Diabetes is one of the leading causes of End Stage Renal Disease (ESRD). Kidney
transplantation is the best form of renal replacement therapy to date but requires that
recipients of transplant organs maintain a complicated medication regimen in order to
prevent graft loss. Their medications include lifelong immunosuppression, anti-microbials
and other maintenance medications (i.e., anti-hypertensives, heart-protective regimens,
bowel care, vitamins and pain medications).
For many transplant patients, glycemic control in the immediate post-operative period can
be an additional challenge. Glycemic control may be hindered by recent surgery,
corticosteroids, immunosuppressants, altered nutritional intake and reduced mobility.
Diabetes professional organizations such as the American Diabetes Association (ADA) and
the American Association of Clinical Endocrinologists (AACE) recommend continuous glucose
monitoring (CGM) for anyone on intensive insulin therapy. The biggest benefit of CGM is
not just the actual glucose value, but also its direction and rate of change. CGM data
can also be downloaded and reflect patterns of glycemic control throughout the day and
night, including not only the average blood glucose but also time-in-range (TIR) and
degrees of glycemic variability. This can help identify unnotified nightly hypoglycemia
or hyperglycemia and help titrate medications to achieve better glycemic control.
Self-Management of blood glucose (SMBG) is a key component in effective glycemic
management, but it places a large burden on the patient. Prior to CGM, SMBG was the only
option to measure daily blood glucose fluctuations, but it is an imperfect tool. For
patients on insulin, a blood glucose is checked at minimum 4 times per day, prior to
meals and at bedtime. Additionally, the utility of SMBG can be endangered by patient
decision making, the ability to check blood glucose, adherence to testing regimen, error
due to poor testing technique, inadequate blood supply, contamination on fingers, or
inaccuracy of some systems.
Numerous studies have shown the clinical benefit of CGM in the type-1 diabetes (T1D) and
type-2 diabetes (T2D) populations (ref: Beck, Olafsdottir). The DIAMOND group (Beck)
showed that CGM improved HBA1C and reduced hyperglycemia (BG>180). Patients wearing the
CGM had high satisfaction scores and low perceived burden. CGM is still a new tool
outside of the Type 1 Diabetes population but may have significant benefits for any
patient on insulin. In Feb 2019 an international guideline on TIR (defined as blood
glucose of 70-180 mg/dL) was published and TIR may become a new standard for assessing
glycemic control.
The investigators research focuses on TIR and the benefits of CGM in the kidney
transplant population. This can be essential for timely adjustments of insulin dosages
when dealing with glycemic derangements and steroid induced hyperglycemia. CGM can
provide an immense opportunity for a continuous 24/7 view of glucose values, glycemic
variability, direction of change and unrecognized blood glucose levels during nighttime,
and influence of food and activity on blood glucose values. In addition to the metrics
described; the glucose management indicator (GMI) or also named estimated A1C (eA1C) is a
measure converting the mean glucose from CGM using a formula derived from glucose
readings from a population of individuals, into an estimate of a simultaneously measured
laboratory A1C, this value may serve as an additional tool in assessing glycemic control.
In conclusion: the use of a CGM can aid the provider and care team in better titration of
insulin and medication regimen adjustment. This research hopes to give insight in a very
complex population that has not had access to CGM before.
