Prothrombin Time and INR in Diabetic Patients: A Case-Control Study in Shendi, Sudan

Background: Hyperglycemia, which impacts the metabolism of fats, proteins, and carbohydrates, is a hallmark of diabetes mellitus (DM). In those with diabetes, macrovascular conditions like atherosclerosis are known to be a leading cause of death. Additionally, because it involves alterations in the fibrinolytic system, endothelium, platelets, coagulation factors, and natural anticoagulants, it predisposes people with diabetes mellitus to hypercoagulability.

Objective: The objective is to assess prothrombin time in individuals with diabetes mellitus while taking into account various factors.

Methodology: This prospective case-control study was conducted in the Hematology laboratory of Shendi University's Faculty of Medical Laboratory Sciences in Shendi City, Sudan, between December 2022 and February 2024. While their blood samples were being taken in trisodium citrate containers, a questionnaire was created to gather data about the study group, which consisted of 50 diabetics and 30 non-diabetic volunteers. Coagulyzer 1 was used to measure the prothrombin time (PT).

Results: According to the study, the case group's mean±SD of PT was lower (10.5±1.9) than the control group's (13.2±1.32), and the difference was statistically significant (P-value 0.000). The case's mean±SD of INR was 0.78±0.14, which was statistically significantly lower than the control's (0.96±0.09) (P-value 0.000).

Conclusion: The results of this investigation demonstrated that, in comparison to normal controls, PT and INR were shortened in diabetic studies. There was no difference in the PT and INR based on gender, age, length, type of DM, type of treatment, and other disorders.

One of the most important maintenance mechanisms in the human body, hemostasis keeps the blood in circulation liquid and stops bleeding when blood vessels are damaged. Three phases are used to halt bleeding following injury: vascular, platelet, and blood coagulation [1]. which is separated into three pathways: common, extrinsic, and intrinsic [2]. The "waterfall" and "cascade" hypotheses, which outline the basic idea of the cascade of pro-enzymes leading to the activation of downstream enzymes, were first presented by Davie, Ratnoff, and Macfarlane in 1960, which is when the concept of blood coagulation first emerged [3]. Haeme, which means blood, and stasis, which means to halt, are the Greek words for hemostasis, which is the arrest of bleeding [4]. Platelets and the vascular wall, as well as the coagulation and fibrinolytic systems, interact intricately to maintain the body's thrombohaemorrhagic balance. Typically, a number of inhibitors regulate the coagulation processes, limiting the creation of clots and preventing the spread of thrombus. Any increase in the coagulation factors' pro-coagulant activity or a decrease in the activity of naturally occurring inhibitors upsets this delicate balance [5]. The complicated process by which blood clots is called blood coagulation. A platelet-and fibrin-containing clot covering a damaged blood artery wall stops bleeding and initiates vascular repair, which is a crucial aspect of homeostasis [6]. The coagulation process, which starts practically immediately after a blood artery injury damages the endothelium, frequently seems to be complicated by thrombosis. Blood platelets and the plasma protein fibrinogen, a clotting factor, undergo alterations when the blood is exposed to proteins, such as tissue factors. Primary hemostasis occurs when platelets instantly form a plug at the site of the damage. Coagulation factors, also known as clotting factors, are proteins in the plasma that react in a complicated cascade to create fibrin strands, which reinforce the plug, causing secondary hemostasis to occur concurrently [7]. In clinical contexts, coagulation assays such as prothrombin time (PT) are used to evaluate the coagulation system globally. The extrinsic clotting system, or factor VII, is being screened for by this test [8]. The hallmarks of diabetes mellitus (DM) include hyperglycemia and changes in lipid, protein, and carbohydrate metabolism [9]. Type 1 diabetes mellitus, also known as insulin-dependent diabetes mellitus (IDDM), type 2 diabetes mellitus, also known as non-insulin-dependent diabetes mellitus (NIDDM), and gestational diabetes, which is categorized as type 2 diabetes mellitus, are the three primary forms of diabetes. Retinopathy and neuropathy with microvascular and macrovascular disorders are among the long-term consequences and complications of diabetes. The circulatory abnormalities associated with diabetes are linked to macrovascular diseases like atherosclerosis, which are acknowledged as a leading cause of death in the diabetic population. Changes in endothelial metabolism, coagulopathy, fibrinolytic aberration, hemorrhageological factors, and platelet count and activity all contribute to the circulatory disruptions [10]. Diabetes is hypercoagulable, according to numerous researches. Increased tissue factor and Von Willebrand factor expression by vascular endothelial cells causes hypercoagulability. Reduced fibrinolytic activity, higher procoagulant factor levels, and enhanced platelet adhesiveness are further contributors [11]. DM has been characterized as a hypofibrinolytic, hypercoagulable state [12-14]. Changes in the endothelium, platelets, coagulation factors, natural anticoagulants, and the fibrinolytic system are among the variables that predispose people with diabetes mellitus to hypercoagulability. Additionally, plasminogen activator inhibitor type 1 is increasing, which reduces fibrinolysis. When combined, they make DM patients more prone to hypercoagulation. Diabetes-related hypercoagulability increases the risk of cardiovascular disease development and may hasten atherosclerosis [15].

