Glycated hemoglobin

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Glycated hemoglobin (glycosylated hemoglobin, hemoglobin A1c, HbA1c, A1C, or Hb1c; sometimes also HbA1c) is a form of hemoglobin used primarily to identify the average plasma glucose concentration over prolonged periods of time. It is formed in a non-enzymatic pathway by hemoglobin's normal exposure to high plasma levels of glucose. Glycation of hemoglobin has been associated with cardiovascular disease, nephropathy, and retinopathy in diabetes mellitus. Monitoring the HbA1c in type-1 diabetic patients may improve treatment.<ref name="pmid2215560">Larsen ML, Hørder M, Mogensen EF (1990). [Expression error: Missing operand for > "Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus"]. N. Engl. J. Med. 323 (15): 1021–5. PMID 2215560. </ref>

Contents

History

Hemoglobin A1c was first separated from other forms of hemoglobin by Huisman and Meyering in 1958 using a chromatographic column.<ref>Huisman TH, Martis EA, Dozy A (1958). [Expression error: Missing operand for > "Chromatography of hemoglobin types on carboxymethylcellulose"]. J. Lab. Clin. Med. 52 (2): 312–27. PMID 13564011. </ref> It was first characterized as a glycoprotein by Bookchin and Gallop in 1968.<ref name="pmid4874776">Bookchin RM, Gallop PM (1968). [Expression error: Missing operand for > "Structure of hemoglobin A1c: nature of the N-terminal beta chain blocking group"]. Biochem. Biophys. Res. Commun. 32 (1): 86–93. doi:10.1016/0006-291X(68)90430-0. PMID 4874776. </ref> Its increase in diabetes was first described in 1969 by Samuel Rahbar and coworkers<ref name="pmid5808299">Rahbar S, Blumenfeld O, Ranney HM (1969). [Expression error: Missing operand for > "Studies of an unusual hemoglobin in patients with diabetes mellitus"]. Biochem. Biophys. Res. Commun. 36 (5): 838–43. doi:10.1016/0006-291X(69)90685-8. PMID 5808299. </ref> The reactions leading to its formation were characterized by Bunn and his co-workers in 1975.<ref name="pmid1201013">Bunn HF, Haney DN, Gabbay KH, Gallop PM (1975). [Expression error: Missing operand for > "Further identification of the nature and linkage of the carbohydrate in hemoglobin A1c"]. Biochem. Biophys. Res. Commun. 67 (1): 103–9. doi:10.1016/0006-291X(75)90289-2. PMID 1201013. </ref> The use of hemoglobin A1c for monitoring the degree of control of glucose metabolism in diabetic patients was proposed in 1976 by Anthony Cerami, Ronald Koenig and coworkers.<ref name="pmid934240">Koenig RJ, Peterson CM, Jones RL, Saudek C, Lehrman M, Cerami A (1976). [Expression error: Missing operand for > "Correlation of glucose regulation and hemoglobin AIc in diabetes mellitus"]. N. Engl. J. Med. 295 (8): 417–20. PMID 934240. </ref>

Underlying principle

In the normal 120-day lifespan of the red blood cell, glucose molecules react with hemoglobin, forming glycated hemoglobin. In individuals with poorly controlled diabetes, the quantities of these glycated hemoglobins are much higher than in healthy people.

Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell, therefore, reflects the average level of glucose to which the cell has been exposed during its life-cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation. The HbA1c level is proportional to average blood glucose concentration over the previous four weeks to three months. Some researchers state that the major proportion of its value is related to a rather shorter period of two to four weeks. <ref>"Hemoglobin A1c Fact Sheet". Michigan Diabetes Research & Training Center. http://www.med.umich.edu/mdrtc/cores/ChemCore/hemoa1c.htm. Retrieved 2007-12-26. </ref>.

The 2010 American Diabetes Association Standards of Medical Care in Diabetes added the A1c ≥ 6.5% as another criterion for the diagnosis of diabetes,<ref>Executive Summary: Standards of Medical Care in Diabetes—2010: Current criteria for the diagnosis of diabetes. Diabetes Care January 2010 33:S4-S10; doi:10.2337/dc10-S004</ref> but this is controversial and has not been universally adopted.<ref name="Kilpatrick 2009">Kilpatrick ES, Bloomgarden ZT, Zimmet PZ (2009). [Expression error: Missing operand for > "Is haemoglobin A1c a step forward for diagnosing diabetes?"]. BMJ 339: b4432. doi:10.1136/bmj.b4432. </ref>

Measuring A1C

There are a number of techniques used to measure A1C.

