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Fructosamine

Fructosamine is a stable ketoamine compound formed through the non-enzymatic glycation of serum proteins, primarily albumin, via the Maillard reaction between glucose's carbonyl group and the protein's amino groups, reflecting average blood glucose levels over the preceding 2 to 3 weeks.^[1] It serves as a biomarker for glycemic control in diabetes mellitus, offering a shorter-term alternative to hemoglobin A1c (HbA1c), which assesses glucose exposure over 2 to 3 months.^[2] Measured via colorimetric assays on serum samples, fructosamine levels typically range from 200 to 285 µmol/L in individuals without diabetes, with elevated values indicating poor glycemic control.^[3] In clinical practice, fructosamine testing is particularly valuable for monitoring diabetes in scenarios where HbA1c may be unreliable, such as hemoglobinopathies, hemolytic anemias, pregnancy, or recent blood transfusions, as it is unaffected by red blood cell turnover or hemoglobin variants.^[1] It correlates strongly with HbA1c, enabling prompt assessment of therapeutic efficacy after medication changes.^[4] No fasting is required, making it convenient and cost-effective compared to some other glycemic markers.^[2] However, fructosamine's utility is limited by factors influencing serum protein levels, such as hypoalbuminemia (e.g., in liver disease or nephrotic syndrome), where results below 3.0 g/dL albumin are unreliable, and interferences from high bilirubin, vitamin C, or temperature variations.^[3] It also lacks standardized reference ranges across laboratories and is not recommended as a primary screening tool for diabetes due to overlapping values with nondiabetic populations.^[1] Despite these constraints, elevated fructosamine has been associated with increased risks of mortality, cardiovascular events, and complications in diabetic and hemodialysis patients, underscoring its prognostic value in specific high-risk groups.^[5]

Definition and Formation

Chemical Definition

Fructosamine refers to a class of ketoamine compounds formed through the non-enzymatic glycation of serum proteins, predominantly albumin, by glucose.^[1] This process involves the spontaneous reaction of glucose with the free amino groups on proteins, resulting in stable adducts that serve as markers of recent glycemic exposure.^[6] These adducts primarily occur at the ε-amino groups of lysine residues in albumin and other serum proteins, reflecting the half-life of these proteins.^[7] The chemical formation of fructosamine begins with the nucleophilic addition of a protein's amino group to the aldehyde carbon of the open-chain form of glucose, yielding an unstable Schiff base intermediate (an imine linkage).^[8] This labile structure then undergoes the Amadori rearrangement, a 1,2-enolization-mediated isomerization, to produce the more stable ketoamine configuration known as 1-amino-1-deoxyfructose.^[9] The resulting fructosamine linkage features a ketose sugar moiety covalently bound to the protein, conferring greater resistance to hydrolysis compared to the initial Schiff base.^[10] Fructosamine constitutes an early reversible stage in the Maillard reaction pathway, distinguishing it from advanced glycation end-products (AGEs), which form through subsequent oxidative and degradative steps involving dehydration, cyclization, and fragmentation of the Amadori product.^[11] Unlike AGEs, which are irreversible and implicated in long-term tissue damage, fructosamine remains a relatively inert biomarker until protein turnover.^[12]

Glycation Mechanism

The formation of fructosamine in vivo proceeds through the non-enzymatic Maillard reaction, a series of chemical transformations between reducing sugars like glucose and free amino groups on proteins.^[13] This process begins with the reversible nucleophilic addition of a protein's primary amine—typically the ε-amino group of lysine residues or, to a lesser extent, the guanidino group of arginine—to the aldehyde group of glucose's open-chain form, yielding an unstable carbinolamine intermediate that dehydrates to form a Schiff base (also called an aldimine).^[13] The reaction is depicted as:

\text{Protein-NH}_2 + \text{open-chain glucose (CHO-(CHOH)}_4\text{-CH}_2\text{OH)} \rightleftharpoons \text{Protein-N=CH-(CHOH)}_4\text{-CH}_2\text{OH} + \text{H}_2\text{O} \quad (\text{Schiff base})

