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Table of Content - Volume 6 Issue 2 - May 2017


 

Prevalence of anemia and left ventricular hypertrophy and their correlation in chronic kidney disease patients

 

Kalakonda Varsha Reddy1, Jayashankar C A2*

                   

1Senior resident, Department of General Medicine, Gandhi Medical College And Hospital, Secunderabad 500003, Telangana, INDIA.

2Professor, Department of General Medicine, Vydehi Institute Of Medical Sciences And Research Centre, Whitefield, Bangalore 560066, Karnataka, INDIA.

Email: drjayashankar.ca@gmail.com

 

Abstract              Background: Left ventricular hypertrophy (LVH) and anemia are highly prevalent in chronic kidney disease (CKD). Anemia may potentiate the adverse effects of LVH on cardiovascular outcomes thereby increasing the risk of morbidity and mortality in chronic kidney disease patients. Objectives: To study the prevalence of anemia and left ventricular hypertrophy and their correlation in chronic kidney disease patients. Methods: The study was conducted on 100 cases of chronic kidney disease (CKD) admitted at Vydehi Institute of Medical Sciences and Research Centre, Bangalore during the year 2014. The cases were divided based on different stages of CKD (stage II-V). Out of 100 cases there were 9 cases in stage II (eGFR - 60-89mL/min/1.73m2), 17 cases in stage III(eGFR - 30-59 mL/min/1.73m2), 32 cases in stage IV(eGFR - 15-29 mL/min/1.73m2), 42 cases in stage V (eGFR <15 mL/min/1.73m2). All cases were subjected to relevant investigations which were noted and analyzed using appropriate statistical methods. Results: Out of 100 cases with chronic kidney disease, maximum patients were in 41-50 years age group with the mean age being 47.7+13.2 years. There were 69 male patients and 31 female patients showing male predominance. The prevalence of anemia in different stages of CKD were 22% in stage II, 64% in stage III, 87.2% in stage IV, 95.2% in stage V (p =0.000). The prevalence of LVH in different stages of CKD were 55.5% in stage II, 76.4% in stage III, 78.1% in stage IV, 97.6% in stage V (p=0.005). There was a significant correlation between anemia and left ventricular hypertrophy with the p value 0.000. Conclusion: In our study, both anemia and left ventricular hypertrophy are highly prevalent in chronic kidney disease (CKD) patients and we found a significant correlation between anemia and LVH in these patients.

Key Words: Anemia; Chronic kidney disease; Left ventricular hypertrophy.

 

INTRODUCTION

Left Ventricular Hypertrophy (LVH) is a frequent occurrence in patients with CKD and is an important adverse prognostic indicator.1,2 Anemia is also frequent finding in CKD patients and is an important determinant of cardiac hypertrophy which can be associated with progressive LV dilation, new-onset cardiac failure, and death.3 There are very few studies done in India which has documented an association between the severity of anemia and left ventricular hypertrophy (LVH) in CKD patients. Hence this study is undertaken to assess the prevalence of anemia, left ventricular hypertrophy and determine the correlation of anemia with left ventricular hypertrophy in CKD patients. Thus reducing the risk of further cardiac complications by treating the patients priorly.

 

 

MATERIALS AND METHODS

This study was approved by the institutional ethics committee, prior to the commencement of data collection. It was a cross sectional study. 100 patients with chronic kidney disease stage 2-5 aged more than 18 years presenting to department of General Medicine and department of Nephrology at Vydehi institute of medical sciences and research centre were included in the study. This study was conducted over a period of 12 months, from January 2014 to December 2014. Patients presenting with anemia without chronic kidney disease, left ventricular hypertrophy with cause other than chronic kidney disease (like primary hypertension, aortic stenosis etc) and aged less than 18 years were excluded from the study. An informed written consent was taken from all the subjects. A pre-structured proforma is used to collect the baseline data. Detailed clinical history was taken and detailed clinical examination was done on participating individuals. Body weight was measured (to the nearest 0.5 kg) with the subject standing motionless on the weighing scale and with the weight distributed equally on each leg, without footwear. Patients were subjected to relevant investigations such as complete blood picture, blood urea, serum creatinine, peripheral blood smear, serum electrolytes, serum iron, serum ferritin, TIBC, chest x-ray, ECG and 2D-Echocardiography. The creatinine clearance was calculated for all the cases according to the Cockcroft-Gault formula.4

Creatinine Clearance (ml/min) = (140-Age) x Weight x (0.85 if female)

 72 x S. Cr

Anemia was defined as reduced level of haemoglobin < 12gm/dl in men and < 10 gm/dl in women. (According to Indian scenario). Echocardiography was performed using the Vingmed System Five echocardiographic system equipped with 2.5 MHz transducers, M-Mode and 2D measurements were done in accordance with methods recommended by American Society of Echocardiography. Crtieria for left ventricular hypertrophy (LVH) were considered :LVMI >131 g/m2 for males and > 110 g/m2 for females.5

Statistical Analysis: Individual case data from study subjects of CKD was transferred on a MS Excel sheet and analyzed further using standard statistical techniques. The collected data was analyzed with SPSS 16.0 version. To describe about the data descriptive statistics frequency analysis, percentage analysis were used for categorical variables and the mean and S.D were used for continuous variables. To find the significance in categorical data Chi-Square test was used. In the above statistical tool the probability value 0.05 was considered as significant.

