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Abstract

Continuous glucose monitoring (CGM) potentially supports diabetes care in dialysis patients. This qualitative study explores the use of CGM in individuals with type 1 diabetes and those with insulin-treated type 2 diabetes undergoing haemodialysis (HD). Twelve HD patients participated in face-to-face interviews between June 2022 and June 2023 at two dialysis wards in Denmark. Data were analysed using reflective thematic analysis. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Six themes emerged: (1) CGM as a tool for managing both hypo- and hyperglycaemia; (2) CGM promotes well-considered choices; (3) CGM reduces practical barriers in diabetes management; (4) CGM enhances security and confidence in diabetes management; (5) Guidance from healthcare professionals maximises the benefits of CGM; and (6) Mixed opinions on CGM alarms. In conclusion, CGM shows promise in improving diabetes management and daily life for HD patients. However, further research is needed to identify optimal candidates, assess cost-effectiveness, and explore healthcare perspectives on CGM use in this population.

Keywords

CGM diabetes mellitus digital health qualitative research renal dialysis

Introduction

Diabetic nephropathy is a primary cause of haemodialysis (HD) dependency in Western countries, accounting for an estimated 22–27% of all new HD treatments.¹ The combination of poorly controlled diabetes and end-stage renal disease is a strong predictor of cardiovascular morbidity and mortality.^2,3 Therefore, maintaining optimal glycaemic control among diabetic patients on HD is essential for reducing the risk of hypo- and hyperglycaemic episodes, as well as related complications.^4,5

Glycaemic control poses a significant challenge in HD patients because the kidneys are essential in regulating insulin and glucose metabolism.^5–8 Additional challenges include cognitive impairment and limited resources to adhere to diabetes management regimens.⁹ As a result, HD patients’ ability to manage their care is often limited, making it difficult for them to prioritise diabetes-related nutrition and blood glucose control.^10,11 This is further complicated by the requirements to navigate dietary restrictions for both kidney disease and diabetes, which can create conflicting nutritional demands and add to the challenges of self-management.^5,12 Furthermore, dialysis contributes to glycaemic variability because glucose passes freely through the dialysis membrane, and dialysis filters can absorb insulin, which is concerning given that glycaemic variability is a risk factor for morbidity and mortality in individuals with diabetes.^1,5,13 These factors highlight why HD patients with diabetes may face unique challenges compared to other diabetes patients, influencing their approach to glucose management and healthcare needs.

Considering the challenges associated with glycaemic control in HD patients and its related consequences, close monitoring is essential to supporting optimal blood glucose management in this patient group. However, standard approaches such as glycated haemoglobin (HbA1c) and self-monitoring of blood glucose (SMBG) have notable limitations. Although HbA1c is commonly used to assess diabetes control, it can be misleading in HD patients.^2,14 Moreover, many HD patients struggle to maintain the energy required for regular SMBG, which also fails to capture daily glycaemic fluctuations, including those induced by dialysis.^11,15 In addition to these monitoring challenges, supporting diabetes in HD patients can be complex for dialysis nurses, who may lack specialised expertise in diabetes care. Their limited familiarity with the effects of dialysis on blood glucose regulation and lifestyle adjustments presents significant challenges in daily clinical practice.¹⁶ This is particularly concerning because dialysis nurses interact with HD patients multiple times per week during dialysis sessions, placing them in a key position to support diabetes management.¹⁷

Given the challenges outlined above, identifying alternative strategies for glycaemic monitoring and support in HD patients is essential not only from a medical perspective, but also to enhance nursing care and patient support. Continuous glucose monitoring (CGM) presents a promising and less invasive solution compared to SMBG. CGM has been shown to improve glycaemic control in HD patients with insulin-treated diabetes.^18–21 Unlike SMBG, CGM provides continuous, real-time interstitial measurements, allowing for more effective monitoring of glucose fluctuations during and between dialysis sessions, with the option to set alarms for levels exceeding or dropping below predefined target ranges.^21,22 Recent international guidelines emphasise the use of CGM in this patient group, recommending its application in patients with advanced chronic kidney disease.²¹ However, despite these potential advantages, CGM has not been a standard option for patients with type 2 diabetes in Denmark. Since 2024, CGM has been gradually introduced for patients with type 1 diabetes, but its implementation is an ongoing process requiring prioritisation of eligible patients. Consequently, CGM use in HD patients is not routine, highlighting the need to explore its potential benefits and challenges.

