Falsely Decreased Hba1c in A Type 2 Diabetic Patient Treated with Dapsone

ObjectiveTo discuss a case of a falsely low hemoglobin A_1c (HbA_1c) in a transplant patient treated with dapsone and its implications. HbA_1c is widely used as a measure of glycemic control in diabetic patients. With the increasing transplant population, it is important to be mindful of medications used in this population that can affect HbA_1c and to use other measures of glycemic control to guide treatment decisions.MethodsWe present details of the case and review the relevant literature.ResultsA 61-year-old patient received a liver transplant in 2012 and subsequently was noted to have a falling HbA_1c despite evidence of hyperglycemia based on fingerstick glucose and fructosamine measurements. Review of the medical records revealed that the discordance between HbA_1c and fingerstick glucose levels developed after initiation of dapsone therapy. Dapsone may lead to a falsely low HbA_1c via several mechanisms. Upon cessation of dapsone therapy, the patient’s HbA_1c returned to pre-dapsone levels.ConclusionIt is important to be aware of medications commonly used in transplant patients that may lead to a falsely low HbA_1c level so that incorrect treatment decisions are not made. Fructosamine correlates with HbA_1c and can be used as a measure of glycemic control in transplant patients when HbA_1c cannot be used. (Endocr Pract. 2014;20:e229-e232)     

Motherhood,Apple Pie,Hemoglobin A1c,and the DCCT

ObjectiveTo review recent literature on the limitations of hemoglobin A_1c (HbA_1c) as a marker of glycemic control.MethodsEnglish-language literature published between 1985 and 2011 was reviewed specific to analyses of major trials relating glycemic control to complications of diabetes mellitus, as expressed through HbA_1c as a marker of glycemic control.ResultsHbA_1c has been accepted as the most fundamental biomarker in diabetes, if not all of medicine, as it clearly predicts risk for diabetes-related complications. What is not generally appreciated is that HbA_1c is a crude marker of glycemia with many limitations. It is now accepted that HbA_1c does not reflect mean glucose for many people, and even for those it does, any level could represent a wide range of glycemia. While we have learned HbA_1c is not a perfect biomarker, we also know that in the Diabetes Control and Complications Trial, HbA_1c could only explain 11% of the variation in retinopathy risk between the conventional and intensive therapy groups. This important finding suggests that other glycemic and nonglycemic factors may be responsible for the pathogenesis of diabetes-related complications. One candidate is glycemic variability, which must be differentiated from postprandial hyperglycemia since hypoglycemia can also result in inflammatory activation. Importantly, although it is clear that in insulin-requiring patients glycemic variability is associated with hypoglycemia, we require a definitive prospective trial to confirm glycemic variability’s association with one or more vascular complications.ConclusionsWhat is abundantly clear is that the HbA_1c message, as we know it, is too simplistic. While certain wholesome concepts such as motherhood and apple pie are accepted by all, the HbA_1c message may be more complex than originally appreciated, and it may be time to reevaluate our most basic premise in diabetes. (Endocr Pract. 2012;18:78-84)     

Sputum Glucose and Glycemic Control in Cystic Fibrosis-Related Diabetes: A Cross-Sectional Study

Cystic fibrosis-related diabetes affects up to half of cystic fibrosis patients and is associated with increased mortality and more frequent pulmonary exacerbations. However, it is unclear to what degree good glycemic control might mitigate these risks and clinical outcomes have not previously been studied in relation to glucose from the lower airways, the site of infection and CF disease progression. We initially hypothesized that diabetic cystic fibrosis patients with glycosylated hemoglobin (HbA_1c) > 6.5% have worse pulmonary function, longer and more frequent exacerbations and also higher sputum glucose levels than patients with HbA_1c ≤ 6.5% or cystic fibrosis patients without diabetes. To test this, we analyzed spontaneously expectorated sputum samples from 88 cystic fibrosis patients. The median sputum glucose concentration was 0.70 mM (mean, 4.75 mM; range, 0-64.6 mM). Sputum glucose was not correlated with age, sex, body mass index, diabetes diagnosis, glycemic control, exacerbation frequency or length, or pulmonary function. Surprisingly, sputum glucose was highest in subjects with normal glucose tolerance, suggesting the dynamics of glycemic control, sputum glucose and pulmonary infections are more complex than previously thought. Two-year mean HbA_1c was positively correlated with the length of exacerbation admission (p < 0.01), and negatively correlated with measures of pulmonary function (p < 0.01). While total number of hospitalizations for exacerbations were not significantly different, subjects with an HbA_1c > 6.5% were hospitalized on average 6 days longer than those with HbA_1c ≤ 6.5% (p < 0.01). Current clinical care guidelines for cystic fibrosis-related diabetes target HbA_1c ≤ 7% to limit long-term microvascular damage, but more stringent glycemic control (HbA_1c ≤ 6.5%) may further reduce the short-term pulmonary complications.     

