|Year : 2018 | Volume
| Issue : 1 | Page : 36-41
Hematological profile of predialysis chronic kidney disease patients in a tertiary hospital in Southern Nigeria
Ikponmwosa O Iyawe1, Oluseyi A Adejumo2
1 Department of Internal Medicine, University of Benin, Benin City, Ondo State, Nigeria
2 Department of Internal Medicine, Kidney Care Centre, University of Medical Sciences Ondo, Ondo State, Nigeria
|Date of Web Publication||29-May-2018|
Dr. Ikponmwosa O Iyawe
Department of Medicine, University of Benin, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Chronic kidney disease (CKD) is associated with variable changes in the hematological parameters. Anemia is the most common abnormality, however, both number and function of white cells and platelets may be affected. These abnormalities are associated with poor overall clinical outcome. This study assessed the hematologic profile of pre-dialysis CKD subjects and associated factors.
Materials and Methods: This was a cross-sectional study that assessed and compared the hematologic profile in 100 pre-dialysis CKD subjects and 90 healthy controls. P value of <0.05 was taken as significant.
Results: Mean age of the CKD and control subjects were 49 ± 14 years and 52 ± 13 years respectively. Ninety (90%) of CKD subjects had anaemia, significantly higher than 26(28.8%) in the control group (P = 0.000). The proportion of CKD subjects with leukocytosis was significantly higher than the control subjects (P = 0.007). There was no significant difference in the proportion of CKD and control subjects with thrombocytopenia (P = 0.64). The mean cell volume was significantly lower in the CKD group compared to the control subjects (P = 0.000) . Severity of anaemia was significantly associated with CKD stage (P = 0.000) but not with etiology (P = 0.27).
Conclusion: Anaemia was highly prevalent in our pre-dialysis CKD patients and was significantly associated with CKD stage. White cell count was also significantly higher in the CKD subjects and this may reflect increased risk of cardiovascular morbidity and mortality.
Keywords: Anemia, chronic kidney disease, hematological, pre-dialysis, profile
|How to cite this article:|
Iyawe IO, Adejumo OA. Hematological profile of predialysis chronic kidney disease patients in a tertiary hospital in Southern Nigeria. J Med Trop 2018;20:36-41
|How to cite this URL:|
Iyawe IO, Adejumo OA. Hematological profile of predialysis chronic kidney disease patients in a tertiary hospital in Southern Nigeria. J Med Trop [serial online] 2018 [cited 2019 Jun 17];20:36-41. Available from: http://www.jmedtropics.org/text.asp?2018/20/1/36/233416
| Introduction|| |
Chronic kidney disease (CKD) is a major health problem with a steady rise in its incidence and prevalence globally. Its burden is in epidemic proportions, affecting both developed and developing nations, especially countries in the sub-Saharan region. The prevalence of CKD worldwide is estimated at 8–16% varying substantially across countries and regions. Even within Nigeria, there are variations in the reported prevalence of CKD, varying between 6 and 12%.,, Anemia is the most commonly reported hematologic abnormality present in CKD. The prevalence of anemia in patients with CKD varies between 77.5 and 94%, depending on the stage of the disease.,,, The cardiovascular disease burden in CKD is further increased in the presence of anemia, particularly in high-risk populations, coupled with the higher risk of progression of CKD to end stage renal disease (ESRD) and frequent hospitalization., The other detrimental effects of anemia include fatigue, depression, reduced exercise tolerance, and cardiovascular consequences, such as left ventricular hypertrophy and left ventricular systolic dysfunction. These effects tend to worsen morbidity and lead to poor clinical outcome in the patients.,,
The number and function of platelets and white cells may also be affected in CKD resulting in attendant complications such as increase in susceptibility to infections and coagulopathy.,, Reduced lymphocyte number may also be a marker of malnutrition in CKD. Elevated total white cell counts and granulocyte counts are associated with the increased progression of CKD, cardiovascular morbidity, and mortality.,, This study assessed the hematologic profile of patients with predialysis CKD and associated factors.
| Materials and methods|| |
This was a hospital-based, cross-sectional analytical study conducted at the University of Benin Teaching Hospital (UBTH). Consecutive patients with predialysis CKD who met the inclusion criteria were recruited over one-year period between October 2014 and September 2015 from the nephrology clinic, medical wards, and the emergency unit of the hospital.
