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How Does Liver Disease Affect A1c

Pitfalls In Hemoglobin A1c Measurement: When Results May Be Misleading

Pitfalls In Hemoglobin A1c Measurement: When Results May Be Misleading

Go to: DESCRIPTION OF HEMOGLOBIN A1C Hemoglobin is the iron-containing oxygen transport metalloprotein in the red blood cells. Hemoglobin’s structure consists of a tetramer of two pairs of protein molecules: two α globin chains and two non–α globin chains. The α globin genes are HbA1 and HbA2, whereas the non–α globin genes include β, γ, δ.5 The normal adult hemoglobin molecule (HbA) consists of two α and two β chains (α2β2), and makes up about 97 % of most normal human adult hemoglobin.6 Other minor hemoglobin components may be formed by posttranslational modification of HbA. These include hemoglobins A1a, A1b, and A1c. Of these, A1c is the most abundant minor hemoglobin component. A1c is formed by the chemical condensation of hemoglobin and glucose which are both present in high concentrations in erythrocytes. This process occurs slowly and continuously over the life span of erythrocytes, which is 120 days on average. Furthermore, the rate of A1c formation is directly proportional to the average concentration of glucose within the erythrocyte during its lifespan.6 Hence, as levels of chronic hyperglycemia increase, so does the formation of A1c. This makes it an excellent marker of overall glycemic control during the time frame of the 120-day lifespan of a normal erythrocyte. Results of the DCCT and UKPDS studies verified the close relationship between glycemic control measured by A1c and the risk for diabetes-related complications. A1c has been widely accepted as the standard used to measure glycemic control over the previous 3 month period and correlates with patients’ risk for developing diabetes-related complications.7 It is important to remember that A1c represents a weighted mean of glucose levels during the preceding 3 month time period. In ot Continue reading >>

Insulin Resistance And Chronic Liver Disease

Insulin Resistance And Chronic Liver Disease

Insulin resistance and chronic liver disease Takumi Kawaguchi , Eitaro Taniguchi , Minoru Itou , Masahiro Sakata , Shuji Sumie , and Michio Sata Takumi Kawaguchi, Michio Sata, Department of Disease Information & Research, Kurume University School of Medicine, Kurume 830-0011, Japan Takumi Kawaguchi, Eitaro Taniguchi, Minoru Itou, Masahiro Sakata, Shuji Sumie, Michio Sata, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan Author contributions: Kawaguchi T, Taniguch E, Itou M, Sakata M and Sumie S drafted the manuscript; Kawaguchi T and Sata M organized and revised the manuscript. Correspondence to: Takumi Kawaguchi, MD, PhD, Department of Digestive Disease Information & Research, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan. [email protected] Telephone: +81-942-31-7902 Fax: +81-942-31-7820 Received 2010 Nov 18; Revised 2011 Mar 26; Accepted 2011 Apr 2. Copyright 2011 Baishideng Publishing Group Co., Limited. All rights reserved. This article has been cited by other articles in PMC. Increased insulin resistance is frequently associated with chronic liver disease and is a pathophysiological feature of hepatogenous diabetes. Distinctive factors including hepatic parenchymal cell damage, portal-systemic shunting and hepatitis C virus are responsible for the development of hepatogenous insulin resistance/diabetes. Although it remains unclear whether insulin secretion from pancreatic beta cells is impaired as it is in type 2 diabetes, retinopathic and cardiovascular risk is low and major causes of death in cirrhotic patients with diabetes are liver failure, hepatocellular carcinoma and gastrointestinal hemorrhage. Hemoglobin A1c is an inaccurate marker for the assessment and management of hepatogenous Continue reading >>

Is It Possible Get Misleading A1c Test Results?

Is It Possible Get Misleading A1c Test Results?

ANSWER People with diseases affecting hemoglobin, such as anemia, may get misleading results with this test. Other things that can affect the results of the hemoglobin A1c include supplements such as vitamins C and E and high cholesterol levels. Kidney disease and liver disease may also affect the test. Continue reading >>

