European Journal of Cardiovascular Medicine

Diabetes mellitus (DM) is a metabolic disease that is characterized by hyperglycemia and abnormalities in insulin secretion & activity. DM has been classified into several forms such as type 1 DM (T1DM), type 2 DM (T2DM), gestational diabetes, and other diabetes subtypes such as maturity onset diabetes of young and latent autoimmune diabetes in adults [1]. The risk factors for diabetes include heredity, obesity, physical inactivity, poor diet, stress, urbanization, impaired glucose tolerance, and hypertension [2]. Patients with diabetes who have chronic hyperglycemia have a higher risk of long-term damage to and dysfunction of many organs, especially the eyes (retinopathy), kidneys (nephropathy), nerves (neuropathy), heart (cardiovasculopathy), and blood vessels (vasculopathy), which ultimately lead to a variety of diabetic complications. These complicated problems of diabetes affect patients' quality of life while also raising the risk of morbidity and mortality [3-4]. The concentration of HbA1c depends on the concentration of glucose in the plasma and the duration of hyperglycemia and is an index of diabetic control for a period over past 12 weeks. High levels of glycated hemoglobin have shown to impair endothelium mediated vasoactive responses, which can lead to hypertension and vascular diseases in diabetic patients [5]. Hematological parameters are routinely measured in diabetic patients. Some of these, such as white blood cell (WBCs) count and hematocrit (HCT) level, have been shown to be associated with insulin resistance and incident T2DM [6]. In diabetic patients, hematological alterations are associated with the production of reactive oxygen species (ROS) as a consequence of long-term hyperglycemia. Excessive ROS production causes oxidative stress, leading to tissue damage, hematological alterations, and endothelial and RBC dysfunction [7-8]. Patients with DM are more prone to anemia. Several studies have revealed that total leukocyte count (TLC), Neutrophil and lymphocyte counts are higher in T2DM patients [9-10]. The hematological parameters study aims to find the association between HbA1c and hematology markers and determine whether there is a significant correlation between the microvascular complications of DM and these parameters.

AIMS AND OBJECTIVES
The purpose of this study is to compare the alteration of hematological parameters among type 2 diabetes mellitus patients and non diabetic subjects in our tertiary care hospital

This is a prospective cross sectional study carried out in the department of biochemistry in collaboration with department of medicine in Radha Devi Jageshwari Memorial Medical College, Turki, Muzaffarpur ,Bihar. Patients diagnosed as type 2 diabetes mellitus attending medicine OPD during the study period were enrolled in this study.

Inclusion criteria:

• Participants age ≥18 years and both genders
• Participants who provided written informed consent for the study

Exclusion criteria:

• Participants age <18 years
• patients using drugs affecting platelet function,
• patients with hemoglobinopathies,
• pregnant females,
• patients with acute or chronic infections, and chronic diseases or malignancies .
• Participants who not provided written informed consent for the study

One hundred and twenty patients with T2DM and same number of age matched controls (healthy subjects) were included. Controls had no concurrent acute illnesses, no known history of diabetes and their fasting blood glucose (FBG) levels were < 110 mg/dl

Type 2 diabetes mellitus was diagnosed by fasting blood sugar (FBS), post prandial blood glucose (PPBS) and glycosylated hemoglobin (HbA1c). The diagnosis of DM was based on the American Diabetes Association diabetes mellitus classification criteria with fasting blood glucose of ≥126 mg/dl being considered as positive for DM. impaired fasting glucose (Prediabetes),  FBG: > 110 mg/dl to <126 mg/dl.

Detailed history and socio-demographic data were collected from each subject. Various investigations like: hemoglobin, HbA1c, WBCs, MCHC, MCH, RBCs, MCV, lymphocytes, neutrophils and PLT were performed on fully-automatic analyzer hematological analyzer. It was calibrated by standardized commercially available calibrated kit.

Statistical analysis: Data was entered into Microsoft Excel and analyzed using SPSS software version 22. All the data from patients and controls were analyzed and compared using Student’s t-test. The results were expressed as mean ± SD. P value< 0.05 was considered significant.

A total of 120 diabetic patients and same number of controls were well matched for age and gender distribution. Majority of the cases (25%) and controls (26.6%) were 41-50 years age group, predominantly male 54.1% cases and 53.3% were control. Most of the participants were residing at urban area (71.6% cases and 69.1% control). Maximum patients belong to upper class whereas maximum control belongs to middle class. BMI were significantly higher among diabetic group as compared to control group.

