Monitoring glycaemic control in patients with diabetes

HbA1c is routinely measured for this purpose. The assay is run daily on weekdays and requires an EDTA plasma sample (purple top). Fructosamine can be used as an alternative when HbA1c is not appropriate. Fructosamine reflects blood glucose over two weeks rather than 2 to 3 months as it reflects glycation of albumin rather than haemoglobin. Fructosamine is performed on serum (yellow or red top) and run daily.

UHB, Clinical Chemistry

Last updated on 17 February 2018.
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Written by Super User on 17 February 2018. Posted in Clinical Services / Interpretation of Results

Diagnosis of Diabetes Mellitus

Conventionally diabetes mellitus was diagnosed by high fasting or random blood glucose concentrations, or an abnormal oral glucose tolerance test (OGTT) whilst haemoglobin A1c (HbA1c) was used to monitor longer term glycaemic control in patients with known diabetes mellitus.

In 2011, the World Health Organisation (WHO 2011) recommended that HbA1c measurements should also be used to diagnose diabetes in the majority of asymptomatic individuals, and this recommendation has been agreed in the UK (NHS Diabetes 2011).

An HbA1c of 48 mmol/mol or more is consistent with diabetes. If the patient has no symptoms then a second HbA1c result must be obtained within 2 weeks, and if it remains ≥48 mmol/mol diabetes mellitus is confirmed.

HbA1c values of 42 to 47 mmol/mol suggest a high risk of future diabetes. Such individuals should be offered structured lifestyle education and support to delay/prevent development of diabetes, and have an annual HbA1c test.

HbA1c must be measured in an accredited laboratory undertaking recommended quality assurance procedures. Near patient testing is not appropriate when HbA1c is used for the diagnosis of diabetes.

HbA1c is now the preferred method to diagnose diabetes, except in the following situations where this test would be unreliable, and in whom the traditional methods of diagnosis with blood glucose concentrations remain the method of choice:

Haemoglobinopathies
Increased red cell turnover
Anaemia (haemoglobin < 80 g/L)
?Type 1 diabetes or acute onset of symptoms of diabetes
?Gestational diabetes
Children and adolescents
Patients taking steroids and antipsychotic or other medications that cause a rapid rise in blood glucose

Despite this new approach, if an individual has abnormally high random or fasting blood glucose levels or abnormal OGTT, which would be consistent with diabetes on the traditional criteria, then that patient should be considered to have diabetes irrespective of their HbA1c value. Without symptoms of diabetes two abnormal tests of the same type (two high fasting/random blood glucoses or a diabetic OGTT) are required to confirm diabetes mellitus.

UHB, Clinical Chemistry, Clinical

Last updated on 17 February 2018.
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Written by Louise Thomas on 30 November 2020. Posted in Clinical Chemistry Fluid Analysis Guidelines

Fluid Analysis Guidelines

Below are some guidelines for fluid analyses which may be of clinical value. Please contact the Duty Biochemist on x16543 if more information is required:

