Indian J. Prev. Soc. Med. Vol. 45 No. 1-2, 2014

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1 ISSN Indian J. Prev. Soc. Med. Vol. 45 No. 1-2, 2014 ANAEMIA IN CHRONIC KIDNEY DISEASE PATIENTS AND ITS RELATION TO GFR AND SOCIO-DEMOGRAPHIC PROFILE Richa Mishra 1, RG Singh 2, CP Mishra 3, Shivendra Singh 4, PN Tiwari 5 ABSTRACT Design of Study: Hospital based cross sectional study designed was adopted for the study. Setting: This study was conducted at the department of Nephrology Institute of Medical Sciences, Banaras Hindu University, and Varanasi. Subjects: 175 patients of chronic kidney disease attending OPD of the nephrology department first time were considered as subjects of the study. Methodology: After taking Consent from the patients they were interviewed by the researcher regarding their socio demographic characteristics. Serum creatinine was measured by Alkaline picrate method and haemoglobin was measured by Draft king method. Weight and age was recorded to measure e glomerular filtration rate (GFR). Results: Mean hemoglobin of stage II CKD patients was ± 2.60 gm/dl. There was gradual decline in hemoglobin level in stage III (10.39 ± 2.06), stage IV (9.09 ± 1.93), Stage V (8.18 ± 2.44). Hemoglobin level of CKD patients differed significantly in different stages. As much as 95.8% male subjects and 89.27% female subjects were anemic on the basis of WHO cut off <13 gm/dl for male and < 12gm/dl for female subjects. There was existed significant difference in the hemoglobin level and socioeconomic status (P<0.05). Conclusions: There is an urgent need for management for treatment of anaemia as well as their nutritional status. Key Words: Chronic kidney Disease, GFR, TIBC. INTRODUCTION Chronic Kidney Disease is worldwide public health issue, with an increasing incidence and prevalence associated with poor out comes and high cost. 1 The association of Chronic Kidney disease and anemia has been recognized since the early 19 th century, first noted by Richard Bright in 1837 when he observed pallor in the development of Bright s disease. 2 CKD population is much larger than the dialysis population 3. According to glomerular filtration rate (GFR) and 2006 NKF-K/DOQI guidelines, chronic kidney disease has been divided into 5 stages. 4 Anaemia usually appears at GFR below 60ml/min or stage Anemia, as defined by the NKF, is a hemoglobin (Hb) concentration < 12 g/dl for women and < 13.5 g/dl for men 8..Anemia is defined in terms of low levels of hematocrit or hemoglobin. 9 Anemia is a common complication of chronic kidney disease which develops quite early in the course of disease. It is common sequelae of the chronic kidney disease, associated with significant morbidity. Anemia of renal failure begins relatively early in the development of kidney disease. As the destruction of the kidney progress, the degree of the anemia increases. 1. Research scholar, 2. Professor & Head, Department of Nephrology, IMS, BHU, Varanasi. 3. Professor & Head, Department of Community Medicine, 4. Associate Professor, Department of Nephrology, IMS, BHU. 5. Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol and Drug Abuse, National Database in TB and Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

