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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 69-75

Study of hematological changes in patients with chronic renal failure undergoing hemodialysis (pre and post)


1 Department of Pathology, Burdwan Medical College, Burdwan, West Bengal, India
2 Department of Pathology, Medical College, Kolkata, West Bengal, India

Date of Submission08-Jul-2022
Date of Acceptance23-Sep-2022
Date of Web Publication10-Jan-2023

Correspondence Address:
Dr. Soma Ghosh
Bahir Sarbomangala Road, Near IIHT Computer Centre, and Carnival Marriage Hall, Burdwan - 713 101, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjmsr.mjmsr_34_22

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  Abstract 


Background: Chronic renal failure (CRF), a debilitating condition responsible for high morbidity and mortality considered a financial burden to the government and society. Determining the prevalence of CRF in any country is important for planning the care of affected patients. Aim and Objectives: The study aimed at looking for the hematological changes before, and following hemodialysis (HD) in CRF patients. The objectives included comparing complete hemogram, coagulation profile, and blood biochemistry before and after HD; determining hematological complications post-HD; taking precautions to reduce morbidity and mortality from hematological point of view; and assessing changes in hematological profile of CRF patients undergoing HD. Materials and Methods: An institutional cross-sectional study was done on 62 patients of CRF undergoing HD. The hematological and biochemical parameters were studied along with urinary findings. Results: Males were more affected in the study. The hematological parameters which were elevated following dialysis were total leukocyte count, erythrocyte sedimentation rate, hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin (MCH), bleeding and clotting time, prothrombin time, activated partial thromboplastin time, but MCH concentration and platelet count showed a fall. Postprandial blood sugar, calcium and erythropoietin showed elevated levels following hemodialysis., while decreased levels were found in fasting blood sugar, sodium, potassium, phosphate, urea, and creatinine. Urinary studies showed a increase in specific gravity and a decrease in 24 h urinary protein. Conclusion: CRF is becoming a dreadful condition in society, with dialysis playing an eminent role in treatment modality. Formulating precautions before and after dialysis based on various hematological and biochemical parameters can help to reduce morbidity and mortality.

Keywords: Chronic renal failure, hematology, hemodialysis, morbidity


How to cite this article:
Das PC, Ghosh S, Banerjee U. Study of hematological changes in patients with chronic renal failure undergoing hemodialysis (pre and post). Muller J Med Sci Res 2022;13:69-75

How to cite this URL:
Das PC, Ghosh S, Banerjee U. Study of hematological changes in patients with chronic renal failure undergoing hemodialysis (pre and post). Muller J Med Sci Res [serial online] 2022 [cited 2023 Jan 27];13:69-75. Available from: https://www.mjmsr.net/text.asp?2022/13/2/69/367403




  Introduction Top


End-stage renal disease is the final stage of chronic renal failure (CRF), where there is progressive, irreversible deterioration in renal structure and function, which can be substituted by renal replacement therapy, hemodialysis (HD), peritoneal dialysis, or transplantation.[1],[2] Various hematological parameters are altered in CRF patients undergoing HD.[1],[2],[3] Therefore, it is recommended that all patients undergoing dialysis need to be screened to avoid complications.[1],[2],[3] Chronic kidney disease is increasingly recognized as a global public health problem.[4] Definition and classification of chronic renal disease may help to identify the affected individuals, possibly resulting in early effective therapy.[4],[5],[6]

