Assessment of PT, APTT & PC in T2DM Vol. 12 (2), Dec 2021 ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573 R A D S J . B i o l . R e s . A p p l . S c i . 108 Op e n Ac c e s s F u l l L e n g t h A r t i c l e Assessment of Variations in PT, APTT and Platelet Count and Their Correlation with Glycated Hemoglobin in Type 2 Diabetes mellitus Sajjad Ahmad1,*, Haji Muhammad Rashid2, Wali Ur Rahman3, Muhammad Mujahid4, Hafiz Muhammad Waleed5, Whied ul Hussan Shahzad6 1Department of Pathology, Quaid-e-Azam Medical College, Bahawalpur, Pakistan. 2Department of Chemical Pathology, University of Health Sciences, Lahore, Pakistan. 3Department of Medical Lab Technology, University of Haripur, Pakistan. 4Pathology Department, BSL-3 Lab, DHQ Hospital Sargodha, Pakistan. 5Pathology Department, THQ Hospital, Mianchannu, Pakistan. 6Institute of Industrial Biotechnology, Government College University, Lahore, Pakistan. A B S T R A C T Background: Diabetic patients are at higher risk of cardiovascular disease than non-diabetics. Elevated glucose level in Type 2 Diabetes mellitus (T2DM) can induce variations in blood composition and blood vesicles, which lead towards coagulation abnormalities and cardiovascular disease. Prothrombin Time (PT) Activated Partial Thromboplastin Time (APTT) and platelet count are commonly used tests to assess the coagulation abnormalities of blood. Objectives: To evaluate the variations in PT, APTT and platelet count in T2DM and their correlation with glycated hemoglobin. Methodology: This cross sectional study was performed at Asia Diagnostic Center, Islamabad. Pre-diagnosed 52 adults with Type 2 Diabetes mellitus, from 35 to 65 years of age, and 52 sex and age matched healthy subjects were considered as control in this study. Glycosylated Hemoglobin (HbA1c), APTT, PT and platelet counts were measured in both groups. Results: PT and APTT were significantly lower in T2DM patients (p value < 0.0001) and platelet count was slightly higher in T2DM (p value = 0.13) than the control group. PT (r2= -0.23) and APTT (r2= -0.16) were negatively correlated with HbA1c, while platelet count was positively correlated with HbA1c (r2=0.23) in T2DM group. Conclusion: From our study, it was concluded that low PT and APTT with relatively high platelet count in T2DM than control group may induce coagulopathies that can lead toward thrombosis in T2DM patients. Keywords Activated Partial Prothrombin Time, Diabetes, HbA1c, Platelet count, Prothrombin Time, T2DM. *Address of Correspondence sajjad.ahmadbwp@gmail.com Article info. Received: June 01, 2021 Accepted: June 29, 2021 Cite this article Ahmad S, Rashid HM, Rahman WU, Mujahid M, Waleed HM, Shahzad WUH. Assessment of Variations in PT, APTT and Platelet Count and Their Correlation with Glycated Hemoglobin in Type 2 Diabeties mellitus. 2021; 12(2):108-112. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited. I N T R O D U C T I O N Diabetes mellitus is the most common disease, which is associated with hyperglycemia. It is mainly divided in to two types. First is Type 1 diabetes that is called as Insulin Dependent Diabetes mellitus (IDDM) and second is Type 2 diabetes that is Non-Insulin Dependent Diabetes mellitus (NIDDM)1. In these two types, different genetical and O R I G I N A L A R T I C L E Assessment of PT, APTT & PC in T2DM Vol. 12 (2), Dec 2021 ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573 R A D S J . B i o l . R e s . A p p l . S c i . 109 environmental factors are involved that can cause the destruction of β-cells of pancreas or they suppress its function2. Diabetic patients are prone to develop a number of serious life threatening health complications, resulting in increased mortality rate3. Persistent high level of blood glucose in T2DM causes generalized endovascular injury, which affects the heart, eyes, kidneys, muscles and nerves4. Worldwide prevalence of diabetes is 8.5%, amongst which 7.3% men and 9.6% women are the affectees5. International Diabetic Federation (IDF) states that Pakistan is at number seven among the countries with highest prevalence of diabetes. About 6.9 million were diabetic in 2007 and it is assumed that there will be 11.5 million diabetic people by the end of 20256. Diabetes mellitus is frequently associated with hypercoagulability resulting in 2 to 4 time higher risk of thrombosis7. The main mechanisms of increased risk of thrombosis in diabetes are diverse, and involve multiple pathways8. Diabetic patients having endovascular dysfunction result in premature atherosclerosis, which