin (GA) to improve glycemic monitoring and risk stratification. However, whether GA associates with clinical outcomes in a non-dialysis-dependent CKD population remains unknown. In this cohort study of 3,110 individuals with non-dialysis-dependent CKD, GA levels were independently associated with risks of end-stage kidney disease, cardiovascular disease (CVD), and mortality. The associations with CVD and mortality appeared to be J-shaped. Among patients with coexisting CKD and diabetes, GA added prognostic value to HbA1c. Thus, GA may be a valuable complementary test to HbA1c in patients with CKD.

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.

Infective spondylodiscitis (ISD), the infection of vertebral bodies and surrounding tissues, is a rare complication with major impact on the long-term survival of hemodialysis (HD) patients. Although the most frequent etiology is staphylococcal, identifying these pathogens in blood cultures and biopsy cultures is often difficult. This paper aims to present suitable antibiotic combinations for the treatment of these patients, which is usually challenging in the case of an unidentified pathogen. We presented the therapies applied for 13 HD patients and 19 patients without chronic kidney disease (CKD), diagnosed with ISD between 2013 and 2023 in Bihor County. The percentage of positive blood cultures was low in both groups (30.78% HD vs. 15.78% non-HD). The average length of antibiotic therapy was 5.15 weeks in HD patients and 6.29 weeks in non-HD patients. The use of Carbapenem alone (e.g., Meropenem) for an average of 19.6 days for patients in HD when the pathogen was not identified has proven to be efficient in most cases, similarly to using Vancomycin and Fluoroquinolone/Cephalosporines in combination. Regarding the non-CKD patients, the use of Clindamycin in various combinations for an average of 30.3 days has proven to be efficient in more than 90% of cases of ISD with a nonidentified pathogen. Within 2 years after ISD was diagnosed, 12 of the 13 HD patients passed away, mainly due to cardiovascular causes. Unfortunately, there are no guidelines in the literature concerning the empiric treatment of ISD in the particular case of HD patients. Upon checking the literature on PubMed and Google Scholar, only 10 studies provided relevant data regarding ISD treatment for HD patients. More data about the treatment and evolution of these patients is needed in order to elaborate a truly relevant metanalysis.

Post-transplant diabetes mellitus occurs in 10-40% of kidney transplant recipients and is associated with increased risk of developing cardiovascular diseases. Early identification of patients with a higher risk of developing diabetes could allow to take timely measures. However, no validated model exists to predict the risk of post-transplant diabetes mellitus.

This retrospective study includes 267 adult patients who underwent kidney transplantation at the Antwerp University Hospital between January 2014 and August 2021. Post-transplant diabetes mellitus was diagnosed based on the American Diabetes Association definition at 3 months post-transplant. First, a logistic regression analysis was used to identify predictors for post-transplant diabetes mellitus. Second, criteria to identify patients with a high risk (> 35%) of developing post-transplant diabetes mellitus at 3 months were established.

At 3 months post-transplantation, 54 (20.2%) patients developed post-transplant diabetes mellitus. Univariable analysis showed that age, body mass index and HbA1c on the day of transplantation were associated with post-transplant diabetes mellitus. However, in a multivariable model with the same parameters, only HbA1c remained statistically significant. An absolute increase in HbA1c of 0.1% increases the odds for developing post-transplant diabetes mellitus by 28% (95% confidence interval 1.15-1.42). An HbA1c level ≥ 5.3% at transplantation, regardless of age or body mass index, is sufficient to identify patients with a post-transplant diabetes mellitus risk of ≥ 35% with a positive predictive value of 39% and a negative predictive value of 88%.

The HbA1c value at transplantation was the strongest predictor for post-transplant diabetes mellitus at 3 months post-transplant. Furthermore, at least in our population, a pre-transplant HbA1c of ≥ 5.3% can be used as an easy tool to identify patients at high risk of early post-transplant diabetes mellitus.