^[13] The Schiff base then undergoes a slower, irreversible Amadori rearrangement, which is acid- or base-catalyzed and rate-limiting in the overall glycation process, converting the aldose-derived imine into a stable ketoamine structure known as fructosamine (e.g., fructosyl-lysine).^[13] This step involves enolization and proton shifts, resulting in the 1-amino-1-deoxy-2-keto form resembling a fructose derivative attached to the protein.^[13] The transformation is represented by:

\text{Protein-N=CH-(CHOH)}_4\text{-CH}_2\text{OH} \rightarrow \text{Protein-NH-CH}_2\text{-CO-(CHOH)}_3\text{-CH}_2\text{OH} \quad (\text{fructosamine})

^[13] Under physiological conditions, fructosamine can persist but may further degrade if unchecked, leading to the formation of reactive dicarbonyl intermediates (e.g., glyoxal or methylglyoxal) that propagate to advanced glycation end products (AGEs) through oxidation, fragmentation, or additional rearrangements.^[13] The rate of fructosamine formation is directly proportional to the prevailing glucose concentration, as higher levels accelerate both Schiff base formation and subsequent rearrangement.^[13] Additionally, the extent of glycation at steady state depends on the half-life of the modified protein; for serum albumin, the primary target, this turnover occurs over approximately 14-21 days, influencing the accumulation of fructosamine relative to shorter- or longer-lived proteins.^[14]

Biochemical Properties

Protein Specificity

Fructosamine arises predominantly from the non-enzymatic glycation of human serum albumin (HSA), the most abundant protein in plasma, which accounts for approximately 60-80% of total serum fructosamine levels.^[2] This dominance stems from HSA's high concentration, typically ranging from 35 to 50 g/L in healthy individuals, representing about 50-60% of total plasma protein content.^[15] Additionally, HSA possesses numerous lysine residues with epsilon-amino groups that serve as primary sites for glucose attachment via the Maillard reaction, forming stable ketoamine linkages known as fructosyl-lysine adducts.^[11] While HSA is the major contributor, fructosamine also incorporates minor glycation products from other circulating serum proteins, such as globulins and lipoproteins, which together make up the remaining approximately 20% of total levels.^[2] These proteins vary in abundance and susceptibility to glycation, but their contributions are limited compared to HSA due to lower concentrations and fewer accessible reactive sites.^[16] Collectively, serum fructosamine thus provides a composite measure of glycation across the entire pool of circulating proteins, reflecting short-term glycemic exposure over their typical half-lives of 1-3 weeks.^[2] The protein specificity of fructosamine, confined to serum-based glycation, distinguishes it from hemoglobin A1c (HbA1c), which exclusively measures glucose binding to hemoglobin within erythrocytes and reflects a longer-term average of 2-3 months. This focus on extracellular, circulating proteins makes fructosamine particularly useful in conditions affecting red blood cell turnover or hemoglobin variants, where HbA1c may be unreliable.^[1]

Stability and Half-Life

The fructosamine linkage, formed through the Amadori rearrangement of early glycation products, represents a relatively stable ketoamine structure compared to the labile Schiff base intermediates that precede it, which can readily revert to free glucose and protein.^[1] This stability allows fructosamine to persist on serum proteins without rapid reversal under physiological conditions.^[17] However, the fructosamine moiety is not entirely inert and can undergo degradation via enzymatic action, primarily through phosphorylation by fructosamine-3-kinase (FN3K), which targets the C3 position of the sugar moiety on lysine residues, leading to spontaneous detachment and protein repair.^[18] Additionally, oxidative cleavage of the fructosamine structure can occur, contributing to the formation of reactive oxygen species and advanced glycation end products (AGEs).^[19] The half-life of fructosamine reflects that of its primary carrier protein, human serum albumin, which circulates with an average half-life of approximately 20 days, thereby providing an integrated measure of glycemic exposure over 2–3 weeks.^[16] This duration is notably shorter than the 120-day lifespan of erythrocytes, which underlies the longer retrospective window of hemoglobin A1c (HbA1c).^[1] Degradation of fructosamine is influenced by plasma environmental factors, including pH, where higher hydroxide concentrations promote enolisation as a rate-limiting step in oxidative breakdown; temperature, which accelerates non-enzymatic rearrangements; and the redox state, which modulates oxidative cleavage pathways.^[20]