Laboratories use :

Point of care (e.g. doctors surgery) devices use :

In the United States, POC A1C tests are certified by the National Glycohemoglobin Standardization Program (NGSP) to standardise them against the results of the 1993 Diabetes Control and Complications Trial (DCCT).<ref>Developing Point of care HbA1c tests for Diabetes monitoring, Barry Plant, Originally Published IVDT July/August 2008</ref>

Switch to IFCC units

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and International Diabetes Federation (IDF) have agreed that, in the future, HbA1c is to be reported in the International Federation of Clinical Chemistry (IFCC) units.<ref name="pmid18539643">Geistanger A, Arends S, Berding C, et al. (August 2008). [Expression error: Missing operand for > "Statistical methods for monitoring the relationship between the IFCC reference measurement procedure for hemoglobin A1c and the designated comparison methods in the United States, Japan, and Sweden"]. Clin. Chem. 54 (8): 1379–85. doi:10.1373/clinchem.2008.103556. PMID 18539643. </ref> IFCC reporting was introduced in Europe except for the UK in 2003,<ref name="pmid15209757">Manley S, John WG, Marshall S (July 2004). [Expression error: Missing operand for > "Introduction of IFCC reference method for calibration of HbA: implications for clinical care"]. Diabet. Med. 21 (7): 673–6. doi:10.1111/j.1464-5491.2004.01311.x. PMID 15209757. </ref> and the UK has as of 1 June 2009 introduced dual reporting<ref>"Standardisation of the reference method for the measurement of HbA1c to improve diabetes care" (PDF). The Association for Clinical Biochemistry and Diabetss UK. April 2008. http://www.acb.org.uk/docs/hba1c.pdf. Retrieved 2009-07-02. </ref> until 1 June 2011.<ref>"All Change For HbA1c" (PDF). University Hospital of South Manchester. http://elearn-uhsm.co.uk/pathhandbook/Pathways_May_09.pdf. Retrieved 2009-07-02. </ref>

Conversion between the units is by the following equation:<ref name="DiabetesUK conversion">"HbA1c Standardisation For Laboratory Professionals" (PDF). Diabetes UK. http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/53130HbA1cLableaflet.pdf. Retrieved 2009-07-02. </ref> IFCC-HbA1c (mmol/mol) = [DCCT-HbA1c (%) - 2.15] × 10.929

DCCT- HbA1c IFCC-HbA1c
(%) (mmol/mol)
4.0 20
5.0 31
6.0 42
6.5 48
7.0 53
7.5 59
8.0 64
9.0 75
10.0 86

Interpretation of results

Laboratory results may differ depending on the analytical technique, the age of the subject, and biological variation among individuals. Two individuals with the same average blood sugar can have A1C values that differ by as much as 3 percentage points. Results can be unreliable in many circumstances, such as after blood loss, for example, after surgery, blood transfusions, anemia, or high erythrocyte turnover; in the presence of chronic renal or liver disease; after administration of high-dose vitamin C; or erythropoetin treatment.<ref name="pmid18540046">Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ (2008). "Translating the A1C assay into estimated average glucose values.". Diabetes Care 31 (8): 1473–8. doi:10.2337/dc08-0545. PMID 18540046. PMC 2742903. http://care.diabetesjournals.org/content/31/8/1473.full. </ref> In general, the reference range (that found in healthy persons), is about 4%–5.9%.<ref>"Hemoglobin A1c Test". MedicineNet.com. http://www.medicinenet.com/hemoglobin_a1c_test/article.htm. Retrieved 2007-12-26. </ref>