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease from 2020 comes at an opportune time when progress in diabetes technology and therapeutics offers new options to manage the large population of patients with diabetes and chronic kidney disease (CKD) at high risk of poor health outcomes. Management of haemoglobin A1c is important in diabetes, but an enlarging base of evidence from large clinical trials has demonstrated important new treatments offering organ protection and not just glucose management, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists. It is the ambition that the guideline can help to optimize the clinical care of people with diabetes and CKD by integrating new options with existing management strategies based on high-quality evidence. Here, the focus has been on comprehensive care of patients with diabetes and CKD, glycaemic monitoring and targets, antihyperglycaemic therapies in patients with diabetes and CKD, and new developments since the guideline was published offering new opportunities and a wider target population for the new interventions.

Blood glucose stability has recently been considered important in the treatment of diabetes. Both hypoglycemia and hyperglycemia can frequently occur in patients with diabetes undergoing hemodialysis. This study aimed to determine the usefulness of continuous glucose monitoring (CGM) for glycemic control and glycemic variability stabilization in patients with diabetes undergoing hemodialysis.

Eighteen patients aged ≥18 years with type 1 or 2 diabetes and ≥3 months on hemodialysis at the Eulji Medical Center, Daejeon, Republic of Korea between November 2021 and May 2022 were included. Patients underwent 7 days CGM twice: the baseline study period (T0) and the follow-up study period (T1), at a 12 weeks interval. Physicians modified the treatment strategy according to the T0 results, and then patients conducted T1. As indicators of glycemic control, the mean glucose levels, glycated hemoglobin A1c (HbA1c), and time in range were measured. As indicators of glycemic variability, standard deviation (SD) and % coefficient variation (%CV) were measured.

Data from 18 patients were analyzed. The mean glucose levels, HbA1c, SD, and %CV improved in T1 compared to T0 (P < 0.05). During T0, the mean glucose level was significantly lower on a day with hemodialysis than on a day without (P < 0.05), and SD and %CV were significantly higher on a day with hemodialysis than on a day without (P < 0.05). After the physicians modified the treatment according to the T0 results, there were no differences in the mean glucose levels, SD, and %CV between days with and without hemodialysis during T1.

Continuous glucose monitoring could be a promising tool for individualizing treatment strategies in patients with diabetes undergoing hemodialysis.

Diabetes mellitus remains the leading cause of end-stage kidney disease worldwide. Inadequate glucose monitoring has been identified as one of the gaps in care for hemodialysis patients with diabetes, and lack of reliable methods to assess glycemia has contributed to uncertainty regarding the benefit of glycemic control in these individuals. Hemoglobin A1c, the standard metric to evaluate glycemic control, is inaccurate in patients with kidney failure, and does not capture the full range of glucose values for patients with diabetes. Recent advances in continuous glucose monitoring have established this technology as the new gold standard for glucose management in diabetes. Glucose fluctuations are uniquely challenging in patients dependent on intermittent hemodialysis, and lead to clinically significant glycemic variability. This review evaluates continuous glucose monitoring technology, its validity in the setting of kidney failure, and interpretation of glucose monitoring results for the nephrologist. Continuous glucose monitoring targets for patients on dialysis have yet to be established. While continuous glucose monitoring provides a more complete picture of the glycemic profile than hemoglobin A1c and can mitigate high-risk hypoglycemia and hyperglycemia in the context of the hemodialysis procedure itself, whether the technology can improve clinical outcomes merits further investigation.

Continuous glucose monitoring (CGM) improves diabetes management, but its reliability in individuals on hemodialysis is poorly understood and potentially affected by interstitial and intravascular volume variations.

We assessed the accuracy of a factory-calibrated CGM by using venous blood glucose measurements (vBGM) during hemodialysis sessions and self-monitoring blood glucose (SMBG) at home.

Twenty participants completed the protocol. The mean absolute relative difference of the CGM was 13.8% and 14.4%, when calculated on SMBG (n = 684) and on vBGM (n = 624), and 98.7% and 100% of values in the Parkes error grid A/B zones, respectively. Throughout 181 days of CGM monitoring, the median time in range (70-180 mg/dL) was 38.5% (interquartile range 29.3-57.9), with 28.7% (7.8-40.6) of the time >250 mg/dL.