2 Although, there is a large degree of patient to patient variability, the hemoglobin begins to fall when the plasma creatinine concentration is above 2mg/dl and gets lower as glomerular filtration rate (GFR) declines Anemia leads to peripheral vasodilatation, causing increase in cardiac output, physiological left ventricular dilatation and hypertrophy that if not reversed leads to pathological left ventricular hypertrophy (LVH). 11 Every 1 gm/dl decline in hemoglobin below 11 gm/dl increase LVH by 6 % and risk of developing congestive heart failure by 49 percent. The LVH increase the risk of death in ESRD patients by 2.9 fold and anemia increase the risk of death by 14 percent. 12 Anemia of CKD is a complex disorder determined by a variety of factors. Although, the primary defect is decreased erythropoiesis due to inadequate erythropoietin (EPO) production from kidneys, a number of other factors may be shortened erythrocyte survival, blood loss, iron and other nutritional deficiency, albumin toxicity and effect of uremic inhibitor on the bone marrow. Severe hyperparathyroidism is one cause of anemia in CKD patients. Non renal and non dialysis factor can also super impose themselves on the anemia of CKD. These include drug induced bleeding, infections and inflammation With this background this study was contemplated in a tertiary care setting of central India to assess hematological profile of Chronic Kidney Disease and its relation to Glomerular Filtration rate and socio-demographic variables. MATERIAL AND METHODS Setting: This study was conducted at the department of Nephrology Institute of Medical Sciences, Banaras Hindu University, and Varanasi. Design of Study: Hospital based cross sectional study designed was adopted for the study. Subjects: 175 patients of chronic kidney disease attending OPD of the nephrology department first time were considered as subjects of the study. Inclusion criteria: All patients of chronic kidney disease who fulfill following criteria were included in the study: [a] Serum creatinine level <6 mg/dl and [b] Clinical and Biochemical evidence of chronic renal failure (Serum Creatinine >1.5%, Urea >40 mg/d for >3 months). Exclusion criteria: [a] Patients with acute on CRF, and [b] Other conditions like malignancy, advance renal disease or any other chronic illness Methodology: After taking Consent from the patients they were interviewed by the researcher regarding their socio-demographic characteristics with the help of predesigned and pretested schedule. Age of each specific subject was assessed by life event and local calendar method. Their weight was recorded by using Libra weighing scale and following standard techniques. 11 Haematological profile (Hb, Iron, and TIBC) and Serum Creatinine level of study subjects were estimated in the Centre for Clinical Investigation (CCI) of the Sir Sunderlal Hospital. However in the case of controls only haemoglobin estimation was done. GFR of the study subject was calculated by using Cockcroft Gault equation. RESULTS Of all patients (175) none were in the stage I. Mean hemoglobin of stage II CKD patients was 10.70±2.60 gm/dl. There was gradual decline in hemoglobin level in stage III (10.39±2.06), stage IV (9.09± 1.93), Stage V (8.18±2.44). Hemoglobin level of CKD patients differed significantly in different stages (Table-1). (140- age)x bogy weight (kg) egfr= 72 x SerumCreatinine x Multiply by 0.85 for women. Table- 1: Stage wise values of hematological parameters Stage N Hemoglobin Iron TIBC Stage I Stage II ± ± ± Stage III ± ± ± Stage IV ± ± ± Stage V ± ± ± Total ± ± ± F value P value Indian J. Prev. Soc. Med Vol. 45 No

3 As per Post Hoc test Hemoglobin level of stage III patients was significantly more than those of stage IV and V. There existed no significant difference in the iron and TIBC levels of patients in different stages of CKD (Table 1). This study was carried out on 119 male and 56 female CKD patients meeting inclusion criteria. As much as 95.8% male subjects and 89.27% female subjects were anemic on the basis of WHO cut off <13 gm/dl for male and <12gm/dl for female subjects. As much as % male and % female subjects has Hb >7 gm/dl (Table-2). Table- 2: Sex wise values of hematological parameters Sex N Hemoglobin Iron TIBC Male ± ± ± Female ± ± ± Total ± ± ± t value df P value Seventy three (65.55 %) and 34 (60.72%) female subject had Hb in the range of 7-12 gm/dl. Over all mean Hb of the study subjects was 9.07±2.22 (Table 2). There existed significant difference in the age wise distribution of Hb (table 3). The Post Hoc test reveals significant difference between the hemoglobin level between age group yrs and more than 60 yrs. The average normal range of serum iron is µg/dl. Serum iron value of 28 (16.0 %) subject was less than 41 µg/dl and in case of 14 subjects serum iron value exceeded upper limit of the normal range (Table-3). Normal range for TIBC is µg/dl in case of 62(35.43%) and 46 (26.29%) subjects TIBC was beyond upper limits respectively. Mean Iron and TIBC levels were ± and ± respectively. There existed no significant difference in the age wise mean value of Iron and TIBC (Table 3). Table- 3: Age wise values of hematological parameters Age N Hemoglobin Iron TIBC < ± ± ± ± ± ± ± ± ± 1.17 > ± ± ± Total ± ± ± 1.03 F value P value Mean Hemoglobin of male CKD subjects (9.31±2.27) was significantly more than female subjects (8.57±2.04). Corresponding value for controls was (11.85±1.62). Iron and TIBC values for male patients were 75.43±32.94 and ± , respectively. These values were not significantly different from female subjects (table 2). Results given in table 4 signify that hematological parameters were similar for rural and urban CKD patients (Table 4). Table -4: Residence wise values of hematological parameters Area N Hemoglobin Iron TIBC Rural ± ± ± Urban ± ± ± Total ± ± ± T test df P value Indian J. Prev. Soc. Med Vol. 45 No