Clinical Applications

Glycemic Monitoring in Diabetes

Fructosamine serves as an intermediate-term biomarker for assessing average glycemia in diabetic patients, reflecting glucose control over approximately 2 to 3 weeks due to the half-life of serum proteins like albumin.^[1] This timeframe makes it particularly valuable for detecting recent changes in therapy efficacy, such as adjustments to insulin regimens or lifestyle interventions, where a downward trend in levels can confirm improved control.^[1] Introduced in the early 1980s as a novel assay for measuring glycated serum proteins, fructosamine was developed as an alternative to hemoglobin A1c (HbA1c) to provide a simpler index of diabetic control without relying on red blood cell turnover.^[21] In general diabetes management, fructosamine offers advantages over HbA1c by not requiring fasting and being less influenced by factors affecting hemoglobin, allowing for more frequent monitoring in dynamic clinical settings.^[1] It correlates well with short-term glucose excursions and can complement self-monitoring of blood glucose to evaluate overall glycemic trends.^[1] Fructosamine is especially beneficial in scenarios where HbA1c is unreliable, such as pregnancy, where physiological changes like increased red blood cell turnover can skew HbA1c results, making fructosamine a more accurate short-term indicator of glycemic status in gestational diabetes.^[1] Similarly, it proves useful in conditions with shortened red blood cell lifespan, such as anemias from iron, vitamin B12, or folate deficiencies, and in patients with variant hemoglobins like sickle cell anemia or hemoglobinopathies, where fructosamine remains unaffected by altered erythrocyte characteristics.^[1]^[22] Clinical guidelines, including those from the American Diabetes Association (ADA), recommend fructosamine as an alternative measure for glycemic monitoring when HbA1c is unsuitable, such as in cases of hemoglobin variants or conditions impacting red blood cell turnover, supported by evidence linking it to diabetes complications.^[23]

Use in Renal Impairment

In patients with end-stage renal disease (ESRD) and chronic kidney disease (CKD), fructosamine provides a reliable measure of glycemic control because it is independent of erythrocyte lifespan alterations and anemia, which commonly distort HbA1c values in these populations.^[24] Unlike HbA1c, which can be falsely lowered by shortened red blood cell survival or erythropoietin therapy in CKD, fructosamine reflects glycation of serum proteins over 2-3 weeks without such hematological interference.^[25] Additionally, while uremia-induced carbamylation historically interfered with older HbA1c assays, modern methods have largely addressed this, yet fructosamine remains unaffected by carbamylation.^[24] Studies demonstrate that fructosamine correlates more strongly with mean glucose levels in dialysis patients compared to HbA1c, particularly when glucose is below 150 mg/dL, making it a preferable marker for short-term glycemic assessment in hemodialysis settings.^[26] For instance, in CKD patients with eGFR <30 mL/min/1.73 m², fructosamine showed a moderate correlation (ρ=0.60) with continuous glucose monitoring-derived mean glucose, supporting its utility over HbA1c in advanced renal impairment.^[25] In kidney transplant recipients, fructosamine exhibits high diagnostic accuracy (AUC 0.92-0.93) for identifying new-onset diabetes after transplantation or impaired glucose tolerance, aiding insulin dose adjustments in this high-risk group.^[27] Research spanning the 1990s to the 2020s indicates that fructosamine levels may be elevated in CKD due to altered protein turnover and reduced catabolism, potentially prolonging serum protein exposure to glucose, though this is often confounded by hypoalbuminemia; despite such variations, fructosamine is generally superior to HbA1c for glycemic monitoring in renal disease.^[25]^[28] Prospective cohorts, such as those involving over 1,000 hemodialysis patients, have linked higher fructosamine to increased mortality risk, underscoring its clinical relevance while highlighting the need for albumin correction in interpretation.^[24]

