Glycated hemoglobin

Glycated hemoglobin
Medical diagnostics
MedlinePlus 003640
eMedicine 2049478
LOINC 41995-2

Glycated hemoglobin (hemoglobin A1c, HbA1c, A1C, or Hb1c; sometimes also referred to as being Hb1c or HGBA1C) is a form of hemoglobin that is measured primarily to identify the three-month average plasma glucose concentration. The test is limited to a three-month average because the lifespan of a red blood cell is four months (120 days). However, since red blood cells do not all undergo lysis at the same time, HbA1C is taken as a limited measure of three months. It is formed in a non-enzymatic glycation pathway by hemoglobin's exposure to plasma glucose.

HbA1c is a measure of the beta-N-1-deoxy fructosyl component of hemoglobin.[1] The origin of the naming derives from Hemoglobin type A being separated on cation exchange chromatography. The first fraction to separate, probably considered to be pure Hemoglobin A, was designated HbA0, the following fractions were designated HbA1a, HbA1b, and HbA1c, respective of their order of elution. There have subsequently been many more sub fractions as separation techniques have improved.[2] 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 in a predictable way. This serves as an indicator that blood sugar is increasing and that action should be taken.

In diabetes mellitus, higher amounts of glycated hemoglobin, indicating poorer control of blood glucose levels, have been associated with cardiovascular disease, nephropathy, neuropathy, and retinopathy. A trial on a group of patients with Type 1 diabetes found that monitoring by caregivers of HbA1c led to changes in diabetes treatment and improvement of metabolic control compared to monitoring only of blood or urine glucose.[3] However, a trial designed specifically to determine whether reducing HbA1c below the normal 6%, using primarily insulin and sulfonylureas (both known to easily drive blood sugar too low), would reduce the rate of cardiovascular events in type 2 diabetes found higher mortality—the trial was terminated early.[4] The negative outcomes may well have been a result of the treatment approach, primarily insulin and sulfonylureas, utilized in the "intensive" treatment group instead of LCHF (Low-Carbohydrate High Fat diet), GlP-1 analogues & SGLT-2 inhibitors, none of which have these problems & lower cardiovascular mortality.

History

Hemoglobin A1c was first separated from other forms of hemoglobin by Huisman and Meyering in 1958 using a chromatographic column.[5] It was first characterized as a glycoprotein by Bookchin and Gallop in 1968.[6] Its increase in diabetes was first described in 1969 by Samuel Rahbar et al.[7] The reactions leading to its formation were characterized by Bunn and his coworkers in 1975.[8]

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.[9]

Damage mechanisms

Glycated hemoglobin causes an increase of highly reactive free radicals inside blood cells. Radicals alter blood cell membrane properties. This leads to blood cell aggregation and increased blood viscosity which results in impaired blood flow.[10]

Another way glycated Hb causes damage is via inflammation which results in atheroscelerotic plaque (atheroma) formation. Free radical build-up promotes the excitation of Fe2+-Hb through Fe3+-Hb into abnormal ferryl Hb (Fe4+-Hb). Fe4+ is unstable and reacts with specific amino acids in Hb to regain its Fe3+ oxidation state. Hb molecules clump together via cross-linking reactions and these Hb clumps (multimers) promote cell damage and the release of Fe4+-Hb into the matrix of innermost layers (subendothelium) of arteries and veins. This results in increased permeability of interior surface (endothelium) of blood vessels and production of pro-inflammatory monocyte adhesion proteins, which promote macrophage accumulation in blood vessel surfaces ultimately leading to harmful plaques in these vessels.[10]

Highly glycated Hb-AGEs go through vascular smooth muscle layer and inactivate acetylcholine induced endothelium-dependent relaxation possibly through binding to nitric oxide (NO) preventing its normal function. NO is a potent vasodilator and also inhibits formation of plaque promoting LDLs (i.e. “bad cholesterol”) oxidized form.[10]

This overall degradation of blood cells also releases heme from them. Loose heme can cause oxidation of endothelial and LDL proteins which results in plaques.[10]

Principle in medical diagnostics

Glycation of proteins is a frequent occurrence, but in the case of hemoglobin, a nonenzymatic condensation reaction occurs between glucose and the N-end of the beta chain. This reaction produces a Schiff base (R-N=CHR', R = beta chain, CHR'= glucose-derived), which is itself converted to 1-deoxyfructose. This second conversion is an example of an Amadori rearrangement.