enhance the chances of a thrombus. These diabetic patients have a high tendency of thrombosis because of increased activation of thrombocytes, excessive activation of prethrombotic coagulation factors, and decreased fibrinolysis9. Pre- thrombosis status can be determined by elevated plasma levels of fibrinogen, elevated Plasminogen Activator Inhibitor (PAI)-1 and abnormal platelet function10. Different studies reported different types of variations in coagulation profiles among diabetic patients9. This study was aimed to determine the variation in PT, APTT and platelet count in T2DM patients along with the analysis of correlation of these coagulation profile parameters with glycemic control (HbA1c) in T2DM. M A T E R I A L S A N D M E T H O D S This cross sectional study was performed at Asia Diagnostic Center, Islamabad from 1st January, 2019 to 31st December, 2019. Already diagnosed Type 2 diabetic patients (both male and females) from 35 to 65 years were diagnosed according to the 1998 World Health Organization (WHO) guidelines11 were taken as cases. Males and females having same age group were taken as control. Patients who had a previous history of susceptibility to hypercoagulation, such as patients with a history of venous thromboembolism, hereditary coagulopathy, malignancy, gestation, recent surgery, hyperthyroidism, Type 1 diabetes, liver and kidney disease were excluded from this study12. Coagulopathies were excluded by medical history, physical examination for Petechiae, and bruises and lab investigations for thrombocytosis. Eventually, the study included 52 pre-diagnosed Type 2 diabetic patients and 52 non-diabetic healthy individuals as controls. T2DM was confirmed by medical history of adult onset of hyperglycemia, fasting glucose level >126mg/dl and negative urinary ketones11. Venous blood samples were collected in sodium citrate tubes for Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) tests. Ethylene Diamine Tetra Acetic Acid (EDTA) tubes were used for HbA1c and platelet count. PT and APTT tests were measured by a coagulation analyzer Sysmax 50. Platelet count were measured by an automated blood analyzer Sysmex XP and HbA1c was measured on a Point-of-Care testing device I-Chroma. I- Chroma was an instrument of choice to measure HbA1c because it is being used for determination of HbA1c in different studies13, due to user friendly operation. This also covers the unavailability of High Performance Liquid Chromatography (HPLC); a reference method for HbA1c measurement. R E S U L T S Microsoft excel was used for analysis and presentation of data in tabular form. Frequency and %age distribution of males and females in this study is given in Table 1. Table 1. Frequency and Percentage Distribution of Males and Females. Patients T2DM % Control group Male 32 (61%) 28 (54%) Females 20 (38%) 24 (46%) Total 52 52 Assessment of PT, APTT & PC in T2DM Vol. 12 (2), Dec 2021 ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573 R A D S J . B i o l . R e s . A p p l . S c i . 110 Table 2. Comparison of PT, APTT and Platelet Count Mean by Two Sample t-test. Tests Control group T2DM p-value PT 12.3 ± 1.3 9.4 ± 1.2 <0.0001 APTT 32.5 ± 2.1 27.6 ± 3.1 <0.0001 Platelet Count 266.6 ± 42.8 280.8 ± 52.7 0.1366 Table 3. Pearson Correlation Coefficient of PT, APTT and Platelet Count with HbA1c (9.2 ± 1.2) in T2DM. Test Parameter Pearson Correlation of co-efficient with HbA1c PT -0.23 APTT -0.16 Platelet Count 0.223 The mean levels of PT, APTT, and platelet count between T2DM and the control group were compared with a two- sample t-test, as shown in Table 2. P-value < 0.05 was considered significant. Mean PT (9.4 ± 1.2) was significantly lower in diabetic group when it was compared in control group (12.3 ± 1.3) (p < 0.0001). The mean APTT (27.6 ± 3.1) in the T2DM group was also lower than that in the control group (32.5 ± 2.1). The average platelet count of T2DM patients (280.8 ± 52.7) was slightly higher than that of the control group (266.6 ± 42.8), but the p value of 0.1366 was not significantly different. Correlation analysis of PT, APTT and platelet count with blood glucose control (HbA1c) was performed with Pearson correlation. Table 3 shows the Pearson correlation coefficients of coagulation parameters with HbA1c. We observed a weak negative correlation of PT, APTT and a weak positive correlation of platelet count with HbA1c in T2DM. D I S C U S S I O N Our results indicates the tendency of coagulation profile towards hypercoagulability in T2DM. We observed decrease