Higher levels of HbA1c are found in people with persistently elevated blood sugar, as in diabetes mellitus. While diabetic patient treatment goals vary, many include a target range of HbA1c values. A diabetic person with good glucose control has a HbA1c level that is close to or within the reference range. The International Diabetes Federation and American College of Endocrinology recommend HbA1c values below 6.5%, while American Diabetes Association recommends that the HbA1c be below 7.0% for most patients.<ref>[Expression error: Missing operand for > "Executive Summary: Standards of medical care in diabetes—2009"]. Diabetes Care 32: S6–S12. 2009. doi:10.2337/dc09-S006. </ref> Recent results from large trials suggest that a target below 7% may be excessive: Below 7% the health benefits of reduced A1C become smaller, and the intensive glycemic control required to reach this level leads to an increased rate of dangerous hypoglycemic episodes.<ref>Lehman R, Krumholz HM (2009). [Expression error: Missing operand for > "Tight control of blood glucose in long standing type 2 diabetes"]. Brit Med J 338: b800. doi:10.1136/bmj.b800. </ref> A retrospective study of 47,970 diabetes patients found that patients with an A1C greater than 6.5% had an increased mortality rate.<ref>doi:10.1016/S0140-6736(09)61969-3</ref> Practitioners must consider an individual patient's health, his/her risk of hypoglycemia, and his/her specific health risks when setting a target A1C level. For example, patients at high risk of microvascular complications may gain further benefits from reducing A1C below 7%. Because patients are responsible for averting or responding to their own hypoglycemic episodes, the patient's input and the doctor's assessment of the patient's self-care skills are also important.

A high HbA1c represents poor glucose control. However, a 'good' HbA1c in a patient with diabetes can still be riddled with a history of recent hypoglycemia, or even spikes of hyperglycemia. Regular blood glucose monitoring is still the best method for the analysis of overall vascular health with respect to blood sugar control. Often, patients with diabetes mellitus are scolded by their doctors[citation needed] for having an HbA1c which is too low, because a lower A1C would indicate a likelihood of frequent hypoglycemia in the recent past. This is often assessed with blood sugar data, and receptions are typically mixed. A balance of long-term health (hyperglycemia prevention) versus short-term health (hypoglycemia prevention) is always a constant concern for both patients and their doctors. Doctors are especially sensitive about lower level HbA1c's with patients who regularly drive, this being a prime example of a short-term motivation for preventing hypoglycemia. Many diabetics have died behind the wheel as a result of a low blood sugar[citation needed], especially for the reason that frequent hypoglycemia results in a higher tolerance (sometimes, the patient is seized with a feeling of panic, an increased heart rate, profuse sweating, etc.) for the condition, and some patients may not even consciously realize their blood sugar has dropped to dangerous levels. In addition to acquired tolerance, the use of alcohol and certain drugs (marijuana, for example) can create moderately similar symptoms to those of hypoglycemia[citation needed] (especially when used in combination) and for this reason the patient may not realize he/she has developed hypoglycemia.

Persistent elevations in blood sugar (and, therefore, HbA1c) increase the risk for the long-term vascular complications of diabetes such as coronary disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach). Poor blood glucose control also increases the risk of short-term complications of surgery such as poor wound healing.

Lower-than-expected levels of HbA1c can be seen in people with shortened red blood cell lifespan, such as with glucose-6-phosphate dehydrogenase deficiency, sickle-cell disease, or any other condition causing premature red blood cell death. On the converse, higher-than-expected levels can be seen in people with a longer red blood cell lifespan, such as with Vitamin B12 or folate deficiency.<ref name="Kilpatrick 2009"/>

The approximate mapping between HbA1c values and eAG (estimated Average Glucose) measurements is given by the following equation:<ref name="pmid18540046"/>

eAG(mg/dl) = 28.7 × A1C − 46.7
eAG(mmol/l) = 1.59 × A1C − 2.59
Data in parentheses are 95% Confidence intervals
HbA1c eAG (estimated Average Glucose)
(%) (mmol/L) (mg/dL)
5 5.4 (4.2–6.7) 97 (76–120)
6 7.0 (5.5–8.5) 126 (100–152)
7 8.6 (6.8–10.3) 154 (123–185)
8 10.2 (8.1–12.1) 183 (147–217)
9 11.8 (9.4–13.9) 212 (170–249)
10 13.4 (10.7–15.7) 240 (193–282)
11 14.9 (12.0–17.5) 269 (217–314)
12 16.5 (13.3–19.3) 298 (240–347)