Glycation pathway via Amadori Rearrangement (in HbA1c, R is typically N-terminal valine).[11]

When blood glucose levels are high, glucose molecules attach to the hemoglobin in red blood cells. The longer hyperglycemia occurs in blood, the more glucose binds to hemoglobin in the red blood cells and the higher the glycated hemoglobin.

Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell, therefore, reflects the average level of glucose to which the cell has been exposed during its life-cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation.

A1c is a weighted average of blood glucose levels during the life of the red blood cells (117 days for men and 106 days in women[12]). Therefore, glucose levels on days nearer to the test contribute substantially more to the level of A1c than the levels in days further from the test.[13]

This is also supported by data from clinical practice showing that HbA1c levels improved significantly after 20 days from start or intensification of glucose-lowering treatment.[14]

Measuring HbA1c

A number of techniques are used to measure hemoglobin A1c.

Laboratories use:

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 (NGSP) to standardise them against the results of the 1993 Diabetes Control and Complications Trial (DCCT).[15] An additional percentage scale, Mono S has previously been in use by Sweden and KO500 is in use in Japan.[16][17]

Switch to IFCC units

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and International Diabetes Federation (IDF) have agreed that, in the future, HbA1c is to be reported in the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) units.[18] IFCC reporting was introduced in Europe except for the UK in 2003;[19] the UK carried out dual reporting from 1 June 2009 [20] until 1 October 2011.

Conversion between DCCT and IFCC is by the following equation:[21]

Interpretation of results

Laboratory results may differ depending on the analytical technique, the age of the subject, and biological variation among individuals. Two individuals with the same average blood sugar can have HbA1c values that differ by as much as 3 percentage points.

Higher levels of HbA1c are found in people with persistently elevated blood sugar, as in diabetes mellitus. While diabetic patient treatment goals vary, many include a target range of HbA1c values. A diabetic person with good glucose control has a HbA1c level that is close to or within the reference range.

The International Diabetes Federation and the American College of Endocrinology recommend HbA1c values below 48 mmol/mol (6.5 DCCT %), while the American Diabetes Association recommends HbA1c be below 53 mmol/mol (7.0 DCCT %) for most patients.[22] Recent results from large trials suggest that a target below 53 mmol/mol (7 DCCT %) for older adults with type 2 diabetes may be excessive: Below 53 mmol/mol (7 DCCT %) the health benefits of reduced A1C become smaller, and the intensive glycemic control required to reach this level leads to an increased rate of dangerous hypoglycemic episodes.[23]

A retrospective study of 47,970 old type 2 diabetes patients found that patients with an HbA1c more than 48 mmol/mol (6.5 DCCT %) had an increased mortality rate,[24] but a later international study contradicted these findings.[25][26][27]

A review of the UKPDS, ACCORD (Action to Control Cardiovascular Risk in Diabetes), ADVANCE and VADT (Veterans Affairs Diabetes Trials) estimated that the risks of the main complications of diabetes (diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, and macrovascular disease) decreased by approximately 3% for every 1 mmol/mol decrease in HbA1c.[28]

However, a trial by ACCORD designed specifically to determine whether reducing HbA1c below 6.0% using increased amounts of medication would reduce the rate of cardiovascular events found higher mortality with this intensive therapy, so much so that the trial was terminated 17 months early.[4]

Practitioners must consider an individual patient's health, their risk of hypoglycemia, and their specific health risks when setting a target HbA1c level. Because patients are responsible for averting or responding to their own hypoglycemic episodes, the patient's input and the doctor's assessment of the patient's self-care skills are also important.

Persistent elevations in blood sugar (and, therefore, HbA1c) increase the risk of long-term vascular complications of diabetes such as coronary disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach). Poor blood glucose control also increases the risk of short-term complications of surgery such as poor wound healing.