This case-control study was conducted to examine the effect of diabetes on prothrombin time. The research took place in Shendi Locality, River Nile State, Sudan, a historic Ja'aliin tribal center and major trading hub located 150 km northeast of Khartoum and 45 km southwest of Meroe. Shendi’s strategic position, with its suburb Al-Matamma serving as a connection to Northwest Sudan via the Bayuda Desert trade route, makes it an important healthcare center with several hospitals serving both residents and visitors. The study was carried out from December 2022 to February 2024. The study included two groups: a control group of patients without diabetes and a case group of patients with diabetes.

Study Population and Sample Size

This study included individuals diagnosed with diabetes mellitus, while patients with other conditions that could affect prothrombin time (PT) were excluded. Venous blood samples were collected using tri-sodium citrate in the correct ratio to ensure accuracy. The sample size was calculated using the formula n=z2pq/d2n = z^{2}pq/d^{2}n=z2pq/d2, where z is the z-score (1.96), p is the population proportion (0.5), q = (1-p), and d is the margin of error (0.05), yielding an estimated sample size of 385. However, due to budgetary constraints, a total of 80 samples were selected, comprising 50 diabetic patients (cases) and 30 healthy individuals (controls).

Data Collection and Analysis

A self-administered questionnaire was utilized, and coding numbers were assigned to facilitate data sorting. The collected data were entered, verified, and analyzed using Microsoft Excel 2007. Results were summarized and presented as frequencies and percentages.

This study involved 80 participants, including 50 diabetic patients (the case group) and 30 healthy individuals (the control group), comprising 62.5% and 37.5% of the total sample, respectively (Table 1). The demographic characteristics are shown in Tables 2 and 3. In the case group, 72% were female and 28% male, while the control group was evenly split with 50 percentage female and 50% male (Table 2). Most diabetic patients (58%) were aged 31-50 years, followed by 24% aged 51-75 years, and 18% aged 20-30 years. The control group had a different pattern, with half of the participants (50%) between 20-30 years old (Table 3). Among the diabetics, 60% had Type 2 Diabetes Mellitus (T2 DM), and 40% had Type 1 Diabetes Mellitus (T1 DM) (Table 4). Diabetes management varied: 60% used oral hypoglycemic agents, 34% used Mixtard insulin, and 6% used soluble insulin (Table 5). The duration of diabetes differed: 32% had it for more than 10 years, 24% for 0-3 years, 24% for 6 years, and 20% for 7-9 years (Table 6). Additionally, 42% of diabetic patients had hypertension, while 58% reported no other conditions (Table 7). The primary laboratory findings are summarized in (Table 8). Significant differences were observed in Prothrombin Time (PT) and International Normalized Ratio (INR) between the case and control groups. The mean PT for diabetic patients was 10.48 ± 1.91 seconds, significantly lower than the control group' s 13.19 ± 1.32 seconds (p = 0.000). The INR was also lower in the case group (0.78 ± 0.14) compared to controls (0.96 ± 0.09), with a p- value of 0.000.000. Subgroup analyses explored the impact of various factors on PT and INR. Table 9 indicates no significant differences in PT or INR between males and females within either group (p> 0.05). Age did not significantly affect these coagulation parameters within the groups (Table 10). The type of diabetes (T1DM versus T2 DM) did not result in significant differences in PT or INR among diabetics (Table 11). Likewise, treatment type- soluble insulin, Mixtard insulin, or oral hypoglycemics- had no significant association with PT or INR variations (Table 12). The duration of diabetes also showed no significant impact on these parameters (Table 13). Lastly, having hypertension as a comorbidity did not lead to significant differences in PT or INR compared to diabetics without hypertension (Table 14).

