Vivian Fonseca, Medicine and Pharmacology, Section of Endocrinology, Tulane University Health Sciences Center, 1430 Tulane Ave - SL 53, New Orleans, Louisiana 70112, USA. Email: vfonseca@tulane.edu
The “KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease”1 is a useful resource for clinicians and patients. The guideline states “Hemoglobin A1c (HbA1c) is recommended to monitor glycemic control in patients with diabetes and CKD”1(pS23) and “Accuracy and precision of HbA1c measurement declines with advanced CKD (G4–G5), particularly among patients treated by dialysis, in whom HbA1c measurements have low reliability.”1(pS23) However, the guideline also states that “HbA1c remains the glycemic biomarker of choice in advanced CKD because glycated albumin [GA] and fructosamine provide no advantages over HbA1c and have clinically relevant assay biases to the low and high levels, respectively, with hypoalbuminemia, a common condition among patients with proteinuria, malnutrition, or treated by peritoneal dialysis.”1(pS40) On the other hand, the American Diabetes Association and European Association for the Study of Diabetes guidelines state the same but also point to the fact that HbA1c may be unreliable in advanced chronic kidney disease (CKD) prior to end-stage kidney disease because of its limitations in the presence of anemia and other conditions, common in this population.