This was calculated using the Leslie Kish formula for sample size determination in a finite population. The prevalence of anemia in patients with CKD used in the sample size calculation was 94% as reported by Shittu et al.
A total of 100 patients with predialysis CKD and 90 age- and sex-matched apparently healthy adults without CKD were included in the study.
Inclusion criteria were newly diagnosed patients with CKD, those on conservative management who were ≥18 years of age and who gave informed consent to participate in the study. Exclusion criteria were patients with CKD on renal replacement therapy, those with urinary or respiratory tract infection, human immunodeficiency virus (HIV) infection, chronic hepatitis B and C infection, tuberculosis, hemoglobinopathies, malignancy, history of cigarette smoking, use of erythropoiesis stimulating agents, iron products or history of blood transfusion 4 weeks prior to the time of the study.
Ten milliliters of blood was collected from participants for serum creatinine, erythrocyte sedimentation rate (ESR), full blood count, and reticulocyte count. Estimated glomerular filtration rate (eGFR) was calculated using modification of diet in renal disease that has been previously validated in Nigerians.
Definition of terms
Anemia was defined using the World Health Organization definition hemoglobin (Hb) concentration <12 g/dl (females), <13 g/dl (males). The severity of anemia was classified as mild anemia (Hb concentration between 11–12.9 g/dl for males and 11–11.9 g/dl for females); moderate anemia (Hb concentration between 8–10.9 g/dl), and severe anemia (Hb concentration <8 g/dl).
CKD was defined as the presence of markers of kidney damage and/or estimated GFR of <60 ml/min/1.73 m2 for at least three months. Patients with predialysis CKD were those patients who fulfilled the criteria for the definition of CKD and had not been dialyzed.
CKD stages were defined according to Kidney Disease Improving Global Outcome as follows: Stage 1: eGFR ≥90 ml/min/1.73 m2 and persistent proteinuria, Stage 2: eGFR of 60–89 ml/min/1.73 m2 and persistent proteinuria, Stage 3: eGFR of 30 to 59 ml/min/1.73 m2, Stage 4: eGFR of 15 to 29 ml/min/1.73 m2, and Stage 5: eGFR less than 15 ml/min/1.73 m2.
Thrombocytopenia was defined as the platelet count of <90 × 109 cells/L.
Leukocytosis was defined as white blood cell count >8.2 × 109 cells/L.
Ethical clearance for this study was obtained from the Ethics and Research Committee of UBTH.
Data entry and analysis was performed using the Statistical Package for Social Sciences version 17.0 software (IBM SPSS Inc., Chicago, IL, United States). Data were presented as frequencies, percentages, and means (standard deviation). Frequencies were compared using chi-square test. Continuous data were compared using Student’s t-test, and Pearson’s correlation test was used to find the association between continuous variables. A P-value <0.05 was considered as statistically significant for all tests conducted.
| Results|| |
One hundred patients with predialysis CKD and ninety age-matched controls participated in the study with a mean age of 49 ± 14 years and 52 ± 13 years, respectively. There were 56 (56%) male and 44 (44%) female patients with CKD. The controls had 39 (43.3%) male and 51 (56.7%) female controls. Sixty-two (62%) of the patients with CKD were young or middle aged. Fourteen (14%) of the patients with CKD were in stage 1, 8 (8%) in stage 2, 29 (29%) in stage 3, 14 (14%) in stage 4, and the remaining 16 (16%) were in stage 5. The etiologies of CKD in the patients recruited were hypertension (32%), diabetes mellitus (31%), chronic glomerulonephritis (CGN) (25%), and obstructive uropathy (12%) [Table 1].
Ninety (90%) of the patients with CKD had anemia which was significantly higher than 26 (28.8%) of the control with anemia (P = 0.000). Among the anemic patients with CKD, it was severe in 46 (51.1%), moderate in 35 (38.8%), and mild in 9 (10%). In the control group, 24 (92.3%) of those with anemia had mild form [Figure 1].
Leukocytosis was significantly higher in the patients with CKD compared to the control group (24% versus 7.8%), P = 0.007. There was no significant difference in thrombocytopenia between the two groups (3% versus 1.1%), P = 0.64 [Figure 2].
|Figure 2: Prevalence of leukocytosis and thrombocytopenia among study groups|
Click here to view
The red blood cell count, Hb concentration, packed cell volume, and mean cell volume were significantly lower in the patients with CKD compared to the controls (P = 0.000). The reticulocyte count of the patients with predialysis CKD (1.62 ± 2.80%) was higher than the controls (1.31 ± 0.67%), P = 0.297. The total white cell count was significantly different between both groups (6.75 ± 3.26 × 109 cells/L versus 5.82 ± 1.72 × 109 cells/L), P = 0.017. The mean ESR value was higher in the patients with CKD with P values of 0.000 [Table 2].