Type 2 Diabetes And Fatty Liver Disease

Type 2 Diabetes And Fatty Liver Disease

Non-alcoholic fatty liver disease is a group of conditions in which fat builds up in the liver, leading to inflammation of the cells where it is stored and causing the liver to get bigger. It can progress to more serious conditions, including fibrosis and cirrhosis of the liver. Fatty liver disease "is so common. It’s present arguably in a majority of type 2 diabetics,” says Daniel Einhorn, MD, clinical professor of medicine at the University of California, San Diego and the medical director of the Scripps Whittier Diabetes Institute. “None of us thought about it more than about 10 years ago, then all of a sudden we discovered it and see it all the time.” Fatty Liver Disease and Type 2 Diabetes: The Connection Diabetes does not cause fatty liver disease. Instead, the two diseases tend to occur in the same people because the same conditions cause both problems. “So, it’s not the diabetes per se. People with diabetes also have obesity and insulin resistance, and so the fatty liver is thought to be part of that,” Dr. Einhorn explains. Einhorn says that most cases of fatty liver disease do not cause any harm. However, since type 2 diabetes and obesity are so common in the United States, fatty liver disease is now a leading cause of end-stage (fatal) liver disease requiring a liver transplant, along with alcohol abuse and hepatitis. Fatty Liver Disease Diagnosis Fatty liver disease has no symptoms. People who are being treated for diabetes will have liver enzyme tests as part of their routine blood work during medical exams. Ninety-nine percent of the cases of fatty liver disease are detected by this test, says Einhorn. In some cases it will be picked up during the physical exam or in imaging studies, like a computed tomography scan of the abdomen or a liver ul Continue reading >>

Diabetes: How Do I Help Protect My Liver?

Diabetes: How Do I Help Protect My Liver?

If I have diabetes, is there anything special I need to do to take care of my liver? Answers from M. Regina Castro, M.D. You're wise to wonder about steps to protect your liver. Diabetes raises your risk of nonalcoholic fatty liver disease, a condition in which excess fat builds up in your liver even if you drink little or no alcohol. This condition occurs in at least half of those with type 2 diabetes. It isn't clear whether the condition appears more often in people with type 1 diabetes than in the general population because obesity, which is a risk factor, occurs with similar frequency in both groups. Other medical conditions, such as high cholesterol and high blood pressure, also raise your risk of nonalcoholic fatty liver disease. Fatty liver disease itself usually causes no symptoms. But it raises your risk of developing liver inflammation or scarring (cirrhosis). It's also linked to an increased risk of liver cancer, heart disease and kidney disease. Fatty liver disease may even play a role in the development of type 2 diabetes. Once you have both conditions, poorly managed type 2 diabetes can make fatty liver disease worse. Your best defense against fatty liver disease includes these strategies: Work with your health care team to achieve good control of your blood sugar. Lose weight if you need to, and try to maintain a healthy weight. Take steps to reduce high blood pressure. Keep your low-density lipoprotein (LDL, or "bad") cholesterol and triglycerides — a type of blood fat — within recommended limits. Don't drink too much alcohol. If you have diabetes, your doctor may recommend an ultrasound examination of your liver when you're first diagnosed and regular follow-up blood tests to monitor your liver function. Continue reading >>

Glycated Hemoglobin Levels In Patients With Decompensated Cirrhosis

Glycated Hemoglobin Levels In Patients With Decompensated Cirrhosis

Copyright © 2016 Jeffrey Nadelson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction. Aim of this study is to determine if HbA1c levels are a reliable predictor of glycemic control in patients with decompensated cirrhosis. Methods. 200 unique patients referred for liver transplantation at University of Tennessee/Methodist University Transplant Institute with a HbA1c result were included. Three glucose levels prior to the “measured” A1c (MA1c) were input into an HbA1c calculator from the American Diabetes Association website to determine the “calculated” A1c (CA1c). The differences between MA1c and CA1c levels were computed. Patients were divided into three groups: group A, difference of <0.5; group B, 0.51–1.5; and group C, >1.5. Results. 97 (49%) patients had hemoglobin A1c of less than 5%. Discordance between calculated and measured HbA1c of >0.5% was seen in 47% (). Higher level of discordance of greater than >1.5 was in 12% of patients (). Hemoglobin was an independent predictor for higher discordance (odds ratio 0.77 95%, CI 0.60–0.99, and value 0.04). HbA1c was an independent predictor of occurrence of HCC (OR 2.69 955, CI 1.38–5.43, and value 0.008). Conclusion. HbA1c is not a reliable predictor of glycemic control in patients with decompensated cirrhosis, especially in those with severe anemia. 1. Introduction Hemoglobin A1c (HbA1c) is the gold standard for the measurement of long-range glycemic control in patients with diabetes mellitus. Many studies have reported diabetes mellitus to be a risk factor in patients with alcoholic liver disease and nonalcoholi Continue reading >>