HD relies on the principles of solute diffusion across a semipermeable membrane.[6],[7] The procedure is targeted at removing solutes of low and high molecular weight.[8],[9] Heparinized blood is pumped through the dialyzer at a flow rate of 300–500 mL/min, while dialysate flows in an opposite counter-current direction at 500–800 mL/min.[8],[9] The efficiency of dialysis is determined by the flow of blood and dialysate through the dialyzer and the efficiency of the dialyzer in removing solute.[8],[9],[10] The dose of dialysis is governed by patient size, residual kidney function, dietary protein intake, degree of anabolism or catabolism, and the presence of comorbidity.[9],[10],[11] It should be individualized, and factors other than urea nitrogen should be considered, including the adequacy of ultrafiltration or fluid removal.[10],[11] Uremic plasma increases the expression of phosphatidylserine on the surface of red blood cells, leading to their subsequent destruction and decreased survival.[11],[12] Uremia is often complicated by abnormal bleeding tendencies.[12],[13] Modern dialysis techniques and the use of erythropoietin (EPO) have reduced the frequency of uremic bleeding, which, however, limits surgery and invasive procedures in these patients.[13],[14],[15]

The result of various hematological tests commonly employed in the present study may be of enormous value in supporting abnormalities in the hematological parameters and in the management of any individual case. Aim and Objectives: The study aimed to look for the hematological changes before and following HD in patients with CRF. The objectives included comparing complete hemogram, coagulation profile, and blood biochemistry before and after HD in CRF; determining hematological complications in patients undergoing HD; taking precautions before and after dialysis to reduce morbidity and mortality from the hematological point of view; and assessing changes in the hematological profile of CRF patients undergoing HD.


  Materials and Methods Top


Sixty-two cases of uremia were randomly selected attending the medicine and nephrology outpatient department, indoor ward, and from dialysis unit of a Teaching Institute in West Bengal for a period of 1 year. The study was cross-sectional study conducted in tertiary care teaching hospital. The study was conducted after Approval from the Institutional Ethics Committee (BMC/PG/1163 dated February 28, 2011). The inclusion criteria were patients with blood urea levels of about 100 mg/dl; the presence of albuminuria, oliguria, pyuria, hematuria, isosthenuria with or without edema; the presence of metabolic acidosis, water, and electrolyte imbalance; the presence of hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; the presence of anemia and abnormal bleeding tendencies. Patients suffering from acute renal failure and acute glomerulonephritis were excluded from the study. The hematological parameters studied were hemoglobin with hematocrit packed cell volume, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), MCH concentration (MCHC), erythrocyte sedimentation rate (ESR), total leukocyte count (TLC), differential count, bleeding time (BT), clotting time (CT), platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT).

The biochemical parameters were fasting blood sugar (FBS) and postprandial blood sugar (PPBS), serum sodium, potassium, calcium, phosphate, urea, and creatinine with EPO assay. Urinary parameters included routine study and 24 h urinary protein estimation.

Hematological parameters were done in a fully automated 5-part Sysmex XN-330 hematology analyzer (Sysmex America, Inc). ESR was performed according to the Westergren method. BT was performed by standard template method and CT by capillary tube method of Wright.[16] PT and aPTT analysis were done on Hemostar 4CA, automated coagulation analyzer (Tulip Diagnostics Private Limited, India). The laboratory control value for the prothrombin assay was 12.0 s. The reference range for aPTT was 21–29 s. The biochemical parameters were conducted in Erba EM-200, a fully automated biochemistry analyzer (Transasia bio-medicals Limited, India). The electrolyte assays were done in Erba automated Easylyte electrolyte analyzer (Transasia Bio-medicals, India). Serum EPO was evaluated in an automated, chemiluminescent immunoassay for EPO (DPC Immulite 2000 – Siemens healthcare laboratory diagnostics) with a reference range of 4.3–29.0 IU/L. Routine urine analysis was done by light microscopy of sediment of the centrifuged urine sample and multistix urine strip having manufacturer's colored scale (Accu-stix 10G Urine strips). The parameters looked for were specific gravity, glucose, urine, pus cells, and various casts. The casts in pre-HD and postdialysis phases were graded by cast scoring index percentage per low power field.[17] The total amount of protein excreted in a day was calculated on the basis of protein concentration analysed by automated biochemistry analyser and total volume of urine excreted.