 

RESULTS

Demographic profile: Age and sex of participants: Out of 100 cases, 10 cases were in the range of 18-30 years, 69 cases were in the range of 31-60 years and 21 cases were above >60years. The mean age±sd of the cases in this study group was 47.73 + 13.266. In our study group out of 100 cases, 31 cases were female and 69 cases were male.

Stages of CKD of participants:

Figure 1: Graphical  representation of stages of  CKD with number of patients

 

Table 1: Stages of CKD with number of patients

Stage of CKD

Number of Patients

II

9

III

17

IV

32

V

42

Maximum number of patients were in stage V


 

Table 2: Prevalence of anemia in different stages of CKD

 

ANEMIA

Total

- ve

+ ve

CKD STAGE

II

Count

7

2

9

% within ANEMIA

36.8%

2.5%

9.0%

III

Count

6

11

17

% within ANEMIA

31.6%

13.6%

17.0%

IV

Count

4

28

32

% within ANEMIA

21.1%

34.6%

32.0%

V

Count

2

40

42

% within ANEMIA

10.5%

49.4%

42.0%

Total

Count

19

81

100

% within ANEMIA

100.0%

100.0%

100.0%

81 patients had anaemia and out of them 49.4 % were in stage V.

 

Table 3: Prevalence of LVH in CKD

 

LVH

Total

-ve

+ve

CKD

STAGE

II

Number of

Patients

4

5

9

% within

LVH

25%

6%

9%

III

Number of

Patients

4

13

17

% within

LVH

25%

15.5%

17%

 

IV

Number of patients

7

25

32

% within

LVH

43.8%

29.8%

32%

V

Number of

patients

1

41

42

% within

LVH

6.3%

48.8%

42%

Total

Number of

patients

16

84

100

% within

LVH

100%

100%

100%

 

Figure 2: Graphical representation of prevalence of LVH in CKD

84 patients had LVH and out of them 48.8% were in stage V

 

Table 4: Anemia and LVH correlation

 

 

Total

A -ve

A +ve

L - ve

L + ve

CKD

II

7

2

4

5

18

III

6

11

4

13

34

IV

4

28

7

25

64

V

2

40

1

41

84

Total

19

81

16

84

200

A+ve is anaemia present,                                           A-ve is anaemia absent

L+ is Left ventricular hypertrophy present             L-ve is Left ventricular hypertrophy absent

 

Figure 3: Graphical representation of Anemia and LVH correlation

 


DISCUSSION

The study was conducted in 100 participants. Their age ranged from 19 to 76 years. Of these, maximum patients were in age group 41-50 years (27%). Mean age of the patients was 47.73 + 13.266years. The prevalence of CKD varied strongly with age. The prevalence of CKD was found to be more in the male (69%) than female (31%), the mean age in male is 47years and in female is 48 years. This study is in accordance with a study in India which showed increased prevalence of CKD in middle aged patients.6 This study reveals a distinct male preponderance in study cases across all age groups. In general, the prevalence of CKD is greater in women than in men, regardless of age. Brown et al7 reported remarkably high prevalence in both men and women, but women had a tendency to have a higher prevalence of CKD than men. In our study out of 100 CKD cases, 42 were in stage V CKD, 32 were in stage IV CKD, 17 were in stage III CKD, 9 were in stage II CKD, with the percentage being 42%, 32%,17%,9% respectively. It was observed that stage V and IV had majority of cases compared to the other stages. This is due to patients presented to this hospital in late stages as patients were asymptomatic in early stages of CKD and most of patients were from rural India with minimal access to tertiary care. A study conducted by Varughese S et al8 had found the same results. The prevalence of anemia in different stages of CKD in our study was 22% in stage II (2 out of 9 cases), 64% in stage III (11 out of 17 cases),87.2% in stage IV (28 out of 32 cases) 95.2% in stage V (40 out of 42 cases). With the above mentioned data we found that anemia is more prevalent in stage III – V CKD as compared to stage II with the p value being significant i.e., p = 0.000. Mc Clellan et.al [9]studied the prevalence of anemia in different stages of CKD and found that the prevalence of anemia was strongly associated with declining glomerular filtration rate. In our study the prevalence of LVH in different stages of CKD was 55.5% in stage II (5 out of 9 cases) 76.4% in stage III (13 out of 17 cases) 78.1% in stage IV (25 out of 32 cases) 97.6% in stage V (41 out of 42 cases). With the above mentioned data LVH is found to be more prevalent in all the stages of CKD and the prevalence was increased with reduction in glomerular filtration rate. The p value for the prevalence of LVH in CKD was = 0.005 and is significant. Sambi RS et.al.[10] in their study observed a progressive rise in prevalence of LVH with the severity of kidney disease from 64% (mild/ moderate CKD group) to 96% (severe CKD group). In our study considering the correlation between anemia and LVH we found that in stage II CKD 2 cases found to be anemic and had LVH, in stage III 11 cases of anemia with had LVH, in stage IV out of 28 anemic patients 25 patients found to have LVH, in stage V 40 anemic patients had LVH and the p value <0.000 was significant. A similar correlation study was done by Datta S. et. Al3 in India found that 82% of male patients with Hb (hemoglobin)<7g/dl, 80% of male patients with Hb between 7.1-11g/dl and 68% of male patients with Hb>11g/dl had LVH. Similarly among female patients, 91% of the patients with Hb<7gm/dl, 89% of the patients with Hb between 7.1-11g/dl and 63% of the patients with Hb >11gm/dl had LVH. Thus this study concluded that with higher hemoglobin level the incidence of LVH is lesser and the severity of anemia is correlated to LVH. In the present study while correlating the anemia and LVH in CKD patients, all the anemic patients are found to have left ventricular hypertrophy. We found that stage V CKD patients has more prevalence of anemia and left ventricular hypertrophy with anemia being a co-morbid factor for further cardiovascular diseases in chronic kidney disease patients.

