International Journal of Pathology; 2010; 8(2): 59-62

Original Article

Correlation between Glycated Haemoglobin and Random Plasma Glucose Levels for the Screening of Diabetes Mellitus
Waqar Azim*, Maria Omair*, Muhammad Qaiser Alam Khan*, Nasira Shaheen*, Saad Azim**

Objective: To find out a correlation between Glycated hemoglobin (HbA1c) and random plasma glucose levels
for the screening of diabetes mellitus.

Study Design: Analytical cross-sectional study. Place and Duration of Study: This study was conducted in the Department of Pathology, Army Medical
College, National University of Sciences and Technology, Rawalpindi, from January 2010 to April 2010. Materials and Method: Three hundred and fifteen patients were included in the study. HbA1c was estimated using Ion Exchange Resin separation kit of Globe Diagnostics, as per guidelines. The Plasma samples received were analyzed on fully automated chemical pathology analyzer Selectra E for random glucose estimation by Glucose Oxidase method. The gender distribution and the relationship of age with HbA1c and random plasma glucose levels were also determined. The results were interpreted using Statistical Package for The Social Sciences (SPSS) version 17. Result: There was a direct correlation between glycated hemoglobin and random plasma glucose levels while there was no correlation between age of the patients and the HbA1c or the age and the random plasma glucose levels. We also found that for every 1% rise in HbA1c, plasma glucose level rose by 2.3mmol/L. Conclusion: Glycated haemoglobin can be used as a reliable, feasible and fairly accurate tool for screening of diabetes mellitus. Key Words: Glycated haemoglobin, Diabetes mellitus, screening for diabetes

Introduction
Diabetes is a metabolic disorder characterized by hyperglycemia leading to damage to all systems of body and thus is one of the leading causes of high morbidity and mortality. 1,2 The number of people with diabetes worldwide is expected to get doubled in the next 20 years(yrs), as a response to increasing obesity and longevity. 3 Besides Europe and America, it is clear that the bulk of the epidemic will be observed in non-European origin populations i.e. in countries undergoing rapid westernization. 2 Presently the prevalence of diabetes mellitus in Pakistan is 1012%.4-5 Excess circulating glucose in diabetes is a reactant molecule, involved in the glycosylation of various
From the Department of Pathology, Army Medical College, Rawalpindi Correspondence Author: Brig Waqar Azeem

biomolecules like hemoglobin.1 This process continues

slowly throughout the lifespan of the erythrocyte.6 Glycated hemoglobin (HbA1c) expressed as a percentage of total blood hemoglobin concentration gives a good retrospective assessment of the mean plasma glucose concentration during the preceding 6 8 weeks while the recent glycemic level has the highest influence and the preceding 30 days contribute only upto 50%. 1,7 The higher the percentage of circulating HbA1c in the diabetes, poorer is the mean diabetic control. 1 According to World Health Organization (WHO) HbA1c level of 7% or higher is taken diagnostic of diabetes 8 while the 2010 American Diabetes Association Standards of Medical Care in Diabetes added the HbA1c 6.5% as another criterion for the diagnosis of diabetes.8-9 HbA1c levels between 6.0 and 6.5% are proposed to identify individuals at high risk of developing diabetes.10 Fasting plasma glucose level estimation has its limitations like the person has to fast for a specified period of time.11 Similarly for random plasma glucose level the health care provider is not sure about the actual number of hours passed after the meal or any

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International Journal of Pathology; 2010; 8(2): 59-62

history of recent intake of any hypoglycemic or hyperglycemic drug. HbA1c on the other hand, is a spot test with no requirement for prior preparation, no risk of misinterpretation owing to recent meal or drug.11 So the need of the hour is to establish a relationship between daily patient-monitored blood glucose and HbA1c to enable the patients and their health care providers set appropriate daily plasma glucose goals. 12 Since no such study has previously been conducted in our set up so this study was planned to find out a correlation between HbA1c and the random plasma glucose levels as a tool for screening of diabetes mellitus.

Materials and Methods

This analytical, cross sectional study with retrospective data was conducted in the Department of Pathology, Army Medical College, National University of Sciences and Technology, Rawalpindi, from January 2010 to April 2010. Three hundred and fifteen patients, reporting for the estimation of HbA1c were included in the study (which is well above the 163 as calculated by applying n = z2pq/e2, for sample size calculation,13 where z = 1.96, p = 0.12, q = 0.88 and e = 0.05). HbA1c was estimated in whole blood, by ion-exchange resin method. The optical density of each proportion was measured spectrophotometrically on semiautomated chemistry analyzer, Microlab 200, followed by an evaluation of the relative proportion of HbA1c with respect to total HbA. Plasma samples of the same patients were analyzed on fully automated chemical pathology analyzer, Selectra E, for the estimation of plasma glucose levels, by Enzymatic (Glucose Oxidase) colorimetric method. For both tests, Globe Diagnostics kits were used, as per guidelines while keeping a strict quality control check by both internal and external controls. Data was analyzed using Statistical Package for the Social Sciences (SPSS), version 17. Descriptive statistics were used to describe the data. Pearson correlation coefficient was calculated between glycated haemoglobin and spot plasma glucose levels and between age of the patients and glycated haemoglobin. A p-value <0.05 was considered significant.

