Glycated albumin, not hemoglobin A1c, predicts cardiovascular hospitalization and length of stay in diabetic patients on dialysis.

BACKGROUND: The utility of glycated hemoglobin (HbA1c) and glycated albumin (GA) in diabetic dialysis patients remains unknown. GA was previously associated with all-cause hospitalization and patient survival. Relationships between GA, HbA1c, and casual plasma glucose (PG) with cause-specific cardiovascular (CV) disease, infectious disease (ID), and vascular access- (VA) related hospitalization rates and length of stay (LOS) were assessed. METHODS: 444 prevalent diabetic dialysis patients had monthly PG, quarterly GA, and all HbA1c values recorded for 2.33 years; hospitalizations within 17 and 30 days of testing were evaluated. Best-fit, time-dependent Cox models were constructed in unadjusted, case-mix-adjusted (age, sex, race, BMI, diabetes duration, dialysis vintage), and case-mix- plus lab-adjusted (hemoglobin, albumin, phosphorus) models. RESULTS: Mean ± SD diabetes duration was 18.5 ± 10.8 years and dialysis vintage 2.9 ± 2.6 years. In fully adjusted models, CV hospitalization rates were associated with increasing GA (HR 1.32; 95% CI 1.11-1.57; p = 0.002 at 17 days; HR 1.21; p = 0.02 at 30 days) and PG (HR 1.10; 95% CI 1.02-1.17; p = 0.01 at 17 days; HR 1.07; p = 0.03 at 30 days), not HbA1c (HR 1.24; 95% CI 0.89-1.73; p = 0.21 at 17 days; HR 1.26; p = 0.10 at 30 days). LOS for CV admissions was positively associated with GA (HR 1.18; 95% CI 1.01-1.39; p = 0.03), not PG (HR 1.04; 95% CI 0.99-1.10; p = 0.15) or HbA1c (HR 1.03; 95% CI 0.92-1.15; p = 0.21). Admissions due to ID and VA complications (and LOS) did not correlate with these assays. CONCLUSIONS: Improved glycemic control based on GA and PG predicted CV-related hospitalizations; GA also predicted CV hospitalization LOS. HbA1c did not predict cause-specific hospitalizations in dialysis populations.

Glycated albumin and risk of death and hospitalizations in diabetic dialysis patients.

BACKGROUND AND OBJECTIVES: Relative to hemoglobin (Hb) A(1c), glycated albumin (GA) more accurately reflects glycemic control in patients with diabetes mellitus and ESRD. We determined the association between GA, HbA(1c), and glucose levels with survival and hospitalizations in diabetic dialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Quarterly GA levels were measured for up to 2.33 years in 444 prevalent patients with diabetes and ESRD. Proportional hazard time-dependent covariate models were computed with adjustment for demographic characteristics, comorbidities, and laboratory variables. Similar analyses were performed for available HbA(1c) and monthly random serum glucose determinations. RESULTS: The participants were 53% male, 54% African American, 43% Caucasian, 90% on hemodialysis, with a mean (SD) age of 62 (12) years and median follow-up duration of 2.25 years. GA and HbA(1c) mean ± SD 21.5% ± 6.0%, median 20.4% and mean ± SD 6.9% ± 6.6%, median 1.6%, respectively. There were 156 deaths during the observation period. In best-fit models, predictors of death included increasing GA, increasing age, presence of peripheral vascular disease, decreasing serum albumin, and decreasing hemoglobin concentrations. HbA(1c) and random serum glucose concentrations were not predictive of survival. Increasing GA levels were associated with hospitalization in the 17 days after measurement, whereas HbA(1c) was not. CONCLUSIONS: In contrast to the HbA(1c) and random serum glucose values, GA accurately predicts the risk of death and hospitalizations in patients with diabetes mellitus and ESRD. The GA assay should be considered by clinicians who care for patients with diabetes on dialysis.

