Abstract

Abstract and objectives: Chronic kidney disease (CKD) is a general term for heterogeneous disorders affecting the structure and function of the kidney. Inflammation is common among hemodialysis patients, and accumulating evidence indicates that chronic inflammation is a major contributor to morbidity and mortality in this population.

Anemia is one of the major medical complications in CKD. Anemia is noticed from the early stages of CKD and further exacerbated in End-Stage Kidney Disease. This study was undertaken to assess the correlation between C-reactive protein and hemoglobin and also to verify whether age, gender, and social factors such as alcohol consumption, smoking affect C-reactive protein levels and hemoglobin concentration.

Materials and methods: 75 CKD patients on hemodialysis took part in the study, blood samples were collected, and CRP and HB were measured.

Results: Among 75 individuals, a negative correlation was observed (Pearson’s correlation coefficient r = -0.333) between C-reactive protein and HB. There was a significant difference in mean CRP levels between those who were on vitamin B- complex and those who were not on B-complex.

Discussion and conclusions: The observed negative correlation between C-reactive protein and HB reiterates the effect of inflammation on hemoglobin concentration and emphasizes the importance of the maintenance of normal CRP levels to prevent further aggravation of anemic state in CKD patients.

CHAPTER ONE

INTRODUCTION

1.1 Background

Patients with chronic kidney disease (CKD) eliminate toxic compounds from their bodies less efficiently, resulting in the accumulation of uremic toxins and maintenance of a chronic inflammatory state [1]. Dialysis is required to clear the toxins from the body. Dialysis is defined as the diffusion of molecules in solution across a semipermeable membrane along an electrochemical concentration gradient [2].

The primary goal of hemodialysis is to restore the intracellular and extracellular fluid environment that is characteristic of normal kidney function. This is accomplished by the transport of solutes such as urea from the blood into the dialysate and by the transport of solutes such as bicarbonate from the dialysate into the blood [2]. End-stage renal disease (ESRD) is worldwide and has been estimated approximately more than 1.1 million patients. ESRD is becoming a popular disease in the world, so far now, the only treatments available are hemodialysis and kidney transplant [3].

Inflammation is common among patients with chronic renal failure (CRF) [4]. Inflammatory reactions originate from several sites including graft or fistula infections, bio-incompatible dialysis membrane, dialysate, endotoxin exposure, back filtration, chronic infections, and malnutrition. Poor oral, dental, and periodontal health in hemodialysis patients can be a source of inflammatory reactions [1, 5].

The development of inflammation in chronic kidney disease (CKD) begins well before the need for repeated dialysis, and elevated levels of inflammatory biomarkers such as interleukin-6 (IL-6), IL-1β, tumor necrosis factor-α (TNF-α),  interleukin-23 (IL-23), and C-reactive protein (CRP) suggest that CKD and dialysis can both be viewed as inflammatory processes. Chronic inflammation is recognized to promote adverse consequences.

In fact, persistent inflammation has been recognized as an important contributor to the risk of mortality, cardiovascular events, kidney disease progression, and other adverse outcomes in both CKD and chronic dialysis patients [1]. Inflammation can be assessed by measuring circulating levels of pro-inflammatory biomarkers, the most commonly used being CRP. CRP is a nonspecific acute-phase reactant protein that is known to increase with declining kidney function, even before patients reach ESRD [6].

Anemia is defined as a reduction in hemoglobin concentration of blood [7]. In end-stage kidney, disease anemia is due to decrease erythropoietin synthesis and iron deficiency. [8]. Increased pro-inflammatory cytokines in the inflammatory state also cause the decreased production of erythropoietin. It is also noticed that inflammatory molecules like CRP, IL-6, and TNF-α contribute to the suppression of bone marrow erythropoiesis, and erythropoietin production [8].

 1.2 Rationale

Chronic kidney disease patients on hemodialysis are at greater risk of inflammatory reactions against factors originating from graft, fistula, dialysis membrane, and infections. Nonetheless, the presence of inflammation is an additional contribution to the development of anemia.

The impact of inflammation in the development of anemia in hemodialysis undergoing patients has been investigated in several studies through evaluation of response to erythropoietin treatment [7, 9, 10-12].

Nevertheless, data regarding a direct relation between hemoglobin level and markers of inflammation in these patients is scarce. In particular, the relationship between the level of serum CRP, a marker of inflammation, and hemoglobin requires further investigation. Hence, the present study was designed to determine the relationship between the markers of inflammation, particularly serum CRP and hemoglobin levels in patients undergoing hemodialysis.

1.3. Hypothesis

Null Hypothesis: There is a direct relationship between serum CRP levels and hemoglobin in patients undergoing hemodialysis.

1.3.1 Objectives

1.3.1.1 General Objectives

To determine the relationship between C-reactive protein a marker of inflammation and hemoglobin in patients undergoing hemodialysis.

1.3.1.2 Specific objective

1. To determine the C-reactive protein levels among hemodialysis patients.
2. To determine the prevalence of anemia among patients undergoing hemodialysis.
3. To evaluate the impacts of age, gender, duration of dialysis on HB and CRP
4. To investigate the correlation between HB and CRP in hemodialysis patients.