Even though numerous studies have quantitatively assessed CGM use in HD patients,^18–20 qualitative research on its role in diabetes care for this population is lacking. HD patients represent a particularly vulnerable group, making it crucial to understand their experiences with CGM. Thus, the dual burden of managing both kidney disease and diabetes, combined with the complexities of HD, such as fluctuations in blood glucose, may shape their experiences with CGM differently from those of other diabetes patients. Gaining insight into their attitudes towards the technology, how they use it in diabetes management and whether they find it beneficial is essential. Additionally, understanding their engagement with dialysis and diabetes nurses regarding CGM use and data sharing can clarify support needs. A deeper understanding of these experiences can help healthcare professionals provide better guidance and inform decision-makers on which patients should be prioritised for CGM access.

The present study aims to explore the experiences with CGM of HD patients with type 1 diabetes and insulin-treated type 2 diabetes, including their attitudes, integration into daily diabetes management, and engagement with healthcare professionals regarding its use and data sharing.

Methods

A phenomenological qualitative approach was adopted to explore the HD patients’ experiences in depth.²³ Given the vulnerability of this patient group, data were collected through semi-structured individual interviews. The interviews were conducted with 12 HD patients who had previously used a non-blinded CGM for 6 weeks as part of a crossover trial (ID: NCT05678712). Data were analysed using reflexive thematic analysis.^24,25

The study followed the reporting guideline Consolidated Criteria for Reporting Qualitative Research (COREQ).²⁶

Context and/or setting

The interviews were conducted between June 2022 and June 2023 at two hospital wards in Denmark, immediately following the 6-week period with open CGM (crossover trial) to minimise the risk of recall bias.²⁷ Depending on the informant's preference, interviews were conducted during dialysis (if the patient was alone), in an office at the ward or at the informant's home.

Recruitment/sample

The informants were recruited for the interview during routine CGM sensor shifts in the crossover trial. Saturation was reached after 10 interviews, with two additional interviews conducted to validate the saturation. A convenience sampling approach was applied, where informants were recruited continuously after completing the open CGM period, with no intentional selection of who should be interviewed.²⁸ One participant declined to be interviewed.

The inclusion criteria for enrolment in the interview study were the same as those used in the crossover trial: adult patients (aged 18 years and older) with type 1 diabetes and insulin-treated type 2 diabetes who were receiving chronic HD or haemodiafiltration at one of the two trial sites or home dialysis affiliated with one of these sites. Participants also needed to be able to handle CGM equipment and provide their written informed consent. Exclusion criteria included pregnancy, breastfeeding, gestational diabetes, acute dialysis, peritoneal dialysis, haemofiltration treatment and conditions preventing trial and interview participation, such as physical or cognitive ability to participate.

Data collection

The interviews were conducted face-to-face with a duration of 25–40 min using a semi-structured approach that provided flexibility throughout the interviews.²³ An interview guide was designed based on relevant methodological sources^23,29,30 and contained both structured and open-ended questions to pursue informants’ replies and promote different degrees of reflection.²³ Two female researchers (IVK and SHL) with experience in conducting qualitative interviews collected the data. SHL (PhD) was employed as a postdoctoral researcher during the study and was previously employed as a registered nurse (RN) at a dialysis unit. SHL only knew the informants through the trial activities. IVK (master's degree), a diabetes specialist nurse and RN, entered the study as a developmental nurse. She knew some of the informants peripherally through her work as a diabetes specialist nurse. This familiarity was considered beneficial in fostering a trusting interview environment and encouraging open dialogue. Moreover, steps were taken to mitigate potential biases, including the use of a structured interview guide, ensuring a comfortable and neutral setting to minimise any influence on the informants’ responses, reflexive journaling and discussion of data interpretations with co-researchers to enhance credibility.³¹ Prior to participation, informants were also assured that they could decline participation without any consequences for their collaboration with the diabetes specialist nurse.