血红蛋白A2现象发生机制的研究——“红细胞HbA2”为HbA2与HbA的结合产物

为了弄清血红蛋白A₂现象的发生机制,我们对“红细胞HbA₂”的化学组成进行了分析。“红细胞HbA₂”的双向电泳结果表明,它含有两种血红蛋白成分:一种相当于HbA,另一种很可能是溶血液HbA₂。其单向二次电泳结果也证明,它是由溶血液HbA₂和HbA所组成。结果初步说明,盘红细胞中HbA₂可能与HbA结合存在。两者可能有相互作用,也许这是产生血红蛋白A₂现象的原因。     

Detection of HbA1c by boronate affinity immunoassay using bacterial magnetic particles

We have developed a boronate affinity immunoassay system using m-aminophenylboronic acid (mAPB) coupling to bacterial magnetic particles (BMPs). Homobifunctional crosslinker, Bis-(succcimidyl)suberate (BS3), was employed for preparation of mAPB-BMPs conjugates (mAPB-BMPs). Quantities of HbA_1c on mAPB-BMPs were evaluated based on luminescence from alkaline phosphatase-conjugated anti-Hb antibody (ALP–antibody) binding to HbA_1c on the BMP surface. The binding of HbA_1c to mAPB-BMPs occurred gradually and was almost completed within 10 mm. The coupling reaction is enhanced due to static electric interaction between the positive charges on HbA_1c and negative charges on BMPs. The amount of HbA_1c binding to mAPB-BMPs increased with increasing sodium chloride concentrations in the range of 0–100 mM. However, the amount of Hb binding to mAPB-BMPs also increased in high concentration of sodium chloride. The Hb binding to mAPB-BMPs was detached from mAPB-BMPs when Hb–mAPB-BMPs were washed with low salt buffer. This indicates that Hb is nonspecifically adsorbed onto the surface of mAPB-BMPs in high concentration of sodium chloride. These results suggest that selective separation of HbA_1c using mAPB-BMPs can be achieved with these conditions. A dose–response curve was obtained between luminescence intensity and HbA_1c concentration using a fully automated boronate affinity immunoassay. A linear relationship between luminescence intensity and HbA_1c concentration was obtained in the range of 10–10⁴ ng/ml.     

Effect of Glycation of Hemoglobin on its Interaction with Trifluoperazine

Trifluoperazine (TFZ), a phenothiazine drug, penetrates into human erythrocytes and releases oxygen by interaction with hemoglobin. TFZ-induced oxygen release from hyperglycemic erythrocytes isolated from diabetic patients is considerably less compared to that from the cells of normoglycemic individuals. In diabetes mellitus, hemoglobin is significantly glycated by glucose. Non-glycated hemoglobin, HbA₀ and its major glycated analog, HbA_1c have been separated from the blood samples of diabetic patients. TFZ releases considerable amount of oxygen from HbA₀, but very little from HbA_1c. Spectrofluorimetric studies reveal that TFZ forms excited state complexes with both HbA₀ and HbA_1c. Titration of HbA₀ with TFZ in a spectrophotometric study exhibits two isosbestic points. Similar experiment with HbA_1c causes gradual loss of the Soret peak without appearance of any isosbestic point indicating a possibility of heme loss during interaction, which is also supported by gel filtration experiment and SDS-PAGE experiment followed by heme staining. The results suggest that drug action on hemoglobin is influenced by glycation-induced structural modification of the protein.     

