Future directions

The standardization of glycated haemoglobin: is it desirable?

y Jean-Claude Mbanya

The measurement of glycated haemoglobin (as HbA1c ) is central to diabetes care. This is the measure by which health-care providers can relate blood glucose control to the risk of complications, such as eye damage or kidney failure. However, a lack of standardization in the methods used to measure glycated haemoglobin has produced wide variations among results and is among the current limitations to the effective use of HbA1c results in gauging a persons risk of these complications. Jean-Claude Mbanya reports on the efforts of a group which includes members from the International Diabetes Federation (IDF), the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) to respond to the need for a more universally applicable method for measuring and reporting glycated haemoglobin.

development of diabetes complications. These landmark investigations used a standardized assay called the DCCT standard. The process of alignment of numerical results with the DCCT method was undertaken largely by the US National Glycohemoglobin Standardization Program (NGSP). The problem Following these studies, there was a widespread harmonization of clinical assays to the DCCT standard throughout the world. However, glycated haemoglobin has several different haemoglobin-glucose compounds, including HbA1a, HbA1b, and HbA1c. Consequently, over 30 different methods are commercially available to measure glycated haemoglobin. Over 30 methods are available to measure HbA1c, leading to wide variations in the results reported by different laboratories. This lack of standardization of the methods used to measure glycated haemoglobin produced very wide variability among the results of

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Two carefully designed studies used measurements of glycated haemoglobin to define the relationships between the control of blood glucose levels and diabetes outcomes: the Diabetes Control and Complications Trial (DCCT), conducted in people with type 1 diabetes; and the UK Prospective Diabetes Study (UKPDS), conducted in people with type 2 diabetes.1,2 These studies demonstrated that levels of glycated haemoglobin are a measure of the risk for the

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different methods, with values ranging from 4.0% to 8.1% on the same blood sample.3 In several countries, including the USA, Sweden and Japan, a standardization process was used that was based on the DCCT reference method and analogous standardization programmes. This has reduced variability among glycated haemoglobin results.4,5,6 Nevertheless there was an urgent need for a more universally applicable method for measuring glycated haemoglobin. Recently, the International Federation of Clinical Chemists (IFCC) Working Group on HbA1c Standardization prepared primary reference materials of pure HbA1c and HbA0 and developed a reference method for glycated haemoglobin.7 When pooled blood samples were compared, a linear relationship was revealed between the HbA1c results of the IFCC reference method and those of the standardization schemes in the United States, Japan, and Sweden.8 Unfortunately, when compared with the NGSP results, the glycated haemoglobin results obtained by the IFCC method were significantly lower (1.3%-1.9% across the relevant glycated haemoglobin range). These findings have generated considerable debate as to the way in which glycated haemoglobin should be reported. Seeking a solution In 2004, a working group was established with a mandate to harmonize glycated haemoglobin reporting. The group, named the ADA/EASD/IDF Working Group of the HbA1c Assay, included members from IDF, ADA and EASD, and representatives from the NGSP and the IFCC. In its first meeting, the charge to the Working Group was two-fold: to review the opportunities arising from the development of a new IFCC reference method for the measurement of glycated haemoglobin to make recommendations on its implementation. The Working Group carefully reviewed the current technology for the measurement of HbA1c and the history of the new IFCC reference method. It was agreed that the IFCC reference method should become the global reference standard, and that all manufacturers should calibrate their instruments to this new anchor standard. This change would imply a reduction in the reported HbA1c readings 1%-2% less than those currently reported. As a result, there would be a reduction of the accepted references for normal, good or poor blood glucose control. Conscious of these implications, the Group discussed two possibilities. Should measurements of glycated haemoglobin be reported using the IFCC numbers? This would imply an abrupt lowering of individual test results. Or should the linear relationship with the DCCT method be used to convert the new readings back to the current range of values? This option would require little or no change in the numbers. Table 1 lists some of the key points.

