Glycemia Assessed by Continuous Glucose Monitoring among People Treated with Maintenance Dialysis

Background: Kidney failure and its treatments disrupt glucose homeostasis in ways that may promote both hyperglycemia and hypoglycemia. Continuous glucose monitoring (CGM) delineates detailed glycemic profiles, but published studies in kidney failure are limited to small, select groups. We aimed to characterize the spectrum of glycemia and its determinants in a large, diverse maintenance dialysis population. Methods: We conducted a prospective community-based cohort study of people treated with maintenance dialysis. Each participant wore a Dexcom G6 Pro CGM for approximately 10 days. Outcomes ascertained by CGM included mean blood glucose, time in range (TIR, 70-180 mg/dL), and hypoglycemia events (sustained <70 mg/dL). Results: We enrolled 420 demographically diverse participants, including 263 with diabetes (of whom 88 were untreated with glucose-lowering medications) and 157 without diabetes. Peritoneal dialysis was used by 55. Outcomes varied by diabetes status and dialysis modality. Among participants without diabetes, mean blood glucose was higher with peritoneal dialysis vs hemodialysis (141 vs 121 mg/dL, p<0.001). Among participants with untreated diabetes, mean blood glucose was 162 mg/dL, mean TIR 71%, and only 64% of participants attained TIR ≥70%, while mean hemoglobin A1c was 5.7%. Among participants with treated diabetes, mean blood glucose was 214 mg/dL, mean TIR 43%, and only 22% of participants attained TIR ≥70%, while mean hemoglobin A1c was 7.0%. 714 unique sustained hypoglycemia events were observed, with highest rates for participants without diabetes. In addition to diabetes and dialysis modality, age, dialysis vintage, insulin use, hemoglobin A1c, and serum albumin were significantly associated with mean blood glucose, hypoglycemia, or both. Conclusions: In maintenance dialysis, CGM frequently identifies both hyperglycemia and hypoglycemia that may not be clinically evident. In particular, hyperglycemia is common with peritoneal dialysis, patients with untreated diabetes maintain a diabetic glycemic profile, and patients with treated diabetes rarely meet contemporary CGM-based treatment targets.