Heterogeneity of hemoglobin A1d: assessment and partial characterization of two new minor hemoglobins, A1d3a and A1d3b, increased in uremic and diabetic patients, respectively

We have separated and quantified two new minor hemoglobins named HbA_1d3a and HbA_1d3b. The level of HbA_1d3a was significantly higher in uremic than in non-uremic patients (3.00 ± 0.50% vs. 1.28 ± 0.26% of total hemoglobin). It correlated well with carbamylated hemoglobin (r=0.80, n=81, p<0.002) and with plasma urea concentration (r=0.78, n=81, p<0.002). These data and the electrospray ionization mass spectrometric analysis provide strong evidence that HbA_1d3a is an α-chain modified by carbamylation. The HbA_1d3b level in the diabetic patients was found to be 1.6-fold that in non-diabetic subjects (3.00 ± 0.49 vs. 1.90 ± 0.33). This was attributed to HbA_1d3 modified by glycation. Indeed HbA_1d3b correlated significantly with HbA_1c (r=0.71, p<0.002) and with serum glucose level (r=0.62, p<0.002). These two new minor hemoglobins may serve as complements for the objective assessment of averagd long-term uremia and glycemia in uremic and diabetic patients.     

Effect of dietary substitution of groundnut oil on blood glucose, lipid profile, and redox status in streptozotocin-diabetic rats

The effect of groundnut oil on blood glucose, lipid profile, lipid peroxidation, and antioxidant status in streptozotocin-diabetic rats was investigated and compared with diabetic and drug-treated rats. Diabetes was induced in adult female Wistar rats by intraperitoneal administration of streptozotocin (40 mg/kg b-wt). Normal and diabetic rats were fed an oil-free diet containing 2 percent oil supplemented with groundnut oil (6g per 94g diet), to give 8 percent oil content, for 42 days. Diabetic rats had elevated levels of glucose (322.61 ± 9.49), glycosylated hemoglobin (HbA_1c), vitamin E, thiobarbituric acid reactive substances (TBARS), and lipid hydroperoxides (HP) and decreased levels of hemoglobin (Hb), vitamin C, and reduced glutathione (GSH). An increase in the activities of glucose-6-phosphatase and fructose-1,6-bisphosphatase and a decrease in hexokinase activity also were observed in the liver and kidney. When diabetic rats were fed groundnut oil, a significant reduction in glucose (244.04 ± 11.66), HbA_1c, TBARS, HP levels, and glucose-6-phosphatase and fructose-1,6-bisphosphatase activities and an elevation in Hb, vitamin E, GSH levels, and hexokinase activity were observed. Diabetic rats had elevated total cholesterol (TC), VLDL-cholesterol, LDL-cholesterol, and triglycerides (TG) and decreased HDL-cholesterol. Diabetic rats fed groundnut oil showed a small but significant reduction in TC, VLDL-C, LDL-C, and TG and an elevation in HDL-C. Groundnut oil consumption slightly but significantly decreases the blood glucose, HbA_1c, lipid peroxidation, and lipid profile and increases antioxidant levels in diabetic rats.     

Markedly Low Hemoglobin A1c in a Patient with an Unusual Presentation of ß-Thalassemia Minor

ObjectiveTo describe very low hemoglobin A_1c levels in a patient with type 2 diabetes mellitus and an unusual presentation of β-thalassemia minor.MethodsWe present the clinical and laboratory findings of the study patient.ResultsA 64-year-old African American man with type 2 diabetes mellitus was referred to the endocrinology clinic with a hemoglobin A_1c level of 1.6% despite elevated blood glucose concentrations. A red blood cell survival study with chromium-51 revealed that he had a reduced erythrocyte life span less than 25% of normal. He also had a markedly elevated reticulocyte count ranging from 236 to 534 x 10³/μL (reference range, 25-75 x 103/μL). The laboratory findings, which are not characteristic of ß-thalassemia minor, could be the cause of the markedly low hemoglobin A_1c in this patient.ConclusionsAlthough rare, when associated with marked erythrocyte turnover, β-thalassemia minor can lead to a severe reduction in HbA_1c levels. In this scenario, glycemic control is best assessed by measuring fructosamine. (Endocr Pract. 2010;16:89-92)     