Table 1: General Distribution of Study Participants.

Table 2: Gender Distribution among Study Participants.

Table 3: Age Distribution among Study Participants.

Table 4: Distribution of Diabetic Participants by Type of Diabetes.

Table 5: Distribution of Diabetic Participants by Type of Treatment.

Table 6: Distribution of Diabetic Participants by Duration of Disease.

Table 7: Distribution of Diabetic Participants by Other Diseases.

Table 8: Comparison of PT and INR between the Study Groups.

Table 9: Effect of Gender on PT and INR among the Study Groups.

Table 10: PT and INR across Different Age Groups among the Study Population.

Table 11: PT and INR by Type of Diabetes Mellitus.

Table 12: PT and INR by Type of Treatment among Diabetic Participants.

Table 13: PT and INR by Duration of Disease among Diabetic Participants.

Table 14: PT and INR in Diabetic Patients with and without Hypertension.

The PT in patients with diabetes mellitus who visit several Shendi hospitals and clinical facilities was examined in this study, and these characteristics were compared to the control. The study sought to determine whether the participants' hemostatic parameter could predict their risk of thrombosis.  Similar to data published in the International Journal of Clinical, which found that DM patients had shorter PT than the healthy non-diabetic controls, the mean prothrombin time (PT) and INR in diabetic subjects in this study were significantly shorter than those of non-diabetic controls (a value of less than 0.000, which is statistically significant). Furthermore, this suggested that DM patients had an increased risk of thrombosis [21,25]. It may be inferred that patients with diabetes mellitus are more likely to develop a hypercoagulation state, and it may be close to the conclusion that diabetic patients are more likely to develop coagulation impairment, according to a study done in Khartoum that disagreed with elevated PT and INR values among diabetic patients [19]. Additionally, the Nigerian study demonstrated that, in comparison to the non-diabetic controls, PT was noticeably longer in diabetic participants. These results indicated that when managing diabetic patients, hemorrhagic tendencies and consequences should not be completely ruled out [22]. Moreover, the data indicate statistically insignificantly lower means of PT and INR not diabetes boys and females compared to the control group (PT P-value 0.6 and INR P-value 0.4). It is consistent with the findings published by Soltani (2011), who found no statistically significant difference in PT between diabetic patients who were male and female [25]. However, a study by J Bangladesh denied that men with diabetes had a higher risk of developing hypercoagulation states since their PT levels are lower than those of men in similar circumstances [16]. Due to financial constraints, the random sample size was reduced to 80 samples, which had an impact on the accuracy of my findings. According to the available data, there is no correlation between age and PT in the study group. It concurred with the KSA study [20]. Contrary to the data published in the International Journal of Contemporary Medical Research, which also found a significant correlation between type 2 DM and coagulation parameters, there was no difference in the hypercoagulability state between the types of DM. Additionally, the data showed that prolonged exposure of blood cells to high glucose concentrations results in hemoglobin glycation and a decrease in the synthesis of clotting factors [17]. I wasn't sure if my results were truly type 1 and type 2, which affected their accuracy. Furthermore, there was a statistically negligible variation of PT and INR means among the various diabetes treatment options (PT P-value 0.6 and INR P-value 0.5). Additionally, there was no statistically significant difference in the means of PT and INR between diabetics with hypertension and diabetics alone (PT p-value 0.3 and INR p-value 0.4). The Int J Pharm Bio Sci article, however, contradicted me in that PT of patients with DM and hypertension had a significant prolongation, a higher blood glucose level, and a higher BMI, all of which contribute to thrombotic events and atherosclerosis changes in diabetic patients compared to those with diabetes alone [18]. However, a Khartoum article disputed this, stating that PT readings are lower in diabetic patients and much lower in hypertensives with DM [24].