Pilot testing was performed on the preliminary interview guide to make relevant adjustments, such as through reformulations, correction of flaws, and time adjustments, to ensure credibility. The pilot testing included field testing with one of the included participants from the crossover trial and internal testing with a researcher from the trial team.³⁰ The pilot test led to revisions of the interview guide. The final interview guide is presented in the supplementary material 1 (File S1). With permission from the individual participants, the interviews were audio recorded.

Data analysis

The data were analysed by two of the researchers (IVK and SHL) through the reflective approach to thematic analysis outlined by Braun and Clarke^24,25 (i.e., a six-phase reflective approach that included coding of the transcribed data and determining themes and subthemes through a non-linear iterative process). The generation of themes and subthemes was performed based on the overall study aim. An inductive approach was adopted during the analytic process to find patterns or a general connection in the datasets without a theoretical framework.^24,25 The NVivo qualitative software package (QSR International Pty Ltd, Burlington, MA, USA) was used to facilitate the coding of the data and the identification of themes and subthemes during the analytic process.

Ethical considerations

The interview study was described in the trial protocol approved by The North Denmark Regional Committee on Health Research Ethics (journal number: N-20210070). However, according to Danish law, formal ethical approval of the interview study was not required.

The interview study was conducted in compliance with data responsibility requirements and the General Data Protection Regulation (GDPR).³² In addition, the study adhered to ethical guidelines derived from the Declaration of Helsinki.³³

The informants were provided with timely written information regarding the interview study, allowing them ample time to familiarise themselves with the study before providing their consent to participate. Furthermore, they received verbal information about the interview immediately before being interviewed. If the patient agreed to participate following the information provided, he or she was asked to sign a written formal consent form. The informants were assured of their voluntary participation, anonymity and confidentiality throughout the interview process. They were also informed that they had the right to withdraw from the study at any time without providing a reason and without any consequences. All data were securely stored under GDPR and institutional data management policies, ensuring restricted access to authorised researchers only.

Results

The following subsections provide an overview of the participant characteristics, followed by a presentation of the interview findings.

Characteristics of the informants

The demographic characteristics of the twelve informants are summarised in Table 1. The informants’ median (range) age was 64.5 (53–76) years. Eight of the 12 informants were males. Two informants had been diagnosed with type 1 diabetes, whereas 10 had been diagnosed with type 2 diabetes. The median (range) number of years since diabetes diagnosis was 27.5 (10–52) years. All the informants used an insulin pen to administer insulin except for one, who used an insulin pump. Four of the ten participants with type 2 diabetes were receiving treatment with fast-acting insulin as a supplement to their long-acting insulin. Diabetes complications included cardiovascular disease, retinopathy, neuropathy, nephropathy, and previous or current foot ulcers. All participants had comorbid diseases (hypertension, obesity, hyperlipidaemia, bone or connective tissue disease, metabolic disease, or/and sleep apnoea). The median (range) HbA1c levels were 52.5 (41–72) mmol/mol and 52.5 (35–65) mmol/mol at baseline and follow-up, respectively. Three of the participants received HD at home, and nine received HD at a dialysis centre. The participants had undergone HD for a median (range) of 42 (1–96) months before the study began, with a median (range) of 3 (1–7) dialysis sessions per week and a median (range) of 4 (3–5) h per dialysis session. Only one informant had previous experience with using CGM, and to a limited extent.

Table 1.

Patient demographic characteristics.

