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Original Article

-ffect of 'ron Deficiency on .lycation of /ae$oglo0in in 1ondia0etics

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ABSTRACT
Background: 9rotein glycation is a s:ontaneous reaction that is 0elie;ed to :lay a <ey role in the :athogenesis of $any clinical disorders. 6he glycation of :roteins is enhanced 0y ele;ated glucose concentrations. 6he $a=or for$ of :rotein glycation >ith a clinical consideration is glycated hae$oglo0in /021c!. 6he /021c fraction is a0nor$ally ele;ated in chronic hy:erglycae$ic dia0etic :atients and it correlates :ositi;ely >ith the glycae$ic control. /o>e;er, increased glycated hae$oglo0in le;els ha;e 0een docu$ented in iron de?ciency anae$ic :atients >ithout any history of dia0etes. Aims and Objective: 6he ai$ of this study >as to deter$ine the effect of 'D2 on the /021c le;els in nondia0etic :atients, so as to consider 'D2 as an i$:ortant factor >hich influenced the /021c le;els, >hile $onitoring the glycae$ic status of dia0etics. Methodology: @ifty non-dia0etic, anae$ic :atients and 50 age-$atched healthy su0=ects >ere enrolled in this study. 6he :atients >ho had glucose tolerance a0nor$alities i$:aired

#ioche$istry %ection

glucose tolerance or dia0etes $ellitus!, hae$oglo0ino:athies, hae$olytic anae$ia, infestation, chronic alcohol ingestion and chronic renal failure >ere eAcluded fro$ the study. /ae$atologic in;estigations >ere done and the fasting and :ost:randial glucose and /021c le;els >ere $easured in all the su0=ects. Results: 6he $ean /021c 7.) B 0.5C! le;el in the :atients >ith 'D2 >as higher than that in the control grou: 5.5C B 0.(! : D 0.001!. 6here >ere no differences in the le;els of fasting and :ost:randial glucose 0et>een the 'D2 and the control grou:s : E 0.05!. 6he hae$oglo0in, seru$ ferritin, fasting and :ost:randial glucose, and the /021c le;els >ere nor$al in the control grou: : E 0.05!. Conclusion: /021c is not affected 0y the 0lood sugar le;els alone, and there are ;arious confounding factors >hen /021c is $easured, es:ecially that of iron de?ciency, >hich is the co$$onest of the de?ciency diseases >orld>ide. 't is hence :rudent to rule out 'D2 0efore $a<ing a thera:eutic decision, 0ased on the /021c le;els.

Fey 8ords" 'ron deficiency, /021c, 9rotein glycation

InTROduCTIOn
.lycated hae$oglo0in is :roduced 0y a <etoa$ine reaction 0e- t>een glucose and the 1-ter$inal ;aline of 0oth G-chains of the hae$oglo0in $olecule. 6he $a=or for$ of glycated hae$oglo0in is hae$oglo0in 21c /021c! H1,2I. 6he $easure$ent of glycated hae$oglo0in is the standard $ethod for assessing the long-ter$ glycae$ic control. 8hen :las$a glucose is consistently ele;ated, the nonenJy$atic glycation of hae$oglo0in increasesK this altera- tion reflects the glycae$ic history o;er the :re;ious 2L3 $onths, since erythrocytes ha;e an a;erage lifes:an of 120 days H3,+I. 6he /021c fraction is a0nor$ally ele;ated in :atients >ith chronic hy:erglycae$ic dia0etes $ellitus and it correlates :ositi;ely >ith the $eta0olic control H5I. 2ccording to the 2$erican Dia0etes 2ssociation 2D2! guidelines, the ;alue of /021c should 0e <e:t 0elo> 7C in all the dia0etics H)I. 6he ;alues >hich are greater than 7C indicate an increased chance of :rogression to the dia- 0etic co$:lications, es:ecially the $icro;ascular ones. /021c is $a=orly affected 0y the 0lood glucose le;els alone. /o>e;er, certain studies ha;e :ro;en that the /021c le;els are altered 0y ;arious other coeAisting factors, along >ith dia0etes, es:ecially that of iron deficiency anae$ia, >hich is a
Journal of Clinical and Diagnostic Research. 2013 January, Vol-7 1!" 15-17

$a=or :u0lic health :ro0le$ in de;elo:ing countries li<e 'ndia.

