Discussion: Glycated hemoglobin, commonly known, as HbA1c is the standard for glycemic control in all subsets of diabetic patients. HbA1c is an indicator of glycemic control within three months of time, essentially the lifespan of a red blood cell. However this marker has not been shown to account for variations in red cell turnover, such as hemolytic anemias and increased red cell turnover secondary to end stage renal disease or cirrhosis. In such patient with diabetes and comorbidities including cirrhosis and end stage renal disease, glycemic control is often compromised. Other markers of glycemic control are now gaining more recognition. These glycemic control markers include 1,5-Anhydroglucitol, glycated albumin, and fructosamine. 1,5-Anhydrgluticol, (1,5-AG), has been FDA approved for glycemic control of two weeks in patients. This marker is more specific to glycemic excursions pre-prandial or post-prandial resulting in more targeted management for glycemic control. 1,5-AG is not affected by lifespan of RBC, however cannot be used in end stage renal disease patients. Fructosamine and glycated albumin are two other methods of glycemic control unaffected by red blood cell lifespan. Ongoing studies have shown they are both safe to use in end stage renal disease as well. Glycated albumin is the measure of albumin that combines with glucose during times of hyperglycemia. In some patients with hypoalbuminemia, this figure can be an inaccurate measure of glycemic control. In our case, we discuss a patient with diabetes and cirrhosis who presents with mean blood glucoses higher than reflective of his HbA1c.
Conclusions: In diabetic patients with comorbidities such as cirrhosis and or end stage renal disease, careful attention needs to be given for glycemic control. Patients can sometimes present with inaccurate measurements of HbA1c. If discordance exists between the HbA1c and blood glucose, other measures of glycemic control should be considered.