Lower-than-expected levels of HbA1c can be seen in people with shortened red blood cell lifespan, such as with glucose-6-phosphate dehydrogenase deficiency, sickle-cell disease, or any other condition causing premature red blood cell death. Blood donation will result in rapid replacement of lost RBCs with newly formed red blood cells. Since these new RBCs will have only existed for a short period of time, their presence will lead HbA1c to underestimate the actual average levels. There may also be distortions resulting from blood donation which occurred as long as two months before due to an abnormal synchronization of the age of the RBCs, resulting in an older than normal average blood cell life (resulting in an overestimate of actual average blood glucose levels). Conversely, higher-than-expected levels can be seen in people with a longer red blood cell lifespan, such as with Vitamin B12 or folate deficiency.[29]

Results can be unreliable in many circumstances, for example after blood loss, after surgery, blood transfusions, anemia, or high erythrocyte turnover; in the presence of chronic renal or liver disease; after administration of high-dose vitamin C; or erythropoetin treatment.[30] In general, the reference range (that found in healthy young persons), is about 30–33 mmol/mol (4.9–5.2 DCCT %).[31] The mean HbA1c for diabetics type 1 in Sweden in 2014 was 63 mmol/mol (7.9 DCCT%) and for type 2, 61 mmol/mol (7.7 DCCT%).[32]

The approximate mapping between HbA1c values given in DCCT percentage (%) and eAG (estimated average glucose) measurements is given by the following equation:[30]

eAG(mg/dl) = 28.7 × A1C − 46.7
eAG(mmol/l) = 1.59 × A1C − 2.59
Data in parentheses are 95% confidence intervals
HbA1ceAG
%mmol/mol[33]mmol/Lmg/dL
5315.4 (4.2–6.7)97 (76–120)
6427.0 (5.5–8.5)126 (100–152)
7538.6 (6.8–10.3)154 (123–185)
86410.2 (8.1–12.1)183 (147–217)
97511.8 (9.4–13.9)212 (170–249)
108613.4 (10.7–15.7)240 (193–282)
119714.9 (12.0–17.5)269 (217–314)
1210816.5 (13.3–19.3)298 (240–347)
1311918.1 (15–21)326 (260–380)
1413019.7 (16–23)355 (290–410)
1514021.3 (17–25)384 (310–440)
1615122.9 (19–26)413 (330–480)
1716224.5 (20–28)441 (460–510)
1817326.1 (21–30)470 (380–540)
1918427.7 (23–32)499 (410–570)

The 2010 American Diabetes Association Standards of Medical Care in Diabetes added the HbA1c ≥ 48 mmol/mol (≥6.5 DCCT %) as another criterion for the diagnosis of diabetes.[34]

Indications and use

Glycated hemoglobin testing is recommended for both checking the blood sugar control in people who might be pre-diabetic and monitoring blood sugar control in patients with more elevated levels, termed diabetes mellitus. For a single blood sample, it provides far more revealing information on glycemic behavior than a fasting blood sugar value. However, fasting blood sugar tests are crucial in making treatment decisions. The American Diabetes Association guidelines are similar to others in advising that the glycated hemoglobin test be performed at least twice a year in patients with diabetes who are meeting treatment goals (and who have stable glycemic control) and quarterly in patients with diabetes whose therapy has changed or who are not meeting glycemic goals.[35]

Glycated hemoglobin measurement is not appropriate where there has been a change in diet or treatment within 6 weeks. Likewise, the test assumes a normal red blood cell aging process and mix of hemoglobin subtypes (predominantly HbA in normal adults). Hence, people with recent blood loss, hemolytic anemia, or genetic differences in the hemoglobin molecule (hemoglobinopathy) such as sickle-cell disease and other conditions, as well as those that have donated blood recently, are not suitable for this test.

