CGM and AID rewrite diabetes management in patients with kidney disease

The growing role of continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems in managing diabetes among individuals with advanced chronic kidney disease (CKD) on dialysis is the focus of a new review, shedding light on how these technologies address longstanding challenges in this complex patient population.

CKD continues to represent a major public health concern, marked by significant morbidity and mortality. Diabetes remains the leading cause of CKD and is a prevalent comorbidity among patients with advanced CKD or end-stage renal disease (ESRD) receiving dialysis – further complicating glucose management in an already vulnerable group.

Traditional monitoring tools like finger-prick testing and haemoglobin A1c (HbA1c) often fall short in this setting. These conventional methods may not accurately reflect glycaemic control in patients with renal impairment, particularly those undergoing dialysis, leaving clinicians with limited insight into daily glucose fluctuations.

Emerging evidence now points to the clinical utility of CGM in these patients. Data from randomised controlled trials (RCTs) and observational studies demonstrate that CGM delivers accurate glucose readings and is linked to improvements in HbA1c and reductions in hypoglycaemic episodes in both type 1 and type 2 diabetes.

“The integration of CGM into the care of people with diabetes and CKD, especially those on dialysis, has the potential to transform the glycaemic management in this high-risk population,” noted the review authors.

AID systems – which connect insulin pumps to CGMs to adjust insulin in real time – are also showing significant benefits. The medical technology is associated with better glycaemic outcomes, lower rates of hypoglycaemia, and high patient satisfaction. As such, AID has become standard of care for the management of people with type 1 diabetes and the UK’s National Institute for Health and Care Excellence (NICE) has rolled out this technology to eligible individuals, including children and young people with type 1 diabetes.

Less than 20% of Australians with type 1 diabetes meet recommended glucose targets. There is a push from Diabetes Australia, the Australian Diabetes Society, and the Australian Diabetes Educators Association, for expanded subsidised access to insulin pumps and AID systems for patients living with type 1 diabetes. Their case is strengthened by new findings from an Australian AID trial which shows a wide spectrum of adults with type 1 diabetes can achieve recommended glucose targets by using this technology.

The review notes that evidence around the use of AID therapies in people with advanced CKD on dialysis is limited, highlighting the need for dedicated studies in this area.

The authors also call for further research to better define how CGM performs during and between dialysis sessions, its impact on outcomes depending on usage patterns, and its cost-effectiveness – particularly in patients not on insulin therapy. Importantly, they stress the need to capture patient-reported outcomes and assess how CGM affects quality of life.

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