Statistical analysis was done by SPSS 20 version (IBM Corp, Armonk, New York, USA). Data were summarized as mean, the standard deviation for numerical variables, and percentages for calculating categorical variables. A two-tailed significance test was done for the statistical hypothesis where the null hypothesis was tested. If the calculated P value was below the threshold, it was chosen for statistical significance (usually 0.10, 0.05, or 0.01 level), then the null hypothesis got rejected in favor of the alternative hypothesis. P ≤ 0.05 was considered for statistical significance.


  Results Top


The age group in the present study was in the range of 7.5 to 75 years, with a mean age of 45.88 years. 59.68% were male and the rest, 40.32% were female. The mean TLC in predialysis and postdialysis phases were 8151.61 and 8302.42/cmm3; ESR were 83.29 and 88.94 mm/1st h in the predialysis and postdialysis patients, respectively [Table 1]a The mean predialysis versus postdialysis Hb and Hct concentrations for all patients were 6.78 g/dL versus 7.06 g/dL (P < 0.0001) and 20.7% versus 21.3% (P < 0.0001).
Table 1:

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The mean MCV, MCH, and MCHC in the predialysis state were 87.9 fl, 28.9 pg, and 32.7 g/dl, whereas those in postdialysis state were 89.2 fl, 29.1 pg, and 32.7 g/dl, respectively [Table 1]a The mean bleeding and CT in the predialysis state were 4.4, 4.2 min; in postdialysis state were 5.02 and 5.08 min [Table 1]b Predialysis mean platelet count was 1.64 lakhs and 1.41 lakhs in postdialysis. Predialysis mean prothrombin, aPTT were 12.5 s and 28.5 s, whereas the values were 13.4 s and 28.9 s in postdialysis state [Table 1]b The predialysis mean fasting, postprandial glucose, urea, creatinine were 123.1, 185.9, 155.9, and 10.3 g/dl.

The same parameters in the postdialysis state were 119.4, 199.08, 59.1, and 4.1 g/dl, respectively [Table 2] Predialysis mean serum EPO was 11.3 and 11.4 in the postdialysis state [Table 2] The electrolytes comprising serum sodium, potassium and phosphate showed fall in values following dialysis, whereas serum calcium showed rise [Table 2]. Daily urinary protein excretion value decreased following HD [Table 3]. Routine analysis of urine excluding specific gravity showed decreased values following HD [Table 3] and [Table 4]. Granular casts in urine decreased post-HD [Table 4].
Table 2: Biochemical parameters (pre- and post-hemodialysis) in chronic renal failure patients

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Table 3: Urinary findings (pre- and post-hemodialysis) in chronic renal failure patients

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Table 4: Presence of casts and crystals (%) in urine (pre- and post-hemodialysis) in chronic renal failure patients

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  Discussion Top


The hospital-based longitudinal study was conducted, including 62 patients whose specific blood and urinary parameters were measured before and after dialysis. The study conducted by Hida and Saito showed the difference in age distribution depending on the primary renal diseases and sex.[18] In chronic glomerulonephritis, males were most numerous in the 30–39 years, followed by the 40–49 and 20–29 years, decreasing with age.[18] Females showed the same frequencies among the 20–29, 30–39, 40–49, 50–59, 60–69, and 70–79 year age groups.[18] However, the 50–59 years had the most cases. Among cases of diabetic nephropathy, males were most numerous in 50–59 years and females in 60–69 years.[18]

The progression of the disease to renal failure seemed to be more rapid in males compared to females.[18] TLC found in the present study in pre-and postdialysis patients resembles the study by Hsu et al., which also depicted a sharp rise in leukocyte counts postdialysis.[19] This suggests that TLC should be measured in future studies that can evaluate the clinical outcome of maintenance hemodialysis patients, and dialysis patients with elevated leukocyte counts require further medical attention to reduce the risks of mortality. In the study conducted by Shusterman and Kimmel, a rise in ESR was noted in patients after receiving dialysis, as evident from the pre-and postdialysis values of 49 ± 26 mm/h and 60 ± 33 mm/h, respectively.[20]