Glycated Hemoglobin Levels In Patients With Decompensated Cirrhosis

Glycated Hemoglobin Levels In Patients With Decompensated Cirrhosis

Glycated Hemoglobin Levels in Patients with Decompensated Cirrhosis 1Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, TN, USA 2Methodist Transplant Institute, Division of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA Received 2016 Apr 20; Revised 2016 Jul 27; Accepted 2016 Sep 18. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Introduction. Aim of this study is to determine if HbA1c levels are a reliable predictor of glycemic control in patients with decompensated cirrhosis. Methods. 200 unique patients referred for liver transplantation at University of Tennessee/Methodist University Transplant Institute with a HbA1c result were included. Three glucose levels prior to the measured A1c (MA1c) were input into an HbA1c calculator from the American Diabetes Association website to determine the calculated A1c (CA1c). The differences between MA1c and CA1c levels were computed. Patients were divided into three groups: group A, difference of <0.5; group B, 0.511.5; and group C, >1.5. Results. 97 (49%) patients had hemoglobin A1c of less than 5%. Discordance between calculated and measured HbA1c of >0.5% was seen in 47% (n = 94). Higher level of discordance of greater than >1.5 was in 12% of patients (n = 24). Hemoglobin was an independent predictor for higher discordance (odds ratio 0.77 95%, CI 0.600.99, and p value 0.04). HbA1c was an independent predictor of occurrence of HCC (OR 2.69 955, CI 1.385.43, and p value 0.008). Conclusion. HbA1c is not a reliable predictor of glyce Continue reading >>

Spectrum Of Liver Disease In Type 2 Diabetes And Management Of Patients With Diabetes And Liver Disease

Spectrum Of Liver Disease In Type 2 Diabetes And Management Of Patients With Diabetes And Liver Disease

It is estimated that 20.8 million people, i.e., 7.0% of the U.S. population, have diabetes (1). Type 2 diabetes, with its core defects of insulin resistance and relative insulin deficiency, accounts for 90–95% of those with the disease. Another 5.2 million people are estimated to have undiagnosed type 2 diabetes. It is the sixth leading cause of death (1) in the U.S. and accounts for 17.2% of all deaths for those aged >25 years (2). Liver disease is an important cause of death in type 2 diabetes. In the population-based Verona Diabetes Study (3), cirrhosis was the fourth leading cause of death and accounted for 4.4% of diabetes-related deaths. The standardized mortality ratio (SMR), i.e., the relative rate of an event compared with the background rate, for cirrhosis was 2.52 compared with 1.34 for cardiovascular disease (CVD). In another prospective cohort study (4), cirrhosis accounted for 12.5% of deaths in patients with diabetes. Diabetes, by most estimates, is now the most common cause of liver disease in the U.S. Cryptogenic cirrhosis, of which diabetes is, by far, the most common cause, has become the third leading indication for liver transplantation in the U.S. (5,6). Virtually the entire spectrum of liver disease is seen in patients with type 2 diabetes. This includes abnormal liver enzymes, nonalcoholic fatty liver disease (NAFLD), cirrhosis, hepatocellular carcinoma, and acute liver failure. In addition, there is an unexplained association of diabetes with hepatitis C. Finally, the prevalence of diabetes in cirrhosis is 12.3–57% (7). Thus, patients with diabetes have a high prevalence of liver disease and patients with liver disease have a high prevalence of diabetes. The management of diabetes in patients with liver disease is theoretically complicated b Continue reading >>

High Liver Enzymes & High Blood Sugar

High Liver Enzymes & High Blood Sugar

A simple blood test can check liver enzyme levels. Elevated levels can indicate liver damage; liver function is usually tightly regulated, but a damaged liver can "leak" extra enzymes into the bloodstream because its function is compromised. This liver damage can be acute or chronic. With either type of liver damage, many physiological functions, including blood sugar control, can be affected. It is important to correct the underlying cause of the liver dysfunction to prevent serious, long-term consequences. Video of the Day The pancreas and liver regulate blood sugar. During digestion, all carbohydrates are eventually broken down into glucose, which is released into the bloodstream. The pancreas senses this increase in blood sugar and signals the secretion of insulin to the surface of cells throughout the body; insulin helps pull glucose from the blood and into the cell where it can be used for energy. Excess glucose is sent to the liver, where it is stored as glycogen; glycogen is used for energy during a state of starvation. Functions of the Liver The liver is located in the upper right portion of the abdomen, and plays a very important and diverse role in the body. It has many functions, including creating bile to digest fat, regulating blood clotting and blood sugar, and producing and regulating proteins, cholesterol and fat transporters. Additionally, all drugs and chemicals that enter the body are first filtered by the liver; harmful substances are broken down and excreted by the kidneys. Liver and Blood Sugar The liver is where excess glucose is brought and stored as glycogen, and it works closely with other organ systems to regulate blood sugar. In a healthy person, the pancreas senses when blood sugar is low, and releases glucagon -- a hormone that signals to Continue reading >>

