Magrey MN, Schreiber MJ, Hoogwerf BJ
Utility of HbA1C in patients with insulin requiring diabetes
mellitus (IRDM) & end stage renal disease
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1361 1996
Also reviewed: Glycosylated hemoglobin A1C values in nondiabetic
hemodialysis patients. by St. Peter et al. JASN 7:1365, 1996.
Glycated hemoglobin (HbA1c) is very useful to assess adequacy of
glycemic control in patients with diabetes mellitus. Anemia
associated with chronic renal failure and the possibility of
carbamylation of hemoglobin may make determination of HbA1c a less
accurate index of glycemic control in diabetic patients with endstage
renal disease.
Magrey et al examined the relationship between HbA1c determinations
and the mean glucose level obtained from frequently obtained
fingerstick glucose determinations (7-14 determinations/week over 8
weeks). Their population consisted of 12 patients requiring insulin
for glycemic control; all 12 patients were on continuous ambulatory
peritoneal dialysis. There was an excellent correlation between the
mean glucose level and HbA1c level obtained at the end of the 8 week
period, rivaling results obtained in diabetics without renal failure
(r = .884, p < .0001). It would seem that HbA1c determinations are
useful in determining glycemic controls in insulin requiring diabetics
on continuous ambulatory peritoneal dialysis.
A note of caution with respect to the variability of HbA1c levels in
patients with endstage renal disease has been raised by the abstract
of St. Peter et al. They retrospectively analyzed 105 HbA1c
determinations from patients with endstage renal disease but without
diabetes. An assay reported to have interference by uremia (87 HbA1c
determinations) was compared to one without reported interference (18
HbA1c determinations). While mean HbA1c levels with both assays were
similar (5.02% vs 5.78%) and not different from variation values
obtained from a normal population, the percent coefficient of
variation (standard deviation/mean) for both assays was approximately
33% in patients with endstage renal disease whereas it was only 9.9%
in patients with normal renal function. The authors suggest that
this variability may be due interference with the assays in uremia or
due to glucose intolerance even in those patients who have relatively
normal fasting blood sugar levels and who are not overtly diabetic.
Comment: While establishing a normal range for HbA1c levels in
patients with
endstage renal disease may be required, the abstract by Magrey suggests
that this measurement is useful in the management of hyperglycemia in
patients with endstage renal disease.
(Gerald Schulman, M.D., Vanderbilt University, Nashville, TN)
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