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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 368-371
Hematological profile of chronic kidney disease (CKD) patients in Iran, in pre-dialysis stages and after initiation of hemodialysis

1 Nephrology Department, Shahed University, Mustafa Khomeini Hospital, Tehran, Iran
2 Vascular Surgery Department, Tehran University of Medical Sciences, Tehran, Iran

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Date of Web Publication9-Mar-2010


Anemia is a common sequealae of chronic kidney disease (CKD), associated with significant morbidity. A cross-sectional study was conducted on 100 CKD patients (54 hemodia­lyzed, 46 pre-dialyzed). Data including, complete blood count, BUN, creatinine, creatinine clea­rance, underlying diseases and hemodialysis duration were collected by a questionnaire. The most frequent morphologic features were normochromic-normocytic (80%), hypochromic-microcytic (15%) and macrocytic (5%). The frequency of anemia in hemodialyzed and pre-dialyzed patients (with mean Hgb level of 10.27 and 11.11 g/dL) were 85% and 75%. Hemoglobin concentration was positively correlated to calculated creatinine clearance (P < 0.001). The severity of anemia among hemodialyzed patients was mild (Hgb > 10 g/dL) in 5%, moderate in 70% and severe (Hgb < 7 g/dL) in 25%, while in pre-dialyzed was mild in 45% and moderate in 55%. There was no correlation between the anemia and CKD causes or hemodialysis duration. In conclusion, data shows that anemia in our patients with CKD is a predominant manifestation, with high frequency but of moderate degree. The most likely cause is inadequate erythropoietin production.

How to cite this article:
Afshar R, Sanavi S, Salimi J, Ahmadzadeh M. Hematological profile of chronic kidney disease (CKD) patients in Iran, in pre-dialysis stages and after initiation of hemodialysis. Saudi J Kidney Dis Transpl 2010;21:368-71

How to cite this URL:
Afshar R, Sanavi S, Salimi J, Ahmadzadeh M. Hematological profile of chronic kidney disease (CKD) patients in Iran, in pre-dialysis stages and after initiation of hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Aug 9];21:368-71. Available from: https://www.sjkdt.org/text.asp?2010/21/2/368/60217

   Introduction Top

The anemia of chronic kidney disease (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 the kidneys, a number of other factors may play contribu­tory roles, for example: iron, B12 and folate deficiency due to nutritional insufficiency or increased blood loss, [1],[2],[3] shortened red blood cells survival, [4] hyperparathyroidism, mild chro­nic inflammation and aluminum toxicity. [5],[6],[7] Un­treated prolonged anemia leads to a number of physiologic disorders, including: cardiovascu­lar complications and increased mortality and morbidity. [8] According to the glomerular filtra­tion rate (GFR) and 2006 NKF-K/DOQI guide­lines, chronic kidney disease has been divided into 5 stages. [9] Anemia usually appears at GFR below 60 mL/min or at stage. [3],[10],[11],[12]

Renal insufficiency is also associated with bleeding tendency attributed to platelet dysfunction due to abnormal platelet aggregation and ad­hesiveness. [13],[14] White blood cells count may be decreased in uremic patients and anemia cor­rection is followed with an increase in natural killer cells and improvement of leukocyte pha­gocytic function. [15],[1]

This study was conducted to determine the hematologic profile of CKD patients and com­pares the hemodialyzed and pre-dialyzed pa­tients.

   Methods Top

This cross-sectional study was designed at the Mustafa Khomeini Hospital, Tehran, Iran over 1 year. The study population consisted of 100 CKD patients (54 hemodialyzed patients undergoing conventional maintenance hemo­dialysis and 46 pre-dialyzed patients).

Inclusion criteria:

  1. Patients providing informed consent.
  2. Patients with documented chronic kidney disease.
Exclusion criteria were consisting:

  1. Acute or chronic inflammatory disease.
  2. Malignancy or known hematological dis­order.
  3. Recent severe hemorrhagic episode.
Data including: age, gender, body weight, CKD causes, hemodialysis duration, complete blood count, erythrocyte sedimentation rate (ESR), serum BUN and creatinine were col­lected in a questionnaire. Estimated creatinine clearance or GFR was calculated by using the Cockcroft-Gault equation, for pre-dialyzed pa­tients:

All data analyses were carried out using the SPSS, v. 16. The Chi-square and t-tests were used in statistical analysis. P-value < 0.05 was considered as statistically significant.