Due to glycated hemoglobin's variability (as shown in the table above), additional measures should be checked in patients at or near recommended goals. People with HbA1c values at 64 mmol/mol or less should be provided additional testing to determine whether the HbA1c values are due to averaging out high blood glucose (hyperglycemia) with low blood glucose (hypoglycemia) or the HbA1c is more reflective of an elevated blood glucose that does not vary much throughout the day. Devices such as continuous blood glucose monitoring allow people with diabetes to determine their blood glucose levels on a continuous basis, testing every few minutes. Continuous use of blood glucose monitors is becoming more common, and the devices are covered by many health insurance plans but not by Medicare in the United States. The supplies tend to be expensive, since the sensors must be changed at least weekly. Another test that is useful in determining if HbA1c values are due to wide variations of blood glucose throughout the day is 1,5-anhydroglucitol, also known as GlycoMark. GlycoMark reflects only the times that the person experiences hyperglycemia above 180 mg/dL over a two-week period.

Concentrations of hemoglobin A1 (HbA1) are increased, both in diabetic patients and in patients with renal failure, when measured by ion-exchange chromatography. The thiobarbituric acid method (a chemical method specific for the detection of glycation) shows that patients with renal failure have values for glycated hemoglobin similar to those observed in normal subjects, suggesting that the high values in these patients are a result of binding of something other than glucose to hemoglobin.[36]

In autoimmune hemolytic anemia, concentrations of hemoglobin A1 (HbA1) is undetectable. Administration of prednisolone (PSL) will allow the HbA1 to be detected.[37] The alternative fructosamine test may be used in these circumstances and it also reflects an average of blood glucose levels over the preceding 2 to 3 weeks.

All the major institutions like International Expert Committee Report, drawn from the International Diabetes Federation (IDF), the European Association for the Study of diabetes (EASD), and the American Diabetes Association (ADA), suggests the HbA1c level of 48 mmol/mol (6.5 DCCT %) as a diagnostic level.[38] The Committee Report further states that, when HbA1c testing cannot be done, the fasting and glucose tolerance tests be done.

Diagnosis of diabetes during pregnancy continues to require fasting and glucose tolerance measurements for gestational diabetes, and not the glycated hemoglobin.

Modification by diet

Meta-analysis has shown probiotics to cause a statistically significant reduction in glycated hemoglobin in type 2 diabetics.[39] Trials with multiple strains of probiotics had statistically significant reductions in glycated hemoglobin, whereas trials with single strains did not.[39]

The dietary fibers, lignans, and omega-3 fatty acids in flaxseed protect against type 2 diabetes.[40] Supplementation of type 2 diabetics with ten grams of flaxseed powder for one month has been shown to reduce fasting blood glucose by 19.7% and glycated hemoglobin by 15.6%.[40]

Modification by exercise training

A meta-analysis of research done to identify the effect of two different kinds of training programs (combined aerobic and eccentric resistance exercise program and aerobic exercise only) on the glycated hemoglobin levels of individuals with type 2 diabetes mellitus (T2DM) found that the effect of combining resistance exercise with aerobic exercise improved the glucose control more than just the aerobics alone, and it should be noted that BMI of the resistance plus aerobic exercise group decreased more than the aerobic only group.

The average effect of the training programs included reductions of glycated hemoglobin of 9 mmol/mol (0.8 percentage points), which was a result similar to that of long-term diet and drug or insulin therapy (which result in a reduction of 6.5–9.0 mmol/mol (i.e. 0.6–0.8 points)).[41]

Standardization and traceability

Hemoglobin A1c is now standardized and traceable to IFCC methods HPLC-CE and HPLC-MS.

A new unit (mmol/mol) is used as part of this standardization. The standardized test does not test for iodine levels in the blood. Hypothyroidism or iodine supplementation are known sources that artificially raise the A1c number.[42]

Veterinary medicine

HbA1c is not generally used in the treatment of cats and dogs with diabetes; fructosamine is favoured instead. HbA1c has not been found useful in these animals.[43]