Both values are significantly higher than normal. Recombination experiments showed that the abnormal factor accelerating erythrocyte sedimentation was a constituent of plasma.[20] Hemoglobin and hematocrit showed an increase in the values in patients after dialysis as compared to those before dialysis in the present study. In a study conducted by Mohamed Ali et al., blood samples were collected from 180 renal failure patients undergoing hemo and peritoneal dialysis (90 each) before and after dialysis sessions. The samples demonstrated increased hemoglobin, hematocrit, and red cell count following both hemo and peritoneal dialysis. MCH, MCHC showed a mild increase after peritoneal dialysis and a slight decrease after HD. Leukocyte and platelet counts also showed a mild increase after HD, while PT and aPTT were significantly prolonged.[21]

In the present study, the values of MCV and MCH undergo a sharp rise in patients after dialysis as compared to the same group of subjects before undergoing dialysis. However, the values of MCHC underwent a decrement in patients after receiving dialysis. In the study by Goldwasser et al., increased MCV values were observed in patients receiving dialysis.[22] They presumed that variations in the level of erythropoiesis among those patients were due to variations in EPO levels, and chronic inflammation, which strongly influenced the determinants of iron stores (marrow utilization of iron, transfusion need); subsequently influenced MCV.[22] The study by Mohamed Ali et al. showed a slight increase in MCH with a decrease in MCHC after dialysis and macrocytosis following dialysis, being the possible offending factor behind it.[21],[22] Both bleeding and CT s in the present study got increased in the patients after receiving dialysis with a statistically significant (P < 0.05) increase in CT; but the platelet count got decreased after dialysis in the same group of patients. However, in the study by Haider Al-Hulli et al. in Iraq, BT, CT, and platelet count were all seemed to increase in patients after receiving dialysis.[23]

In their study, it was observed that the mean platelet count in patients treated with peritoneal dialysis was 233.6 × 109 (range 150–340 × 109) before dialysis; immediately after dialysis, it was 238.4 (155–350 × 109) and subsequently 250.2 × 109 (160–365 × 109) 24 h after dialysis.[23] The mean percentage of improvement in platelet count in patients treated with HD was 7.1% immediately after dialysis and 25.4% 24 h later.[23] The mean BT in peritoneal dialysis improved from 4.39 min (ranged 2.25–7 min) before peritoneal dialysis to 3.7 min (2–6 min) immediately after peritoneal dialysis and to 3.2 min (2–5.15 min) 24 h after peritoneal dialysis.[23] The mean percentage of improvement in BT was 11.5% immediately after peritoneal dialysis and 20.9% 24 h after peritoneal dialysis.[23] The mean CT in peritoneal dialysis improved from 4.57 min.(3–7.20 min) before peritoneal dialysis to 4 min (2.20–5.35 min) immediately after peritoneal dialysis then to 3.50 min (2–5 min). Twenty four hour later.[23] The mean percentage of improvement in CT was 9% immediately after peritoneal dialysis and 17% 24 h later.[23]

However, the present study parameters showed dissimilar results. The possible explanation of increased bleeding and CT may be the administration of heparin at the time of dialysis coupled with degradation of platelets during HD, explaining the fall in platelet count in patients postdialysis. PT and aPTT in the present study were prolonged after dialysis with a statistically significant rise in PT. Similar results were depicted in the study by Mohamed Ali et al., which revealed a significant rise in PT and aPTT in patients after receiving dialysis[21],[23] There were variations in FBS and PPBS levels in patients after receiving dialysis in the present study.

No accurate studies are found in the electronic or other media, which clearly reflected the glucose levels in the patients after receiving HD. However, the possible explanation, in this case, maybe in varied types of dialytic fluids, containing or devoid of sugar. The possible variations in fasting and postprandial blood sugar levels may be due to inaccurate choice of fluids in the present study, which got reflected in the results.