Haemoglobin (Hb) is the protein in the red blood cells which carries oxygen to the cells. HbA1c (glycated haemoglobin also known as glycohaemoglobin in the USA) is haemoglobin which has combined permanently with the glucose present in the blood. Because the amount of the complex which forms is proportional to the average glucose concentration in the blood, and because glucose stays attached to the HbA1c for the life of the blood cell (about 3 months), a blood test to measure HbA1c reflects the persons average blood glucose for that period of time, and can therefore be used as a measure of longterm blood glucose control. An assay is an analysis of a substance to determine its concentration.

Many people do not understand the connection between the HbA1c test, blood glucose levels and diabetes.

It was agreed that the very name of the test HbA1c, A1c or haemoglobin A1c is confusing, suggesting a blood disorder. Many people do not understand the connection between the test, blood glucose levels and diabetes. Furthermore, the small numbers (7% or 9% for instance) do not readily

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convey to people with diabetes that a major effect on health can be provoked even by a change of 0.5%-1%. For many people, a change of 10-40 units is required in most measurements such as outdoor temperature for a difference to be meaningful. Thus, when a diabetologist reports a change of 1% in a persons HbA1c levels, this is often perceived as trivial. The Working Group decided that, given the concerns described above, the opportunity should be taken to re-define the entire assay. It was decided that the name of the assay should be changed to reflect mean blood glucose (MBG) and that we should make use of the fact that there is a close (and directly proportional) relationship between HbA1c and mean blood glucose. This relationship was observed in a retrospective examination of glucose assays during the DCCT study and can be represented mathematically as: MBG (mmol/l) = 1.84 x IFCC A1c (a different MBG reading will result if expressed in mg/dl as is done in some countries). If this relationship can be confirmed in a prospective study, the opportunity will arise to report the new IFCC figures as the corresponding mean blood glucose. Hence the HbA1c test will have a new name (MBG for example), a new range in familiar glucose units, and thus, a direct and recognizable link to glucose levels for people with diabetes and their health-care providers. Although substantial preparation and re-education will be required, there is no real risk of confusion. A simplification of the range used to express blood glucose levels will allow all people with diabetes to understand their own target levels, particularly if they already use home glucose monitoring. Also, the potential of the simplified assay for future use as a diagnostic tool will be increased. The disadvantages include the possibility that the simple proportionality may not apply to all populations, or to extremes of MBG/ A1c. In this case, it may be necessary to adopt more complex conversions, or reconsider the idea altogether. Also, to obtain the full benefit of a link with home tests, the MBG will be reported in two different units (mmol/l or mg/dl), with the usual minor but frustrating conversion problems. Overall, the Working Group favoured proceeding with this innovative approach to implementation of the new standard. Update on progress Prospective studies are planned and several other initiatives have been proposed. The aim will be to ascertain whether the above relationship between HbA1c and MBG

Table 1: Changing vs maintaining the reporting of glycated haemoglobin Report new IFCC range The reported values reflect the actual values. Maintain current values Familiar to people with diabetes and health-care providers. Relates HbA1C values to existing evidence base, UKPDS and DCCT for example.

Advantages

Opportunity to re-educate people with diabetes and professionals about meaning and value of the HbA1C test. Opportunity to re-define HbA1C (see below). Timeline for the education necessary to prevent confusion is prolonged and implementation will be costly.

Not the pure result. Frequently confused with glucose levels in countries where mmol/l is used. Missed opportunity to reinforce the importance of the test.

Disadvantages

Partial or piecemeal implementation will worsen existing differences between laboratories. Risk of deterioration in glucose control as experienced in a Swedish study.1 Lower numbers make it even more difficult to convince people that small percentage changes in HbA1C have a big impact on health.