Laboratory Measurement

Assay Methods

The primary method for quantifying fructosamine in clinical laboratories is the colorimetric assay utilizing the reduction of nitroblue tetrazolium (NBT) to formazan. In this procedure, the ketoamine moieties of fructosamine react under alkaline conditions (pH approximately 10.8) at 37°C to reduce NBT, forming a stable purple formazan product whose concentration is determined by absorbance at 540 nm.^[2]^[29]^[30] This assay, first described in the early 1980s, provides a non-specific measure of total glycated serum proteins and has been widely adopted due to its simplicity and cost-effectiveness.^[31] Alternative techniques offer greater specificity or applicability in certain contexts. Immunoassays, such as enzyme-linked immunosorbent assays (ELISA), employ antibodies targeted against fructosamine or glycated albumin to enable quantitative detection in serum or plasma, though they are less common in routine clinical settings compared to colorimetric methods.^[32]^[33] High-performance liquid chromatography (HPLC) separates glycated proteins for precise quantification, often using furosine derivatization as a reference standard for validation. Enzymatic methods, incorporating ketoamine oxidase to cleave the Amadori product and generate detectable chromogenic or fluorogenic signals, are primarily used for the measurement of glycated albumin—a major contributor to total fructosamine—and provide improved specificity by minimizing interference from non-glycated reducing substances.^[34]^[16] Fructosamine results are standardized and reported in micromoles per liter (μmol/L), reflecting the concentration of glycated proteins. The transition from manual NBT assays to automated commercial kits in the 1990s enhanced inter-laboratory reproducibility, with modern systems from manufacturers like Roche Diagnostics and Beckman Coulter achieving intra- and inter-assay coefficients of variation typically below 4%.^[1]^[35]^[36] These automated platforms integrate the assay into routine workflows on clinical chemistry analyzers, supporting high-throughput testing while maintaining calibration traceable to reference materials.^[37]

Sample Collection and Processing

Fructosamine testing requires serum or plasma as the sample type, with serum being preferred over whole blood to prevent interference from cellular components.^[38]^[2] Samples are collected through standard venipuncture using gel-barrier tubes, red-top tubes, or plasma tubes with heparin or EDTA anticoagulants, and no fasting is necessary.^[38]^[1] A volume of 1 mL is typically recommended, with a minimum of 0.5 mL.^[2]^[38] Hemolysis and lipemia must be avoided, as grossly hemolyzed or lipemic samples are rejected due to potential assay interference.^[38]^[2] Following collection, serum or plasma should be separated from cells by centrifugation within 45 minutes to 2 hours, depending on the tube type, to maintain sample integrity.^[38]^[2] Fructosamine samples are typically stable at room temperature for up to 7 days, refrigerated for 7 to 14 days, or frozen for 14 to 60 days (stability varies by laboratory protocol), with up to two freeze-thaw cycles tolerated; consult specific laboratory guidelines for precise requirements.^[38]^[2] Gross icterus also prompts rejection, though mild icterus may be addressed through sample dilution to minimize bilirubin interference.^[2]^[1] All processing must adhere to Clinical Laboratory Improvement Amendments (CLIA) standards to ensure quality and accuracy.

Interpretation of Results

Reference Ranges

The reference range for serum fructosamine in non-diabetic adults is typically 200–285 μmol/L, assuming a normal serum albumin concentration of 5 g/dL.^[1]^[3] This range reflects the average glycation of circulating proteins over their typical half-life of 2–3 weeks and serves as a benchmark for assessing short-term glycemic status.^[1] Reference intervals can vary modestly by laboratory assay and method; for instance, the Roche colorimetric assay establishes a range of 205–285 μmol/L based on community-derived data from non-diabetic populations.^[39] In some population-specific studies, such as those in Brazilian adults, narrower intervals have been reported, like 186–248 μmol/L for women and 196–269 μmol/L for men, though these align closely with the broader standard.^[40] Reference ranges may also vary with assay type, population, and factors like serum albumin levels, with modern standardization using μmol/L units as of 2025.^[1] For individuals with diabetes, fructosamine levels above 285 μmol/L signal poor glycemic control, often correlating with elevated average blood glucose over the preceding 2–3 weeks.^[1]^[41] In pediatric populations, reference ranges are slightly lower than in adults, with mean values approximately 5% reduced due to higher rates of protein turnover; for example, newborns may exhibit median levels around 199 μmol/L.^[42] Fructosamine levels tend to increase with age in adults, with significant differences observed in older age groups (e.g., higher in those >65 years), and reference ranges may vary by population or ethnicity.^[43]

