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Application of A 1c Assay in Renal Disease

Application of A 1c Assay in Renal Disease. Reference: Sharif A, Baboolal K. Diagnostic application of the A1c assay in renal disease. J Am Soc Nephrol. 2010;21:383–385.

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Application of A 1c Assay in Renal Disease

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  1. Application of A1c Assayin Renal Disease Reference: Sharif A, Baboolal K. Diagnostic application of the A1c assay in renal disease. J Am Soc Nephrol. 2010;21:383–385.

  2. The International Expert Committee, which was cumulatively appointed by the International Diabetes Federation, the European Association for the Study of Diabetes and the American Diabetes Association, has supported the use of glycated hemoglobin evaluated by A1c assay, for diabetes diagnosis in nonpregnant patients. • The benefits of the A1c assay like precision, accurate chronic glycemia measurement, connection with diabetic complications, and ease of use, in comparison to existing diagnostic measures, drives the rationale behind its adoption. • The use of A1c assay for the diabetes diagnosis in the setting of renal impairment and renal replacement therapy (RRT), is under consideration by diabetic associations but lacks validity analysis of the assay. • A non-enzymatic reaction between circulating hemoglobin and glucose results in the production of hemoglobin A1c.

  3. The connection between A1c and diabetes-related complications have been established Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS), conducted of patients with type 1 and type 2 diabetes, respectively. • The authenticity of the assay in the setting of renal impairment or RRT, in combination with appropriate concomitant pharmacotherapy or co-morbidities, will be influenced by several cofounders. • Iron-deficiency anemia, occurring due/associated with to renal anemia with advancing renal dysfunction, elevates A1c in non-diabetic patients, pharmacologic replacement reversing the effect. • Additionally, the A1c level is further affected by altered folate metabolism, declining renal function and oxidative stress. • Other factors, which that artificially lowers the A1c assay in patients on hemodialysis include shortened red blood cell survival, erythropoietin treatment, red blood cell transfusions and blood loss (during treatment or frequent blood sampling).

  4. The diagnosis of new-onset diabetes after transplantation (NODAT), which has been allied with the guidelines of American Diabetes Association since 2003, do not advocate A1c assay usage for NODAT diagnosis. • The disapproval comes from the lack of sensitivity in line with contemporary statements regarding the general population. • However, the new recommendations for A1c assay, provide substantiation to eliminate these apprehensions and therefore abrogate earlier statements. • The original NODAT guidelines advocates the use of A1c assay for examining acquired NODAT, but advises careful interpretation of the assay in the context of renal impairment and anemia. • The occurrence of late post transplantation anemia has a significant implication for the adoption of glycated hemoglobin for diagnostic use after transplantation.

  5. The effect of immunosuppression, especially anti-proliferative agents, on post transplantation anemia is well-documented. • Vanrenterghem et al. observed major variations in the Hb levels of transplantation candidates receiving mycophenolate mofetil (MMF). • The incidence of post transplantation anemia when treated with sirolimus is higher than MMF, irrespective of graft function and other variables. In addition, agents that inhibits the reninangiotensin- aldosterone system, antithymocyte globulin, trimethoprim-sulfamethoxazole, ganciclovir and OKT3, are also found to be linked with post transplantation anemia. • Nonimmunosuppression-related factors like nonpolycystic kidney disease, iron/B12/folate deficiency, infection, allograft dysfunction, rejection, antihypertensive use, and age of the donor also contributes to post transplantation anemia.

  6. Diabetic patients on RRT or with renal failure are burdened with analytical queries, which will influence A1c assay’s validity. • These apprehensions are more justifiable in patients on hemodialysis in comparison with other renal patients, due to the large number of significant confounders that impede the assay. • There is a scarcity of data across a broad-spectrum of chronic kidney disease, which in turn will affect the validity of the A1c assay in the view of progressing renal failure. • Due to the high-risk status and the uncertainty of logistical benefits of the assay over existing glucose based strategies, there is a major argument related to the use of A1c assay in renal transplant recipients. • Global diabetes associations have to recommend for adoption of the International Expert Committee proposals for the transition to an A1c-based diagnosis of diabetes.

  7. Nephrologists will need to construe such recommendations in the background of the unique conditions across an • array of renal patients than just directly interpreting the guidelines. • Further research and debate in this area should be carried out to figure out the best diabetes diagnostic principle for renal disease patients.

  8. Comprehensive Basketin Anemia Management

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