The overall performance of a factory-calibrated CGM appears reasonably accurate and clinically relevant for use in practice by individuals on hemodialysis and health professionals to improve diabetes management.

Reliable assessment of glycemia is central to the management of diabetes. The kidneys play a vital role in maintaining glucose homeostasis through glucose filtration, reabsorption, consumption, and generation. This review article highlights the role of the kidneys in glucose metabolism and discusses the benefits, pitfalls, and evidence behind the glycemic markers in patients with chronic kidney disease. We specifically highlight the role of continuous glucose monitoring as an emerging minimally invasive technique for glycemic assessment.

Studies highlight the inaccuracy of glycated hemoglobin (HbA1c) for the assessment of glycemic control in dialysis diabetics and suggest the use of continuous glucose monitoring (CGM) as an alternative. Of the CGMs, FreeStyle Libre^® is the most used in worldwide, but there is still no consensus on its use in dialysis.

A 3-week prospective study was performed with 12 patients comparing capillary and interstitial glucose during dialysis.

Comparing capillary and interstitial measurements, similar values were observed in pre-dialysis in the 1st week (184.1 ± 69.5 mg/dl and 173.1 ± 78.9 mg/dl, respectively, p = 0.303), in patients with body mass index less than 24.9 kg/m² (214.2 ± 72.2 mg/dl and 201.3 ± 77.0 mg/dl respectively, p = 0.466), in those dialysis fluid loss less than 2 l (185.5 ± 82.6 mg/dl and 183.1 ± 94.0 mg/dl respectively and p = 0.805) and in those with hemoglobin greater than 12 g/dl (152.0 ± 35, 5 mg/dl and 129.5 ± 47.4 mg/dl respectively, p = 0.016). In the correlation of the capillary measurement with the interstitial sensor, it was observed that the proportions in the Clarke Error Grid of zone A, zone B, zone C, zone D and zone E were 62.5%, 27.1%, 0.0%, 10.4% and 0.0% respectively and in the Parkes error grid in zone A, zone B, zone C, zone D and zone E were 80.6%, 9.7%, 9.7% 0.0% and 0.0%, respectively.

The mean absolute relative difference in dialysis patients is higher than the general population without end-stage renal disease. However, clinical decision-making based on the values measured by the system can be made with a good margin based on the correlation between interstitial and capillary measurements.

Diabetes is the leading cause of end-stage renal disease (ESRD) and contributes to heightened morbidity and mortality in dialysis patients. Given that ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, adequate glycemic monitoring and control is a cornerstone in diabetic kidney disease management. In ESRD, existing glycemic metrics such as glycated hemoglobin, self-monitored blood glucose, fructosamine, and glycated albumin have limitations in accuracy, convenience, and accessibility. In contrast, continuous glucose monitoring (CGM) provides automated, less invasive glucose measurements and more comprehensive glycemic data versus conventional metrics. Here, we report a 48-year-old male with ESRD due to diabetes receiving thrice-weekly hemodialysis who experienced decreased patient-burden, greater glucose monitoring adherence, improved glycemic parameters, and reduction in hypoglycemia after transitioning to CGM. Through this case, we discuss how CGM is a practical, convenient patient-centered tool that may improve metabolic outcomes and quality of life in ESRD patients with diabetes.

Glycated hemoglobin (HbA1c) is a product of the spontaneous reaction between hemoglobin and elevated glucose levels in the blood. It is included among the so-called advanced glycation end products, of which is the most important for the clinical diagnosis of diabetes mellitus, and it can serve as an alternative to glycemia measurement. Compared to the diagnosis of diabetes mellitus by glycemia, the HbA1c level is less influenced by a short-term problem with diabetes compensation. Mass spectroscopy and chromatographic techniques are among the standard methods of HbA1c level measurement. Compared to glycemia measurement, there is lack of simple methods for diabetes mellitus diagnosis by means of the HbA1c assay using a point-of-care test. This review article is focused on the surveying of facts about HbA1c and its importance in diabetes mellitus diagnosis, and surveying standard methods and new methods suitable for the HbA1c assay under point-of-care conditions. Various bioassays and biosensors are mentioned and their specifications are discussed.