Faculty: Faculty of Health and Applied Sciences
Department: Department of Health Sciences
Program: Biomedical Sciences Program
Diabetes
Surname Thomas
Name Jackson
Email address [email protected]
Name of course Work Integrated Learning
Course code WILB821S
Couse coordinator Ms. Eva Uumati
Name of training institution Oshakati NIP
Discipline in which training is Chemistry
received
Name of training officer Mrs. Rosalia Shaumbwa
Period of training
23/09/24 14/11/24
Table of Contents
1
Introduction...................................................................................................................... 3
Methods........................................................................................................................... 5
Results............................................................................................................................. 6
Discussion........................................................................................................................7
Conclusion....................................................................................................................... 9
References.....................................................................................................................10
Appendix........................................................................................................................ 12
2
INTRODUCTION
When glucose is in its open chain structure it binds to the N-terminal end of the beta-
chain of hemoglobin to form a Schiff base. This is a non-enzymatic reaction that
ultimately results in the formation of glycated hemoglobin (HbA1c). The process forms
part of the normal physiologic function cycle, but as the average plasma glucose
increases the amount of HbA1c also increases (Sherwani et al., 2016).
The HbA1c test is comprised of two separate concentration measurements namely
glycated hemoglobin (HbA1c) and total hemoglobin (THb). After the concentrations of
HbA1c and THb are obtained they are utilized to calculate the percent of HbA1c (NGSP
units) and the hemoglobin fraction measured in mmol/mol (IFCC units) (Chauhan,
2017). The test provides a time period trend of the average glucose levels over a two to
three-month time period making it an essential biomarker in the diagnosis of diabetes
mellitus (Sherwani et al., 2016). HbA1c is measured via the photometric technology,
which measures the end-point reaction of HbA1c. Photometry is the measurement of
the amount of light a sample absorbs and involves passing a beam of light through a
sample and measuring the intensity of light that reaches a detector.
The photometry method works as follows; light from a tungsten halogen lamp is
converged with a convex lens and passed into a reaction cuvette where changes in
absorbance are detected as the reaction proceeds. Another convex lens concentrates
the onto a reflector or mirror, the mirror then reflects the light onto a diffraction grating
through a slit. This is followed by the light spectrum being reflected to the photodiode
array by the grater, which results in the division of the concentrated light beam into 16
independent wavelengths from 340 to 804 nanometers. The light intensity at various
wavelengths is then measured by a photodiode array. A preamplifier board converts
and amplifies the signal coming from the photodiode array through the DAQ board and
CPU board allowing the signal to be sent to the system control center where the data
reduced and the calculation of the results is performed (Abbott Laboratories, 2013).
Individuals that are non-diabetic usually have HbA1c values in the range of 29 - 42
mmol/l (IFCC) or 4.8 - 5.9% (NGSP). Patients with HbA1c values in the range of 39 – 46
3
mmol/l (IFCC) or 5.7 – 6.4 % (NGSP) are classified as pre-diabetics or at the risk
developing and diabetes, while patients with values above 48 mmol/l (IFCC) or 6.4 %
(NGSP) are said to be suitable for diagnosis of diabetes mellitus. Individuals with values
below the normal reference range may be associated with recent episodes of
hypoglycemia, anemia or shortened erythrocyte lifetime (Sherwani et al., 2016) (Chen et
al., 2022).
4
METHODS
The assay is initiated by loading reagent 1 and reagent 2 on the Architect c4000 system
followed by placing the A1cDILL in the reagent supply center. The A1cDIL was then
configured in the Configure reagent setting screen by selecting new, followed by
selecting configure. This was then succeeded by entering the reagent name as A1cDIL,
the sample type as Sample Diluent, the lot number and serial number as shown on the
bottle label. The A1cDIL was finally assigned a location.
After assigning of location the hemolysate was prepared, it is initiated by using a
calibrated pipette to dispense 220 microliters (µl) of A1cDIL into a sample cup. Another
calibrated pipette was used to withdraw 10 µl of well mixed whole blood from an EDTA
tube, followed by wiping off excess blood from the exterior of the pipette with tissue. The
pipette was then inserted into the sample cup containing the A1cDIL allowing for the tip
of the pipette to just make surface contact with the A1cDIL followed by dispensing the
10 µl, the mixture was then withdrawn and dispensed twice while keeping the pipette tip
in contact with the fluid. The hemolysate was then homogenized by low speed vortex
and allowed to stand for a minimum of 1 minute at room temperature followed by finally
loading the sample cup holder onto the Architect c4000 system.