Basic performance of an enzymatic method for glycated albumin and reference range determination.

BACKGROUND: Glycated albumin (GA) is a medium-term glycemic control marker of diabetes and may be more sensitive to changes in plasma glucose than hemoglobin A1c. We studied where and how many fructosyl groups bind to albumin, and which glycation sites are measured by the enzymatic method for GA. We also studied the basic performance of the enzymatic method for GA. METHODS: Glycated albumin was measured using an enzymatic method (Lucica®GA-L, Asahi Kasei Pharma) on a biochemical autoanalyzer. Molecular weights of purified GA and nonglycated albumin were measured by a mass spectrometry system. Two hundred one healthy volunteers with normal results of oral glucose tolerance testing were recruited to determine the reference range in Americans. RESULTS: The present method measured only glycated amino acids from albumin in serum protein. We estimate that the number of glycated amino acids measured by this method was approximately two per molecule of albumin. The general performance (sensitivity, specificity, reproducibility, linearity, interference) of the method was good. The reference range of GA% in Americans with normal glucose tolerance was determined to be 11.9-15.8% (mean ± 2 standard deviations). Significant differences were not observed between the sexes; however, race differences were observed (higher levels in blacks relative to whites). CONCLUSIONS: The method was specific for measuring glycated amino acids in albumin and had good basic performance characteristics. The reference range in Americans was 11.9-15.8%. This method may be a useful indicator for diabetes control.

Relationship between assays of glycemia in diabetic subjects with advanced chronic kidney disease.

BACKGROUND: Relative to hemoglobin A(1c) (HbA(1c)), glycated albumin (GA) more accurately reflects recent glycemic control in diabetic patients on hemodialysis and peritoneal dialysis. These assays have yet to be compared in patients with advanced chronic kidney disease (CKD). METHODS: HbA(1c) and GA were simultaneously measured in 303 diabetic subjects: 70 with CKD prior to dialysis (CKD-stage 4), 184 with CKD after transplantation (TXP-stage 3) and 49 non-nephropathy controls. RESULTS: Mean estimated GFR was 76, 46 and 26 ml/min in controls, TXP-3 and CKD-4 cases, respectively. Mean (SD) HbA(1c) (%) and GA (%) concentrations were 7.30 (1.40) and 16.8 (4.9) in controls, 7.28 (1.66) and 21.5 (6.4) in CKD-4 cases, and 7.21 (1.62) and 21.2 (5.5) in TXP-3 cases, respectively. The GA:HbA(1c) ratio differed significantly between non-nephropathy controls and both groups of CKD patients (both p < 0.001), but not between CKD-4 and TXP-3 cases (p = 0.92). The glucose:HbA(1c) ratio was inversely associated with GFR in all 254 nephropathy cases (r = -0.13; p = 0.04), while glucose:GA did not vary significantly based upon GFR (r = -0.08; p = 0.24). CONCLUSIONS: The relationship between glycated albumin and HbA(1c) is influenced by the presence of reduced GFR in diabetic patients with CKD. The accuracy of the HbA(1c) assay in diabetic subjects with severe nephropathy requires further investigation, although HbA(1c) performs relatively well with milder CKD.

Comparison of glycated albumin and hemoglobin A1c concentrations in diabetic subjects on peritoneal and hemodialysis.