Expression and transcriptional activity of alternative splice variants of Mitf exon 6

Heme proteins––hemoglobin and myoglobin possess esterase activities. Studies with purified hemoglobin from normal individuals and diabetic patients revealed that the esterase activity as measured from hydrolysis of p-nitrophenyl acetate (p-NPA) was higher in diabetic condition and increased progressively with extent of the disease. HbA_1c, the major glycated hemoglobin, which increases proportionately with blood glucose level in diabetes mellitus, exhibited more esterase activity than the non-glycated hemoglobin fraction, HbA₀, as demonstrated spectrophotometrically as well as by activity staining. Glycation influenced esterase activity of hemoglobin by increasing the affinity for the substrate and the rate of the reaction. Both HbA₀ and HbA_1c-mediated catalysis of p-NPA hydrolysis was pH-dependent. Esterase activity of in vitro-glycated myoglobin (GMb) was also higher than that of its non-glycated analog (Mb). The amplified esterase activities of hemoglobin and myoglobin might be associated with glycation-induced structural modifications of the proteins.     

An enzymatic method for the determination of hemoglobinA<Subscript>1C</Subscript>

Fructosyl peptide oxidase is a flavoenzyme that catalyzes the oxidative deglycation of N-(1-deoxyfructosyl)-Val-His, a model compound of hemoglobin (Hb)A_1C. To develop an enzymatic method for the measurement of HbA_1C, we screened for a proper protease using N-(1-deoxyfructosyl)-hexapeptide as a substrate. Several proteases, including Neutral protease from Bacillus polymyxa, were found to release N-(1-deoxyfructosyl)-Val-His efficiently, however no protease was found to release N-(1-deoxyfructosyl)-Val. Neutral protease also digested HbA_1C to release N-(1-deoxyfructosyl)-Val-His, and then the fructosyl peptide was detected using fructosyl peptide oxidase. The linear relationship was observed between the concentration of HbA_1C and the absorbancy of fructosyl peptide oxidase reaction, hence this new method is a practical means for measuring HbA_1C.     

Does polyamine oxidase activity influence the oxidative metabolism of children who suffer of diabetes mellitus?

Diabetes mellitus is a metabolic disease characterized by inadequate secretion of insulin. Polyamine oxidase (PAO), a FAD-containing enzyme is involved in the biodegradation of Sp and Spd, catalyzing the oxidative deamination of Sp and Spd, resulting in production of amonia (NH₃), corresponding amino aldehydes and H₂O₂. Malondialdehyde (MDA) and acrolein (CH2=CHCHO), potentially toxic agents, which induce oxidative stress in mammalian cells, are then spontaneously formed from aminoaldehydes. The main signs of oxidative stress in diabetic children were the values of HbA1c and MDA levels. Polyamines have an insulin-like action. Antiglycation property of spermine and spermidine has been recently confirmed. There are no data in the literature about plasma polyamine oxidase (PAO) activities in children with type 1 diabetes. The idea of this study was to evaluate the polyamine metabolism through the estimation of polyamine oxidase activity. We have study children with newly diagnosed type 1 diabetes mellitus (n = 35, age group of 5–16 years, as well as age-matched healthy control subjects (n = 25). The biochemical investigations were done on diabetic children who have the pathological values of glucose (9.11–17.33 mmol/l) and glycosylated Hb (7.57–14.49% HbA_1c). The children in the control group have referent values of glucose and glycated hemoglobin (4.11-5.84 mmol/L and HbA_1c 4.22-6.81% of the total Hb. Glucose levels in blood plasma and glycosylated hemoglobin in erythrocythes hemolysates (HbA1c) were measured by using standard laboratory methods. PAO activity in venous blood plasma and the amount of malondialdehyde (MDA) were measured by the spectrophotometric methods. PAO activity, glycemia, HbA1c and MDA were significantly increased in diabetic children compared to the control subjects. PAO activity in children with type 1 diabetes mellitus was very high. The findings of higher blood HbA_1C and MDA levels confirm the presence of oxidant stress in children with type 1 diabetes mellitus and demonstrate that PAO activity may participate in these circumstances.     