The prevalence of anemia increased from 64.2% at stage 1 to 87.5% at stage 2, 89.6% at stage 3, 96.9% and 100% at stage 4 and 5 CKD respectively (P = 0.000). There was a significant association between the severity of anemia and stage of CKD (P = 0.000) [Table 3]. There was no significant difference between Hb concentration of the various etiologies of CKD (P = 0.27) [Table 4].
|Table 4: Comparison of hemoglobin concentration among the various etiologies of CKD|
Click here to view
| Discussion|| |
This study showed a high prevalence of anemia (90%) among our predialysis CKD patients. This finding is comparable to studies by Shittu et al. and Arun et al. who reported the prevalence of anemia to be 94 and 98%, respectively. A lower prevalence of 77.5% was reported by Ijoma et al. in a study conducted in Southeastern Nigeria. The finding of our study is at variance with studies conducted in Spain and United States of America, which showed that the prevalence of anemia was 58.5% and 15.4%, respectively., Anemia is more prevalent among patients with CKD in developing nations than developed nations. Possible reasons include the presence of factors that are not directly due to kidney disease which include high burden of infections, poor nutrition, racial and ethnic factors. In addition, the etiology of CKD and time of presentation of these patients to nephrologist may also be partly responsible.
The prevalence of anemia in the control group was 28.8% with majority having a mild form of anemia. This is similar to the prevalence of anemia in the general population reported by McLean et al. as 24.8%. Anemia is known to be relatively common among apparently healthy population in the sub-Saharan region., Possible reasons for this include malnutrition and helminthic infections which are common in this region. The prevalence of anemia in the control participants is also similar to 21.7% reported in apparently healthy Nigerian adults by Ugwuja et al.
The severity of anemia was shown to be significantly associated with the stage of CKD. This is consistent with the fact that as the GFR declines, there is a corresponding decline in the Hb concentration, which is mostly due to the reduced synthesis of erythropoietin.,,
The comparison of the mean red cell indices between the CKD and control groups showed that only the mean cell volume was significantly lower in the patients with CKD. There was no significant difference with the other red cell indices. A similar finding was observed in the study by Shittu et al. There was no association between these red cell indices and the degree of renal impairment in this study. This also agreed with the report of study conducted in Nigeria.
CGN accounted for the lowest mean Hb concentration (7.86 ± 2.74%), closely followed by hypertension (8.76 ± 2.66%), then diabetes mellitus (9.07 ± 2.73%), and obstructive uropathy (9.41 ± 2.49%). There was no significant association between the etiology of CKD and anemia similar to an earlier report. However, in variance to our finding, Loutradis et al. reported that anemia is more common in patients with diabetic kidney disease compared to other kidney disease.
About a quarter of the patients with CKD had leukocytosis compared to 7.8% in the control group. The mean total white cell count and granulocyte count were significantly higher in the CKD group compared to control. This finding is similar to the report by Shittu et al. but different from report by Suresh et al. and Islam et al. Suresh et al. reported no significant difference in the mean white cell count and granulocyte count between their patients with CKD and controls; however, Islam et al. reported a significantly lower white cell count in their patients with CKD compared to controls. This elevated white cell count and ESR may be associated with inflammation in the absence of infection which was excluded in our study. Coronary heart disease risk ratio is associated with high white blood cell count which is comparable with other inflammatory markers such as C-reactive protein.
White blood cells play a key role in the initiation and progression of atherosclerosis; these cells release cytokines that cause macrophage recruitment and proliferation of vascular smooth muscle. Elevated white cell count and granulocyte have been associated with rapid progression to ESRD, cardiovascular morbidity, and mortality.,, This may therefore imply that our patients with CKD are at increased risk of developing cardiovascular disease; hence, there is a need for aggressive cardiovascular risk factor modification and treatment.