in PT, APTT and increased platelet in T2DM group as compared with control group. T2DM patients are considered to be more susceptible than non-diabetic patients to macrovascular complications and thrombotic events14. Type 1 or Type 2 diabetic patients with increased activation of the coagulation system has been previously reported. This coagulation activation is an important factor in the occurrence of vascular complications of diabetes15. Many researches have shown that coagulation activation markers such as antithrombin-thrombin complex and prothrombin activating fragments are elevated in diabetes. The plasma levels of coagulation factors, such as fibrinogen level, Factor VII, VIII, XI, XII (Kallikrein) and von villi brond Factor (vWF) are increased in diabetes16. T2DM is correlated with decreased APTT and elevated fibrinogen levels12. Similar results were reported for PT and APTT in a study conducted by Ephraim et al in 20179. Here, we also performed correlation of PT, APPT and platelet count with HbA1c in T2DM and the results were also supporting the tendency of hypercoagulability with poor glycemic control. The UK Prospective Diabetes Study (UKPDS) has shown that the risk of complications in patients with T2DM is closely related to previous hyperglycemia. Decrease in HbA1c may reduce the risk of complications, HbA1c within the normal range (<6.0%) is good indicator of lowest risk of atherosclerosis17. In a study conducted by Kaur et al. in 2018, they also observed that diabetic patients develop complications according to the glycemic control and risk of microvascular complication and thrombus formation is decreased with good glycemic control14. Some studies indicate that strength of clot formation is correlated with blood sugar level in diabetes18. In diabetic patients with non-insulin dependence, there is structural damage and functional impairment of the endothelium, which has proven to be essential for stimulating different coagulation factors. It is believed that high levels of von villi brand factor (vWF) in DM indicate excessive activation of coagulation factors in diabetes, Assessment of PT, APTT & PC in T2DM Vol. 12 (2), Dec 2021 ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573 R A D S J . B i o l . R e s . A p p l . S c i . 111 which may result in shorter PT and APTT in diabetic patients than the healthy control, as shown in Table 2 of our study19. Diabetic patients are at high risk of developing hypercoagulability and good glycemic control can reduce the risk of thrombosis20. C O N C L U S I O N This study concluded that mean PT and APTT are shorter and mean platelet count is higher in T2DM patients than controls, and that is the indication of hypercoagulability and higher tendency of thrombus formation in T2DM patients. Decrease in PT, APTT and increase in platelet count are also associated with glycemic control status of the T2DM patients. Therefore, it can be said that T2DM induce hypercoagulability and tendency of thrombus formation which is associated with glycemic status of the patient. E T H I C A L A P R O V A L Ethical approval for the study was obtained from Ethical Board of Medical Laboratory Technology, University of Haripur, Pakistan. C O N F L I C T S O F I N T E R E S T The authors declare that there is no conflict of interest regarding the publication of this article. F U N D I N G S O U R C E The project was not funded by any external funding body. The required funds were managed by self-contributions of authors. A C K N O W L E D G M E N T S We are thankful to CEO of Asia Diagnostic Center, Blue area Islamabad, for technical support. L I S T O F A B B R E V I A T I O N S APTT Activated Partial Prothrombin Time DM Diabetes mellitus EDTA Ethylene Diamine Tetra Acetic acid HbA1c Glycosylated Hemoglobin IDDM Insulin Dependent Diabetes mellitus IDF International Diabetic Federation NIDDM Non-Insulin Dependent Diabetes mellitus PAI-1 Plasminogen Activator Inhibitor-1 PT Prothrombin Time T2DM Type 2 Diabetes mellitus UKPDS UK Prospective Diabetes Study vWF Von Willebrand Factor R E F E R E N C E S 1. Bishop ML, Fody EP, Schoeff LE. Clinical chemistry: Techniques, principles, correlations/ [edited by] Michael L. Bishop, Edward P. Fody, Larry E. Schoeff.; 2010. 2. Zaccardi F, Webb DR, Yates T, Davies MJ. Pathophysiology of Type 1 and Type 2 diabetes mellitus: a 90-year perspective. Postgra Med J. 2016; 92(1084):63-9. 3. Cho N, Shaw J, Karuranga S, Huang Y, da Rocha Fernandes J, Ohlrogge A, et al. 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