Building Competency in Diabetes Education THE ESSENTIALS

MONITORING| 7- Factors that negatively impact glycemic control in dialysis patients with diabetes include the following (22): • Loss of appetite associated with uremia, often resulting in irregular meals. • Insulin resistance and reduced insulin clearance. • Insufficient and unpredictable gastrointestinal glucose absorption. • Polypharmacy. Proposed BG targets for patients with diabetes and renal disease are presented in Table 9. Table 9. BG targets for patients with diabetes and renal disease . A1C (%)** FBG (mmol/L) 2-hr postprandial BG (mmol/L) Diabetic nephropathy* <7.0 4.4–6.7 <7.8 Predialysis (CrCl) mL/min† <7.5 5.6–6.7 <7.8–8.9 Dialysis‡ 7.5–8.0 5.6–7.8 <11.1 Renal transplantation§ <7.0 4.4–6.7 <7.8 *Diabetic nephropathy: to prevent the onset and progression of diabetic nephropathy ** the A1c in PWD and advanced renal impairment can be falsely lower (22) †Predialysis: higher risk for hypoglycemia related to decreased insulin clearance and GFR decline taken into consideration ‡Dialysis: to avoid hypoglycemia, associated with comorbidity and hypoglycemia awareness. Higher incidence of hypoglycemia in type 2 patients §Renal transplantation: to decrease mortality rate and promote graft and patient survival A1C = glycated hemoglobin; BG = blood glucose; CrCl = creatinine clearance; FBG = fasting blood glucose; GFR = glomerular filtration rate Adapted from Iglesias et al (22) As previously noted, the A1C test remains an essential marker of glycemic control and potential for long term complications (23). It reflects the average levels of pre- and postprandial glycemia present over the preceding two to three months (the normal lifespan of erythrocytes [red blood cells]); however, it does not capture glucose variability or excursions. A1C has also proven to be a difficult test to explain to patients with diabetes. Consequently, most providers have been translating A1C results in terms of its relationship to average BG levels. This effort has been made easier with the reporting of mean glucose and the GMI- glycemic management indicator. (23,24).