Fluid type	Clinical Indication	Analyses available	Specimen Container	Comments
Ascitic Fluid	? cirrhotic or malignant	Albumin Total protein Cholesterol Triglycerides LDH	Plain universal	Serum albumin should be simultaneously measured for comparison.
	? SBP	pH Total protein	See comment Plain universal	For rare instances pH should be collected anaerobically with heparin and then measured in a blood gas analyser using clot filter.
	? pancreatic fistula ?pancreatitis	Amylase	Plain universal	Serum amylase should be measured.
	? tubercular	Glucose	Fluoride oxalate (grey top)
Chest Drain Fluid	? chylothorax	Chylomicrons Cholesterol Triglycerides	Plain universal
CSF	? bacterial meningitis	Protein Glucose	Plain universal Fluoride oxalate (grey top)
	? Subarachnoid haemorrhage	Xanthochromia	Plain universal protected from light	Do not use pod system to send sample to lab. Serum total protein and bilirubin should be measured simultaneously.
	?congenital disorder ?cerebral ischaemia	Lactate	Fluoride oxalate (grey top)	Sent to BCH Biochemistry.
	?brain metastases	AFP, HCG, placental ALP	Plain Universal	Sent to Charing Cross for analysis.
	Diagnosis/investigation of inborn errors of neurotransmitter metabolism	Neurotransmitters	See comment	Specific collection requirements – contact Duty Biochemist on ext. 16543 well in advance of arranging test. Sent to Neuroimmunology lab, London.
	?narcolepsy with cataplexy	Orexin/Hypocretin	Plain Universal	Sent to Immunology, Oxford.
	?neurosarcoidosis	ACE	Plain Universal	CSF total protein also required for interpretation. Sent to Neurometabolic unit, London.
Cyst Fluid	?thyroid tissue/met	Thyroglobulin	Plain universal	Requires discussion with laboratory prior to request (contact Duty Biochemist on ext. 16543)
Drain Fluid	? contains urine	Urea Creatinine	Plain universal	Comparison of fluid urea and creatinine with serum will identify significant contamination with urine
Drain Fluid	?biliary fistula Post surgery	Amylase Bilirubin	Plain universal
Gastric Aspirate	? reflux ?achlorhydria	pH	Plain universal	Occasionally gastric pH may be requested in patients suspected of intestinal reflux or achlorhydria. Normally the fasting gastric pH is about 1-2.
Pancreatic Cyst Fluid	? Ca pancreas	CEA CA 19-9 Amylase Glucose	Plain universal Fluoride oxalate (Grey top) required
Pleural Fluid Four types of fluids can accumulate in the pleural space: Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyema)	? transudate or exudates A transudate fluid is produced through pressure filtration without capillary injury while exudate is "inflammatory fluid" leaking between cells. Most common causes of pleural exudates are bacterial pneumonia and malignancy. Most common causes of pleural transudates are left ventricular failure and cirrhosis.	Total Protein LDH	Plain universal	TP <25g/L indicates transudate. TP >35g/L indicates exudate. Light’s criteria applies to pleural fluid TP between 25 and 35g/L. A fluid is an exudate if any of the following apply: Ratio of fluid protein to serum protein is >0.5 Ratio of fluid LDH to serum LDH is >0.6 Pleural fluid LDH is > 2/3rds the upper reference limit for plasma LDH. Measure serum protein and LDH simultaneously
	? infected	pH	See comment	This is part of British Thoracic Society’s guidelines for differentiating infective from non-infective pleural effusions, can only be measured on fresh specimen collected anaerobically using a dedicated blood gas analyzer. This analyser can be found on W513 (respiratory).
	? chylothorax	Chylomicrons Cholesterol Triglyceride	Plain universal
	? pancreatitis	Amylase	Plain universal	Patient's serum amylase should be measured for comparison.
	? rheumatic cause	Glucose	Fluoride oxalate (grey top) tube required.
Nasal Fluid	? CSF	Tau protein	Plain universal	Sent to Immunology, Sheffield.
Salivary Cortisol	?Cushing’s ONDST	Salivary Cortisol	Salivette or Plain universal	Saliva specimens should be collected using a Sarstedt cortisol salivette (these can be requested from Chromatography). Saliva collected into a plain container by passive drool is also acceptable.
Synovial Fluid	Refer to Microbiology	N/A		N/A.
Urine pH	?cause of metabolic acidosis	pH	Plain universal	In patients with a metabolic acidosis and suspected renal tubular acidosis, urine pH measurement is indicated.

Last updated on 05 January 2021.
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Monitoring glycaemic control in patients with diabetes

Diagnosis of Diabetes Mellitus

Fluid Analysis Guidelines

Below are some guidelines for fluid analyses which may be of clinical value. Please contact the Duty Biochemist on x16543 if more information is required:

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