2ccording to the 8orld /ealth &rganiJation 8/&!, iron deficiency is the co$$onest of the deficiency diseases >orld>ide H7I. &ne

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of the >ell-studied :athological ill-effects of 'D2 in the 0iological syste$ is the glycation of :roteins H(I. 6he nonenJy$atic glyca- tion of :roteins has :ronounced effects on the structure and the function of :roteins. 6he :athological conseMuences of these al- terations de:end on the nature of the :roteins >hich are in;ol;ed, as >ell as on their functions and concentrations in s:ecific tissue localiJations H,I. 6he t>o <no>n factors >hich can $odulate the glycation of :roteins are the :re;ailing concentration of glucose and the half life of the :rotein H10I. #ut e;idences in the literature ha;e docu- $ented increased glycated :rotein le;els in so$e non-dia0etic :athological states, li<e iron deficiency anae$ia. %o$e authors ha;e also found that on su::le$entation >ith iron thera:y, there >as a significant decrease in the le;els of glycated hae$oglo0in H11I. -;idence has accu$ulated, >hich su::orts the hy:othesis that the glycation reaction, a:art fro$ the traditional chronic hy- :erglycae$ia ,can 0e $odulated 0y the iron status of the :atient. 'f the degree of glycation of other :roteins in anae$ic :atients >as si$ilar to that of the glycated hae$oglo0in, it >ould ha;e i$:ortant clinical i$:lications. 6hus, the o0=ecti;e of the :resent study >as to deter$ine >hether the /021c le;els >ere increased a$ong the anae$ic :atients >ithout dia0etes. 'f so, the iron de- ficiency had to 0e corrected 0efore any diagnostic or thera:eutic decision >as $ade 0ased on the /021c le;el.

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#alasu0ra$anian %hanthi et al., -ffect of 'ron De?ciency on .lycation of /e$oglo0in in 1ondia0etics

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&ATIenTS And MeThOdS

#lood sa$:les 3$l! >ere o0tained fro$ 50 anae$ic :atients of the $ean age, +3.52B7.7, years, a$ong >hich 1, >ere $ales and 31 >ere fe$ales and 50 age-$atched healthy su0=ects. 6he anae$ic :atients >ere recruited fro$ the 5edicine &ut:atients De:art$ent of our institute, %ree #ala=i 5edical College, Chro$- :et, Chennai, 'ndia. 6he anae$ic :atients >ere selected, 0ased on their hae$oglo0in le;els /0 D 11 g*dl!, ferritin le;els D, ng* $l for >o$en, D15 ng*$l for $en! and on their :eri:heral 0lood s$ears $ostly $icrocytic hy:ochro$ic!, >hich suggested iron deficiency anae$ia and on their hae$atologic in;estigations and seru$ fasting and :ost:randial glucose le;els. 6he :atients >ho had glucose tolerance a0nor$alities i$:aired glucose tolerance or dia0etes $ellitus!, hae$oglo0ino:athies, hae$olytic anae$ia, chronic alcohol ingestion, and chronic renal failure >ere eAcluded fro$ the study.

trol grou: 5.5C B 0.(! : D 0.001!. 6here >ere no differences in the le;els of fasting and :ost:randial glucose 0et>een the 'D2 and the control grou:s : E 0.05!. 6he hae$oglo0in, seru$ ferritin, fasting and :ost:randial glucose, and the /021c le;els >ere nor$al in the control grou: : E 0.05!.

dISCuSSIOn
&ur results suggested that 'D2 >as associated >ith higher con- centrations of /021c. %i$ilarly, #roo<s et al., H12I sho>ed higher /021c concentrations in iron-deficient nondia0etic adults, >hich decreased to nor$al after iron re:lace$ent. /ansen et al., H13I sho>ed nor$al /021c concentrations in iron deficiency, >hich dro::ed to su0nor$al le;els after iron su::le$entation. Rai et al., H1+I in;estigated the different $ethods and no difference >as de- tected a$ong the colori$etric $ethods, ioneAchange chro$a- togra:hy and affinity chro$atogra:hy. 6he co$$only :erfor$ed i$$unotur0ido$etric $ethod >as :erfor$ed to deter$ine the /021c le;els in this study. 'n anae$ic :atients, the concentration of glycated hae$oglo0in has 0een re:orted to 0e increased des:ite the shortened life s:an of the erythrocytes. %e;eral $echanis$s ha;e 0een ad;ocated for this increase in the le;els of glycated hae$oglo0in in anae$ic :atients. 't has 0een :ro:osed that in iron deficiency, the Muaternary structure of the hae$oglo0in $olecule $ay 0e altered, and that the glycation of the -glo0in chains occurs $ore readily. 2ccording to so$e in;estigators, the increase in the gly- cated hae$oglo0in le;els in non-dia0etic anae$ic :atients has 0een $ainly attri0uted to the decrease in the hae$oglo0in le;els in these :atients H15I. #ut studies >hich ha;e in;estigated the glycation le;els of other :roteins ha;e not 0een carried out. 6his study has got a significant rele;ance 0ecause iron deficiency anae$ia is ;ery highly :re;alent in a tro:ical country li<e 'ndia. 'D2, 0eing a co$$on ;aria0le, influences the /021c le;els >hen they are esti$ated 0y the $ost co$$only e$:loyed $ethods li<e i$$unotur0ido$etry and so, the 'D2 $ust 0e corrected 0e- fore $a<ing any diagnostic or thera:eutic decision 0ased on the /021c le;els. /021c is co$$only used to assess the long-ter$ 0lood glucose control in the :atients >ith dia0etes $ellitus, 0e- cause the /021c ;alue has 0een sho>n to :redict the ris< for the de;elo:$ent of $any of the chronic co$:lications in dia0etes H1),17I.