Characteristic(s)
Sex
Female, n (%)	4 (33.3)
Male, n (%)	8 (66.7)
Age (years), mean ± SD	64.9 ± 5.3
Diabetes type
Type 1, n (%)	2 (16.7)
Type 2, n (%)	10 (83.3)
Years since diabetes diagnosis, mean ± SD	27.7 ± 11.4
Insulin type
Fast-acting insulin, n (%)	1(8.3)
Slow-acting insulin, n (%)	6(50.0)
Both fast-acting and slow-acting insulin, n (%)	5(41.7)
Diabetes complications
Retinopathy, n (%)	10 (83.3)
Nephropathy, n (%)	11 (91.7)
Neuropathy, n (%)	10 (83.3)
Cardiovascular disease, n (%)	9 (75.0)
Previous or current foot ulcer, n (%)	6 (50.0)
HbA1c
Baseline (mmol/mol), mean ± SD	53.7 ± 9.9
Follow-up (mmol/mol), mean ± SD	52.3 ± 9.4
Duration of haemodialysis (months), mean ± SD	39.8 ± 32.6
Number of dialysis sessions per week, mean ± SD	3.4 ± 1.6
Dialysis duration (hours), mean ± SD	4.0 ± 0.5

Interview findings

Six main themes were identified from the analysis. Table 2 provides a brief introduction to these themes. Pseudonyms are used throughout the findings to ensure anonymity of the quotes.

Table 2.

Introduction to the themes.

Themes	Description
Theme 1: CGM as a tool for managing both hypo- and hyperglycaemia	This theme covers participants’ experiences with using CGM to manage both low and high blood glucose levels
Theme 2: CGM promotes well-considered choices	This theme focuses on how CGM helps participants make informed decisions about food and insulin, improving their diabetes management and control
Theme 3: CGM reduces practical barriers in diabetes management	This theme focuses on how CGM helps participants overcome practical challenges in managing diabetes, making monitoring easier and more convenient, both at home and on the go
Theme 4: CGM enhances security and confidence in diabetes management	This theme covers how CGM provides participants with a sense of security and confidence in managing their diabetes, offering reassurance through continuous monitoring and alerts for both hypoglycaemia and hyperglycaemia
Theme 5: Guidance from healthcare professionals maximises the benefits of CGM	This theme focuses on how professional guidance, particularly from nurses, enhances the value of CGM by supporting better understanding, informed decision-making, and greater engagement in diabetes management
Theme 6: Mixed opinions on CGM alarms	This theme highlights participants’ differing views on CGM alarms, with some appreciating them for glucose monitoring, while others found them disruptive, particularly during sleep

Abbreviation: CGM = continuous glucose monitoring.

Theme 1: CGM as a tool for managing both hypo- and hyperglycaemia

Participants highlighted CGM as a valuable tool for managing both hypoglycaemia and hyperglycaemia by providing real-time monitoring and early warnings. Many found CGM particularly useful for preventing hypoglycaemia, as it alerted them before symptoms appeared. As William (Type 2) explained:

Getting the warning earlier is definitely a plus. It cannot be very healthy to have such low blood sugars (…) Now I got the warning before I experienced any symptoms.

For some, CGM provided peace of mind at night by detecting low blood glucose levels before they became critical:

It's great not to have to constantly check my blood sugar. Instead, you will receive a helpful reminder [alarm]. This is such a relief, especially at night when I may not be eating as much. (James, Type 2)

Additionally, CGM helped participants prevent hypoglycaemia by not only giving early warnings but also enabling them to quickly verify if they had taken the correct insulin dose:

I was alerted about low glucose levels before I felt any symptoms. The CGM also allows me to quickly check if I took the right amount of insulin for my meals. (William, Type 2)

For many participants, CGM also proved useful on dialysis days, helping them prevent hypoglycaemia by adjusting their carbohydrate intake or insulin dosage. Some increased their carbohydrate intake during dialysis: “Ever since I started using CGM, I’ve noticed my blood sugar dropping during dialysis. Now I drink juice instead of just water” (Jonas, Type 2). Others consumed carbohydrates beforehand: “I’ve learned that eating a certain amount of carbs before dialysis is key” (Anders, Type 2). Similarly, some participants adjusted their insulin regimen on dialysis days to avoid hypoglycaemia: “I have arranged with my diabetes nurse that I should avoid taking insulin during breakfast on dialysis days” (Anne, Type 1).