See also

References

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  2. ↑ Peterson KP, Pavlovich JG, Goldstein D, Little R, England J, Peterson CM (1998). "What is hemoglobin A1c? An analysis of glycated hemoglobins by electrospray ionization mass spectrometry". Clinical Chemistry. 44 (9): 1951–58. PMID 9732983.
  3. ↑ Larsen ML, Hørder M, Mogensen EF (1990). "Effect of long-term monitoring of glycosylated haemoglobin levels in insulin-dependent diabetes mellitus". N. Engl. J. Med. 323 (15): 1021–25. doi:10.1056/NEJM199010113231503. PMID 2215560.
  4. 1 2 Gerstein HC, Miller ME, Byington RP, et al. (2008). "Effects of Intensive Glucose Lowering in Type 2 Diabetes". New England Journal of Medicine. 358 (24): 2545–59. doi:10.1056/NEJMoa0802743. ISSN 0028-4793. PMC 4551392. PMID 18539917.
  5. ↑ Huisman TH, Martis EA, Dozy A (1958). "Chromatography of hemoglobin types on carboxymethylcellulose". J. Lab. Clin. Med. 52 (2): 312–27. PMID 13564011.
  6. ↑ Bookchin RM, Gallop PM (1968). "Structure of haemoglobin A1c: nature of the N-terminal beta chain blocking group". Biochem. Biophys. Res. Commun. 32 (1): 86–93. doi:10.1016/0006-291X(68)90430-0. PMID 4874776.
  7. ↑ Rahbar S, Blumenfeld O, Ranney HM (1969). "Studies of an unusual hemoglobin in patients with diabetes mellitus". Biochem. Biophys. Res. Commun. 36 (5): 838–43. doi:10.1016/0006-291X(69)90685-8. PMID 5808299.
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  15. ↑ Developing Point of care HbA1c tests for Diabetes monitoring, Barry Plant, Originally Published IVDT July/August 2008
  16. ↑ [Clinical Chemistry 50:1 166–74 (2004)]
  17. 1 2 HbA1c in a new way By the Swedish Diabetes Association. Retrieved Mars 2011
  18. ↑ Geistanger A, Arends S, Berding C, Hoshino T, Jeppsson JO, Little R, Siebelder C, Weykamp C (August 2008). "Statistical methods for monitoring the relationship between the IFCC reference measurement procedure for hemoglobin A1c and the designated comparison methods in the United States, Japan, and Sweden". Clin. Chem. 54 (8): 1379–85. doi:10.1373/clinchem.2008.103556. PMID 18539643.
  19. ↑ Manley S, John WG, Marshall S (July 2004). "Introduction of IFCC reference method for calibration of HbA: implications for clinical care". Diabet. Med. 21 (7): 673–76. doi:10.1111/j.1464-5491.2004.01311.x. PMID 15209757.
  20. ↑ "Standardisation of the reference method for the measurement of HbA1c to improve diabetes care" (PDF). The Association for Clinical Biochemistry and Diabetss UK. April 2008. Archived from the original (PDF) on 2011-07-22. Retrieved 2009-07-02.
  21. ↑ "HbA1c Standardisation For Laboratory Professionals" (PDF). Diabetes UK. Retrieved 2009-07-02.
  22. ↑ "Executive Summary: Standards of medical care in diabetes—2009". Diabetes Care. 32: S6–S12. 2009. doi:10.2337/dc09-S006.
  23. ↑ Lehman R, Krumholz HM (2009). "Tight control of blood glucose in long standing type 2 diabetes". Br Med J. 338: b800. doi:10.1136/bmj.b800.
  24. ↑ Currie, Craig J; Peters, John R; Tynan, Aodán; Evans, Marc; Heine, Robert J; Bracco, Oswaldo L; Zagar, Tony; Poole, Chris D (2010). "Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study". The Lancet. 375 (9713): 481–89. doi:10.1016/S0140-6736(09)61969-3.
  25. ↑ "ADVANCE Study Contradicts ACCORD Findings". Diabetes Self-Management. 2008-03-07. Retrieved 2013-06-10.
  26. ↑ "The largest ever study of diabetes shows intensive glucose control reduces serious complications". Advance-trial.com. Retrieved 2013-06-10.