What Clinical Laboratorians Should Do In Response To Extremely Low Hemoglobin A1c Results

What Clinical Laboratorians Should Do In Response To Extremely Low Hemoglobin A1c Results

Extremely low hemoglobin A1c (HbA1c) results below reference range are rare, and the causes and clinical implications associated with low HbA1c results are not well understood among clinical laboratorians. A case of extremely low HbA1c results was reported, in which liver cirrhosis, subacute hemorrhage and recent transfusion all contributed to the low result. This case illustrates when HbA1c should not be used as a clinically relevant diabetes marker. However, low or extremely low HbA1c (<5.0% or <4.0%) may occur in apparently healthy individuals. When this occurs, it is an independent risk factor associated with liver diseases, hospitalization, and all-cause mortality. From the clinical laboratory perspective, the clinical cause of extremely low HbA1c should be determined, and suggestions of different test utilization or increased health surveillance should be given to care providers. Continue reading >>

Inaccuracies Of Hemoglobin A1c In Liver Cirrhosis: A Case Report

Inaccuracies Of Hemoglobin A1c In Liver Cirrhosis: A Case Report

Articles © The authors | Journal compilation © J Endocrinol Metab and Elmer Press Inc™ | www.jofem.org This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited 30 Case Report J Endocrinol Metab. 2016;6(1):30-32 ressElmer Mathew Clarkea, Jamila Benmoussaa, Amulya Penmetsaa, b, Philip Otterbecka, Farhang Ebrahimia, Jay Nfonoyima Abstract Hemoglobin A1c (HbA1c) is the gold standard for the measurement of long-range glycemic control in patients with diabetes mellitus type 2 (T2DM). In a rare subset of patients, this measurement may not be reliable. Inaccuracies of HbA1c in liver cirrhosis are rare, but docu- mented. The objective of this study was to increase awareness about low HbA1c in liver cirrhosis and discuss alternative biomarkers that can be used to measure glycemic control. We present the case of a 61-year-old Caucasian female, with history of hepatitis C and uncon- trolled T2DM, who was admitted for evaluation of compensated liver cirrhosis. She was found to have blood glucoses greater than 500 mg/ dL; however, her HbA1c was measured at 5.5%. Ultrasound of the abdomen showed liver cirrhosis, ascites, and splenomegaly. Blood work revealed acute kidney injury, anemia of chronic disease, normal albumin level, and low HbA1c. Fructosamine and glycated albumin were high, indicating a hyperglycemic status during the last 3 weeks. HbA1c can be falsely low in liver cirrhosis, and can give a false as- sumption about control of the diabetic disease process. In this case, other biomarkers can be used to monitor glycemic control; by far fre- quent fing Continue reading >>

When The A1c Is Unreliable

When The A1c Is Unreliable

Although hemoglobin A1c is usually the best test to estimate the average glycemic control in patients with diabetes, it is unreliable in some clinical circumstances. In select patient populations, measuring fructosamine and glycated albumin levels may also be useful. _______________________________________________________________________________________________________________________________________________________ Related Content Diabetes and Cardiovascular Disease: Does Lowering Hemoglobin A1c Help or Harm? Structured Diet Plan Improves A1c in Type 2 Diabetes _____________________________________________________________________________________________________________________________________________________ Q1. What is the A1c and why is it important? A: A1c represents the percent of hemoglobin A with glucose bound to it. While the percent is normally low, in diabetics the higher glucose circulating in the blood causes more hemoglobin binding which results in a higher A1c level. It also can correlate with average glycemic control during the past 2 to 3 months. The American Diabetes Association recommends measuring A1c—≥ 6.5% (48mmol/mol)—as a diagnostic criterion for diabetes and quantifying A1c as the standard laboratory assessment to determine control of type 1 and type 2 diabetes.1 Since the publication of the Diabetes Control and Complications Trial in 1993, we know that A1c levels also directly correlate to the risk of developing diabetic complications such as retinopathy, neuropathy and nephropathy.2 Q2. When is the A1c unreliable? A: For A1c standard test results to be reliable, normal adult hemoglobin A must be present for glucose binding. However, a number of clinically significant disorders alter hemoglobin either structurally or chemically thereby aff Continue reading >>

