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Table of Content - Volume 3 Issue 3 - September 2017

 

Evaluation of pancreatic enzymes in mild and moderate renal failure patients: A hospital based prospective study

 

Deepa V S1*, Mariappan A2

 

1Assistant Professor, Kanyakumari Government Medical College, Asaripallam, Kanyakumari (Dist), Tamil Nadu, INDIA.

2Associate Professor, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari (Dist), Tamil Nadu.

Email: johamaha15@gmail.com

 

Abstract               Background: Renal failure is a condition characterized by decreased glomerular filtration rate (GFR). Renal failure can lead to the development of other co-morbid conditions including pancreatitis. The present study is aimed at evaluating the pancreatic enzymes in patients suffering with mild and moderate renal failure. Materials and Methods: This study was conducted in the department of Biochemistry, Sree Mooakmbika Institute of Medical Sciences, Kulasekharam, Tamil Nadu. Renal failure patients were selected for the study and divided into mild and moderate renal failure patients. Informed consent was obtained from the study population. Blood and urine samples were collected for the estimation pancreatic and renal parameters by standard methods. Results: Serum amylase, Serum creatinine and urine-amylase clearance, showed statistical significance in mild renal failure compared with moderate renal failure patients. Urine amylase, serum lipase, Serum calcium and Serum phosphorous showed increase in moderate renal failure compared with mild renal failure but not statistically significant. Conclusion: Renal failure significantly affects the pancreatic enzymes. More attention has to be given for pancreatitis when patients have renal failure.

Key Words: Pancreas, renal failure, amylase, creatinine, lipase, GFR

 

 

INTRODUCTION

Chronic Renal Failure (CRF) is characterized by a progressive and generally irreversible decline in GFR1. Renal failure can be defined as either a decreased level of GFR (< 60 ml/mt/1.73 m2) for more than three months which is accompanied in most cases by signs and symptoms of uraemia, structural or functional abnormalities of the kidney with normal or decreased GFR in the beginning, but progresses to decreased GFR with time2,3. CRF is caused by many diseases, out of which glomerulonephritis is the most important cause. Increase in the blood levels of non-protein nitrogenous substances is referred to as azotemia which is the hallmark of Kidney failure. When azotemia is associated with signs and symptoms of end stage renal failure it is termed as uraemic syndrome which is the terminal manifestation of renal failure. It is characterized by failure of renal excretory functions as well as metabolic and endocrine abnormalities4-6. It is also associated with electrolyte disturbances, anaemia, atherosclerosis and hypertension leading to cardiovascular dysfunctions, poor immunity due to leucocyte dysfunctions altered calcium metabolism leading to renal osteodystrophy, gastrointestinal abnormalities causing anorexia, nausea, vomiting and even gastrointestinal bleeding, neuromuscular abnormalities, myopathy and very rarely acute pancreatitis also7. Pancreatitis occurs with a high frequency in uraemic patients. Hemodialysis patients are more likely to suffer from triglyceridemia which is a predisposing factor for pancreatitis. Diagnosis of these complications of CRF is also important as we can prevent the further worsening of the condition of the CRF patient. Most of the complications of CRF can be diagnosed based on clinical signs and symptoms. Some symptoms of CRF like abdomen pain and vomiting can also be due to the development of acute pancreatitis in these patients. Therefore pancreatic enzymes like amylase and lipase should be quantitated, which will show a marked raise in their levels, when compared to the minimal raise of these enzymes in CRF, if acute pancreatitis had complicated the CRF8-10. Even though acute pancreatitis is a complication of CRF, the incidence and aetiopathology of acute pancreatitis complicating CRF is not known in our population. So the present study was done to study the variations in pancreatic enzymes levels in CRF patients without already known pancreatitis and also to determine the incidence of acute pancreatitis in CRF patients.

 

MATERIALS AND METHODS

Study settings and time: The present study was carried out at the Nephrology unit of Sree Mookambika Institute of Medical Sciences, Kulasekaram from August 2012 to May 2013 for a time period of 10 months. This cross sectional study was approved by the institutional Human Ethical Committee. Voluntary informed consent was taken from all the subjects of the study. This is a cross sectional study.

Inclusion Criteria

  • Serum Urea levels between 40-100 mg/dL
  • Age between 30-80 years

Exclusion Criteria

  • Chronic alcoholics
  • Patients having portal hypertension
  • Known case of Chronic Pancreatitis

Groups

Group I: Mild chronic renal failure patients (Serum Urea 40-80 mg/dL and serum creatinine 0 to 3 mg/dL)

Group II: Moderate chronic renal failure patients (Serum Urea 81-100 mg/dL and serum creatinine 3.1 to 4.5 mg/dL)

Procedure: The total of 50 patients was considered in the study. Based on the Serum Creatinine levels they were divided into two groups. In the patients studied, a sample of timed 4 hours urine was collected in sterile containers during which period about 5 ml blood was collected in a red capped Vaccutainer. Blood samples were then centrifuged at 3000 rpm for 10 minutes and the serum was separated for further tests. The parameters Serum Urea, Serum Creatinine, Serum Amylase, Serum Lipase, Serum Calcium, Serum Phosphorus, Urine Creatinine, Urine Amylase, Urine Creatinine clearance (Ccr) and Urine Amylase clearance (Cam) were studied by standard methods11-13.