A sharp decrease in urea and creatinine levels in patients after dialysis as compared to the patients prior to dialysis with statistical significance evident in the present study (P < 0.01). Similar results were also depicted in the study conducted by Hesmatullah and Ahmed, which showed significant falls in serum urea and creatinine levels postdialysis.[24] A statistically significant decrease in urea and creatinine was also observed in the study by Ozmen et al. conducted in Istanbul.[25] The present study showed a decrease in the 24 urinary protein in the patients after dialysis as compared to the same group before dialysis.

Though not many direct reports about the levels of 24 h urinary protein assays before and after dialysis are available, the study by Mehrotra et al. found to depict similar results.[26] The present study showed a smart rise in EPO levels after dialysis. The same results were depicted in the study by DeGowin et al.[27] Snyder and Foley in their extensive studies in Minnesota, U.S.A., found a sharp increase in EPO levels in the patients after receiving dialysis.[28] Administration of EPO at the time of dialysis is the possible contributing factor resulting in the rise of EPO in patients after receiving dialysis. The leukocyte count underwent a sharp increase in the patients after dialysis, as compared to those before dialysis in the present study. Similar results are also seen in the study by Abdullah and Abbas in Saudi Arabia.[29]

In their study, leukocyte counts showed a statistically significant increase in post-HD patients (7.46 ± 1.87) when compared to that in the control group (6.30 ± 1.88) (P < 0.05).[29] The neutrophil count increased significantly in post-HD patients (3.89 ± 1.31) as compared to the control group (3.40 ± 1.31) (P < 0.05); the lymphocyte counts also increased significantly in post-HD patients (2.33 ± 0.76) when compared to control group (2.05 ± 0.63) (P < 0.05); the monocyte counts significantly increased in post-HD patients (0.76 ± 0.34) compared to the control group (0.55 ± 0.17) (P < 0.05); the eosinophil counts showed a statistically significant increase in post-HD patients (0.46 ± 0.35) compared to that of control group (0.30 ± 0.13) (P < 0.05).[29] However, the basophil count did not show any statistically significant difference in post-HD patients compared to the control group (P > 0.05).[29] The leukocyte count showed a statistically significant increase in post-HD patients (7.46 ± 1.87) when compared to pre-HD values (6.32 ± 1.82) (P < 0.05).

The neutrophil counts showed significant increase in post-HD (3.89 ± 1.31) when compared to that of predialysis (3.42 ± 1.35) (P < 0.05); the lymphocyte counts increased significantly in post-HD (2.33 ± 0.76) when compared to pre-HD values (1.92 ± 0.75) (P < 0.05); the monocyte counts significantly increased post-HD (0.76 ± 0.34) when compared to predialysis count (0.61 ± 0.28) (P < 0.05); the eosinophil counts increased in post-HD (0.46 ± 0.35) when compared to the pre-HD count (0.35 ± 0.31) (P < 0.05).[29] The basophil counts did not show statistically significant differences in post-HD when compared to pre-HD counts (P > 0.05).[29]

However, even after a through search in the various journals and electronic media, convincing works on the study of routine analysis of urine and observing the various casts and crystals after and before dialysis are seriously lacking.

Routine urine analysis, cast, and crystal status were observed in the present study group before and after dialysis [Table 3] and [Table 4]. Cabaluna et al. could not find correlation between end-stage renal disease and the characteristic presence of numerous pus cells and pus cell casts in urine. Microscopic hematuria was an unusual finding even in patients whose original disease was a proliferative nephritis.[30]

The electrolyte status in the present study group before and after dialysis comprising sodium, potassium, and phosphate was seen to decrease as compared to their predialysis values, whereas calcium was seen to increase in patients after dialysis. However, studies on this electrolyte status post and before dialysis are still not reported and hence, could not be compared with other studies.


  Conclusion Top


Complete hemogram including coagulation marker status with biochemical parameter assessment study considered beneficial to patients of end-stage renal disease before and following HD treatment procedure for proper monitoring and reducing the morbidity and mortality in such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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