BACKGROUND: Relative to hemoglobin A(1c) (HbA(1c)), percentage of glycated albumin (GA%) more accurately reflects recent glycemic control in diabetic hemodialysis (HD) patients. METHODS: To determine the accuracy of glycemic assays in a larger sample including patients on peritoneal dialysis (PD), HbA(1c) and GA% were measured in 519 diabetic subjects: 55 on PD, 415 on HD, and 49 non-nephropathy controls. RESULTS: Mean +/- SD serum glucose levels were higher in HD and PD patients relative to non-nephropathy controls (HD 169.7 +/- 62 mg/dL, PD 168.6 +/- 66 mg/dL, controls 146.1 +/- 66 mg/dL; p = 0.03 HD vs controls, p = 0.13 PD vs controls). GA% was also higher in HD and PD patients (HD 20.6% +/- 8.0%, PD 19.0% +/- 5.7%, controls 15.7% +/- 7.7%; p < 0.02 HD vs controls and PD vs controls). HbA(1c) was paradoxically lower in dialysis patients (HD 6.78% +/- 1.6%, PD 6.87% +/- 1.4%, controls 7.3% +/- 1.4%; p = 0.03 HD vs controls, p = 0.12 PD vs controls). The serum glucose/HbA(1c) ratio differed significantly between dialysis patients and controls (p < 0.0001 HD vs controls, p = 0.002 PD vs controls), while serum glucose/GA% ratio was similar across groups (p = 0.96 HD vs controls, p = 0.64 PD vs controls). In best-fit multivariate models with HbA(1c) or GA% as outcome variable, dialysis status was a significant predictor of HbA(1c) but not GA%. CONCLUSIONS: The relationship between HbA(1c) and GA% differs in diabetic patients with end-stage renal disease who perform either PD or HD compared to those without nephropathy. HbA(1c) significantly underestimates glycemic control in peritoneal and hemodialysis patients relative to GA%.

Enhanced detection in capillary electrophoresis: example determination of serum mycophenolic acid.

In order to overcome the poor absorbency detection limits in CE, two simple strategies were combined to increase the amount of the sample injected: a long capillary to hold extra sample while leaving adequate room for the separation and acetonitrile stacking, which concentrated the sample based on transient pseudo-ITP. The combination of these two strategies yielded sensitivity comparable or better than that of the HPLC with good separation and with better theoretical plate number. The analysis of mycophenolic acid, a common immunosuppressant drug, in serum was used here as an example to illustrate this enhanced detection and its applicability to therapeutic drug monitoring. Acetonitrile was used to remove serum proteins followed by direct injection filling 5-21% of the capillary volume and separation in a borate buffer. The overall CE method compared well to an assay by HPLC as far as sample preparation, correlation coefficient, and especially sensitivity of detection.

A chronic iron-deficient/high-manganese diet in rodents results in increased brain oxidative stress and behavioral deficits in the morris water maze.

Iron deficiency (ID) is especially common in pregnant women and may even persist following childbirth. This is of concern in light of reports demonstrating that ID may be sufficient to produce homeostatic dysregulation of other metals, including manganese (Mn). These results are particularly important considering the potential introduction of the Mn-containing gas additive, methyl cyclopentadienyl manganese tricarbonyl (MMT), in various countries around the world. In order to model this potentially vulnerable population, we fed female rats fed either control (35 mg Fe/kg chow; 10 mg Mn/kg chow) or low iron/high-manganese (IDMn; 3.5 mg Fe/kg chow; 100 mg Mn/kg chow) diet, and examined whether these changes had any long-term behavioral effects on the animals' spatial abilities, as tested by the Morris water maze (MWM). We also analyzed behavioral performance on auditory sensorimotor gating utilizing prepulse inhibition (PPI), which may be related to overall cognitive performance. Furthermore, brain and blood metal levels were assessed, as well as regional brain isoprostane production. We found that treated animals were slightly ID, with statistically significant increases in both iron (Fe) and Mn in the hippocampus, but statistically significantly less Fe in the cerebellum. Additionally, isoprostane levels, markers of oxidative stress, were increased in the brain stem of IDMn animals. Although treated animals were indistinguishable from controls in the PPI experiments, they performed less well than controls in the MWM. Taken together, our data suggest that vulnerable ID populations exposed to high levels of Mn may indeed be at risk of potentially dangerous alterations in brain metal levels which could also lead to behavioral deficits.

Rapid quantitation of hemoglobin S in sickle cell patients using the Variant II Turbo analyzer.