Statistical Analysis: The data was expressed in mean and standard deviation. Statistical Package for Social Sciences (SPSS 16.0) version used for analysis. Unpaired t test applied to find the statistical significant between the groups. P value less than 0.05 (p<0.05) considered statistically significant at 95% confidence interval.

 

RESULTS

Moderate renal failure patients showed significant increase in serum amylase, serum creatinine, urine amylase clearance compared to mild renal failure patients (p<0.05). There was no significant difference observed in urinary amylase, serum lipase, calcium, phosphorous and Cam/Ccr % between mild and moderate renal failure patients (p>0.05). Moderate renal failure patients showed lesser urinary amylase levels compared to mild renal failure patients (p=0.07)

 

Table 1: Comparison of Serum Amylase Urinary amalyse and Amylase clearance between the mild and moderate renal failure patients

Groups

Serum Amylase

U/100ml

Urinary amylase

U/100ml

Amylase clearance (Cam)

ml/min

Serum creatinine

Mild renal failure

158.36±31.45

101.15±25.45

1.44±0.41

2.52±0.26

Moderate renal failure

185.72±71.28*

83.94±27.85

0.62±0.25*

3.68±0.63*

T-value

2.08

3.44

47.05

0.46

P-value

0.16

0.07

0.00

0.03

Significance

NS

NS

S

S

(*p<0.05 significant compared mild renal failure with moderate renal failure patients)

 

Table 2: Comparison of serum lipase, calcium and phosphorus between the mild and moderate renal failure patients

Groups

Serum Lipase

U/L

Serum Calcium

mg%

Serum phosphorous

mg%

Mild renal failure

153.32±73.81

8.4±0.65

4.88±0.71

Moderate renal failure

166.53±99.64

8.19±0.46

5.07±0.62

T-value

0.19

1.17

0.68

P-value

0.67

0.29

0.42

Significance

NS

NS

NS

 

1

Figure 1: Comparison of Cam/Ccr% values between the mild and moderate renal failure patients

 

DISCUSSION

Increased levels of pancreatic enzymes have been studied in patients with renal failure. Seno et.al., and Duanne WC et.al., have showed that the increase in serum lipase is approximately three times the reference value14,15. The vast difference in the significance of lipase can be accounted as being due to enormous variation in the percentage of increase in its level as the disease progresses. The profound increase in serum lipase level in mild renal failure is not maintained thereafter in moderaterenal failure. The urinary lipase is normally undetectable in urine as lipase is completely reabsorbed by the tubules16, when compared to the tubular reabsorption of amylase. The normal reference interval for serum calcium by arsenazo 111 method is 8.6 to 10.3 mg%. But the serum calcium values were 8.4 mg% and 8.19 mg% in mild and moderate renal failure respectively. This lowering of serum calcium in CRF is attributed to decreased absorption of calcium from the gut. This is due to impaired synthesis of 1, 25-Dihydroxy cholecalciferol (calcitriol) which is the active form of vitamin D, which is synthesized by the kidney and is essential for the absorption of dietary calcium from the gut. The normal reference interval for serum phosphorus by molybdate/UV method is 2.5 to 5 mg%. The serum phosphorus values in this study were 4.88 mg% and 5.07 mg% in mild and moderate renal failure respectively. This increase in serum phosphorus level from the normal range is due to decreased renal phosphate clearance. On trying to correlate the levels of serum amylase with serum urea and serum creatinine in various study groups, it is observed that there is almost no correlation in their levels in various study groups except in moderate renal failure where there is a significant correlation between serum amylase and serum creatinine. However the reason for this correlation only in moderate renal failure is unexplainable. The non-correlation of these parameters in the other study groups is because only a small proportion of amylase is being handled by the kidney as opposed to the nearly entire proportion of urea and creatinine being handled by the kidneys with some reabsorption of urea and no reabsorption of creatinine by the renal tubules17. When amylase clearance was compared with serum creatinine there is an inverse correlation in moderate renal failure (P<0.05). This is because some amount of amylase is cleared by urinary excretion. Renal excretion of amylase occurs by glomerular filtration and tubular reabsorption18,19. When the Cam/Ccr ratio of various study groups is compared, there is no correlation between their levels in mild and moderate renal failure. This correlation is said to be due to more rapid fall of creatinine clearance than amylase clearance as the renal impairment progresses20. It is evident that serum calcium level has inverse non-significant correlation with serum creatinine. It explains the correlation of serum creatinine and serum phosphorus. The serum phosphorus gradually increases as the extent of renal damage increases, but the increase is not significant as renal phosphate clearance is less. The correlation between serum calcium and serum phosphorus is significant in mild renal failure. This is because of the hyper phosphatemia which increases PTH levels which decrease serum calcium up to certain extent of creatinine clearance after which this correlation is not of much significance21. From the observations made so far, it is clear that there is a gradual increase in the level of serum amylase, lipase and phosphorus and a decrease in the level of urinary amylase, amylase clearance and serum calcium as the disease advances in severity. Having analyzed the results of various study groups, on keeping in mind the aim of this study, i.e., to determine the presence of acute pancreatitis in renal failure cases, in the fifty cases of renal failure investigated, as the analysis of the parameters did not reveal the picture as specified above, it is inferred both from biochemical results and clinical picture that there was no case of renal failure with the complication of acute pancreatitis at the time of study. This compares well with the documented literature that this complication is rare in renal failure.