Patients Achieving Good Glycemic Control (HBA1c <7%) Experience A Lower Rate of Hypoglycemia With Insulin Degludec Than with Insulin Glargine: A Meta-Analysis of Phase 3A Trials

Objective: Meta-analysis to compare hypoglycemia rates of basal insulin degludec (IDeg) with insulin glargine (IGlar) in patients with diabetes achieving good glycemic control (hemoglobin A_1c [HbA_1c] <7% at end of trial).Methods: In a preplanned meta-analysis, patient data from 7 randomized, treat-to-target, 26- or 52-week trials in patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) who administered IDeg (n = 2,899) or IGlar (n = 1,431) once daily were analyzed. Using a negative binomial regression model, this meta-analysis compared hypoglycemia rates in patients achieving HbA_1c <7% at end of trial with IDeg (n = 1,347) and IGlar (n = 697).Results: In all trials, IDeg was noninferior to IGlar in HbA_1c reduction from baseline. At end of trial, 2,044 patients (T2DM, n = 1,661; T1DM, n = 383) achieved HbA_1c <7%. The overall confirmed hypoglycemia rate, defined as plasma glucose <56 mg/dL or severe hypoglycemia if requiring assistance, was significantly lower with IDeg versus IGlar (estimated rate ratio [ERR] IDeg:IGlar, 0.86; 95% confidence interval [CI], 0.76 to 0.98). The nocturnal confirmed hypoglycemia rate, defined as occurring between midnight and 6:00 am, was significantly lower with IDeg (ERR, 0.63; 95% CI, 0.52 to 0.77). In the maintenance period (16 weeks onward when average insulin dose and glycemic levels stabilized), the overall confirmed hypoglycemia rate was significantly lower (ERR, 0.79; 95% CI, 0.68 to 0.92) and the nocturnal confirmed hypoglycemia rate was significantly lower (ERR, 0.57; 95% CI, 0.45 to 0.72) with IDeg versus IGlar.Conclusion: Patients with T1DM and T2DM achieved HbA_1c <7% with significantly lower rates of overall and nocturnal confirmed hypoglycemia with IDeg versus IGlar. The lower hypoglycemia rate with IDeg was more pronounced in the maintenance period.Abbreviations: ERR = estimated rate ratio; HbA_1c = hemoglobin A_1c; IDeg = insulin degludec; IGlar = insulin glargine; NPH = Neutral Protamine Hagedorn; PG = plasma glucose; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus     

Achieving further glycemic control in type 2 diabetes mellitus

Objectives To identify patients with type 2 diabetes mellitus who were in poor glycemic control and therapeutic adjustments that might improve control. Design Using electronic pharmacy data, we assigned subjects to 1 of 4 therapeutic categories. We then identified patients within each category who did not meet the recommended standard of glycemic control (glycosylated hemoglobin [Hb A_1c] <0.08 [<8.0%]) and studied their therapetic regimens for possible improvements. Subjects The subjects were 5,061 members of a large group-model health maintenance organization who had type 2 diabetes and 12 months of 1997 health plan eligibility. Main outcome measures The dosage of antihyperglycemic agents (sulfonylureas, metformin, and insulin) in relation to glycemic control as measured by the Hb A_1c. Results A significant number (n = 1,570 [31.0%]) of persons with type 2 diabetes might improve their glycemic control with simple adjustments to their pharmacologic therapy. Conclusion Busy clinicians with heavy workloads can improve their management of diabetes by identifying patients whose glycemic control could be improved through a change in medication or simple adjustment in dosage.     

