Glycated hemoglobin, also called glycohemoglobin, is any form of hemoglobin (Hb) that is chemically linked to a sugar. Most monosaccharides, including glucose, galactose, and fructose, spontaneously (that is, non-enzymatically) bond with hemoglobin when they are present in the bloodstream. However, glucose is only 21% as likely to do so as galactose and 13% as likely to do so as fructose, which may explain why glucose is used as the primary metabolic fuel in humans. The formation of excess sugar-hemoglobin linkages indicates the presence of excessive sugar in the bloodstream and is an indicator of diabetes or other hormone diseases in high concentration (HbA1c > 6.4%). A1c is of particular interest because it is easy to detect. The process by which sugars attach to hemoglobin is called glycation and the reference system is based on HbA1c, defined as beta-N-1-deoxy fructosyl hemoglobin as a component. There are several ways to measure glycated hemoglobin, of which HbA1c (or simply A1c) is a standard single test. HbA1c is measured primarily to determine the three-month average blood sugar level and is used as a standard diagnostic test for evaluating the risk of complications of diabetes and as an assessment of glycemic control. The test is considered a three-month average because the average lifespan of a red blood cell is three to four months. Normal levels of glucose produce a normal amount of glycated hemoglobin. As the average amount of plasma glucose increases, the fraction of glycated hemoglobin increases predictably. In diabetes, higher amounts of glycated hemoglobin, indicating higher blood glucose levels, have been associated with cardiovascular disease, nephropathy, neuropathy, and retinopathy.
Terminology Glycated hemoglobin is preferred over glycosylated hemoglobin to reflect the correct (non-enzymatic) process. Early literature often used glycosylated as it was unclear which process was involved until further research was performed. The terms are still sometimes used interchangeably in English-language literature.
HbA1c Hemoglobin A1c (HbA1c) was originally (1958) the designation of one of the factions formed, when doing cation exchange chromatography. The species forming this faction were only later described in detail. It has since been rendered more precisely to be "a stable minor Hb variant formed in vivo by post-translational modification by glucose", containing primarily glycated N-terminal β-chains. The naming of HbA1c derives from hemoglobin type A being separated on cation exchange chromatography. The first fraction to separate, considered to be pure hemoglobin A, was designated HbA0, and the following fractions were designated HbA1a, HbA1b, and HbA1c, in their order of elution. Improved separation techniques have subsequently led to the isolation of more subfractions.
History Hemoglobin A1c was first separated from other forms of hemoglobin by Huisman and Meyering in 1958 using a chromatographic column. It was first characterized as a glycoprotein by Bookchin and Gallop in 1968. Its increase in diabetes was first described in 1969 by Samuel Rahbar and coworkers. The reactions leading to its formation were characterized by Bunn and coworkers in 1975. The use of hemoglobin A1c for monitoring the degree of control of glucose metabolism in diabetic patients was proposed in 1976 by Anthony Cerami, Ronald Koenig, and coworkers.
Measurement Several techniques are used to measure hemoglobin A1c. Laboratories may use high-performance liquid chromatography, immunoassay, enzymatic assay, capillary electrophoresis, or boronate affinity chromatography. Point of care (e.g., doctor's office) devices use immunoassay boronate affinity chromatography. In the United States, HbA1c testing laboratories are certified by the National Glycohemoglobin Standardization Program to standardize them against the results of the 1993 Diabetes Control and Complications Trial (DCCT). An additional percentage scale, Mono S has previously been in use by Sweden and KO500 is in use in Japan.
Switch to IFCC units The American Diabetes Association, European Association for the Study of Diabetes, and International Diabetes Federation have agreed that, in the future, HbA1c is to be reported in the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) units. IFCC reporting was introduced in Europe except for the UK in 2003; the UK carried out dual reporting from 1 June 2009 until 1 October 2011. Conversion between DCCT and IFCC is by the following equation:
I F C C H B A 1 c ( mmol mol ) = [ D C C T H B A 1 c ( % ) − 2.14 ] × 10.929 {\displaystyle \mathrm {IFCC\ HBA1c} \,{\Big (}{\frac {\text{mmol}}{\text{mol}}}{\Big )}=[\mathrm {DCCT\ HBA1c} \,(\%)-2.14]\times 10.929}
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