Additionally, there is no statistically significant difference in the duration of PT between the study group. However, the International Journal of Biotechnology and Biochemistry published data indicating that patients with T1DM who have been afflicted for more than five years require more medical attention when taking medications that may affect the coagulation process, as their coagulation profile differs significantly from that of the healthy population [23]. However, I concurred with the KSA study that found that PT was minor in patients of all ages, with and without therapy, and that PT findings varied significantly between case and control [20]. Diabetes mellitus is strongly associated with an increased risk of atherosclerosis and is therefore regarded as a procoagulant condition. Patients with diabetes are prone to developing atherothrombotic complications that involve the coronary, cerebral, and peripheral vasculature. This syndrome is characterized by persistent hyperglycemia resulting from defective insulin secretion, impaired insulin action, or both. In addition to its profound effects on carbohydrate, lipid, and protein metabolism, diabetes also interferes with essential biological processes, notably coagulation and fibrinolysis, thereby contributing to vascular complications [26].

Limitations

This study was limited by the small sample size, single-center design, and financial constraints that restricted the assessment of additional coagulation parameters. Therefore, the findings may not be generalizable to all diabetic populations.

Additionally, there is no statistically significant difference in the duration of PT between the study group. However, the International Journal of Biotechnology and Biochemistry published data indicating that patients with T1DM who have been afflicted for more than five years require more medical attention when taking medications that may affect the coagulation process, as their coagulation profile differs significantly from that of the healthy population [23]. However, I concurred with the KSA study that found that PT was minor in patients of all ages, with and without therapy, and that PT findings varied significantly between case and control [20]. Diabetes mellitus is strongly associated with an increased risk of atherosclerosis and is therefore regarded as a procoagulant condition. Patients with diabetes are prone to developing atherothrombotic complications that involve the coronary, cerebral, and peripheral vasculature. This syndrome is characterized by persistent hyperglycemia resulting from defective insulin secretion, impaired insulin action, or both. In addition to its profound effects on carbohydrate, lipid, and protein metabolism, diabetes also interferes with essential biological processes, notably coagulation and fibrinolysis, thereby contributing to vascular complications [26].

Limitations

This study was limited by the small sample size, single-center design, and financial constraints that restricted the assessment of additional coagulation parameters. Therefore, the findings may not be generalizable to all diabetic populations.

This study demonstrates that diabetic patients have significantly shortened PT and INR, suggesting a state of hypercoagulability. These findings highlight the need for routine coagulation assessment in diabetes management.

Recommendations

1. To detect abnormalities early, patients with diabetes mellitus should regularly evaluate their coagulation profile.
2. To help diabetic patients maintain adequate glycemic control.
3. To reduce errors and generate accurate results, future research should employ a carefully selected study group in all variables. Examine the other coagulation profile test values as well.
4. C peptide measurement to distinguish between type 1 and type 2.

Acknowledgment

The authors appreciate the ethical review committee, and thanks are also due to the Department of Microbiology at the Faculty of Medical Laboratory Sciences providing the research facilities for this study.

Sources of Funding

There was no specific grant for this research from any funding organization in the public, private, or nonprofit sectors.

Conflict of Interest

The authors have declared that no competing interests exist.