Analysis of hemoglobin variants using nondenaturing gel electrophoresis and matrix-assisted laser desorption ionization mass spectrometry

Molecular analysis of hemoglobin variants is crucial in the diagnosis of hemoglobinopathies. Routinely used techniques for identifying variants include alkaline gel electrophoresis and automated HPLC. Sometimes comigration of variants in electrophoresis or coelution in HPLC provides ambiguous results. Due to high sequence homology between normal and variant hemoglobin, proteomic analysis using LC/ESI-MS data is also challenging. Here we describe a novel method wherein alkaline gel electrophoresis and MALDI-MS were used in combination to characterize variant samples such as Hb FSD and Hb D-Iran unambiguously. The method is rapid, efficient, and cost effective. In the future, it can be applied as a diagnostic tool.     

Assessment of AACE/ACE Recommendations for Initial Dual Antihyperglycemic Therapy Using the Fixed-Dose Combination of Sitagliptin and Metformin Versus Metformin

ObjectiveThe American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) diabetes algorithm recommends a stratified approach to initial therapy to achieve a glycated hemoglobin (HbA_1c) goal of <6.5% in patients with type 2 diabetes mellitus (T2DM) who have inadequate glycemic control. Data from a double-blind study in drug-naïve T2DM patients comparing initial monotherapy with metformin (MET) with initial dual therapy with a fixed-dose combination of sitagliptin and MET (SITA/MET FDC) was used to determine AACE/ACE HbA_1c goal attainment in these treatment groups.MethodsA total of 1,250 patients (mean baseline HbA_1c = 9.9%) were randomized 1:1 to SITA/MET FDC 50/500 mg twice daily (b.i.d.) or MET 500 mg b.i.d. for 18 weeks. SITA/MET FDC and MET were uptitrated over 4 weeks to 50/1,000 mg b.i.d. and 1,000 mg b.i.d., respectively.ResultsAt week 18, a higher percentage of patients receiving SITA/MET FDC had HbA_1c levels <6.5% and <7% than those receiving MET alone within each of the 3 AACE/ACE HbA_1c categories (6.5-7.5%, >7.5-9.0%, and >9.0%). Of patients with a baseline HbA_1c >7.5-9.0% who initiated SITA/MET FDC, 48.6% achieved an HbA_1c <6.5% at week 18 compared with 23.1% of patients who initiated MET monotherapy (P<.001). In patients with a baseline HbA >9.0%, 24.0% on SITA/MET FDC achieved an HbA_1c <6.5% compared with 12.8% on MET alone (P<.001).ConclusionIn T2DM patients with a baseline HbA_1c >7.5-9.0%, substantially more achieved the HbA_1c goal of <6.5% with initial dual therapy (SITA/MET FDC) than with initial monotherapy (MET), which is in agreement with the AACE/ACE diabetes algorithm.(Endocr Pract. 2013;19:751-757)     

Association between insomnia symptoms and hemoglobin A1c level in Japanese men

Background

The evidence for an association between insomnia symptoms and blood hemoglobin A_1c (HbA_1c) level has been limited and inconclusive. The aim of this study was to assess whether each symptom of initial, middle, and terminal insomnia influences HbA_1c level in Japanese men.

Methods

This cross-sectional study examined 1,022 male workers aged 22–69 years with no history of diabetes at a Japanese company''s annual health check-up in April 2010. High HbA_1c was defined as a blood level of HbA_1c ≥6.0%. Three types of insomnia symptoms (i.e., difficulty in initiating sleep, difficulty in maintaining sleep, and early morning awakening) from the previous month were assessed by 3 responses (i.e., lasting more than 2 weeks, sometimes, and seldom or never [reference group]).

Results

The overall prevalence of high HbA_1c was 5.2%. High HbA_1c was positively and linearly associated with both difficulty in maintaining sleep (P for trend  = .002) and early morning awakening (P for trend  = .007). More specifically, after adjusting for potential confounding factors, high HbA_1c was significantly associated with difficulty in maintaining sleep lasting more than 2 weeks (adjusted odds ratio, 6.79 [95% confidence interval, 1.86–24.85]) or sometimes (2.33 [1.19–4.55]). High HbA_1c was also significantly associated with early morning awakening lasting more than 2 weeks (3.96 [1.24–12.59]).

