Our aim of this work was to study the Contributors and Consequences of Haemoglobin Variability in Patients with Chronic Kidney Disease (Stage 5) under haemodialys.
In our study we found that:
Group A: Mean haemoglobin in haemoglobin variability less than 11 gm/dl. includes 41 patients of the sixty patients of the study population with percentage 68%.
80% of patients in group A who started with mean haemoglobin less than 11 gm/dl in the second month of the study remain in the same group A in the sixth month of the study.
14.5% of patients in group A who started with mean haemoglobin less than 11 gm/dl in the second month of the study crossed to group B in the sixth month of the study.
5.5% of patients in group A who started with mean haemoglobin less than 11 gm/dl in the second month of the study crossed to group C in the sixth month of the study.
73.3% of total population of the study was in group A in the sixth month of the study.
The mean haemoglobin of the group A varied from one month to another but didn't cross to any other group in any month throughout the study time.
Secondary hyperparathyroidism was present in group A (334.15±100.83) pg/ml.
HCV infection was found in 66% of patients of group A and this was statistically significant.
Iron deficiency was found in 95% of patients of group A and this was statistically highly significant.
Cardiac diseases were found in 92.5% of patients of group A and this was statistically highly significant.
Autonomic dysfunction was found in 36.5% of patients of group A.
Thrombotic events were found in 2.4% of patients of group A and this was statistically significant toward the absence of thrombotic events.
The percentage of hospitalization in group A was less than 5 % in the last three months of the study and 0 % in the first three months of the study and this was highly significant statistical difference toward the absence of hospitalization.
The percentage of mortality in group A was 2.4 % and this was highly significant statistical difference toward the absence of mortality.
Group B: Mean haemoglobin in haemoglobin variability between 11 and 13 gm/dl. Includes 16 patients of the sixty patients of the study population with percentage 27 %.
62.5% of patients in group B who started with mean haemoglobin between 11and 13 gm/dl in the second month of the study crossed to group A in the sixth month of the study.
18.75% of patients in group B who started with mean haemoglobin between 11and 13 gm/dl in the second month of the study remain in the same group B in the sixth month of the study.
18.75% of patients in group B who started with mean haemoglobin between 11and 13 gm/dl in the second month of the study crossed to group C in the sixth month of the study.
18.3% of total population of the study was in group B in the sixth month of the study.
The mean haemoglobin of the group B varied from one month to another and crossed to group A in two months throughout the study time.
Gender: 62.5% of group B were males and 37.5% were females and this was statistically significant toward male gender.
Secondary hyperparathyroidism was present in group B (383.44±125.27) pg/ml.
HCV infection was found in 62.5% of patients of group B and this was statistically significant.
Cardiac diseases were found in 100% of patients of group B.
Interfering drugs with haematopoiesis e.g., (ACEI and ARBs) were received by 37.5% of patients of group B and this was statistically significant toward the absence of interfering drugs with haematopoiesis.
Other infections e.g., UTI, chest infections, gum and catheter related infections were found in less than 25% of patients of group B in month one, three and four of the study and this was statistically significant toward the absence of other infections.
Thrombotic events were found in 6.25% of patients of group B and this was statistically significant toward the absence of thrombotic events.
The percentage of hospitalization in group B was less than12. 5 % in the last three months of the study and 0 % in the first three months of the study and this was highly significant statistical difference toward the absence of hospitalization.
Group C: Mean haemoglobin in haemoglobin variability more than 13gm/dl. Includes 3 patients of the sixty patients of the study population with percentage 5 %.
33% of patients in group C who started with mean haemoglobin more than 13 gm/dl in the second month of the study crossed to group A in the sixth month of the study
67% of patients in group C who started with mean haemoglobin more than 13 gm/dl in the second month of the study crossed to group B in the sixth month of the study
0% of patients in group C who started with mean haemoglobin more than 13 gm/dl in the second month of the study remain in the same group C in the sixth month of the study
8.4% of total population of the study was in group C in the sixth month of the study
The mean haemoglobin of the group varied from one month to another and crossed to group A in one month and crossed to group B in three months through the study time and overshoot in two months through the study time.
100% of the patients of group C were males.
HCV infection was found in 100% of the group C.
Interfering drugs with haematopoiesis e.g., (ACEI and ARBs) were received by 66.5% of patients of group C and this was statistically significant
Cardiac diseases were found in 100% of patients of group C.
Other infections e.g., UTI, chest infections, gum and catheter related infections were found in less than 33% of patients of group C.
Weakness and fatigue were found in less than 33% of patients of group C.
There was significant statistical difference between the three groups according to iron dose per month. In group A (209.52± 62.49 mg/month), in group B (240.00±129.61mg/month) and in group C (400.00±0.0 mg/month).
There was highly significant statistical difference between the three groups according to serum iron level. In group A (40± 20.42 µg/dL), in group B (70.49±36.90 µg/dL) and in group C (79.44±49.96 µg/dL).
There was highly significant statistical difference between the three groups according to ferritin level. In group A (89.85± 58.09 ng/ml), in group B (206.81±65.08 ng/ml) and in group C (323.67±142.39 ng/ml).
There was highly significant statistical difference between the three groups according to transferrin saturation level. In group A (11.9± 6.1%), in group B (22.7±8.5%) and in group C (27.6±9.3%).
There was highly significant statistical difference between the three groups according to iron deficiency
There was significant statistical difference between the three groups according to duration of haemodialysis. In group A (5.29± 4.11 years), in group B (3± 2.02 years) and in group C (9.33±6.43 years).
There was statistical difference between all patients in the study throughout the different quartiles according to serum creatinine levels and this difference was statistically significant. In the first quartile (8.41±3.44 mg/dl), in the second quartile (7.08±3.07 mg/dl) and in the third quartile(6.24±2.80 mg/dl) .
There was statistical difference between all patients in the study throughout the different quartiles according to blood Bicarbonate level levels and this difference was statistically significant. In the first quartile (20.12±1.66 meq/l), in the second quartile (21.11±1.95 meq/l) and in the third quartile(21.11±1.42 meq/l).
There was statistical difference between all patients in the study throughout the different quartiles according to serum phosphorus levels and this difference was statistically significant. In the first quartile (5.54±2.63 mg/dl), in the second quartile (6.34±1.71 mg/dl) and in the third quartile(5.1±1.15 mg/dl).
Conclusion
We have found haemoglobin variability to be a frequent finding in haemodialysis patients treated with rHuEPO.
Iron treatment, iron deficiency, secondary hyperparathyroidism, HCV virus infection, interfering drugs with haematopoiesis e.g., ACEI or ARBs and male gender were significant contributing factors for haemoglobin variability.
Other infections e.g., UTI, chest infections, gum and catheter related infections might play a role as a contributing factor for haemoglobin variability .
Cardiac diseases were a significant consequence of haemoglobin variability.
Weakness, fatigue and autonomic dysfunction might be consequences of haemoglobin variability.
Recommendations
We need to do every effort to minimize haemoglobin variability in haemodialysis patients treated with rHuEPO by reducing incidence of contributing factors of haemoglobin variability by:
Applying smart anemia management protocol or individualized anemia management protocol with avoidance of drastic changes in ESA dose and better management of iron status.
Proper management of secondary hyperparathyroidism.
Prophylaxis and treatment of HCV infection and other infections.
Reducing the use of drugs that interfere with haemtopoiesis unless indicated.
We need a study with large sample size, multicenter design and longer duration to make the results be easily generalzable. |