A rapid ( approximately 90 sec), fully automated method is described for quantifying hemoglobin S (HbS) by high performance liquid chromatography (HPLC) using the Bio-Rad Variant II Turbo analyzer. Although this instrument is designed to quantify only blood hemoglobin A1c (HbA1c), we show that it can also quantify accurately, without modification, HbS levels in sickle cell patients, provided the blood samples meet certain conditions. The samples should contain detectable hemoglobin F (HbF), but should not contain hemoglobin C (HbC). Under these conditions, blood HbS levels obtained by this method correlate well with those obtained by agarose electrophoresis (r(2) = 0.97, n = 81 patients). We also show that quantitation of blood HbF in sickle cell patients is more accurate by this method than by agarose electrophoresis when the HbF level is in the range from 0.2 to 10%.

Analysis of immune complexes by capillary electrophoresis.

A simple method for immune complexes (IC) analysis by CE is described. This method combines the ease of precipitation of the IC by polyethylene glycol with the separation power of CE. The advantage of this method is a better quantitation of the IC, since it corrects and eliminates the interferences from other serum proteins. It also reveals the composition (monoclonality) of the precipitate. Three types of IC have been detected in this method: monoclonal, polyclonal and mixed (mono-polyclonal) IC. Furthermore, the method is rapid and simple.

Direct injection of organic solvent extracts for capillary electrophoresis.

It is demonstrated here that organic solvents immiscible in water used in sample extraction, such as chloroform, can be injected directly and successfully on the capillary without the need for evaporation and reconstitution. Current continuity was maintained all the time during the run. In order to avoid the rapid evaporation of the organic solvent during the analysis, the aqueous layer was left over the chloroform. This simplified the extraction step, and enabled the injection from the same vial over several hours without dealing with problem of evaporation. The relative peak heights in the electropherograms can be modified by the inclusion in the chloroform of a more polar solvent, by adjusting the pH, or adjusting the salt content of the sample. Addition of a polar solvent to the chloroform improved greatly the precision of the analysis for both the peak height and migration time.

Cryoglobulins: an important but neglected clinical test.

Cryoglobulin (CR) denotes a serum immunoglobulin that precipitates at temperatures below 37 degrees C and dissolves on re-warming. CRs are heterogeneous in chemical composition and behave differently in vivo and in vitro. The majority are mixed antigen-antibody complexes that occur with high incidence in autoimmune and infectious disorders. Their measurement is important in the management of patients with vasculitis. CRs elicit variable symptoms in patients, mostly purpura, weakness, and arthralgias, and they require various methods of treatment. Sometimes CRs are not associated with any symptoms; but they can be associated with very severe conditions such as nephropathy and neuropathy. Treatment depends on the symptoms and causes, and on the phenotyping of the CR. Considering the high incidence of CR in diseases such as hepatitis C virus (HCV) infection, together with the high worldwide prevalence of this disease, it is clear that testing for CR is underutilized in clinical practice. CR testing has been neglected in routine clinical laboratories and by clinicians due to several factors, such as the lengthy time for serum CR analysis and failure to appreciate that low levels of CR can be associated with severe symptoms. In a series of 194 serum samples that gave positive tests for CR at our institution, the majority contained low CR concentrations (65% of the samples were type II with a mean of 372 mg/L and 39% of type III with a mean of 216 mg/L; reference range 0-60 mg/L). Case studies are presented to illustrate the importance of such low levels of CR. There is a need for more rapid and more reliable methods for quantification and phenotyping of low concentrations of serum CR. Based on our experience in the routine analysis, quantification, and phenotyping of serum CR, some practical solutions to these problems are presented.

Direct analysis of hydrogen peroxide by capillary electrophoresis.

