Case Presentation: 59-year-old male with history of hypertension, insulin dependent diabetes mellitus type two, alcohol abuse, and depression/anxiety presented to the Intensive Care Unit by emergency medical service after being found down by his neighbors with multiple empty alcohol bottles around him. Vital signs were significant for heart rate 115. Lab data included sodium 146, potassium 3.2, chloride 108, anion gap 25.2, glucose 152, albumin 2.3, creatine phosphokinase 1570, gamma glutamyl transpeptidase1844, lipase 963, alkaline phosphatase 417, and platelets 77. Computerized tomography head, chest, abdomen/pelvis, x-rays were all ordered and negative for fracture. Computerized tomography abdomen revealed cirrhosis. During his course, he was stabilized in the intensive care unit, and transferred to floors for further monitoring. For his pancreatitis, he was treated with fluids a long with a dobhoff tube for nutrition. Once patient began to tolerate feeds, the dobhoff tube was removed, carbohydrate consistent diet was started, and patient was put back on his home dose regimen of 10units lantus and a low dose sliding-scale insulin (two units aspart). Despite receiving insulin, patient’s fingerstick blood glucoses consistently remained above 160, becoming as high as 294. Hemoglobin A1c was drawn and found to be 5.3 and fructosamine level was 421.

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.