While CGM helped many participants prevent hypoglycaemia, others also experienced improvements in managing hyperglycaemia. Some reported fewer instances of high blood glucose. As Anne (Type 1) explained, “Ever since I got this CGM, my high blood sugar is no longer a problem”. However, for some, maintaining good routines after discontinuing CGM was difficult, highlighting the potential need for continuous access: “I don’t monitor it [blood glucose] anymore, so I can’t see how my blood sugar fluctuates” (Anders, Type 2).

These findings suggest that CGM not only supports self-management of hypoglycaemia and hyperglycaemia, but also influences insulin adherence and glucose monitoring behaviours. While some participants experienced greater stability, others faced challenges in maintaining routines once CGM was discontinued, indicating that continuous access to CGM could enhance long-term diabetes management.

Theme 2: CGM promotes well-considered choices

CGM encouraged most participants to make more informed decisions about their food and insulin doses, making it easier to manage their diabetes. As Teddy (Type 2) shared, “It´s easier to know if Ím eating something inappropriate because the CGM shows me immediately (laughs)”. For many participants, the ability to instantly see the effects of their choices made them feel more in control.

I have greater control over my condition – understanding what is happening, what needs to be done, and what actions are required in the moment. It's a contrast to my previous indifferent attitude. (Anders, Type 2)

This sense of control was particularly important for those struggling with dietary restrictions, as many found it challenging to adhere to both diabetes and kidney disease diets. In this context, CGM provided a clearer picture of their glucose levels, helping them navigate competing dietary needs and ultimately make more informed, deliberate choices.

Similarly, participants treated with multiple daily insulin injections found that CGM helped establish better mealtime habits by providing visual guidance: “Now I can get visual guidance. If it shows this, I shouldn’t take too much insulin – maybe I need less” (Ellie, Type 1). Other participants appreciated the trend arrows on CGM, which helped them make more accurate insulin adjustments: “When it comes to satisfying my sweet tooth, this has been particularly relevant” (Anders, Type 2). Social situations, where eating and insulin adjustments can be challenging, were also easier to navigate with CGM: “When I’m out, I use it to decide what to eat and how much” (Henrik, Type 2).

Overall, many participants valued the ability of CGM to provide real-time glucose data and trends, offering an easy-to-understand overview of their diabetes management:

It provides a great overview. I can glance at the screen and see my blood sugar in real-time and get a summary of the past few hours. I find it very satisfying, to be honest. (William, Type 2)

Theme 3: CGM reduces practical barriers in diabetes management

It was highlighted how CGM helped reduce practical challenges for participants in managing their diabetes. Several participants noted that CGM made diabetes management easier in daily life. As Anne (Type 1) puts it, “It is much easier. Much easier”. In this context, several participants appreciated the convenience of easily accessible measurements, with James (Type 2) stating, “You just have to press the receiver, and then you can see your sugar levels”. Furthermore, some reported that CGM made it easier to manage diabetes outside the home.

You typically keep all your blood sugar measuring stuff at home, not carrying it around with you. Instead of having to find a needle and other items, it´s much more convenient to simply click on the CGM receiver. (Henrik, Type 2)

According to this participant, CGM has made it more manageable for him to measure and monitor his diabetes when he is away from his home.

Some participants found SMBG challenging due to difficulties drawing blood for measurements: “I simply dońt measure it because there's just no blood in my fingers” (Esther, Type 2). For these participants, CGM offered a significant advantage by allowing them to track their glucose levels more accurately: “I have found the CGM helpful since it has allowed me to track my levels” (Esther, Type 2).

Theme 4: CGM enhances security and confidence in diabetes management

Overall, CGM offered participants a sense of security, empowering them to manage their diabetes with greater confidence. Most participants trusted CGM readings to monitor glucose levels and prevent both hypoglycaemia and hyperglycaemia: As one participant stated: “I haven’t had any concerns regarding safety” (Esther, Type 2). CGM offered reassurance through continuous monitoring and alarms for high and low glucose levels. One participant described it as providing “calmness and safety” (Teddy, Type 2) in daily life, whereas others valued the security it provided in detecting sudden drops in glucose levels: “If there is a sudden drop in your blood sugar, I don’t think you achieve greater security” (James, Type 2).

