Discordance Between Glycated Hemoglobin A1c and the Glucose Management Indicator in People With Diabetes and Chronic Kidney Disease.

INTRODUCTION: Assessment of glucose exposure via glycated hemoglobin A1c (HbA1c) has limitations for interpretation in individuals with diabetes and chronic kidney disease (CKD). The glucose management indicator (GMI) derived from continuous glucose monitoring (CGM) data could be an alternative. However, the concordance between HbA1c measured in laboratory and GMI (HbA1c-GMI) is uncertain in individuals with CKD. The purpose of this study is to analyze this discrepancy. MATERIAL AND METHOD: We performed a multicentric, retrospective, observational study. A group of individuals with diabetes and CKD (n = 170) was compared with a group of individuals with diabetes without CKD (n = 185). All individuals used an intermittently scanned continuous glucose monitoring (isCGM). A comparison of 14-day and 90-day glucose data recorded by the isCGM was performed to calculate GMI and the discordance between lab HbA1c and GMI was analyzed by a Bland-Altman method and linear regression. RESULTS: HbA1c-GMI discordance was significantly higher in the CKD group versus without CKD group (0.78 ± 0.57 [0.66-0.90] vs 0.59 ± 0.44 [0.50-0.66]%, P < .005). An absolute difference >0.5% was found in 68.2% of individuals with CKD versus 42.2% of individuals without CKD. We suggest a new specific formula to estimate HbA1c from the linear regression between HbA1c and mean glucose CGM, namely CKD-GMI = 0.0261 × 90-day mean glucose (mg/L) + 3.5579 (r2 = 0.59). CONCLUSIONS: HbA1c-GMI discordance is frequent and usually in favor of an HbA1c level higher than the GMI value, which can lead to errors in changes in glucose-lowering therapy, especially for individuals with CKD. This latter population should benefit from the CGM to measure their glucose exposure more precisely.

[Diagnostic trap: Lithium neurotoxicity with normal lithemia]. / Piège diagnostique : neurotoxicité au lithium avec lithémie normale.

We describe here the case of a 54-year-old bipolar woman, followed in psychiatry and treated with lithium and a selective serotonin reuptake inhibitor (escitalopram) and lamotrigine, presenting a lithium poisoning with an altered state of consciousness caused by a supposed mismanagement of her treatment. Lithium poisoning was suggested based on neurological clinical features, but the blood test brought out a lithium concentration within the therapeutic values at 1,2 mmol/L (N: 0,6-1,2 mmol/L). The classic biological complications related to lithium poisoning (hypercalcemia, diabetes insipidus) confirmed the diagnosis. The patient has been transferred to our nephrology department where she got two hemodialysis sessions conducting to clinical and biological improvement, confirming the diagnosis of lithium poisoning despite the normal blood levels. Later, she was transferred to the psychiatry department for follow-up and for treatment adjustment.

[Renewed interest for the control of post-prandial hyperglycaemia]. / Regain d'intérêt pour le contrôle de l'hyperglycémie postprandiale.

Postprandial hyperglycaemia (PPH) may sometimes be relegated to the background in the treatment of diabetic patients, while its control seems important if not essential to reach an adequate overall glycaemic control. PPH is correlated with glycated haemoglobin and diabetic complications. It is also identified as a cardiovascular risk factor. PPH's monitoring and adequate control are not only a therapeutic goal for diabetes itself but also for reducing associated adverse outcomes other than diabetic complications. PPH is related to the quality of life of patients. Continuous glucose monitoring allows a better appraisal of PPH. The use of new insulin formulations as ultra-fast insulins seems to be the better way to manage post-prandial blood glucose peaks.

L'hyperglycémie postprandiale (HGPP) peut parfois passer au second plan lors de la prise en charge globale du patient diabétique. Néanmoins, sa maîtrise est indispensable pour obtenir un équilibre glycémique global optimal. L'HGPP est corrélée à l'hémoglobine glyquée ainsi qu'aux complications du diabète. Elle semble également jouer un rôle par rapport au risque cardiovasculaire. Outre son intérêt dans la prise en charge thérapeutique du diabète proprement dit, l'HGPP doit être maîtrisée en raison de son lien avec d'autres conséquences médicales et de son impact négatif sur la qualité de vie des patients. Le monitoring continu du glucose permet une meilleure appréciation de l'HGPP. Les nouvelles insulines ultra-rapides paraissent être les molécules les plus adéquates pour réduire, au mieux et au plus vite, l'HGPP.

[Gestational diabetes mellitus : what after delivery ?] / Diabète gestationnel : et après ?

Gestational diabetes mellitus (GDM) occurs in an increasing number of pregnancies. Due to its disappearance after delivery, GDM can be underestimated despite description of many risks for mothers and offsprings later in life. These women are at higher risk for metabolic abnormalities and cardiovascular disease. Overweight/obesity, metabolic disturbances, cardiovascular complications and lower cognitive abilities are more frequent in offsprings. These two populations need an early and adequate prevention of metabolic and cardiovascular disorder from a public health point of view. Lifestyle (healthy diet and exercise) is the best advice to promote in these families. For these women with previous DG, breast-feeding as long as possible and metformin may also be part of the management.

Le diabète gestationnel (DG) complique un nombre croissant de grossesses. Parfois banalisé en raison de sa fréquente disparition après l'accouchement, le DG expose pourtant les mères et leur progéniture à des risques non négligeables dans leur vie. Les mamans ayant présenté un DG sont à plus haut risque sur les plans métabolique et cardiovasculaire. Parallèlement, les enfants présentent des risques accrus sur les plans pondéral, métabolique et cardiovasculaire ainsi que d'éventuels troubles cognitifs. Identifier ces deux populations et leurs risques respectifs est une mesure importante en termes de santé publique. Une bonne hygiène de vie est le meilleur conseil à prodiguer à ces familles tout au long de leur vie. L'allaitement prolongé et la metformine peuvent également être suggérés comme éléments protecteurs sur le plan métabolique.