 

CONCLUSION

  • Anemia is a common complication in patients with CKD with high prevalence in stage IV and V.
  • Left ventricular hypertrophy is more common in patients with chronic kidney disease in all the stages and is an independent risk factor for the cardiovascular diseases. Anemia being a complication of CKD also contribute to the further worsening of the cardiac disease. CKD patients with anemia have left ventricular hypertrophy regardless of patient being hypertensive. Hence All patients with CKD with anaemia should be evaluated for LVH so that early identification and treatment of anaemia will decrease LVH and thereby reduces adverse cardiovascular outcomes.

 

REFERENCES

  1. Daniel E. Weiner, Hocine Tighiouart, Panagiotis T. Vlagopoulos, John L. Griffith,Deeb N. Salem, Andrew S. Levey et al. Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. 2005 Jun; 16(6):1803-10. 
  2. Zoccali C. Arterial pressure components and cardiovascular risk in end-stage renal disease Nephrol Dial Transplant (2003) 18: 249–252
  3. Sanchari Datta, G Abraham, Milly Mathew, H Somasundaram, TR Muralidharan, Asha Moorthy et al. Correlation of Anemia, Secondary Hyperparathyroidism with Left Ventricular Hypertrophy in Chronic Kidney Disease Patients. JAPI. Sept 2006; 54: 699-703.
  4. Inal BB, Oguz O, Emre T, Usta M, Inal H, Altunoglu E, Topkaya C. Evaluation of MDRD, Cockcroft-Gault, and CKD-EPI formulas in the estimated glomerular filtration rate. Clin. Lab. - January 1, 2014; 60 (10); 1685-94.
  5. Patrianakos AP, Parthenakis FI, Karakitsos D, De Groot E, Skalidis EA, Nyktari E et al. Relation of proximal aorta stiffness to left ventricular diastolic function in patients with end-stage renal disease. J Am Soc Echocardiogr 2007; 20:314–23.
  6. P P Varma. Prevalence of chronic kidney disease in India - Where are we heading? Indian J Nephrol, 2015 May-Jun; 25(3): 133–135.
  7. Brown WW, Peters RM, Ohmit SE, Keane WF, Collins A, Chen SC et al: Early detection of kidney disease in community settings: the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis, 2003 Jul; 42(1):22-35.
  8. Varughese S, John GT, Alexander S, Deborah MN, Nithya N, Ahamed I, Tamilarasi V, Jacob CK : Pre-tertiary hospital care of patients with chronic kidney disease in India. Indian J Med Res 126: 28–33, 2007
  9. McClellan W., Aronoff SL, Bolton WK, Hood S, Lorber DL,Tanq KLet al. The prevalence of anemia in patients with chronic kidney disease. Curr Med Res Opin. 2004 Sep; 20(9):1501-10.
  10. Sambi RS, Gaur AK, Hotchandani R, Aggarwal KK, Kaur S, Gupta M, et al. Patterns of left ventricular hypertrophy in chronic kidney disease: an echocardiographic evaluation. Indian Heart J. 2011 May-Jun; 63(3):259-68.

 

 


 


 


 


 

 

 


 


 



 


 

 


 

 

 


 


 









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