الفهرس 
Introduction and Aim of The WorkOnly 14 pages are availabe for public view
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Abstract
The current study is prospective cross- sectional study aiming to evaluate the significance of glycated albumin (GA), compared to glycated haemoglobin (HbA1c%), as an indicator of the glycaemic control state in haemodialysis (HD) patients with Type 2-diabetes mellitus.
Patients and Methods:
This study was carried out in the Internal Medicine Department, Minia University at Haemodialysis unit along period from May 2018 to February 2019.The study included 40 type-2 diabetic patients with end-stage renal disease and were maintained on regular haemodialysis. They were studied at base time at the start of haemodialysis and followed up after 6 months of regular haemodialysis (3 sessions per week). The patient group were subdivided in to 2 groups according to presence or absence of diabetic complications (controlled group and uncontrolled group). Twenty healthy volunteers free of medical diseases were included as control group.
All study groups subjected to:
- Thorough clinical history and carful clinical evaluation.
- complete blood count, liver function tests, renal function tests, HbA1c%, Glycated albumin, fasting blood sugar, Fasting insulin, Serum total cholesterol and triglyceride concentration.
- We calculated Insulin resistance by HOMA-IR and adequacy of haemodialysis by URR to the patients group only.
- All the investigations were done to the patients at start and after 6 months of regular haemodialysis.
Results:
At base line of the study; this study included 16 males and 44 females with the mean age of 27.9 years for control group and 62.5 for patient group. Patients group have higher BMI than control group. Patients group had a median duration of DM about 15 years. Fifty-five% of DM patients suffered from diabetic complications (17.5 % diabetic foot, CVS 22.5 %, recurrent infection 20 %, retinopathy with about 5%). The patient group had significantly lower serum albumin and Hb while they have significantly higher serum creatinine than the control group. Diabetic group had significantly higher HbA1c %, GA (%), Fasting insulin, FBS and HOMA IR. BMI, DM complications, total leucocytic count and AST of controlled diabetic patient were significantly lower than uncontrolled.
After 6 months follow up;
HbA1c, GA and Serum urea after 6 months follow up were significantly lower than that at start of study while fasting insulin, Platelets, URR and serum albumin were significantly higher. HbA1c and GA were significantly lower in controlled group than uncontrolled group. Glycated albumin is more sensitive but less specific, less accurate than HbA1c% in prediction of DM complication in patients on regular haemodialysis. Glycated albumin revealed optimal cut- off = >2 with sensitivity 90.91%, specificity 50% and accuracy 72.5%.
HbA1c% correlated to Hb level but not correlated to FBS, dose of erythropoietin. Glycated albumin correlated to FBS, HbA1c%, fasting insulin and HOMA- IR.The glycaemic markers (both HbA1c% and Glycated albumin) are significantly lower than at start of dialysis.
At start of haemodialysis shows significant correlation between HbA1c% and IHD and DM retinopathy while glycated albumin shows no correlation with IHD. Insulin resistance is closely associated with atherosclerosis and cardiovascular mortality in the patient’ group. Patients with end-stage renal disease (ESRD) are known to have insulin resistance. HOMA-IR shows sensitivity 100%, specificity 66.67% and accuracy 85% in prediction of DM complications. GA is useful in monitoring of glucose homeostasis in type-2 DM patients maintained on HD. However, GA can be also affected by protein loss in urine and HD fluid. Haemodialysis using high flux dialyzers and online hemodiafiltration (HDF) are known to cause albumin leakage larger than that caused by conventional HD.
Compared to HbA1c%, GA can promptly indicate either an improvement or a worsening of the patient’s glycaemic status. Therefore, it could be useful in all those conditions requiring short-term glycaemic control, such as after starting or modifying a drug therapy.
Conclusion:
The current study showed that GA is more sensitive than HbA1c%. (90.91% Vs 86.36%) but less specific (50% Vs 61.11) respectively in follow up of diabetes homeostasis in diabetic patients maintained on hemodialysis. Diagnostic accuracy is high in HbA1c% than GA (75%, 72.5%) respectively. HOMA-IR is superior for both as regard sensitivity (100%) and diagnostic accuracy (85%). See table 26.
Kobayashi et al., (2016), Dozio et al., (2018) and (Abe et al., 2019) concluded that GA is useful in monitoring of glucose homeostasis in type-2 DM patients maintained on HD. However, GA can be also affected by protein loss in urine and HD fluid. Recently, (HD) using high flux dialyzers and online hemodiafiltration (HDF) are known to cause albumin leakage larger than that caused by conventional HD (Ueda et al.,2019). GA in patients undergoing HD or online HDF was practically reliable even if dialysis modality was changed. The preferable marker of glycemic status depends on the albumin and hemoglobin metabolism in each patient undergoing dialysis (Ueda et al.,2019).
Albumin leakage in HD or online HDF fluid could affect GA but was not practically important in controlling diabetic medication. If albumin leakage is clinically acceptable and red blood cell lifespan is stable, both GA and HbA1c will be correlated with glycaemic status (Ueda et al.,2019).
Compared to HbA1c%, which is a long-term glycemic indicator, GA is a medium-term glycemic marker because it reflects the average life of albumin (about 20 days). This means that, compared to HbA1c, GA can promptly indicate either an improvement or a worsening of the patient’s glycemic status. Therefore, it could be useful in all those conditions requiring short-term glycemic control, such as after starting or modifying a drug therapy (Lu et al., 2016, b).
GA >15.2% (Ikezaki et al., 2015) or >15.5% (Furusyo et al., 2011) were the cut-offs proposed for DM screening.
Since albumin is very sensitive to glycation, GA could also be a valid indicator of postprandial glycemic fluctuations, making it possible to identify changes that are not easily detectable with spot blood glucose monitoring, unless done continuously, or with HbA1c%, which is less sensitive to sudden, short-lasting glycemic peaks (Takahashi et al., 2007).
The HbA1c% assay had limitations as an indicator of glycemic control in diabetic patients on HD as the assessment of glycemic control by HbA1c% in those patients might lead to under-estimation due to EPO therapy and anemia. In the future, further studies are needed to determine the target GA level that is necessary to ensure a good prognosis for diabetic patients on dialysis. Similarly, more data are needed to determine the stage of chronic kidney disease when GA levels are preferable over HbA1c levels for the assessment of glycemic control (Kobayashi et al., 2016).