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Diabet Med. 2018 Nov 26. doi: 10.1111/dme.13870. [Epub ahead of print]

Utility of HbA1c assessment in people with diabetes awaiting liver transplantation.

Author information

Medical School, University of Birmingham, Birmingham.
Clinical Laboratory Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham.
Diabetes Translational Research Group, Diabetes Centre, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham.
Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham.
Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham.
Mammalian Genetics Unit, Medical Research Council Harwell Institute, Harwell.
Gloucester Retinopathy Research Group, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham.
Leeds Liver Unit,, St James's University Hospital, Leeds.
Diabetes Research Group, Swansea University, Swansea, UK.
HRB-Clinical Research Facility, University College Cork, Cork, Ireland.



To investigate the relationship between HbA1c and glucose in people with co-existing liver disease and diabetes awaiting transplant, and in those with diabetes but no liver disease.


HbA1c and random plasma glucose data were collected for 125 people with diabetes without liver disease and for 29 people awaiting liver transplant with diabetes and cirrhosis. The median (interquartile range) Model for End Stage Liver Disease score for the study cohort was calculated as 12 (9-17; normal <6). In those with cirrhosis, this was caused by non-alcoholic fatty liver disease, hepatitis C, alcoholic liver disease, hereditary haemochromatosis, polycystic liver/kidneys, cryptogenic/non-cirrhotic portal hypertension and α-1-antitrypsin-related disease.


The median (interquartile range) age of the diabetes with cirrhosis group was 55 (49-63) years compared to 60 (50-71) years (P=0.13) in the group without cirrhosis. In the diabetes with cirrhosis group there were 21 men (72%) compared with 86 men (69%) in the group with diabetes and no cirrhosis (P=0.82). Of the group with diabetes and cirrhosis, 27 people (93%) were of white European ethnicity, two (7%) were South Asian and none was of Afro-Caribbean/other ethnicity compared with 94 (75%), 16 (13%), 10 (8%)/5 (4%), respectively, in the group with diabetes and no cirrhosis (P=0.20). The median (interquartile range) HbA1c concentrations were 41 (32-56) mmol/mol [5.9 (5.1-7.3)]% vs 61 (52-70) mmol/mol [7.7 (6.9-8.6)%; P<0.001], respectively, in the diabetes with cirrhosis group vs the diabetes without cirrhosis group and the glucose concentrations were 8.4 (7.0-11.2) mmol/l vs 7.3 (5.2-11.5) mmol/l (P=0.17). HbA1c concentration was depressed by 20 mmol/mol (1.8%; P<0.001) in 28 participants with cirrhosis but elevated by 28 mmol/mol (2.6%) in the participant with α-1-antitrypsin disorder. Those with cirrhosis and depressed HbA1c concentrations had fewer larger erythrocytes, and higher red cell distribution width and reticulocyte count. This was reflected in the positive association of glucose with mean cell volume (r=0.39) and haemoglobin level (r=0.49) and the negative association for HbA1c concentration (r=-0.28 and r=-0.26, respectively) in the diabetes group.


HbA1c is not an appropriate test for blood glucose in people with cirrhosis and diabetes awaiting transplant as it reflects altered erythrocyte presentation. This article is protected by copyright. All rights reserved.


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