Relationship Between Hba1c And Chronic Glycemia In Patients With Cirrhosis

Relationship Between Hba1c And Chronic Glycemia In Patients With Cirrhosis

You have reached the maximum number of saved studies (100). Please remove one or more studies before adding more. Relationship Between HbA1c and Chronic Glycemia in Patients With Cirrhosis The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. ClinicalTrials.gov Identifier: NCT02389127 Information provided by (Responsible Party): Study Description Study Design Groups and Cohorts Outcome Measures Eligibility Criteria Contacts and Locations More Information Cirrhosis and advanced liver disease have been associated with an increased risk for hyperglycemia and type 2 diabetes mellitus (T2DM). The diagnostic yield of common tests used to define diabetes and insulin resistance in the general population differs significantly from the one observed in patients with liver disease. Glycosylated hemoglobin A1c (HbA1c), a reliable test to assess chronic glycemia and recommended both for the diagnosis and monitoring of T2DM, is neither accurate nor reliable in patients with cirrhosis. A validation study has not been performed to define its true usefulness in the setting of cirrhosis. The study aims to determine the level of HbA1c that better corresponds to the diagnosis of T2DM - as determined by an oral glucose tolerance test (OGTT) - and to correlate the levels of HbA1c with the average glucose over a 12-week period in patients with cirrhosis and known T2DM, in cirrhotic patients with different degrees of liver impairment as compared to patients with T2DM and no liver disease. Device: Continuous glucose monitor (Dexcom, San Diego, CA) Relationship Between HbA1c and Chronic Glycemia in Patients With Cirrhosis: a Continue reading >>

Metformin, The Liver, And Diabetes

Metformin, The Liver, And Diabetes

Most people think diabetes comes from pancreas damage, due to autoimmune problems or insulin resistance. But for many people diagnosed “Type 2,” the big problems are in the liver. What are these problems, and what can we do about them? First, some basic physiology you may already know. The liver is one of the most complicated organs in the body, and possibly the least understood. It plays a huge role in handling sugars and starches, making sure our bodies have enough fuel to function. When there’s a lot of sugar in the system, it stores some of the excess in a storage form of carbohydrate called glycogen. When blood sugar levels get low, as in times of hunger or at night, it converts some of the glycogen to glucose and makes it available for the body to use. Easy to say, but how does the liver know what to do and when to do it? Scientists have found a “molecular switch” called CRTC2 that controls this process. When the CRTC2 switch is on, the liver pours sugar into the system. When there’s enough sugar circulating, CRTC2 should be turned off. The turnoff signal is thought to be insulin. This may be an oversimplification, though. According to Salk Institute researchers quoted on RxPG news, “In many patients with type II diabetes, CRTC2 no longer responds to rising insulin levels, and as a result, the liver acts like a sugar factory on overtime, churning out glucose [day and night], even when blood sugar levels are high.” Because of this, the “average” person with Type 2 diabetes has three times the normal rate of glucose production by the liver, according to a Diabetes Care article. Diabetes Self-Management reader Jim Snell brought the whole “leaky liver” phenomenon to my attention. He has frequently posted here about his own struggles with soarin Continue reading >>

What Does Liver Disease Have To Do With Diabetes?

What Does Liver Disease Have To Do With Diabetes?

The American College of Gastroenterology released new guidelines on liver chemistry tests in December 2016. Changed level recommendations were included for ALT- alanine aminotransferase, AST- aspartate aminotransferase, and alkaline phosphatase and bilirubin levels. In the past, ALT levels were accepted at a range from 30-40 IU/L and up to 70-80 IU/L while being hospitalized (body under stress). The new acceptable levels are 19-25 IU/L for women and 29-33IU/L for men. The vast change in “normal levels” of liver enzymes were updated since “multiple studies have demonstrated that if you have ALT levels even innocuously elevated, your risk of liver related death is significantly higher” according to Paul Kwo, MD from Stanford University. Liver disease can stem from alcohol, viral hepatitis A, B or C, genetic disorders, liver injury, drugs, supplements, Lyme disease and non-alcoholic fatty liver disease – NAFLD. Liver disease can often tell us about your overall health and liver function tests should be part of the work up utilized by your MD. What does this all mean for people with type 2 diabetes? What Does the Liver Do? The liver turns food into nutrients and filters toxins from the blood. The toxins include alcohol, medications, supplements, pollutants and insecticides. When the fat content of the liver reaches 10%, due to weight gain especially around the middle section and in visceral organs (internal fat), the spongy texture of the liver becomes coarse and the function declines. Liver problems begin. Non-Alcoholic Fatty Liver Disease – NAFLD Elevated ALT levels are common in people with pre-diabetes or diabetes and are often the first documented abnormal lab test, even prior to elevated fasting blood sugars or A1C values. NAFLD is common worldwide but muc Continue reading >>

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