5
RESULTS
TEST REFERENCE RESUL FLAG
T
HBA1C
Estimated Average Glucose 13.3 High
HbA1c IFCC 29 – 42 mmol/mol 60.2 High
HbA1c NGSP 4.8 – 5.9 mmol/mol 7.7 High
Glucose Tolerance Test
Fasting Glucose <11.1 mmol/l 13.3 High
Urea and Electrolytes
Potassium 3.6 – 5.1 mmol/mol 3.3 Low
Sodium 136 – 144 mmol/l 138
Urea 2.1 – 7.1 mmol/l 6.5
Creatinine 35 – 88 mmol/l 71
Estimated GFR >90 ml per minute 86.5 Low
LIVER FUNCTION TESTS
Alkaline Phosphatase 32 – 91 U/l 116 High
Gamma Glutamyl Transferase 7 – 50 IU/l 168 High
Aspartate Amino Transferase 15 – 41 IU/l 62 High
Alanine Transaminase 7 – 35 IU/l 55 High
Lactate Dehydrogenase 98 – 192 IU/l 304 High
Total Protein 61 – 79 g/l 89 High
C-REACTIVE PROTEIN 0 – 10 mg/l 12.9 High
6
DISCUSSION
HbA1c, or glycated hemoglobin, reflects average blood glucose levels over the past 2-3
months. It is a crucial marker for diagnosing and monitoring diabetes (Chen et al.,
2022). Fasting plasma glucose (FPG) and random glucose tests measure blood glucose
at a single point in time. The patient at hand identified as ChemP01 had markedly
elevated levels of HbA1c. The HbA1c IFCC is 60.2 mmol/mol were the normal reference
range is 29-42 mmol/mol and a HbA1c NGSP of 7.7 % were the normal reference range
is 4.8-5.9 %. The results are therefore suggestive of a differential Diabetes Mellitus
diagnosis.
The Oral Glucose Tolerance Test (OGTT) is done to assess the normal glucose
tolerance of a patient. A standard dose of glucose is ingested orally in a fasted state
and 2 hours postprandial, plasma glucose levels are measured. The patient at hand had
a fasting glucose level of 13.3 mmol/l which is above the normal reference range of
<11.1 mmol/l, which is also suggestive of Diabetes Mellitus diagnosis.
The patient has a potassium level of 3.3 mmol/mol which is slightly short off the normal
reference range of 3.6-5.1 mmol/mol.
Diabetes condition is mainly characterized by hyperglycaemia, which causes an
increase in the plasma osmolality, the increase in plasma osmolality ultimately results in
an osmotic driving force that moves water from the intracellular spaces into extracellular
spaces (Engwa et al., 2018). This osmotic drift and water movement can cause one of
two things, firstly it can lead to the dilution of extracellular electrolytes thereby
decreasing their concentration in plasma and it can secondly lead to the deposition of
intracellular electrolytes carried with the water into the extracellular spaces increasing
the concentration of these intracellular electrolytes in plasma (Engwa et al., 2018).
Rising blood glucose levels drive increased delivery of glucose into the Bowman’s
space by glomerular filtration. Glomerular hyper-filtration places physical stress on the
filtration barrier and increases the demand for oxygen to reabsorb the filtered load;
hypertrophic tubular cells exhibit a senescence-like phenotype, with pro-inflammatory
and pro-fibrotic consequences that might promote the development of diabetic
7
nephropathy which is characterized by impaired kidney function (Vallon & Thomson,
2020). As a consequence of damage to the nephrons, electrolyte absorption and
reabsorption is altered either leading to an increase or decrease in the serum levels of
these electrolytes (Engwa et al., 2018).
The patient has markedly elevated ALP, GGT, AST, ALT, LDH and TP. In normal
circumstances insulin produced by the beta-islet cells of the pancreas promotes the
uptake of glucose metabolism by adipose and hepatic tissue and thereby also
preventing the synthesis of glucose by the liver (Tanase et al., 2020). However, in type
two diabetes mellitus the liver is forced to become the main source of glucose synthesis
(Tanase et al., 2020). This comes as a result of the diminishing of the compensatory
increase in insulin secretion, which maintains glucose levels in the normal range
(Tanase et al., 2020). As the disease progresses, the beta-islet cells become
dysfunctional, and insulin secretion is unable to maintain glucose homeostasis (Goyal
R, Singhal M, 2023). Insulin resistance leads to increased lipolysis, triglyceride
synthesis, increased hepatic uptake of free fatty acids, and accumulation of hepatic
triglyceride (Saligram et al., 2012). High caloric consumption impairs insulin receptor
signaling, leading in a faulty inhibition of free fatty acid release from adipose cells, as
well as flawed nitric oxide (NO) release, which becomes pro-inflammatory when in
excess amounts. Insulin resistance and the inflammation caused by nitric oxide creates
a vicious loop that enhances the development of NAFLD which leads to the release of
liver enzymes as the liver undergoes damage over time (Saligram et al., 2012)(Tanase
et al., 2020). Studies done previously suggested that ALT specifically was elevated in
40.4% of the diabetic population, were as ALP and AST where increased by 16 and 17
percent respectively (Saligram et al., 2012).