A method is described for analysis of hydrogen peroxide directly by CZE in borate buffer based on its absorption in UV light at 185 nm, without reaction with dyes. The absorption at 185 nm was about 3.5 times better than that at 214 nm. Hydrogen peroxide was generated enzymatically from glucose in aqueous solutions and in serum and was removed by the catalase enzyme. To improve the sensitivity of detection, samples were concentrated on the capillary based on stacking by ACN. The method is rapid (approximately 7 min) and specific.

Serum iohexol analysis by micellar electrokinetic capillary chromatography.

A simple and rapid ( approximately 4 min) method for the measurement of iohexol in serum for assessing the glomerular filtration rate is described. It is based on direct serum injection on the capillary by MEKC. The method is linear between 8 and 260 mg/L, with an RSD of peak height of 2.9%. Several simple steps have contributed to an improved daily precision, such as choosing a high pH buffer, increasing the SDS concentration, frequent standardization, and eliminating any sample pretreatment.

Organic solvent high-field amplified stacking for basic compounds in capillary electrophoresis.

Many water-miscible organic solvents, especially acetonitrile and acetone, bring along significant degrees (approximately 30 times) of stacking by electroinjection through high-field amplified injection for the basic compounds compared to that for aqueous buffers or water. The relative stacking of different compounds in acetonitrile or acetone is different compared to that for water. Stacking by electroinjection in organic solvents is less stringent and easier to accomplish in practice. Acids and salts, in aqueous solutions, can ruin the stacking for both organic and aqueous solvents; however, this effect can be better tolerated by diluting the sample in acetonitrile. Thus, this stacking is termed "organic solvent high-field amplified injection". This stacking by electroinjection is enhanced by increasing the electrophoresis buffer concentration and can be better than that by pressure injection. From the practical aspects, some cationic drugs present in serum such as amiodarone can be detected at the therapeutic levels by electroinjection on the capillary after protein precipitation by acetonitrile.

Simplified hemoglobin chain detection by capillary electrophoresis.

Hemoglobin (Hb) chains have been analyzed traditionally by cellulose acetate electrophoresis after sample extraction with acetone and denaturation with concentrated urea in order to detect thalassemia (Thal). A few capillary electrophoresis (CE) methods have been also described for separation of Hb chains also after sample extraction. We describe a CE method for analysis of Hb chains without sample preparation. Red blood cells were diluted (hemolyzed) in water and injected directly onto the capillary. The separation was performed in concentrated phosphate buffer at pH 12.6 and 2.15. Under these conditions of pH and buffer concentration, the chains were denatured and separated from the heme during electrophoresis. The common variants of the beta-chains, such as beta(S), beta(C), and beta(E), are also separated from each other. The intact Hb molecule is analyzed using the same sample and CE conditions but in an arginine-Tris buffer, pH 8.6. The data from the three separations are used to complement each other for interpretation of the presence of Hb variants and for thalassemia. The main advantages of this method are simplicity and speed. This method illustrates the flexibility and simplicity of the CE for analysis of the hemoglobinopathies.

Fenofibrate and fenofibric acid analysis by capillary electrophoresis.

A capillary electrophoresis method has been developed to measure fenofibrate in capsules based on micellar electrokinetic capillary chromatography with detection at 280 nm using a borate buffer containing sodium dodecyl sulfate (SDS). However, the metabolite of this drug (fenofibric acid) in serum and whole blood was analyzed by capillary zone electrophoresis (CZE) in a borate-carbonate buffer using acetonitrile stacking. The analysis is rapid, < 7 min with no interferences. Incubation of fenofibrate in whole blood caused hydrolysis of the ester bond with the release of fenofibric acid.

Analysis of Tamm-Horsfall protein by high-performance liquid chromatography with native fluorescence.