4 Socio-economic status wise distribution of hematological parameter is given in table-5. Minimum and maximum hemoglobin levels were observed in upper middle and high socioeconomic status. There was existed significant difference in the hemoglobin level and socioeconomic status (P<0.05). Serum iron levels were similar in all socioeconomic categories. TIBC was maximum (369.41±166.00) in high socio-economic status and minimum in (276.53±106.29) in lower middle socioeconomic status (P<0.05) (table 5). Table-5: Socio-economic status wise values of hematological parameters Socioeconomic status N Hemoglobin Iron TIBC Very low ± ± ± Low ± ± ± Lower middle ± ± ± Middle ± ± ± Upper middle ± ± ± High ± ± ± Total ± ± ± F value P value Sex wise distribution of study subject is given in table 6. As much as % male and % female had hemoglobin level <7gm /dl. Mean hemoglobin level of controls (11.57 ±2.16) was significantly (t = 7.53, P = <.01) more than that of cases. DISCUSSION Table-6: Sex wise distribution of study subjects Hemoglobin Male Female No % no % < > F value 2 P value.033 Anaemia is a common sequealae of chronic kidney disease associated with significant morbidity. As a diseased kidney loses its ability to produce erythropoietin hormone, essential for production of hemoglobin, anemic ensues. In conformity with findings of the present study several workers have reported high level of anemia. 6,13-15 This study amply highlights that in advance stage likelihood of anemia increases significantly with lower levels of hemoglobin oxygen decreases and therefore capacity to work saturation decreases and therefore capacity of work detoriates. Further management of anemic CKD patients becomes difficult. Therefore it becomes imperative to focus attention primary prevention of CKD and in the event of disease progressive should be arrested by adhering to treatment guidelines dietary modification and adapting healthy lifestyle practices. Indian J. Prev. Soc. Med Vol. 45 No

5 REFERENCES 1. National Kidney Foundation: K/DOQI clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and stratification. Am J Kidney Dis2002;39(1) S1- S National Kidney Foundation: K/DOQI clinical Practice Guidelines 2000 update. Am J Kidney Dis 2001; 37 (suppl 1): NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Dis 2006; 47 (Suppl 4):S1. 4. Radtke HW, Claussner A, Erbes PM, et al. Serum erythropoietin concentration in chronic renal failure: Relationship to degree of anaemia and excretory renal function. Blood 1979:54: McGonigle RS, Wallin JD, Shadduck RK, et al. Erythropoietin deficiency and inhibition of erythropoiesis in renal insufficiency. Kidney Dis 1984;25: Afshar R, Sanavi S, Salimi J, Epidemiology of Chronic renal failure in Iran:a four year single centre experience. Saudi J Kidney Dis Transpl 2007;18(2): National Kidney Foundation: Clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease in adults. Am J Kidney Dis 2006; 5 (Suppl. 3): S1 S108, 8. Remuzzi G, Rossi Ec. Hematologic consequences of renal failure. In: Brenner BM, Ed. The Kidney. 5th edition. Philadelphia: WB Saunders Co; P Lee GR. The anemias associated with renal disease, liver disease, endocrine disease, and pregnancy. In: Lee GR, Foester J, Lekuns J, Paraskevas F. Greer JP Rodgers GM, eds. Wintrobe Clinical Hematology. 10 th ed. Baltimore: Williams & Wilkins A Walverly Co.; P Monograph, sign and symptoms of uremia, In Block RM, Alfred HJ, Fan PY, Stoff JS, (eds). Rose and Block s Clinical problems in nephrology. 1st ed Little Brown and company: Boston; Pp Levin A, Thompson CR, Ethier J, et al. Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin. Am J kidney Dis 1999;34: Silberberg JS, Barre PE, Prichard SS, et al. Impact of left ventricular hypertrophy on survival in end stage renal disease. Kidney Int 1989; 36: Besarab A, McCrea JB, Anemia in ESRD, In: Nissenson MR, Fine RN,(eds). Dialysis therapy. 2nd ed. Philadelphia: Hanley Inc; 1993, pp Spivak JL. The blood in systemic disorders. Lancet 2000; 355: Dianiak N. Hematologic complications in renal disease, In: Hoffman R, Benz EJ, Shattil SJ, Furie B, Cohen HJ, Silberstein Le, Mcc Grave P(eds). Hematology basic principles and practice. 3rd ed. Churchill Livingstone: New York; 2000, Rice L, Alfrey CP, Driscoll T, Whitley CE, Hachey DL, Suki W. Neocytolysis contributes to anemia of renal disease. Am J Kidney Dis 1999; 33: Indian J. Prev. Soc. Med Vol. 45 No

ORIGINAL ARTICLE. Ketut Suega, Made Bakta, Tjok Gde Dharmayudha*, Jodi S Lukman, Ketut Suwitra

ORIGINAL ARTICLE. Ketut Suega*, Made Bakta*, Tjok Gde Dharmayudha*, Jodi S Lukman**, Ketut Suwitra** ORIGINAL ARTICLE Profile of Anemia in Chronic Renal Failure Patients: Comparision Between Predialyzed and Dialyzed Patients at The Division of Nephrology, Department of Internal Medicine, Sanglah Hospital,