   Results Top

Out of 100 CKD patients [54 hemodialyzed and 46 pre-dialyzed (stage2, stage3 and stage4 in 10%, 35% and 55% of cases)], 55% were male and 45% were female. The mean age of hemodialysis group (HDG) and pre-dialyzed group were: 57 ± 15 and 60 ± 16 yrs, respec­tively. The mean duration of hemodialysis was 31 ± 2 months. Out of 54 HDG patients, 90.7% (n=49) received 50U/kg of recombinant ery­thropoietin, 3 times per week subcutaneously, compared to only 18.5% of pre-dialyzed pa­tients who received erythropoietin. About half of the patients in each group had anemic symptoms. The most frequent causes of CKD were diabetes mellitus (49.1%), hypertension (28.3%), glomerular disease (17.1%) and poly­cystic kidney disease (5.6%) [Figure 1]. Accor­ding to 2006 NKF-K/DOQI guidelines for CKD anemia [hemoglobin (Hgb) level < 13.5 in males and below 12 g/dL in females] 85% of HDG (mean Hgb level = 10.27 ± 1.8 g/dL) and 75% of pre-dialyzed patients (mean Hgb level = 11.11 ± 2.26 g/dL) had anemia.

The morphologic feature of anemia consisted of: normochromic-normocytic (80%), hypo­chromic-microcytic (15%) and macrocytic ane­mia (5%) [Figure 2]. Macrocytosis in hemodia­lyzed patients was seen slightly more than pre­dialyzed (5.9 vs. 4.8%). A significant difference between hemoglobin - hematocrit levels in he­modialyzed and pre-dialyzed patients was found (P< 0.001). Hemoglobin concentration was posi­tively correlated to estimated creatinine clea­rance (P< 0.001). The severity of anemia among HDG patients was: mild (Hgb > 10 g/dL) in 5%, moderate (Hgb = 7-10 g/dL) in 70% and severe (Hgb < 7 g/dL) in 25%, while in pre­dialyzed was: mild in 45% and moderate in 55%. There was no correlation between the anemia and CKD causes or hemodialysis duration (P> 0.05). The platelets and white cells count were within normal limits (except mild thrombocytosis in 5% of hemodialyzed patients). The erythrocyte sedimentation rate (ESR) did not correlate to anemia (P= 0.07), despite being elevated in 48% of patients.

   Discussion Top

This study, like others, revealed presence of moderate degree of anemia in pre-dialyzed and hemodialyzed patients. [16] In progressive renal insufficiency, the degree of anemia is in gene­ral, proportional to the severity of azotemia. [17] We also found a positive correlation between creatinine clearance and hemoglobin concentra­tion in pre-dialyzed patients. [18] However, among CKD patients, the correlation of hematocrit with GFR or serum creatinine is imprecise and some studies did not find such correlation. [16] The lower GFR or EPO production, greater loss of hematopoietic nutrient elements and in­flammation due to dialytic membrane [19] can lead to lower mean hemoglobin and hematocrit levels in hemodialysis patients. In our study, the most frequent morphologic feature of anemia was normochromic-normocytic followed by hypo­chromic-microcytic anemia. The latter anemia has different causes, but the most common is iron deficiency particularly due to decreases iron intake or iron loss. [20] With early recogni­tion and treatment of anemia, prevalence of iron deficiency anemia among CKD patients, has decreased notably. [16] In comparison to other studies, [21] the frequency of hypochromic-micro­cytic anemia in our study is not very high. Mac­rocytosis in the HDG was seen slightly more than pre-dialyzed patients suggesting loss of water soluble B12 and folate during hemodialysis. No correlation was found between the ESR and anemia of CKD and microcytosis was not associated with low ESR.[22] A raised ESR in about half of the patients may be due to the presence of low grade chronic inflam­mation in CKD, especially in hemodialyzed patients.[19] Mild thrombocytosis was seen in 5% of hemodialyzed patients indicating pre­sence of simultaneous iron deficiency[23] or mild inflammation status (as an acute phase reaction).

In conclusion, anemia as a hallmark of chro­nic kidney disease, is mostly normochromic­normocytic and moderate in degree in pro­portion to impaired renal function in CKD patients. Hemodialysis patients are more ane­mic compared to pre dialysis group. Further evaluation of iron and water soluble vitamins in CKD patients will help in establishing the true cause of anemia in this population.