and p<0.001) between the HbA1c and random plasma glucose levels (Figure-1). This correlation between the HbA1c and the random plasma glucose was strongest in an age bracket of 50-59 yrs (subject number(n=86, r-value 0.705, p-value=<0.001) followed by 40-49 yrs (n=72, r-value 0.701,p-value=<0.001) while no correlation was found in the age bracket of 20-29 yrs (correlation coefficient value of 0.437 and pvalue=0.156) as shown in the table-1 and figure-II. On studying the relationship of the age of the patients with other two variables, we found no correlation between the age of the patients and HbA1c levels (r = 0.026, p = 0.668) as well as between age and plasma glucose levels (r = -0.069, p = 0.256). On applying linear regression analysis, we found that for every 1% rise in HbA1c, plasma glucose levels rise by 2.3mmol/L. Taking HbA1c 6.5% and random plasma glucose level of 11.1 mmol/L as diagnostic, HbA1c had a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 72%, 66.5%, 61.7%, 83% and 74% respectively.

Discussion
Pakistan has seventh largest population of diabetic patients which is a cause of great economic burden on the already poverty stricken people of Pakistan.14 HbA1c estimation not only helps us in diagnosis of diabetes, but also guides in taking appropriate therapeutic decisions as higher levels of HbA1c are associated with higher risks of microvascular complications.8, 15 In our study, significant correlation was found between the HbA1c and the random plasma glucose levels. Studies conducted in various parts of the world, reveal similar results. Nielsen et al showed that mean and standard deviation of glucose, hyperglycemic and hypoglycemic states, all correlated with HbA1c, but with decreasing statistical power. 16 In multiple linear regression analysis, it was also found that mean glucose was the sole independent variable (r = 0.626, p< 0.0001).16 They observed that both types of patients, i.e. those exhibiting vast diurnal glucose oscillations as well as patients with seemingly stable elevated glycemic levels, displayed poor long term regulation in terms of HbA1c suggesting that both duration and amplitude of hyperglycemia have an impact on glycosylation.16 Similarly, a study conducted by Distiller et al demonstrated that although the HbA1c level correlated significantly with a single random post-prandial blood glucose estimation and appeared to reflect diabetic control more accurately than a single blood glucose estimation, yet the HbA1c concentration does not reflect the simultaneous blood glucose concentration, nor is it influenced by short-term fluctuations in blood glucose.6 Another study published in Annals of Clinical biochemistry, 2002 revealed that the mean interstitial

Results
In our study, out of 315 patients, having mean age ( Standard deviation, SD) of 53.6 13.7 yrs, 60% (189) were males and 40 % (126) were females. Mean (SD) HbA1c of the patients was 6.341.5%, while the random plasma glucose levels ranged from, 10.2 5.2 mmol/L. There was a significant correlation (r = 0.647

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glucose concentration recorded with the continuous glucose monitoring system correlates (r= 0.59 and p= 0.002) with HbA1c level recorded at the same time.17 In a study conducted in China, Hu et al recommended combined use of HbA1c and FPG for the diagnosis of diabetes while an expert committee comprising members appointed from the American Diabetes Association (ADA), the European Association for the Study of Diabetes (EASD) and the International Diabetes Federation (IDF) in 2008 have discouraged the use of combined use of these two tests and has proposed adoption of only HbA1c for diagnosis of diabetes.11,18 Rholfing et al, reported that mean plasma glucose (MPG), per increase of 1% HbA1c was 1.98mmol/L.12 Similarly in Malaysia in study revealed that both postprandial plasma glucose (PPG) and fasting plasma glucose (FPG) correlated significantly with HbA1c but PPG showed better correlation with HbA1c than FPG (r= 0.604 vs.0.575). In the same study, Rosediani et al also found that in predicting good glycaemic control (HbA1c<7.0%), the sensitivity, specificity and positive predictive value of PPG were 75.0%, 80.6% and 82.5% whereas FPG were 81.8%, 58.3% and 70.6% respectively.19 Riet et al, demonstrated strong correlations between glucose and HbA1c in known diabetics; however, moderate correlations were found in the general population.10 Likhari et al, on the contrary, found that HbA1c estimation only has a limited value for diagnosis of diabetes. 20 We have found highest prevalence of diabetes in age bracket of 50-59yrs followed by 60-69 yrs and 40-49 yrs. Parkin et al in their study, conducted in 2002, have found highest prevalence in age bracket of 3039yrs.21 Our data suggest that prolonged course of disease process increased the chances of increased co-morbidities which should be prevented by early diagnosis and proper glycemic control.

Conclusion
Glycated hemoglobin correlated significantly with random plasma glucose levels and it saves us from the risk of misinterpretations resulting from lack of correct information about the time passed after meal and the effects of drugs. We conclude that HbA1c correlates significantly with the random plasma glucose levels and for every 1% rise in HbA1c, plasma glucose levels rise by 2.3 mmol/L. Therefore Glycated Hemoglobin can be used as a reliable, feasible and fairly accurate tool for the screening of diabetes mellitus.

References
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