Conclusion

Insomnia symptoms, particularly difficulty in maintaining sleep and early morning awakening, were found to have a close association with high HbA_1c in a dose-response relationship.     

HbF-新晋[~Gy~I119(GH2)Gly→Arg]一种新的不稳定胎儿血红蛋白变异体

 1988年我室又发现一种新的慢泳异常胎儿血红蛋白(HbF)。先证者为一健康汉族女婴。醋纤膜电泳(pH8.6)示变异体区带位于HbF与Hb A_2之间,反相高效液相色谱(HPLC)示正常GγI峰前方出现一异常峰。异常Hb含量为Hb总量的16.8％。理化性质测定该变异体为一轻度不稳定Hb。结构分析证明该变异体为GγI链第119位(GH2)的甘氨酸(Gly)被精氨酸(Arg)取代。γ链GH2位于α_1γ_1接触面,此处的氨基酸置换可导致Hb的不稳定。此变异体被命名为HbF-新晋[~(GγI)119(GH2)Gly→Arg]。     

A Study Assessing the Association of Glycated Hemoglobin A1C (HbA1C) Associated Variants with HbA1C,Chronic Kidney Disease and Diabetic Retinopathy in Populations of Asian Ancestry

Glycated hemoglobin A_1C (HbA_1C) level is used as a diagnostic marker for diabetes mellitus and a predictor of diabetes associated complications. Genome-wide association studies have identified genetic variants associated with HbA_1C level. Most of these studies have been conducted in populations of European ancestry. Here we report the findings from a meta-analysis of genome-wide association studies of HbA_1C levels in 6,682 non-diabetic subjects of Chinese, Malay and South Asian ancestries. We also sought to examine the associations between HbA_1C associated SNPs and microvascular complications associated with diabetes mellitus, namely chronic kidney disease and retinopathy. A cluster of 6 SNPs on chromosome 17 showed an association with HbA_1C which achieved genome-wide significance in the Malays but not in Chinese and Asian Indians. No other variants achieved genome-wide significance in the individual studies or in the meta-analysis. When we investigated the reproducibility of the findings that emerged from the European studies, six loci out of fifteen were found to be associated with HbA_1C with effect sizes similar to those reported in the populations of European ancestry and P-value ≤ 0.05. No convincing associations with chronic kidney disease and retinopathy were identified in this study.     

Association of HbA1c values with mortality and cardiovascular events in diabetic dialysis patients. The INVOR study and review of the literature

Background

Improved glycemic control reduces complications in patients with diabetes mellitus (DM). However, it is discussed controversially whether patients with diabetes mellitus and end-stage renal disease benefit from strict glycemic control.

Methods

We followed 78 patients with DM initiating dialysis treatment of the region of Vorarlberg in a prospective cohort study applying a time-dependent Cox regression analysis using all measured laboratory values for up to more than seven years. This resulted in 880 HbA_1c measurements (with one measurement every 3.16 patient months on average) during the entire observation period. Non-linear P-splines were used to allow flexible modeling of the association with mortality and cardiovascular disease (CVD) events.

Results

We observed a decreased mortality risk with increasing HbA_1c values (HR = 0.72 per 1% increase, p = 0.024). Adjustment for age and sex and additional adjustment for other CVD risk factors only slightly attenuated the association (HR = 0.71, p = 0.044). A non-linear P-spline showed that the association did not follow a fully linear pattern with a highly significant non-linear component (p = 0.001) with an increased risk of all-cause mortality for HbA_1c values up to 6–7%. Causes of death were associated with HbA_1c values. The risk for CVD events, however, increased with increasing HbA_1c values (HR = 1.24 per 1% increase, p = 0.048) but vanished after extended adjustments.

Conclusions

This study considered the entire information collected on HbA_1c over a period of more than seven years. Besides the methodological advantages our data indicate a significant inverse association between HbA_1c levels and all-cause mortality. However, for CVD events no significant association could be found.