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Evaluation of Biological Variations in Glucose and Glycated Hemoglobin Turk J Biochem 2018; 43(5): 495–501 Research Article Cihan Coskun*, Berrin Bercik Inal, Humeyra Ozturk Emre, Sehide Baz, Alper Gumus, Derya Sonmez, Bagnu Orhan, Muhammed Emin Duz, Erdinc Serin and Macit Koldas Evaluation of biological variations in glucose and glycated hemoglobin levels in healthy individuals Sağlıklı Kişilerde Glukoz ve Glike Hemoglobinin Biyolojik Varyasyonlarının Değerlendirilmesi https://doi.org/10.1515/tjb-2017-0165 individuality (II) of glucose was higher than 0.6 while Received June 23, 2017; accepted November 7, 2017; previously HbA1c’s II was lower than this value. published online December 8, 2017 Conclusion: We thought that guidelines from relevant Abstract international organizations should be followed to stand- ardize the study design and to appropriately calculate Objective: In this study, we firstly aimed to determine BVCs for any analyte in BV studies. Finally, reference components of biological variations (BVCs) in levels of change value should be used to evaluate meaningful dif- glucose and glycated hemoglobin (HbA1c) in detail based ferences in HbA1c levels instead of reference interval. on guidance from relevant organizations and experts. We Keywords: Biological variation; Glucose; Glycated hemo- also investigated whether reference intervals for both ana- globin; The index of individuality; Reference change lytes were useful for evaluations, particularly consecutive value; Analytical performance specification. test results. Methods: The study group consisted of 36 healthy volun- teers. Samples were collected from each individual 4 times Özet every 2 weeks for 45 days. All samples were assayed in duplicate within a single run. Finally, we estimated BVCs Giriş ve amaç: Biz bu çalşımada öncelikle ilgili kuruluşlar and the analytical performance specifications of both ve uzmanların rehberliğinde glukoz ve glike hemoglobin analytes. (HbA1c)’in biyolojik varyasyon komponent (BVK)’lerini Results: Our results were fairly compatible with current detaylı olarak tespit etmeyi amaçladık. Ayrıca bu analit- biological variations (BVs) in both analytes reported in a lere ait referans aralıklarının özellikle ardışık test sonuç- database. It was calculated as within biological variation ları değerlendirilirken yararlı olup olmadığını araştırdık. (CVI) = 4.2% and between-subject variation (CVG) = 5.3% Yöntem ve gereçler: Çalışma grubu gönüllü olan 36 sağ- for glucose while calculating as CVI = 1.7% and CVG = 4.5% lıklı kişiden oluşmaktaydı. Her bir hastanın numunesi 45 for HbA1c. According to these results, the index of gün boyunca 2 haftada bir olmak üzere ardışık olarak 4 kez alındı. Tüm numuneler iki kez olmak üzere tek seferde ölçüldü. Son olarak her iki analitin BVK’leri ve analitik *Corresponding author: Cihan Coskun, Department of Biochemistry, Haseki Traning and Research Hospital, Istanbul, Turkey, performans spesifikasyonları hesaplandı. e-mail: [email protected]. Bulgular: Sonuçlarımız, her iki analite ait güncel biyolo- http://orcid.org/0000-0001-8288-8741 jik varyasyon (BV) veri tabanı ile uyumluydu. HbA1c için Berrin Bercik Inal, Sehide Baz, Derya Sonmez, Bagnu Orhan and bireyiçi varyasyon (CVI) = 1.7% ve bireylerarası varyasyon Department of Biochemistry, Istanbul Traning and Erdinc Serin: (CV ) = 4.5% olarak hesaplanırken, glukoz için CV = 4.2% Research Hospital, Istanbul, Turkey G I = Humeyra Ozturk Emre, Alper Gumus, Muhammed Emin Duz and ve CVG 5.3% olarak hesaplandı. Bu sonuçlara göre, glu- Macit Koldas: Department of Biochemistry, Haseki Traning and kozun bireysellik indeksi 0.6’dan büyük iken, HbA1c’nin Research Hospital, Istanbul, Turkey bireysellik indeksi bu değerden daha küçüktü. 496 Cihan Coskun et al.: Biological variations in glucose and glycated hemoglobin Sonuç: BV çalışmalarında çalışma tasarımını standar- population-based reference interval for any analyte dize etmek için ve herhangi bir analitin BVK’sini uygun are useful. Moreover, the reference change value (RCV) bir şekilde hesaplamak için konu ile ilgili kuruluşların derived from BV data (BVD) is also particularly helpful for yayınlarının takip edilmesi gerektiği düşüncesindeyiz. the clinician to decide whether the changes in values for Son olarak, HbA1c düzeyleri arasındaki anlamlı farkları any analyte between consecutive tests are significant for değerlendirmek için referans aralığı yerine referans deği- patient health [7]. şim değeri kullanılmalıdır. However, in the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) 1st Strategic Anahtar kelimeler: Biyolojik varyasyon; Glukoz; Glike Conference, doubts about the quality of BVD in current hemoglobin; Bireysellik indeksi; Referans değişim değeri; clinical use were raised, and its utility was suggested Analitik