Table 1: Socio-demographic characteristics of cases and controls

Thirty percent of diabetic cases had positive family history of DM whereas 20% control had family history of DM. Over half of the patients had diabetes for 5 years. Significant difference of FBG among diabetic and control group.

Table 2: Metabolic characteristics of cases and controls

Measurements of hemoglobin, RBCs count, MCV, HCT, MCH and MCHC were significantly lower in diabetic patients as compared to healthy controls, whereas RDW was significantly higher among diabetic patients.  Total white blood cell count, lymphocytes, neutrophils counts and NLR were significantly higher in the diabetic patients than in the controls. However, no significant differences were observed in platelet counts between patients and controls.

Table 3: Hematological parameters among diabetic patients and healthy controls

NLR: Neutrophil/lymphocyte ratio; PLR: Platelet/lymphocyte ratio; MPV: Mean platelet volume

All results are expressed as mean± SD (range as min-max), *p < 0.05 for diabetic compared to control group. 

The high prevalence of DM and its complications, present a significant public health concern. Microvascular complications may be associated with certain hematologic parameters, as suggested by comparisons both between diabetics and healthy individuals and within the group of diabetic individuals. The main aim of this evidence-based study was to assess changes in hematological parameters (WBC and RBC) in T2DM in order to provide accurate and substantial information for proper management of diabetes.

The mean age in the diabetic group and healthy controls was 56±5 and 54±8 years, respectively; there is no significant difference in terms of socio-demographic characteristics among diabetic and healthy control (p<0.05), similar findings were reported by Ebrahim H, et al [11] and Olana C, et al [12].

Present study observed that BMI of the diabetic patients and healthy control was statistically significantly differing, in agreement with the Onalan E, et al [13].

Duration of diabetes mellitus were less than five years in the most of the study patients, concordance with the Al Salhen et al [14].

Among hematological parameters current study showed that patients with T2DM had lower hemoglobin concentrations, consistent results shown by Rossing K, et al [15]. In type 2 Diabetes Mellitus, life span of RBC may be decreased due to disturbances in the hematopoietic milieu, such as chronic hyperglycemia and hyperosmolarity . These disturbances can lead to increased internal viscocity and increased membrane rigidity in these blood cells so that number of red blood cells decreases[12]. Low hemoglobin concentration has strong associations with the diabetic complications , but has no demonstrated mechanisms to explain such correlations [16].

The present study shows significant reduction in RBCs levels, MCV, HCT, MCH and MCHC levels in the diabetic population when compared with the healthy control group (p<0.05), our finding correlate with the Rafaqat S et al [17] and Tamariz LJ, et al [18]. The possible explanation for decreased RBCs count might also be that persistent hyperglycemia causes increased production of ROS and nonenzymatic glycosylation of Hemoglobin and RBC membrane proteins leading to reduced deformability, increased aggregation, and accelerated aging of RBCs.

We have found that there is significant decrease in the MCH and MCHC levels in diabetic patients compared with the healthy control group (p<0.05), constant observation reported by Farooqui et al [19].

The present study revealed that RDW values were significantly higher in T2DM patients than control groups. This finding is in harmony with the findings of previous studies like Biadgo B, et al [20] and ArkewM, et al [21].

Our study indicated that total WBCs counts, lymphocytes and neutrophils were jointly associated with development of type 2 diabetes; comparable with prior findings observed by other researchers: A Mansoori, et al [22] and Twig G, et al [23].

MPV and NLR were found to be significantly associated with diabetes mellitus as compared to the healthy control, accordance to the AlShareef et al [24] and Bambo GM, et al [25].

There was no differences in platelet count between diabetic cases and the control group. These results are in general agreement with the Alexopoulos D, et al [26] emphasized no interaction between DM and platelet function.

The findings in the present study have implications for diabetes management in that they appear to indicate a need for routine hematological parameters for early detection and management of anemia in diabetic patients at the primary care setting as anemia was more prevalent among poor control diabetic patients than healthy control. RBC counts, MCV, MCH , MCHC and HCT were significantly decreased whereas RDW were significantly increased among diabetic patients. Early detection of hematological parameters in diabetic patients can reduces the diabetes associated complications, morbidity and mortality.

Conflict of interest: None

Source of funding: None

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