 

CONCLUSION

Moderate renal failure can affect the pancreatic enzymes. From this study observation it can be concluded that there is a requirement of special knowledge to treat renal failure patients with diabetes.

 

REFERENCES

  1. Mohammad RT, Seyed SBM. Stability of renal function in spite of low glomercular filtration rate: A case report. Iran Red Crescent Med J 2015; 17(2):21604.
  2. Macaulay ACO, Nneoma A. Diabetic nephropathy and CKD- analysis of individual patient serum creatinine trajectories: A forgotten diagnostic methodology for diabetic CKD prognostication and prediction. J Clin Med 2015;4(7):1348-68.
  3. Levey AS. Measurement of renal function in chronic renal disease. Kidney Int 1990; 38:167-84.
  4. Akbar D, Mohammad M, Shadi T, Zahra KK, Gholam HT, Esmaeli S et.al. Anemia and thrombocytopenia in acute and chronic renal failure. Inj J Hematol Oncol Stem Cell Res 2013; 7(4):34-9.
  5. Star RA. Treatment of acute renal failure. Kindly Int 1998; 54(6):1817-31.
  6. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. NEJM 1996; 334(22):1448-60.
  7. Haller M, Schelling G. Acute kidney failure. Physiopathology clinical diagnosis therapy. Der Anaesthesist 2000; 49(4):349.
  8. Petejova N, Martinek A. Acute kidney injury following acute pancreatitis: A review. Biomed Pap Med Fac 2013; 157(2):105-13.
  9. Hung YL, Jiun IL, Yi CL, Po CL. Acute renal failure in severe pancreatitis: A population based study. Ups J Med Sci 2011; 116(2):155-9.
  10. Bradley EL. A Clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta. Arch Surg 1993; 128:586-90.
  11. Collen MJ, Ansher AF, Chapman AB, Macknow RC, Lewis JH. Serum amylase in patients with renal insufficiency and renal failure. Am J Gastroenterol 1990; 85(10):1377-80.
  12. Jiang CF, Ng KW, Tan SW, Wu CS, Chen HC, Liang CT. Serum level of amylase and lipase in various stages of chronic renal insufficiency. Zhonghua Yi Xue Za Zhi 2002; 65(2):49-54.
  13. Usha Rani S, Ram Rao J, Ambika Devi K. Effect of renal insufficiency on pancreatic enzyme activities in serum. Journal of Science 2015; 5(4):232-4.
  14. Seno T et al. Serum levels of six pancreatic enzymes as related to the degree of renal dysfunction. Am J Gastroenterol 1995; 90 (11): 2002-5.
  15. Duane W C, Frerichs R, Levitt M D. Distribution, turnover and mechanism of renal excretion of amylase in the baboon. J Clin Invest 1971; 50 (1): 156-65.
  16. Soezima A, Yomogida S, Suzuki M, Tuzill, Nakabayasik, Kitamoto K, Nagasawa T. High sensitive photometric assay of pancreatic lipase and clinical investigation of urinary lipase in patients with various histopathological types of primary glomerulonephritis. Nihon JinzoGakkai Shi 1990; 32 (10): 1103-7.
  17. Schrier R W. Blood Urea Nitrogen and serum creatinine. Circ Heart Fail 2008; 1:2-5.
  18. Wetzele J F M, Scheld J C M H, Hesseles M, Holtama A J, Koene R A P. Renal clearance of pancreatic and salivary amylase relative to creatinine clearance in patients with Renal Disease and Proteinuria. Clin Chem 1988; 34(3): 589-91.
  19. Warshaw AL. The Kidney and changes in amylase clearance. Gastroenterol 1976; 71:702 – 4.
  20. Marten A, Beales D, Elias E. Mechanism and Specificity of increased amylase / creatinine ratio in pancreatitis. Gut 1977; 18 (9): 703-8.

 
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