lABORATORy InveSTIgATIOnS
6he 0lood s:eci$ens >ere dra>n after an o;ernight fast. 2 %ys- $aA auto$ated hae$atology analyser >as used for the >hole 0lood counts Hhae$oglo0in /0!, hae$atocrit /ct!, $ean cor:us- cular ;olu$e 5CV!, and $ean cor:uscular hae$oglo0in 5C/!IK the seru$ ferritin le;els >ere $easured 0y using a Diate< <it in a 3a0o>ind se$iauto$ated analyser, and the :eri:heral 0lood s$ears >ere eAa$ined in all the :atients. 6he /021c le;els >ere deter$ined 0y tur0idi$etric i$$unoinhi0ition. 6his study >as a::ro;ed 0y the ethics Co$$ittee of %ree #ala=i 5edical College and /os:ital, Chro$:et ,Chennai, 'ndia. 2n in- for$ed consent >as o0tained fro$ all the su0=ects.

STATISTICAl AnAlySIS
2ll the results are :resented as $ean B %.D. 6he statistical significance of the difference 0et>een the grou:s >as e;aluated 0y the %tudentPs t-test. 6he correlation >as assessed 0y the :artial correlation analysis. 2 : ;alue of 0.05 >as selected as the :oint of $ini$al statistical significance.

ReSulTS
2ll the :ara$eters >hich >ere tested in 0oth the grou:s ha;e 0een re:orted in H6a0le*@ig-1I. 6he fasting and the :ost:randial 0lood glucose le;els confir$ed the nondia0etic status. 6he seru$ ferritin le;els indeA of the iron deficiency status! >ere lo> a$ong the iron deficient su0=ects 3.)(B1.( ng*$l! and the :eri:heral 0lood s$ears sho>ed a hy:ochro$ic $icrocytic :icture. 6he /021c le;els >ere significantly increased a$ong the 'D2 :atients as co$:ared to those in the controls. 6he $ean /021c 7.) B 0.5C! le;el in the :atients >ith 'D2 >as higher than that in the con9ara$eters 'D2 grou: nN50! Control grou: nN50!
/0, g*dl /ct, C 5CV, fl 5C/, :g @erritin, ng*$l @asting glucose, $g*dl 9ost:randial glucose, $g*dl /021c, C 10.)B1.+O 33.2B3.0O 72.3B+.2O 22.)B2.2O 3.)(B1.(O ,2.(B,.+ 10+.)B).1 7.) B 0.5CO 13.+B0.,) +1.+B2.7 (+.2B+.) 32.,B1.7 22.3B).1 ,0.7B10.) 101.,B5.( 5.5C B 0.(

COnCluSIOn
&ur results sho>ed that iron deficiency >as associated >ith higher :ro:ortions of /021c, >hich could cause :ro0le$s in the diagnosis of uncontrolled dia0etes $ellitus in iron-deficient :atients. 6he iron status $ust 0e considered during the inter:reta- tion of the /021c concentrations in Dia0etes $ellitus. 6he iron re:lace$ent thera:y is thus es:ecially i$:ortant in dia0etic :a- tients >ith iron deficiency, as it >ould also increase the relia0ility of the /021c deter$inations.

Re"eRenCeS
H1I De Rosa 5C, %anna 56, 5essana ', Castagno-la 5, .altieri 2, 6el- lone -,et al., .lycated hu$an hae$oglo0in /021c!" @unctional characteristics and $olecular $odeling studies. Biophys Chem. 1,,( K 72"323L35. H2I 9eterson F9, 9a;lo;ich J., .oldstein D, 3ittle R, -ngland J, 9eter- son C5. 8hat is hae$oglo0in 21cQ 2n analysis of glycated hae$o- glo0ins 0y electros:ray ioniJation $ass s:ectro$etry. Clin Chem. 1,,(K ++"1,51L5(.

