Oei E, Samad N, Visser A, Chowdhury T A, Fan S L
Department of Renal Medicine and Transplantation, Singapore General Hospital, Singapore.
Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.
Diabet Med. 2016 Sep;33(9):e17-20. doi: 10.1111/dme.12988.
Achieving adequate glycaemic control in patients with diabetes on peritoneal dialysis is challenging. Traditional assessment of glycaemia using HbA1c is difficult in such patients because of renal anaemia or carbamylation of haemoglobin, and significant glucose excursions may be masked. We describe three patients with diabetes on peritoneal dialysis with similar HbA1c levels, but with very different glucose profiles shown on continuous glucose monitoring.
Patient 1 was treated with gliclazide, and had a number of solutions with high glucose concentration in his dialysis prescription. Continuous glucose monitoring showed glucose levels > 11 mmol/l for > 17 h per day, and < 4 mmol/l for 72 min per day with no symptoms. His HbA1c level was 61 mmol/mol (7.7%). Patient 2 was treated with insulin. Continuous glucose monitoring showed glucose levels > 11 mmol/mol for 3.8 h per day, and < 4 mmol/mol for 3.8 h per day. His HbA1c level was 59 mmol/mol (7.6%). Patient 3 was treated with pioglitazone and gliclazide, and glucose levels were > 11 mmol/l for 8 h per day and < 4 mmol/l for 1.6 h per day. His HbA1c was 62 mmol/mol (7.8%). None of the patients was aware of hypoglycaemia during the periods of low glucose recorded on continuous glucose monitoring.
Despite similar HbA1c levels, our three patients had very different glucose profiles. These cases highlight the fact that HbA1c is frequently inadequate in reflecting glucose control in patients with diabetes on peritoneal dialysis, and we suggest that intermittent continuous glucose monitoring may allow safer management of glycaemia in such patients.
对接受腹膜透析的糖尿病患者实现充分的血糖控制具有挑战性。由于肾性贫血或血红蛋白的氨甲酰化，此类患者难以使用糖化血红蛋白（HbA1c）进行传统的血糖评估，且显著的血糖波动可能被掩盖。我们描述了3例接受腹膜透析的糖尿病患者，他们的HbA1c水平相似，但连续血糖监测显示的血糖谱却大不相同。
患者1接受格列齐特治疗，其透析处方中有多种高糖浓度的溶液。连续血糖监测显示，其血糖水平每天有超过17小时高于11 mmol/L，每天有72分钟低于4 mmol/L，且无症状。其HbA1c水平为61 mmol/mol（7.7%）。患者2接受胰岛素治疗。连续血糖监测显示，其血糖水平每天有3.8小时高于11 mmol/mol，每天有3.8小时低于4 mmol/mol。其HbA1c水平为59 mmol/mol（7.6%）。患者3接受吡格列酮和格列齐特治疗，血糖水平每天有8小时高于11 mmol/L，每天有1.6小时低于4 mmol/L。其HbA1c为62 mmol/mol（7.8%）。在连续血糖监测记录的低血糖期间，没有患者意识到低血糖情况。
尽管HbA1c水平相似，但我们的3例患者血糖谱却大不相同。这些病例凸显了HbA1c在反映腹膜透析糖尿病患者血糖控制情况方面常常不足这一事实，我们建议间歇性连续血糖监测可能有助于对此类患者进行更安全的血糖管理。