There was no significant difference between the platelet count of CKD and control groups in this present study. This is similar to the report by Van Blade et al. but differs from other reports where patients with CKD had significantly lower platelet count.,, Only 3% of the patients with CKD in our study had thrombocytopenia unlike 7.7 and 52% reported by Akinsola et al. and Talwar et al., respectively. The difference in the prevalence of thrombocytopenia in these studies may be related to differences in the cutoff value of platelet count used to define thrombocytopenia and severity of the CKD of the studied participants. Akinsola et al. used a higher cutoff value of <100 × 109 cells/L unlike our study that used a lower count of <90 × 109 cells/L. In addition, Talwar et al. who reported a high prevalence of thrombocytopenia studied patients on maintenance HD unlike our study which involved patients with predialysis only. The effect of heparin, dialyzer membrane, and extracorporeal circulation on platelet during HD may account for the very high prevalence of thrombocytopenia in the study by Talwar et al. compared to our study. Abnormal platelet function has been reported in patients with CKD even when the platelet count is normal as reported by Van Blade et al.
This study revealed a high prevalence of anemia among our predialysis CKD patients, pronounced in the later stages. White cell count was also significantly higher in the predialysis CKD patients compared to the control group, this may reflect increased risk of cardiovascular morbidity and mortality in our patients, hence the need for prompt and aggressive intervention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arogundade F, Barsoum R. CKD prevention in sub-Saharan Africa: A call for governmental, nongovernmental, and community support. Am J Kidney Dis 2008;51:515-23.
Kadiri S, Arije A. Temporal variations and meteorological factors in hospital admissions of chronic renal failure in south west Nigeria. West Afr J Med 1999;18:49-51.
Akinsola W, Odesanmi WO, Ogunniyi JO, Ladipo GO. Diseases causing chronic renal failure in Nigerians − A prospective study of 100 cases. Afr J Med Med Sci 1989;18:131-7.
Ulasi II, Ijoma CK, Onodugo OD, Arodiwe EB, Ifebunandu NA, Okoye JU. Towards prevention of chronic kidney disease in Nigeria: A community-based study in Southeast Nigeria. Kidney Int Suppl 2013;3:195-201.
Akinsola A, Durosinmi MO, Akinola NO. The haematological profile of Nigerians with chronic renal failure. Afr J Med Med Sci 2000;29:13-6.
Shittu AO, Chijioke A, Biliaminu SA, Makusidi AM, Sanni MA, Abdul-Rahman MB et al.
Haematologic profile of patients with chronic kidney disease in Nigeria. J Nephrol Ren Transplant 2013;5:2-10.
Ijoma C, Ulasi I, Ijoma U, Ifebunandu N. High prevalence of anemia in predialysis patients in Enugu, Nigeria. Nephro Rev 2010;2:61-5.
Talwar VK, Gupta HL, Shashinarayan XX. Clinicohaematological profile in chronic renal failure. J Assoc Physicians India 2002;50:228-33.
Silverberg DS, Wexler D, Iaina A, Schwartz D. The correction of anemia in patients with the combination of chronic kidney disease and congestive heart failure may prevent progression of both conditions. Clin Exp Nephrol 2009;13:101-6.
Keane WF, Brenner BM, de Zeeuw D, Grunfeld J-P., McGill J, Mitch WE et al.
The risk of developing end-stage renal disease in patients with type 2 diabetes and nephropathy: The RENAAL study. Kidney Int 2003;63:1499-507.
Review E, National Kidney Foundation. KDOQI clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease. Am J Kidney Dis 2006; 47(5 Suppl 3):S11-145.
Levin A, Foley RN. Cardiovascular disease in chronic renal insufficiency. Am J Kidney Dis 2000;36(6 Suppl 3):S24-30.
Levin A, Thompson CR, Ethier J, Carlisle EJ, Tobe S, Mendelssohn D et al.
Left ventricular mass index increase in early renal disease: Impact of decline in hemoglobin. Am J Kidney Dis 1999;34:125-34.
Kaw D, Malhotra D. Platelet dysfunction and end stage renal disease. Semin Dial 2006;19:317-22.
Dorgalaleh A, Mahmudi M, Tabibian S, Khatib ZK, Tamaddon GH, Moghaddam ES et al.
Anaemia and thrombocytopaenia in acute and chronic renal failure. Int J Hematol Oncol Stem Cell Res 2013;7:34-9.
Kato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y et al.
Aspects of immune dysfunction in end stage renal disease. Clin J Am Soc Nephrol 2008;3:1526-33.
Kovesdy CP, George SM, Anderson JE, Kalantar-Zadeh K. Outcome predictability of biomarker of protein energy wasting and inflammation in moderate and advance chronic kidney disease. Am J Clin Nutr 2009;90:407-14.