The patient has an elevated CRP level of 12.9 mg/l which is above the normal reference
range of 0 – 10 mg/l. CRP is an acute-phase protein generated in the liver in response
to cytokines such tumor necrotic factor (TNF), interleukin-1 (IL-1), and interleukin-6 (IL-
6) which are all pro-inflammatory cytokines (Ebrahimi et al., 2016)(Gohel & Chacko,
2013). IL-6 is produced in adipose tissue under inflammation situations. It controls CRP
release in hepatocytes on a transcriptional level. CRP has been identified as the
8
primary indicator of inflammation as it indicates greater inflammation in the artery wall
(Ebrahimi et al., 2016). Chronic systemic inflammation has been linked to metabolic
syndrome and diabetes mellitus (Ebrahimi et al., 2016). Studies conducted also showed
a statistically significant elevation in the concentration of hs-CRP in the serum of type 2
diabetes mellitus patients with poor glycemic control when compared to persons that
are healthy and also those that have type 2 DM but have properly maintained glucose
(Gohel & Chacko, 2013).
CONCLUSION
The associations between HbA1c and other clinical tests reinforce the idea that
glycemic control involves complex factors that have an impact on overall health.
Consistent poor management of glucose will eventually result in increased levels of
HbA1c which are associated with kidney, liver, and lipid abnormalities as well as
systemic inflammation. These results underscore the need for adequate HbA1c control
in patients to prevent the subsequent complications and improve their prognosis.
9
REFERENCES
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Chauhan, N. (2017). Laboratory Diagnosis of HbA1c: A Review. Journal of Nanomedicine
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Chen, Z., Shao, L., Jiang, M., Ba, X., Ma, B., & Zhou, T. (2022). Interpretation of HbA1c lies at
the intersection of analytical methodology, clinical biochemistry and hematology (Review).
Experimental and Therapeutic Medicine, 24(6), 707.
https://doi.org/10.3892/etm.2022.11643
Ebrahimi, M., Heidari-Bakavoli, A. R., Shoeibi, S., Mirhafez, S. R., Moohebati, M., Esmaily, H.,
Ghazavi, H., Saberi Karimian, M., Parizadeh, S. M. R., Mohammadi, M., Mohaddes
Ardabili, H., Ferns, G. A., & Ghayour-Mobarhan, M. (2016). Association of Serum hs-CRP
Levels With the Presence of Obesity, Diabetes Mellitus, and Other Cardiovascular Risk
Factors. Journal of Clinical Laboratory Analysis, 30(5), 672–676.
https://doi.org/https://doi.org/10.1002/jcla.21920
Engwa, G. A., Nwalo, F. N., Attama, T. J. C., Abonyi, M. C., Akaniro-Ejim, E. N., Unachukwu, M.
N., Njokunwogbu, A. N., & Ubi, B. E. (2018). Influence of type 2 diabetes on serum
electrolytes and renal function indices in patients. Journal of Clinical and Diagnostic
Research, 12(6), BC13–BC16. https://doi.org/10.7860/JCDR/2018/35940.11673
Gohel, M. G., & Chacko, A. N. (2013). Serum GGT activity and hsCRP level in patients with
type 2 diabetes mellitus with good and poor glycemic control: An evidence linking oxidative
stress, inflammation and glycemic control. Journal of Diabetes and Metabolic Disorders,
12(1), 1–8. https://doi.org/10.1186/2251-6581-12-56
Goyal R, Singhal M, J. I. (2023). Type 2 Diabetes. StatPearls [Internet].
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Saligram, S., Williams, E. J., & Masding, M. G. (2012). Raised liver enzymes in newly
diagnosed Type 2 diabetes are associated with weight and lipids, but not glycaemic
control. Indian Journal of Endocrinology and Metabolism, 16(6), 1012–1014.
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Sherwani, S. I., Khan, H. A., Ekhzaimy, A., Masood, A., & Sakharkar, M. K. (2016). Significance
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of HbA1c Test in Diagnosis and Prognosis of Diabetic Patients. Biomarker Insights, 11, 95–
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Tanase, D. M., Gosav, E. M., Costea, C. F., Ciocoiu, M., Lacatusu, C. M., Maranduca, M. A.,
Ouatu, A., & Floria, M. (2020). The Intricate Relationship between Type 2 Diabetes Mellitus
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Vallon, V., & Thomson, S. C. (2020). The tubular hypothesis of nephron filtration and diabetic
kidney disease. Nature Reviews Nephrology, 16(6), 317–336.
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Appendix
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