Some participants also found that CGM increased their sense of security when concerned about hyperglycaemia.

When the blood sugar level rises, I always get nervous. Therefore, it is truly comforting to witness how rapidly it drops back down again [using the CGM]. (Anton, Type 2)

The alerts for high glucose levels were particularly important for those who struggled to recognise symptoms until their levels became extremely high: “I only notice an increase in my blood glucose when it reaches a significantly elevated stage” (Ellie, Type 1).

Despite some discrepancies between CGM readings and traditional SMBG measurements, participants generally felt safe relying on CGM. One participant explained:

When I use my blood glucose meter, the measurement may not always match up perfectly with my CGM reading, but they are usually pretty similar. Therefore, I feel confident wearing it and confident that what it tells me is true. (Anne, Type 1)

While some participants occasionally used SMBG to verify CGM readings, others relied solely on CGM for glucose monitoring.

Theme 5: Guidance from healthcare professionals maximises the benefits of CGM

Several participants emphasised that guidance from healthcare professionals, such as dialysis and diabetes specialist nurses, significantly enhanced the value of CGM. Discussions with nurses about CGM readings fostered learning and engagement, whereas using a sensor without professional guidance did not necessarily lead to reflection or changes in daily life. One participant stated:

Even if I observe that my blood sugar is high [on CGM], it is difficult to determine the appropriate amount of insulin. However, if I receive feedback [from a nurse] on the readings (…) then I think it makes sense to wear the CGM. (Esther, Type 2)

Several participants felt more engaged in managing their diabetes when their CGM data was reviewed by a nurse, as reflected in the following statement:

You pay more attention to the measurements when they are available to others [nurses]. Then, you become more observant of your measurements. (Henrik, Type 2)

Discussing the visual data from CGM also helped participants better understand their condition. William (Type 2) shared: “The visual aspects of the graphs have been particularly helpful (…) They have helped me understand the relationship between diet and insulin”. Moreover, feedback from the nurses increased the participants’ diabetes knowledge and supported them in making informed decisions about their care. One participant explained: “It has helped guide me through a journey of understanding my diabetes on a deeper level” (Cathrine, Type 2).

Theme 6: Mixed opinions on CGM alarms

Some participants valued the CGM alarms, particularly for detecting high glucose levels. One participant stated: “I truly appreciate having the high alarm connected” (William, Type 2). However, others found the alarms disruptive and irritating, especially when they served as reminders of dietary choices. Alarms indicating signal loss and high glucose values were perceived as particularly bothersome, especially during sleep. One participant compared the alarms to the persistent noise from the dialysis machine:

The CGM alarm can be quite bothersome for me. Just like when the dialysis machine keeps on alarming, it can truly get on your nerves. Having a constant bell ringing like that can have a psychological impact on you. (Esther, Type 2)

While some participants chose to deactivate alarms, others kept low glucose alarms active for detecting hypoglycaemia. In some cases, the alarms also helped participants identify factors influencing their blood sugar, such as illness. As William (Type 2) explained: “My CGM readings have made it evident that my blood sugar is highly responsive in relation to illness”.

Discussion

According to the study findings, CGM provides a promising alternative without placing additional strain on patients. Compared to SMBG measurements, which were considered burdensome, CGM offered a simpler and more convenient method of glucose monitoring. This aligns with previous research demonstrating CGM as a less invasive and more practical solution for glucose monitoring, increasing flexibility in daily life.³⁴ For HD patients with diabetes, the benefits of CGM are particularly significant. The dual burden of diabetes and kidney disease can be overwhelming, as dialysis demands significant time and energy, whereas additional symptoms and comorbidities further complicate glucose management.^5,35–37 In this context, CGM offers a valuable alternative by reducing the need for frequent, invasive finger-prick testing and enabling real-time continuous glucose monitoring. This targeted approach improves glycaemic management for HD patients and helps alleviate strain on patients and healthcare resources.