Reddan DN, Klassen PS, Szczech LA, Coladonato JA, O’Shea S, Owen WF et al.
White blood cells as a novel mortality predictor in hemodialysis patients. Nephrol Dial Transpl 2003;18:1167-73.
Bash LD, Erlinger TP, Coresh J, Marsh-Manji J, Folsom AR, Astor BC. Inflammation, hemostasis and the risk of kidney function decline in atherosclerosis risk in community (ARIC) study. Am J Kidney Dis 2009;53:596-605.
Fried L, Solomon C, Shlipak M, Seliger S, Stehman-Breen C, Bleyer AJ et al.
Inflammatory and prothrombotic markers and the progression of renal disease in elderly individuals. J Am Soc Nephrol 2004;15:3184-91.
Abefe SA, Abiola AF, Olubunmi AA, Adewale A. Utility of predicted creatinine clearance using MDRD formula compared with other predictive formulas in Nigerian patients. Saudi J Kidney Dis Transpl 2009;20:86-90.
] [Full text]
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011 (WHO/NMH/NHD/MNM/11.1). Available from: http://www.who.int/vmnis/indicators/haemoglobin
. [Last accessed on 2018 Feb 12].
Kidney Disease Improving Global Outcome (KDIGO) 2012. Clinical practice guideline of evaluation and management of CKD. Kidney Int Suppl 2013;3:1-150.
Halim NK, Famodu AA., Wemambu SN. Textbook of Clinical Haematology and Immunology. 2nd
ed. Benin: Ambik Press; 2001.
Arun S, Prabhu MV, Chowta KN, Bengre ML. The haematological pattern of the patients with chronic kidney disease in a tertiary care setup in south India. J Clin Diagn Res 2012;6:1003-6.
Cases-Amenós A, Martínez-Castelao A, Fort-Ros J, Bonal-Bastons J, Ruiz MP, Vallés-Prats M et al.
Prevalence of anaemia and its clinical management in patients with stages 3–5 chronic kidney disease not on dialysis in Catalonia: MICENAS I study. Nefrologia 2014;34:189-98.
Stauffer ME, Fan T. Prevalence of anemia in chronic kidney disease in the United States. PLoS One 2014;9:e84943. doi:10.1371/journal.pone.0084943
McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia. WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutr 2009;12:444-54.
Miller LJ. Iron deficiency anemia: A common and curable disease. Cold Spring Harb Perspect Med 2013;3. doi:10.1101/cshperspect.a011866.
Ugwuja EI, Ogbonnaya LU, Obuna AJ, Awelegbe F, Uro-Chukwu H. Anaemia in relation to body mass index (BMI) and socio-demographic characteristics in adult Nigerians in Ebonyi State. J Clin Diagn Res 2015;9:4-7.
McClellan W, Aronoff SL, Bolton WK, Hood S, Lorber DL, Tang KL et al.
The prevalence of anemia in patients with chronic kidney disease. Curr Med Res Opin 2004;20:1501-10.
Asfar R, Sanavi S, Salimi I, Ahmadzadeh M. Hematological profile of chronic kidney disease in Iran, in predialysis stages and after initiation of hemodialsysis. Saudi J Kidney Dis Transpl 2010;21:368-71.
Loutradis C, Skodra A, Georgianos P, Tolika P, Alexandrou D, Avdelidou A et al.
Diabetes mellitus increases the prevalence of anemia in patients with chronic kidney disease: A nested case-control study. World J Nephrol 2016;5:358-66.
Suresh M, Mallikarjuna RN, Sharan SM, Hari KB, Shravya KG, Chandrasekhar M. Haematological changes in chronic renal failure. Int J Sci R Pub 2012;2:1-4.
Islam MN, Ferdous A, Zahid AZ, Alam M, Islam MN. Hematological profile of patients with chronic kidney disease in northern Bangladesh. Dinajpur Med Coll J 2015;8:21-7.
Madjid M, Fatemi O. Components of complete blood count as a risk predictor for coronary heart disease. Text Heart Inst J 2013;40:17-29.
Van Blade RE, de Jager RL, Walter D, Cornelissen L, Gaillard CA, Broven LA et al.
Platelets of patients with chronic kidney disease demonstrate deficient platelet reactivity in vitro
. BMC Nephrol 2012;13:127. doi:10.1186/1471-2369-13-127.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]