   References Top

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2.Eschbach JW, Adamson JW. Anemia of end-stage renal disease (ESRD). Kidney Int 1985; 28:1.  Back to cited text no. 2  [PUBMED]    
3.Hampers CL, Streiff R, Nathan DG. Megalo-blastic hematopoiesis in uremia and in patients on long-term hemodialysis. N Engl J Med 1967;276: 551.  Back to cited text no. 3      
4.Eschbach JW Jr, Funk D, Adamson J, Kuhn I, Scribner BH, Finch CA. Erythropoiesis in patients with renal failure undergoing chronic dialysis. N Engl J Med 1967;276:653-8.  Back to cited text no. 4  [PUBMED]    
5.Potasman I, Better OS. The role of secondary hyperparathyroidism in the anemia of chronic renal failure. Nephron 1983;33:229.  Back to cited text no. 5  [PUBMED]    
6.Weiss G. Pathogenesis and treatment of anemia of chronic disease. Blood Rev 2002;16:87.  Back to cited text no. 6  [PUBMED]    
7.Kaiser L, Schwartz KA. Aluminum-induced ane-mia. Am J Kidney Dis 1985;6:348.  Back to cited text no. 7  [PUBMED]    
8.Grutzmacher P, Scheuermann E, Low I. Correc-tion of renal anemia by recombinant human erythropoietin: Effects on myocardial function. Contrib Nephrol 1988;66:176.  Back to cited text no. 8      
9.NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease. Am J Kidney Dis 2006;47(Suppl 4):S1.  Back to cited text no. 9      
10.Radtke HW, Claussner A, Erbes PM, et al. Serum erythropoietin concentration in chronic renal failure: Relationship to degree of anemia and excretory renal function. Blood 1979;54:877.  Back to cited text no. 10  [PUBMED]    
11.McGonigle RS, Wallin JD, Shadduck RK, et al. Erythropoietin deficiency and erythropoie-sis in renal insufficiency. Kidney Int 1984;25:437.  Back to cited text no. 11      
12.Afshar R, Sanavi S, Salimi J. Epidemiology of chronic renal failure in Iran: a four year single-center experience. Saudi J Kidney Dis Transpl 2007;18(2):191-4.  Back to cited text no. 12      
13.Hassanein AA, McNicol GP, Douglass AS. Rela-tionship between platelet function tests in normal and uremic subjects. J Clin Invest 1970;23:402.  Back to cited text no. 13      
14.Collart FE, Dratwa M, Witteck M, et al. Effect of recombinant human erythropoietin on T-cell lym-phocyte subsets in hemodialysis patients. ASAIO Trans 1990;36:M219.  Back to cited text no. 14      
15.Iacob HS, Amsden T, Acute hemolytic anemia with rigid red cells in hypophosphatemia. N Engl Med 1996;285:1146.  Back to cited text no. 15      
16.Suega K, Bakta M, Dharmayudha TG, Lukman JS, Suwitra K. Profile of anemia in chronic renal failure patients. Acta Med Indones (serial online) 2005;37(4):190-4. Available from: http:// www.pubmed.com . Accessed April 20, 2007.  Back to cited text no. 16      
17.Astor BC, Muntner P, Levin A, et al. Association of kidney function with anemia: The Third Na-tional Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2002;162:1401-8.  Back to cited text no. 17  [PUBMED]    
18.Valderrabano F, Horl WH, Macdouqall IC, Rossert J, Rutkowski B. Pre dialysis survey on anemia management. Nephrol Dial Transplant 2003;18(1):89-100.  Back to cited text no. 18      
19.Raji D, Dominic E, PaI A. Skeletal muscle, cyto-kines and oxidative stress in ESRD. Kidney Int 2005;68:2338-44.  Back to cited text no. 19      
20.Fernandez-Rodriguez AM, Guindeo-Casasus MC, Molero-Labarta T. Diagnosis of iron deficiency in chronic renal failure. Am J Kidney Dis 1999; 34:508.  Back to cited text no. 20      
21.Vikrant S, Pandey D, Machhan P. Anemia profile of predialysis patients with chronic renal failure. Department of Nephrology, Indira Gandhi Medical College.medind.nic.in/iav/to4/i3/ iavto4i3p128.by HEATA TERTIARY. Indian J Nephrol 2004;14:99-156.  Back to cited text no. 21      
22.Wallach J. Interpretation of Diagnostic Tests. 7 th ed, Boston, Little Brown, 2000;3: 57.  Back to cited text no. 22      
23.Fischbach F. A manual of Laboratory& Diagnos-tic Tests. 6 th ed, Philadelphia, Lippincott, 2000; 2:1.  Back to cited text no. 23      

Correspondence Address:
Suzan Sanavi
Nephrology Department Mustafa Khomeini Hospital, Italia St, Tehran 1416645185
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Source of Support: None, Conflict of Interest: None

PMID: 20228535

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