Another key finding was that many participants perceived CGM as a source of increased safety, particularly in preventing hypoglycaemia. Participants highlighted the ability of CGM to provide early alerts to detect hypoglycaemia, enabling timely interventions, especially for those with impaired awareness of low blood sugar. This aligns with previous research demonstrating the role of CGM in hypoglycaemia prevention among diabetes patients.^34,38,39 The fear of hypoglycaemia is a well-documented concern among insulin-treated patients,⁴⁰ including those undergoing HD.⁴¹ In a recent qualitative review, CGM was described as lifesaving, particularly for those with poor hypoglycaemic awareness.³⁹ For HD patients, the need for reliable glucose monitoring is particularly critical. Unlike other diabetes patients, those on HD face additional challenges due to dialysis-related metabolic shifts, which contribute to unpredictable glucose fluctuations.⁵ Studies report that up to 46.6% of diabetic HD patients experience hypoglycaemia during treatment,⁵ with 16% of patients having asymptomatic hypoglycaemia only detected through CGM and not by SMBG.⁶ The prevalence of impaired hypoglycaemia awareness is also high in HD patients (23.2%), further increasing their vulnerability.⁴¹ Given these risks, CGM provides a crucial advantage by offering continuous, real-time glucose insights that enable timely intervention and more precise insulin adjustments. These findings strongly support the integration of CGM into routine care for HD patients to improve safety and prevent hypoglycaemia. However, some participants found the low CGM alarms irritating and distracting. Because alarm fatigue is a known barrier to sustained CGM use,⁴² adjusting alarm settings or providing customisable options based on individual preferences may be necessary to improve adherence at the same time as preserving the safety benefits of CGM. Despite these challenges, the ability of CGM to mitigate hypoglycaemia risk and improve glycaemic stability highlights its essential role in optimising diabetes management for HD patients.

Participants in this study highlighted the significant role nurses play in guiding the use of CGM. Participants reported that their engagement with CGM was greatly enhanced when they received feedback and support from dialysis and diabetes nurses. Many participants described feeling more confident using CGM when they received personalised guidance and regular feedback, which improved their understanding of managing glucose levels effectively. These findings underscore the vital role of nurses not only in the technical aspects of CGM use, but also in providing individualised support that maximises its benefits for HD patients. This perspective is supported by previous research highlighting the frequent interactions dialysis nurses have with HD patients, positioning them as key figures in diabetes management.¹⁷ By offering professional guidance, nurses can help overcome barriers to CGM use, enhance glycaemic control and ultimately improve patient outcomes.⁴³ However, their ability to provide effective support depends on sufficient knowledge, particularly regarding how dialysis affects blood glucose regulation and the practical use of CGM. Given that limited familiarity with these aspects has been identified as a challenge in clinical practice,¹⁶ training dialysis staff to interpret CGM data and integrate it into patient care is essential for optimising CGM benefits in this population, ensuring patients receive the most effective support possible in managing their diabetes.

This study suggests that CGM may be a relevant solution for HD patients with insulin-treated diabetes, given their limited resources and daily symptom burden. However, several factors must be considered when determining which patients should be offered CGM. HD patients often require significant insulin reductions due to the heightened risk of hypoglycaemia, highlighting the need for continuous glucose monitoring.^12,44 However, because of current economic limitations, prioritising could be necessary. The study findings suggest that the decision should be based on individual needs, including available resources, blood glucose fluctuations, insulin requirements and practical challenges such as difficulties with SMBG. Patients with significant glucose variability, frequent hypoglycaemic episodes, hypoglycaemia unawareness or poor self-management skills may benefit most from CGM, while others may be adequately monitored with periodic CGM. Periodic CGM use could reduce costs while still providing the benefits of continuous monitoring.⁴⁵ The effectiveness of periodic versus daily CGM use remains unclear, but period use combined with staff analysis could be a feasible option. However, daily use of CGM may be more appropriate for certain HD patients, especially those who tend to revert to unhealthy habits when the CGM is discontinued. Both daily and periodic use of CGM have potential to prevent hypoglycaemia, reduce glucose variability and improve average sensor glucose levels.⁴⁵ However, further research is needed to determine how CGM can be more effectively targeted to specific patient groups. This could ensure that resources are allocated to those who require intensive diabetes monitoring the most at the same time as addressing economic and practical constraints.