Tamm-Horsfall (TH) is a large glycoprotein which originates in the kidney and is very abundant in the urine. This protein has been measured mainly by immunoassays. Here we describe a different approach for its measurement based on high-performance liquid chromatography (HPLC) using a molecular exclusion column with native fluorescence detection in the ultraviolet range. This method in addition to measuring the level of the protein has the advantage of detecting changes in size or aggregation. Urine, 1 ml was mixed with 100 microl of 30% NaCl and left at 37 degrees C for 30 min. The urine was centrifuged at 12000 rpm for 20 s. The precipitate was vortex-mixed and dissolved in a triethanolamine buffer. A 20 microl aliquot was injected on a Macrosphere GPC column which was eluted with phosphate buffer and the effluent was detected by a fluorometer set at 280 nm for excitation and 325 nm for emission. Since the protein has a very large molecular mass compared to other urinary and serum proteins we did not experience any interference. It elutes as the first peak (in approximately 2.5 min on a 500 A and 2.7 min on 1000 A). The protein precipitates rapidly < 60 min at 37 degrees C. The detection in the UV is sensitive for this protein down to 1 mg/l in absence of any concentration steps. The method was linear between 1 and 100 mg/l. The R.S.D. was 10.4% (mean 62, n = 10). The mean level in 42 normal individuals was 31 mg/g creatinine and in 30 patients with proteinuria (different renal disorders) was 23 mg/g creatinine.

Effect of sample composition on electrophoretic migration application to hemoglobin analysis by capillary electrophoresis and agarose electrophoresis.

The electrophoretic migration, in routine analysis, is crucial for compound identification especially when multiple components are present in the sample. In complex or crude samples, such as those obtained from biological fluids, electrophoretic migration often does not correspond well to that of a pure standard compound. Several factors, related to the sample itself, have been identified as modulating the electrophoretic migration in zone electrophoresis both in gel and capillary electrophoresis (CE): solute mobility and concentrations, salt content, and protein interaction in the sample. Peak shape asymmetry often signals changes in migration especially when comparing samples with wide differences in concentration or those containing high ionic strength. Also, the migration of a protein can be influenced by the presence of a high concentration of another slowly migrating protein in the sample. A weak interaction during the separation between the two proteins which lead to a decreased velocity has been postulated. This was confirmed by finding a curve-linear relationship between the ratio of the two hemoglobin (Hb) variants, hemoglobin F (Hb F) and hemoglobin S (Hb S), and the distance between the two in gel electrophoresis (GE); and also by the observation of formation of a new small peak based on the analysis of hemoglobin F by capillary electrophoresis upon the addition of Hb S to the separation buffer. These factors when present together have an additive effect on the migration. As an example, Hb F, present in low but variable concentration in patients with sickle cell disease (Hb S), migrates in gel electrophoresis slightly slower than it is expected; enough to be confused with other unknown variants. However, the small peaks with different migration distances between Hb S and the adult Hb (Hb A) correlated well (r = 0.98) with Hb F performed by an alkali-denaturing assay indicating that these peaks are indeed Hb F in spite of the difference in their migration.

IgD-kappa myeloma: an unusual case.

A rare case of biclonal IgD-kappa and IgG-kappa myeloma is described. The patient initially presented with anemia, renal insufficiency, and proteinuria. The IgD-kappa, initially, was overlooked as a light chain; however, it decreased in serum concentration after treatment by approximately 90%, in contrast to the IgG-kappa that decreased in serum by approximately 40 % over a 9-yr period. Clinically, the patient responded well to treatment and improved greatly during this period. Practical recommendations are suggested in order to detect such cases.

Stacking by electroinjection with discontinuous buffers in capillary zone electrophoresis.

The work presented here demonstrates that electroinjection can be performed using discontinuous buffers, which can result in better stacking than that obtained by hydrodynamic injection. The sample can be concentrated at the tip of the capillary leaving practically the whole capillary for sample separation. This results in several advantages, such as better sample concentration, higher plate number and shorter time of stacking. However, sample introduction by electromigration is suited for samples free or low in salt content. Samples, which are high in salt content, are better introduced by the hydrodynamic injection for stacking by the discontinuous buffers. Different simple methods to introduce the discontinuity in the buffer for electroinjection are discussed.