Indications and use

Glycated hemoglobin is recommended for both (a) checking blood sugar control in people who might be pre-diabetic and (b) monitoring blood sugar control in patients with more elevated levels, termed diabetes mellitus. There is a significant proportion of people who are unaware of their elevated HbA1c level before they have blood lab work.<ref>Walid MS, Newman BF, Yelverton JC, Nutter JP, Ajjan M, Robinson JS Jr (2009). [Expression error: Missing operand for > "Prevalence of previously unknown elevation of glycosylated hemoglobin (HbA1c) in spine surgery patients and impact on length of stay and total cost"]. J Hosp Med: NA. doi:10.1002/jhm.541. PMID 19753643. </ref> For a single blood sample, it provides far more revealing information on glycemic behavior than a fasting blood sugar value: Fasting blood sugar tests are crucial in making treatment decisions. The American Diabetes Association guidelines are similar to others in advising that the glycosylated hemoglobin test be performed at least two times a year in patients with diabetes that are meeting treatment goals (and that have stable glycemic control) and quarterly in patients with diabetes whose therapy has changed or that are not meeting glycemic goals.<ref>American Diabetes Association (2007). [Expression error: Missing operand for > "Standards of medical care in diabetes--2007"]. Diabetes Care 30 (Suppl 1): S4–S41. doi:10.2337/dc07-S004. PMID 17192377. </ref>

Glycated hemoglobin measurement is not appropriate where there has been a change in diet or treatment within 6 weeks. Likewise, the test assumes a normal red blood cell aging process and mix of hemoglobin subtypes (predominantly HbA in normal adults). Hence, people with recent blood loss, hemolytic anemia, or genetic differences in the hemoglobin molecule (hemoglobinopathy) such as sickle-cell disease and other conditions, as well as those that have donated blood recently, are not suitable for this test.

Due to glycated hemoglobin's variability (as shown in the table above), additional measures should be checked in patients at or near recommended goals. People with hemoglobin A1C values at 8.0% or less should be provided additional testing to determine whether the HbA1c values are due to averaging out high blood glucose (hyperglycemia) with low blood glucose (hypoglycemia) or the HbA1c is more reflective of an elevated blood glucose that does not vary much throughout the day. Devices such as continuous blood glucose monitoring allow people with diabetes to determine their blood glucose levels on a continuous basis, testing every few minutes. Continuous use of blood glucose monitors is becoming more common, and the devices are covered by many health insurance plans but not by Medicare. The supplies tend to be expensive, since the sensors must be changed at least weekly. Another test that is useful in determining if HbA1c values are due to wide variations of blood glucose throughout the day is 1,5 Anhydroglucitol, also known as GlycoMark. GlycoMark reflects only the times that a person is experiencing hyperglycemia above 180 mg/dL of glucose (glucosuria) over a two-week period.

Concentrations of hemoglobin A1 (HbA1) are increased, both in diabetic patients and in patients with renal failure, when measured by ion-exchange chromatography. The thiobarbituric acid method (a chemical method specific for the detection of glycation) shows that patients with renal failure have values for glycated hemoglobin similar to those observed in normal subjects, suggesting that the high values in these patients are a result of binding of something other than glucose to hemoglobin.<ref>"Glycated Hemoglobin in Uremic Patients as Measured by Affinity and Ion-Exchange Chromatography". clinchem.com. http://www.clinchem.org/cgi/reprint/30/3/485.pdf. Retrieved 2009-08-31. </ref>

In autoimmune hemolytic anemia, concentrations of hemoglobin A1 (HbA1) is undetectable. Administration of prednisolone (PSL) will allow the HbA1 to be detected.<ref>"Undetectable Glycated Hemoglobin in Autoimmune Hemolytic Anemia". repository.oai.yamaguchi-u.ac.jp. http://repository.oai.yamaguchi-u.ac.jp/yunoca/A02/A020052000103.pdf. Retrieved 2009-08-31. </ref> The alternative fructosamine test may be used in these circumstances and it also reflects an average of blood glucose levels over the preceding 2 to 3 weeks.

All the major institutions like International Expert Committee Report, drawn from the International Diabetes Federation (IDF), the European Association for the Study of diabetes (EASD), and the American Diabetes Association (ADA), suggests the A1C level of 6.5% as a diagnostic level.<ref>The International Expert Committee (2009). [Expression error: Missing operand for > "International expert committee report on the role of the A1C assay in the diagnosis of diabetes"]. Diabetes Care 32 (7): 1327–1334. doi:10.2337/dc09-9033. PMID 19502545. </ref> The Committee Report further states that, when A1C testing cannot be done, the fasting and glucose tolerance tests be done.

Diagnosis of diabetes during pregnancy continues to require fasting and glucose tolerance measurements for gestational diabetes, and not the glycated hemoglobin.

See also

References

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