Strengths and limitations

The present study provides valuable insights into HD patients’ perspectives on CGM, a topic underreported in the literature but important for nurses, other healthcare professionals and decision-makers. The sample was representative, including patients of different ages, sexes, diabetes types and dialysis settings (two hospitals and home dialysis), although type 1 diabetes was underrepresented, with only two participants. Additionally, a robust qualitative methodology was applied, following recognised guidelines to ensure credibility, reflexivity, transparency and reliability. This included the use of Braun and Clarke's reflexive thematic analysis, which provided a structured yet flexible approach to identifying patterns in the data.²⁵ Additionally, rigor was enhanced through real-time response verification and collaborative analysis to strengthen trustworthiness.³¹

However, there are some limitations. As a qualitative study, the findings are limited to the participants’ personal experiences.⁴⁶ Furthermore, a potential limitation is the inclusion of both type 1 and type 2 diabetes patients. Differences in the management and pathophysiology of these two groups may have influenced their experiences with CGM, potentially limiting the transferability of the findings.³¹ Future research could explore these groups separately. Additionally, two researchers conducted the interviews, which may have influenced consistency, although a standardised interview guide was used.⁴⁷ Lastly, the researchers’ involvement in sensor shifts and the diabetes specialist nurse's prior familiarity with some patients may have influenced responses. However, their expertise enabled in-depth questioning, and measures were taken to build trust and reduce bias. Moreover, studies suggest greater trust in insider interviewers than outsiders.⁴⁸

Conclusions

The present study contributes important insights into CGM use in HD patients treated with insulin, with implications for patient care, nursing practice and research. The study highlights the valuable role of CGM in managing diabetes for HD patients, demonstrating its potential to enhance patient safety, improve glycaemic control and reduce the practical challenges of SMBG. Preventing hypoglycaemia, especially in those with impaired awareness, was a key benefit. Despite challenges such as alarm fatigue, the overall impact of CGM was positive. The study further emphasises the importance of personalised guidance from dialysis and diabetes nurses in maximising the effectiveness of CGM. Training healthcare staff in technical and practical aspects of CGM is therefore crucial to fully leveraging its benefits for this patient group. The integration of CGM into routine care for insulin-treated HD patients appears to be a promising approach for improving diabetes management. However, due to economic and resource limitations, it could be necessary to prioritise which patients should be offered CGM. Based on the study findings, priority could be given to those with significant blood glucose fluctuations, frequent hypoglycaemic episodes, hypoglycaemic unawareness or difficulties with self-management. Further research is needed to explore whether periodic use could be a viable alternative to continuous monitoring. Identifying which HD patients benefit most from CGM technology remains essential. Additionally, exploring healthcare providers’ perspectives on its implementation could inform future practice and policy.

Supplemental Material

sj-docx-1-njn-10.1177_20571585251331199 - Supplemental material for A continuous glucose monitoring device as a valuable tool for supporting diabetes care in haemodialysis patients: A qualitative interview study

Supplemental material, sj-docx-1-njn-10.1177_20571585251331199 for A continuous glucose monitoring device as a valuable tool for supporting diabetes care in haemodialysis patients: A qualitative interview study by Sisse Heiden Laursen, Inger Vestergaard Kristensen, Hanne Ravn Larsen, Peter Vestergaard, Morten Hasselstrøm Jensen and Ole Kristian Hejlesen in Nordic Journal of Nursing Research

Footnotes

Acknowledgements

We are sincerely thankful to the informants who voluntarily participated in this study.

Author contributions

SHL, IVK, MHJ, PV and OKH conceptualised the study and designed the methodology. IVK and SHL conducted the data collection. IVK and SHL performed the data analysis with input from HRL, MHJ and PV. SHL drafted the manuscript, and all authors contributed to reviewing and editing the final version. OKH and PV supervised the project. All authors approved the final version of the manuscript submitted for publication.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Sisse Heiden Laursen

Supplemental material

Supplemental material for this article is available online.

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