Correlation with Other Markers

Fructosamine levels exhibit a strong positive correlation with hemoglobin A1c (HbA1c), serving as an indicator of average glycemia over a shorter timeframe of 2 to 3 weeks, in contrast to the 8 to 12 weeks reflected by HbA1c. This relationship allows for approximate conversions between the two markers, with the formula HbA1c (%) ≈ 0.017 × fructosamine (μmol/L) + 1.61 commonly used in clinical practice. The inverse calculation yields fructosamine (μmol/L) ≈ (HbA1c (%) – 1.61) × 58.82, enabling clinicians to estimate one value from the other when direct measurement is unavailable.^[44]^[45] Fructosamine also correlates with estimated average glucose (eAG), providing insight into mean blood glucose levels over the preceding 2 to 3 weeks. A validated linear regression model derives eAG from fructosamine using the equation eAG (mg/dL) = 0.5157 × fructosamine (μmol/L) – 20, based on longitudinal cohort data from patients with type 2 diabetes. For instance, fructosamine levels exceeding 350 μmol/L correspond to eAG values above approximately 160 mg/dL, signaling suboptimal glycemic control; this association has been confirmed in studies evaluating glycemic markers in controlled trial settings analogous to the Diabetes Control and Complications Trial (DCCT).^[46]^[3] In comparison to glycated albumin (GA), fructosamine demonstrates a robust linear correlation, with Pearson coefficients typically ranging from 0.85 to 0.95 across diverse populations including those with diabetes and chronic kidney disease. Both markers primarily reflect albumin glycation due to its prevalence among serum proteins, yet GA offers greater specificity to albumin alone, whereas fructosamine encompasses a broader range of glycated proteins. This distinction enhances their utility in comparative diagnostics, particularly when assessing discrepancies in protein turnover or in conditions affecting albumin levels.^[16]^[47]

Limitations and Considerations

Interfering Factors

Hypoalbuminemia, often associated with conditions such as liver disease or malnutrition, lowers fructosamine levels due to reduced availability of albumin as the primary substrate for non-enzymatic glycation.^[3] This reduction can lead to underestimation of glycemic control unless corrected. A common adjustment uses the formula for corrected fructosamine: measured fructosamine × (40 / albumin in g/L), normalizing values to a standard albumin concentration of 40 g/L.^[48] Hyperbilirubinemia and elevated triglycerides can interfere with the nitroblue tetrazolium (NBT) assay method for fructosamine by acting as reducing agents, potentially causing falsely elevated results.^[49] Such interferences are particularly relevant in patients with jaundice or dyslipidemia.^[50] However, newer enzymatic assays exhibit reduced interference from these factors compared to traditional NBT methods.^[1] Acute illness can alter fructosamine levels as it is a negative acute phase reactant, with inflammation accelerating protein turnover and degradation, leading to short-term decreases.^[51] Certain drugs, such as high doses of salicylates or vitamin C (ascorbic acid), may also interfere by directly reducing NBT in the assay, resulting in negative bias or falsely low readings.^[52]^[53]

Comparison to HbA1c

Fructosamine and HbA1c are both markers of glycemic control in diabetes, but they differ significantly in the timeframe they reflect. Fructosamine primarily measures the average blood glucose levels over the preceding 2 to 3 weeks by assessing the glycation of serum proteins, such as albumin, making it particularly useful for evaluating recent changes in therapy or short-term glycemic fluctuations.^[54]^[55] In contrast, HbA1c reflects average glucose over 2 to 3 months, corresponding to the lifespan of red blood cells, which provides a longer-term view but may lag behind acute adjustments in treatment.^[56] This shorter window for fructosamine allows clinicians to monitor the impact of interventions more promptly, such as in patients with rapidly changing glucose control.^[57] In terms of reliability, fructosamine offers advantages in specific clinical scenarios where HbA1c is unreliable. Unlike HbA1c, which can be inaccurately elevated or lowered by hemoglobinopathies (e.g., sickle cell disease or thalassemia) or recent blood transfusions due to altered red blood cell turnover, fructosamine remains unaffected because it relies on serum proteins rather than hemoglobin.^[1]^[58] However, fructosamine is more sensitive to variations in serum protein levels, such as hypoalbuminemia or proteinuria, which can lead to falsely low readings, whereas HbA1c is generally less impacted by these factors.^[1] These differences make fructosamine a preferred alternative in populations with hemoglobin variants or anemia.^[59] Regarding cost and availability, fructosamine testing is typically cheaper and provides same-day results compared to HbA1c, which often requires more specialized laboratory processing and may take longer.^[57] Studies have shown that fructosamine can have comparable utility to HbA1c in predicting certain complications when adjusted for individual factors.^[60]

