Thanatochemical Study of Glycated Hemoglobin in Diabetic Status Assessment

Abstract

Background and objectives. In forensic medicine, the postmortem determination of glycated hemoglobin (HbA1c) helps identify undiagnosed cases of diabetes or cases with uncontrolled glycemic status. In order to contribute to the solidification of thanatochemistry, both globally and especially nationally, we aimed to determine this biomarker postmortem, for the first time in our institution, in order to identify undiagnosed pre-mortem diabetics, as well as those with inadequate glycemic control. Materials and Methods. Our research consisted of analyzing a total number of 180 HbA1c values, 90 determinations from the peripheral blood and 90 from the central blood. The determination of HbA1c was performed by means of a fully automatic analyzer (HemoCue HbA1c 501), certified by the National Glycohemoglobin Standardization Program (NGSP)/Diabetes Control and Complications Trial (DCCT) and calibrated according to the standards developed by the International Federation of Clinical Chemistry (IFCC). According to ADA criteria, HbA1c values can provide us with the following information about the diagnosis of diabetes: normal 4.8–5.6%; prediabetes 5.7–6.4%; diabetes ≥ 6.5%. Results. A considerable number of cases with an altered glycemic status (cases that had HbA1c values equal to or greater than 5.7%) were identified—51% demonstrable by peripheral blood determinations and 41% by central blood determinations. Notably, 23 people with diabetes (25%) were identified by analyzing the peripheral blood; 18 other people with diabetes (20%) were identified by analyzing the central blood. Conclusions. Our study managed to confirm the antemortem diagnosis of DM using a simple point-of-care analyzer and applying standardized and certified criteria on HbA1c levels measured postmortem. We also identified a considerable number of cases with DM in patients with no antemortem history of glucose imbalance—at least 20% more cases. Although the two different sites used for blood collection showed a strong statistical correlation, it seems that the peripheral site could have a higher sensibility in detecting postmortem altered glycemic status.

The Vital Role of Thanatochemistry in the Postmortem Diagnostic of Diabetic Ketoacidosis—Case Report

“…Another useful marker in demonstrating carbohydrate imbalance is glycated hemoglobin (HbA1c), which provides information on glycemic status 8-12 weeks prior to testing. HbA1c can be determined only from the blood, corresponds well to antemortem values, and shows good stability in the early phase of PMI [14,18,25].…”

“…It is stated that HbA1c represents a helpful post-mortem tool in identifying undiagnosed diabetes as well as in differentiating DKA from alcoholic ketoacidosis [28][29][30]. This marker corresponds well to antemortem values, and it seems that it is stable after death for at least 36 h [16,25]. In order to determine an accurate value, any interference that could affect its value (i.e., anemia, splenectomy, polycythemia, pregnancy) must be excluded [16,24].…”

“…A study recently published in 2021 states that postmortem determination of BHB should be carried out routinely in all forensic cases [23]. BHB has proven to be the most faithful ketone body for ketoacidosis, and can increase in DKA, but also in alcoholic ketoacidosis or hypothermia [23,25,34,35]. Recent studies show that BHB is stable postmortem, unlike Ac or isopropanol, which can increase postmortem in advanced cases of decomposition; the latter two may also have an exogenous origin [34,35].…”

“…Results for the biochemical parameters studied.According to the International Expert Committee, the American Diabetes Association (ADA) and the World Health Organization (WHO), the diagnosis of DM can be established when HbA1c values are ≥6.5% (≥48 mmol/mol)[25][26][27].2.9. Postmortem Diagnostic Criteria for DKAPostmortem diagnostic criteria for DKA include increased glucose values in VH and/or CSF >10 mmol/L (>180 mg/dL)…”