  27. ↑ Heller, Simon R. (2009-11-01). "A Summary of the ADVANCE Trial". Diabetes Care. 32 (Suppl 2): S357–61. doi:10.2337/dc09-S339. ISSN 0149-5992. PMC 2811451. PMID 19875581.
  28. ↑ Shubrook JH, Shubrook J (2010). "Risks and benefits of attaining HbA(1c) goals: Examining the evidence". The Journal of the American Osteopathic Association. 110 (7 Suppl 7): e7–e12. PMID 20644204.
  29. ↑ Kilpatrick ES, Bloomgarden ZT, Zimmet PZ (2009). "Is haemoglobin A1c a step forward for diagnosing diabetes?". BMJ. 339: b4432. doi:10.1136/bmj.b4432. PMID 19903702.
  30. 1 2 Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ (2008). "Translating the A1C assay into estimated average glucose values". Diabetes Care. 31 (8): 1473–78. doi:10.2337/dc08-0545. PMC 2742903. PMID 18540046.
  31. ↑ Saaddine, Jinan B.; Fagot-Campagna, Anne; Rolka, Deborah; Narayan, K. M. Venkat; Geiss, Linda; Eberhardt, Mark; Flegal, Katherine M. (2002-08-01). "Distribution of HbA(1c) levels for children and young adults in the U.S.: Third National Health and Nutrition Examination Survey". Diabetes Care. 25 (8): 1326–30. doi:10.2337/diacare.25.8.1326. ISSN 0149-5992. PMID 12145229.
  32. ↑ "Nationella Diabetesregistret Årsrapport 2014 års resultat" (PDF). Nationella Diabetesregistret Årsrapport 2014 års resultat (in Swedish). Nationella Diabetes Registret. Retrieved 2015-12-14.
  33. ↑ Change to HbA1c values at Diabetes UK, 2013
  34. ↑ "Executive summary: Standards of medical care in diabetes—2010". Diabetes Care. 33 (Suppl 1): S4–10. January 2010. doi:10.2337/dc10-S004. PMC 2797389. PMID 20042774.
  35. ↑ American Diabetes Association (2007). "Standards of medical care in diabetes". Diabetes Care. 30 (Suppl 1): S4–S41. doi:10.2337/dc07-S004. PMID 17192377.
  36. ↑ "Glycated Hemoglobin in Uremic Patients as Measured by Affinity and Ion-Exchange Chromatography" (PDF). clinchem.com. Retrieved 2009-08-31.
  37. ↑ "Undetectable Glycosolated Hemoglobin in Autoimmune Hemolytic Anemia" (PDF). repository.oai.yamaguchi-u.ac.jp. Retrieved 2009-08-31.
  38. ↑ The International Expert Committee (2009). "International expert committee report on the role of the A1C assay in the diagnosis of diabetes". Diabetes Care. 32 (7): 1327–34. doi:10.2337/dc09-9033. PMC 2699715. PMID 19502545.
  39. 1 2 Sun J, Buys NJ (2016). "Glucose- and glycaemic factor-lowering effects of probiotics on diabetes: a meta-analysis of randomised placebo-controlled trials" (PDF). British Journal of Nutrition. 115 (7): 1167–77. doi:10.1017/S0007114516000076. PMID 26899960.
  40. 1 2 Goyal A, Sharma V, Upadhyay N, Gill S, Sihag M (2014). "Flax and flaxseed oil: an ancient medicine & modern functional food". Journal of Food Science and Technology. 51 (9): 1622–53. doi:10.1007/s13197-013-1247-9. PMC 4152533. PMID 25190822.
  41. ↑ Marcus RL, Smith S, Morrell G, Addison O, Dibble LE, Wahoff-Stice D, Lastayo PC (November 2008). "Comparison of combined aerobic and high-force eccentric resistance exercise with aerobic exercise only for people with type 2 diabetes mellitus". Phys Ther. 88 (11): 1345–54. doi:10.2522/ptj.20080124. PMC 2579905. PMID 18801851.
  42. ↑ "Hypothyroidism Falsely Raises HbA1c and Glycated Albumin Levels". Diabetes In Control. 12 November 2010.
  43. ↑ Delack, J. B., & Stogdale, L. (1983). Glycosylated Hemoglobin Measurement in Dogs and Cats: Implications for its Utility in Diabetic Monitoring. The Canadian Veterinary Journal, 24(10), 308–11.
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