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is confirmed by a prospective analysis in different populations worldwide. The development of educational programmes is envisaged to inform health-care providers and the general public about the new reporting system. These recommendations have been endorsed by ADA, EASD, IDF, and NGSP. The initiative has the support of the US Centers of Disease Control. that were selected for participation to participate in the selection of the successful proposals. The Working Group will review these proposals and make the final selection. The fundamental concept is that HbA1c will be compared with MBG. The latter will be derived from 48-hour continuous glucose monitoring, supplemented by the measurement of capillary blood glucose at least eight times a day. Concurrent HbA1c measurements will be performed. Evaluations will be made of people with type 1 diabetes and people with type 2 diabetes (with stable glycaemic control), as well as people (controls) without the condition. At the time of writing, the protocol has been developed, centres in Europe and the rest of the world selected, and funds for the studies set aside by EASD and ADA. With the recruitment of study participants starting in June 2005, the studies should be completed by June 2006, allowing preliminary findings to be reported at the 19th IDF World Diabetes Congress in December 2006, in Cape Town, South Africa. We anxiously await the results from these studies which will help to facilitate the global harmonization of HbA1c. y Jean-Claude Mbanya for the ADA/ EASD/IDF Working Group of the HbA1c Assay
Jean-Claude Mbanya is an IDF VicePresident and a member of the IDF Board of Management. He is Professor of Endocrinology at the Faculty of Medicine and Biomedical Sciences, University of Yaound, Cameroon.

References
1 The Diabetes Control and Complications Trial (DCCT) Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86. 2 UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-53. 3 Little RR, Wiedmeyer HM, England JD, Wilke AL, Rohlfing CL, Wians FH Jr, Wians FH Jr, Jacobson JM, Zellmer V, Goldstein DE. Interlaboratory standardization measurements of glycohemoglobins. Clin Chem 1992; 38: 2472-8. 4 Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of glycemia in diabetes. Diabetes Care 2004; 27: 1761-73. 5 Shima K, Endo J, Oimomi M, Oshima I, Omori Y, Katayama Y. Inter-laboratory difference in HbA1c measurement in Japan. A report of the Committee on an Inter-laboratory Standarization of HbA1c Determination, the Japan Diabetes Society. J Jpn Diabetes Soc 1994; 37: 855-64. 6 Arnquist H, Wallensteen M, Jeppsson JO. Standardization of long-term glucose measurements established. Lakartidningen 1997; 50: 4789-90. 7 Jeppsson JO, Kobold U, Barr J, Finke A, Hoelzel W, Hoshino T, Miedema K, Mosca A, Mauri P, Paroni R, Thienpont L, Umemoto M, Weykamp C; International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Approved IFCC reference method for the measurement of HbA1c in human blood. Clin Chem Lab Med 2002; 40: 78-89. 8 Hoelzel W, Weykamp C, Jeppsson JO, Miedema K, Barr JR, Goodall I, Hoshino T, John WG, Kobold U, Little R, Mosca A, Mauri P, Paroni R, Susanto F, Takei I, Thienpont L, Umemoto M, Wiedmeyer HM; IFCC Working Group on HbA1c Standardization. IFCC reference system for measurement of hemoglobin A1c in human blood and the national standardization schemes in the United States, Japan, and Sweden: a method-comparison study. Clin Chem 2004; 50: 166-74.

In a follow-up meeting in September 2004, several critical questions were identified: Is there a relationship between HbA1c and MBG in type 1 and type 2 diabetes and in all ethnic groups? Is this relationship the same at different concentrations of MBG? Is HbA1c altered by fluctuations in glucose concentrations at the same MBG value? Is the relationship between HbA1c and MBG stable despite fluctuations in MBG? Is this relationship altered by medication or pregnancy? In order to answer these questions, a sub-committee was established to design the core protocol for the prospective analysis. The charge to this sub-committee included the following: to develop the protocol to prepare a document for the request for proposals to invite input into the design of the study from experts at the centres

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The fundamental concept is that HbA1c will be compared with MBG.

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