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[PDF] المجلد الثاني العدد 1
Dec 8, 2024 · FAc3 = FAm x 40/albumin concentration (g/l)[20]. 4. FAc4 = FAm x 70 ... However, correction of fructosamine for albumin or total protein ...
[51]
Fructosamine - an overview | ScienceDirect Topics
A second historically important assay to measure fructosamine is the thiobarbituric acid assay [90,91]. ... (1990) reported the development of chronic renal ...
[52]
[PDF] Thermo DMA - accessdata.fda.gov
Oct 4, 2001 · At a fructosamine level of 4.1 mmol/L a positive interference was observed at bilirubin levels greater than 13.5 mg/dL. 2. Hemoglobin ...Missing: hyperbilirubinemia | Show results with:hyperbilirubinemia
[53]
Fructosamine: A Negative Acute Phase Reactant - PMC - NIH
Fructosamine is a negative acute phase reactant and should not be used as glycemic biomarker in acutely ill patients.Missing: interference salicylates vitamin
[54]
FRUCT - Overview: Fructosamine, Serum - Mayo Clinic Laboratories
Interferences are seen from ascorbic acid (vitamin C) and elevated bilirubin values. ... Uricase serves to eliminate uric acid interference and detergent ...
[55]
Interference in the Fructosamine Assay on the Technicon RA 1000 ...
The estimation of the serum glycosylated pro- tein (fructosamine) provides the clinician with a means of monitoring the short-term glycaemic.Missing: hyperbilirubinemia | Show results with:hyperbilirubinemia
[56]
Discordance Between HbA1c and Fructosamine | Diabetes Care
Jan 1, 2003 · We developed a measure of discordance between HbA1c and fructosamine (FA) (glycosylated serum proteins) to conduct a systematic evaluation.
[57]
A comparison of fructosamine and HbA1c for home self-monitoring ...
In type 2 diabetes, serum fructosamine assay can better reflect average blood glucose concentration over the previous 3 to 6 weeks and HbA1c is better ...
[58]
September Blog - Fructosamine Testing for Glycemic Control
Sep 27, 2024 · Therefore, fructosamine is not influenced by hemoglobin levels and may be a more useful measure of blood sugar control than HbA1c in conditions ...
[59]
Fructosamine Test for Diabetes: Pros, Cons, Compared to A1C
Aug 26, 2025 · This test is beneficial for determining if your diabetes is well-controlled and can be used if other blood sugar tests may be unreliable.
[60]
Glycemic Control and Hemoglobinopathy: When A1C May Not Be ...
Jan 1, 2008 · Because fructosamine is dependent on serum protein glycation, results are unaffected by presence of a hemoglobinopathy.24 In a group of ...
[61]
HbA1c or fructosamine on evaluating glucose intolerance in children ...
Apr 4, 2024 · Furthermore, the normal ranges for fructosamine in non-diabetes mellitus individuals are 2.0 to 2.85 mmol/L. Unlike HbA1c, there is no reference ...
[62]
Hemoglobin A1c—Using Epidemiology to Guide Medical Practice ...
Sep 30, 2021 · The results of our studies—particularly evidence of similar prediction relative to that of HbA1c—suggest that fructosamine and glycated albumin ...
[63]
Fructosamine is a better glycaemic marker compared with glycated ...
Jul 7, 2019 · In fact, two recent systematic reviews found no association between HbA1c and complications following TJA.10,19 Moreover, HbA1c lev- els take at ...