Table!"ig#$%: 3a0oratory :ara$eters of study grou:s

#alasu0ra$anian %hanthi et al., -ffect of 'ron De?ciency on .lycation of /e$oglo0in in 1ondia0etics

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1)

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#alasu0ra$anian %hanthi et al., -ffect of 'ron De?ciency on .lycation of /e$oglo0in in 1ondia0etics

H3I %ha:iro R, 5c5anus 5, .arric< 3, 5cDonald 5J, #unn /@. 6he nonenJy$atic glycolisation of hu$an hae$oglo0in at $ulti:le sites. Metabolism. 1,7,K2( su::l!"+27L30. H+I #raun>ald -, @auci 2%, Fas:er D3, /auser %3, 3ongo D3, Ja$eson J3" Dia0etes $ellitus. /arrisonPs 9rinci:les of 'nternal 5edicine, ed 15, 2001K 22" 2105L0,. H5I Fi$ C, #ullard F5, /er$an 8/, #ec<les .3. 6he association 0e- t>een iron deficiency and the /021c le;els a$ong adults >ithout dia0etes in the 1ational /ealth and 1utrition -Aa$ination %ur;ey, 1,,,L200). Diabetes Care. 2010K 33" 7(0L(5. H)I 5ayer 6F, @reed$an RR. 9rotein glycosylation in dia0etes $ellitus" a re;ie> of the la0oratory $easure$ents and of their clinical utilities. Clin Chim Acta. 1,(3K 127"1+7e(+. H7I Co0an -, &Jdogan 5, 6i$uragaoglu 2. 6he effect of iron deficiency ane$ia on the le;els of hae$oglo0in 21c in nondia0etic :atients. Acta Haematol. 200+K 112" 12)L2(. H(I 3a:olla 2, 6raldi 9, @edele D. 6he i$:ortance of $easuring the :rod- ucts of the non enJy$atic glycation of :roteins. Clin Biochem. 2005K 3("103e15. H,I #ro>nlee 5. 6he negati;e conseMuences of glycation. Metabolism. 2000K +,",e13.

H10I 5ayer 6F, @reed$an RR. 9rotein glycosylation in dia0etes $ellitus" a re;ie> of the la0oratory $easure$ents and their clinical utilities. Clin Chim Acta. 1,(3K127"1+7e(+. H11I Cho>dhury 62, 3as<er %%. 6he ele;ated glycated hae$oglo0in in nondia0etic :atients is associated >ith an increased $ortality in $yocardial infarction. Postgrad Med J. 1,,(K7+"+(0e1. H12I #roo<s 29, 5etcalfe J, Day J3, -d>ards 5%. 'ron deficiency and glycosylated hae$oglo0in 21. Lancet. 1,(0K1, ii!"1+1. H13I /ansen 9., -ri<sen J, 2ndersen 65, &lesen 3. .lycosylated hae- $oglo0in /021c! in iron and ;ita$in #12 deficiency. J Intern Med. 1,,0K 227"133L3). H1+I Rai F#, 9atta0ira$an 61. 6he glycosylated hae$oglo0in le;els in iron-deficiency anae$ia. Indian J Med. 1,()K(3"23+L3). H15I -l-2gouJa ', 20u %hola 2, %irdah 5. 6he effect of iron deficiency anae$ia on the le;els of the hae$oglo0in su0ty:es" the :ossi0le conseMuences in a clinical diagnosis. Clin Lab Haematol. 2002K 2+"2(5e,. H1)I %tetler C, 5ueller #, Die$ 9. 8hat you al>ays >anted to <no> a0out /021c. Schwei Med !ochenschr. 2000K 130 ",,3L1005. H17I -del$an %V. 6he i$:ortance of glucose control. Med Clin "orth Am. 1,,(K (2"))5L(7.

246/&R %!" 1. Dr. #alasu0ra$anian %hanthi 2. Dr. Carnagarin Re;athy 3. Dr. 2rcot Jagdeesh>aran 5an=ula De;i +. Dr. %u0hashree 92R6'C432R% &@ C&16R'#46&R%" 1. 2ssociate 9rofessor, De:art$ent of #ioche$istry, 2. 9ostgraduate, De:art$ent of #ioche$istry, 3. 9rofessor S /od, De:art$ent of #ioche$istry, +. 2ssociate 9rofessor, De:art$ent of 9athology, %ree #ala=i 5edical College and /os:ital, Chennai, 'ndia.

125-, 2DDR-%%, --52'3 'D &@ 6/C&RR-%9&1D'1. 246/&R" Dr. Carnagarin Re;athy, 9ostgraduate, De:art$ent of #ioche$istry, %ree #ala=i 5edical College 2nd /os:ital, Clc 8or<s Road ,Chro$:et, Chennai-)000++, 'ndia. 9hone" ,,522)+,)2 --$ail" re;athycarnagarinTyahoo.co$ @'121C'23 &R &6/-R C&59-6'1. '16-R-%6%" 1one.
Date of %u0$ission" Jul 2+, 2012 Date of 9eer Re;ie>" 2ug 12, 2012 Date of 2cce:tance" %e: 03, 2012 Date of &nline 2head of 9rint" %e: 1(, 2012 Date of 9u0lishing" Jan 01, 2013

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