performans spesifikasyonu. to be limited [8]. Indeed, existing BVD exhibit marked heterogeneity in terms of study design, as well as uncer- tainty in the calculations [9]. In particular, the EFLM has Introduction continued to work to overcome the challenges in these issues and endeavor to expand reliable BVD through the Most clinical laboratory tests are commonly requested by Working Group on BV (WG-BV) [10, 11]. In this context, clinicians for various clinical situations, including diag- the BV database (BV-DB) that were previously prepared nosis, monitoring, assessment of risk factors and screen- by Ricos and colleagues [12] were recently updated by ing [1]. Glucose and glycated hemoglobin (HbA1c) levels are gathering data from new publications that have been also assessed for similar purposes. In this context, plasma continuously expanded, updated and published online. glucose criteria, either the fasting plasma glucose (FPG) In addition, analytical performance specifications (APS) levels or the 2-h value in the 75-g oral glucose tolerance for imprecision (I%), bias (B%) and total error (TE%) of test have been used to diagnose diabetes mellitus (DM) various analytes calculated from BVD were also pub- for several years. An International Expert Committee that lished on the same website [13]. Moreover, Bartlett and included representatives of the American Diabetes Associ- colleagues [9] have recently published a critical appraisal ation (ADA), the International Diabetes Federation (IDF), checklist to enable the standardized assessment of papers and the European Association for the Study of Diabetes on BV in the name of the EFLM WG-BV. Perich and col- (EASD) recommended that both the glucose test and the leagues [14] have also reported criteria used to evaluate HbA1c test should be used to diagnose DM, and the ADA the reliability of the BV-DB. adopted this criterion in 2010 [2–4]. Moreover, numerous Consequently, our initial goal was to estimate BVD for diabetes organizations have defined the range of HbA1c both analytes in detail based on the guidance of relevant levels and FPG levels to predict the progression to DM [5]. organizations and experts. The other goal was to guide to Techniques used to monitor glucose and HbA1c levels the clinician to make decision about reference interval or are important tools in assessing DM management, since RCV should be used for both analytes while managing the poor glycemic control over time has been specifically DM process. linked to the development and progression of microvas- cular DM complications [6]. But, it sometimes is really difficult for clinicians to decide upon in some cases, although most tests have various clinical decision limits. Materials and methods Alterations observed in consecutive test results may be clinically significant, even if these results are within their Systematic search strategy and participants’ reference intervals. This condition may also related to characteristics inherent variation [expressed as the coefficient of varia- tion (CV)], which consist of the variations in pre-analyt- The study was conducted at two centers. Working samples ical (CVP), analytical (CVA) and within-subject biological were measured in the Biochemistry Department of Haseki variation (CVI). Hospital after they were collected from Haseki Training Between-subject biological variation (CVG) defined as and Research Hospital and Istanbul Training and Research the differences between the set points of different indi- Hospital. Thirty-six healthy volunteer subjects (19 males viduals is another component of biological variation (BV) and 17 females between 20 and 45 years of age) partici- as well as CVI. The CVI/CVG ratio is also used to calculate pated in this study. Volunteers were all selected from the the index of individuality (II) which determines whether laboratory staff and their friends or relatives. The study Cihan Coskun et al.: Biological variations in glucose and glycated hemoglobin 497 was approved by the Ethics Committee of Haseki Hospital. centrifuged at 3000 g for 10 min at 4°C. All samples were All procedures were conducted according to institutional aliquoted and stored at −80°C until analysis [8]. ethical and legal standards. Each sample collected from the study participants was assayed in duplicate within a single run [15, 16]. All samples were studied on the same day by the same labo- Exclusion criteria ratory staff to exclude interassay variation. Samples were incubated at room temperature until they dissolved and We excluded subjects with a history of chronic dis- then studied. Before measuring the levels of these ana- eases, including DM, coronary artery disease, hyperten- lytes, both analytical systems were calibrated, and then sion, anemia, thyroid diseases, hepatic diseases,
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