Delaying the Onset and Progression of CKD in People with Diabetes: Technology and Effectiveness in Achieving Glucose Control

Diabetes is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease (ESRD) in the USA and worldwide. Intensive glucose-lowering therapy in people with diabetes decreases the progression of microvascular complications, including nephropathy. Observational studies of pancreatic transplantation patients with type 1 diabetes provide evidence that prolonged optimization of glycemic status can in some cases reverse renal damage, with structural improvement noted 10 years after transplantation. Therefore, prevention of the development and progression of CKD should begin with adequate glucose management lifelong. Traditionally, hemoglobin A1c (hbA1c) is the gold standard for assessment of glycemic control. However, hbA1c is not an adequate measure of glucose excursions throughout the day and does not capture hypoglycemia, a key safety concern when attempting to maintain optimal glucose control. With technological advances, continuous glucose monitoring (CGM) can provide a more detailed and actionable evaluation of glycemic patterns. The value of a CGM parameter known as the glycemic “time in range” or TIR was demonstrated by the iDCL trial wherein two patients with the same hbA1c can have different times in range. The goal of CGM and other technology is to improve glycemic control safely and thereby reduces the risk or slow the progression of developing CKD in diabetes as well as to improve glycemic control and TIR in ESRD patients treated by hemodialysis. CGM is likely to be valuable in achieving this goal. Despite Joubert’s early promising results with CGM in hemodialysis patients, studies of its use in this population continue to be sparse. Demonstrating the effectiveness of CGM and other technology throughout the spectrum of diabetic nephropathy from early to end stage mandates further study.