RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-11003-0146 |
Analysis of Changes in Hematological Parameters of Patients with Chronic Kidney Disease before and after Dialysis
1,2Department of Pathology, Army College of Medical Sciences, Delhi, India
3Department of Community Medicine, Army College of Medical Sciences, Delhi, India
4Department of Biochemistry, Safdarjung Hospital, Delhi, India
Corresponding Author: Archna Rautela, Department of Pathology, Army College of Medical Sciences, Delhi, India, Phone: +91 9582700591, e-mail: rarchnarautela@gmail.com
Received: 22 July 2024; Accepted: 23 August 2024; Published on: 31 December 2024
ABSTRACT
Background: End-stage renal disease is the final stage of chronic renal failure where there is a progressive irreversible worsening of renal function. This requires dialysis, a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate). It corrects fluid and electrolyte imbalances and removes waste products in renal failure. Hemodialysis (HD) remains an important form of therapy in end-stage renal disease (ESRD) patients. Dialysis is known to have variable effects on various blood components. It has been reported that dialysis lowers the hemoglobin (Hb) level and red blood cell (RBC) count. This study was primarily conducted to determine the differences between various hematological parameters that occur in renal failure patients before and after HD.
Materials and methods: This study is a prospective observational study in which we enrolled 51 patients suffering from renal failure and who are on hemodialysis. The following parameters were recorded: Hb, RBC, packed cell volume (PCV), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), total leukocyte count (TLC), differential leukocyte count (DLC)—neutrophil and lymphocyte percentage, platelet count, platelet distribution width (PDW), and platelet large cell ratio (P-LCR). Serum creatinine and blood urea were also observed to assess the improvement with dialysis. All parameters were recorded both pre- and postdialysis. Statistical analysis of data was performed.
Results: The RBC count, Hb levels, PCV, MCHC, and percentage neutrophils show significant elevation (p-value < 0.05) in samples obtained after dialysis compared to those obtained before dialysis. On the other hand, there is significant decrease in MCV, lymphocyte percentage, and P-LCR in postdialysis samples compared to predialysis samples. The study showed no significant alterations in many parameters like MCH, RDW, platelet count, TLC, and PDW. The biochemical findings were significant decrease in the blood urea and serum creatinine levels postdialysis which was expected and desirable in patients with chronic kidney disease.
Conclusion: The effects of dialysis on Hb and RBC parameters have been studied in many studies but they also have conflicting reports. This may be due to the fact that there can be other factors that may have influence on the values of these parameters that may have not been taken into account. We have documented effects on many other parameters as well but studies with larger sample size that take into account confounding factors like position of patient, gender, etc., need to be done to obtain more conclusive evidence.
Keywords: Chronic kidney disease, Dialysis, Hematological parameters
How to cite this article: Rautela A, Dudani S, Sharma V, et al. Analysis of Changes in Hematological Parameters of Patients with Chronic Kidney Disease before and after Dialysis. J Med Acad 2024;7(2):43–46.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
The kidneys excrete metabolic byproducts, control and dissolve water concentration in the body, and control acid-base balance in the body. They also secrete hormones such as erythropoietin (EPO), renin, prostaglandins, and play a role in vitamin D metabolism. In end-stage renal disease (ESRD), glomerular filtration rate (GFR) is <5% of normal.
End-stage renal disease often occurs with diabetes and hypertension and is one of the most common causes of death. The prevalence of ESRD in India is approximately 6.3%. It is irreversible, but requires support including kidney transplantation, hemodialysis (HD), peritoneal dialysis, or transplantation.1,4
Dialysis is a process in which fluid is passed from the blood through a semipermeable material to a commercial drug (dialysate). It helps regulate fluid and electrolyte imbalances in renal failure and eliminates nitrogenous wastes.
Hemodialysis is a process in which venous blood flows through an additional electrolytic material and is forced through a semipermeable membrane, bringing the blood into contact with a product preparation called dialysate, which helps remove accumulated waste products from the blood.5,6
The blood is then returned to the body. This process is performed for 3–4 hours at a dialysis center, several times a week, depending on the degree of renal failure. It is still an important treatment in India due to the increasing incidence of ESRD and the lack of donor and transplant centers. These results will depend on many physiological and nonphysiological factors such as age, gender, race, muscle mass, patient position during dialysis, time, and type of dialysis. Dialysis has been reported to decrease hemoglobin (Hb) levels and red blood cell (RBC) counts more in women than in men and in the elderly due to decreased EPO concentrations.7,9
Cardiovascular diseases are the most common cause of morbidity and mortality in hemodialysis patients. Factors that increase the risk of cardiovascular disease such as hypertension, uremia, oxidative stress, dyslipidemia, and inflammation.
MATERIALS AND METHODS
This study is a prospective study comparing pre- and posthemodialysis measurements.
Ethics committee approval was obtained before starting the study.
We obtained informed consent in a language that all subjects understood before conducting the study. Examination of complete medical and treatment records and recording of physical examination tests was done. The study included 51 patients with renal failure receiving hemodialysis. The dialysis duration was approximately 3–4 hours each using a polysulfone hollow fiber filter and a blood flow of 250–350 mL/minute. We excluded subjects who were on medication having direct effects on hematological characteristics and pregnant women.
We collected venous blood (whole blood) with EDTA suction and monitored the following: Hb, RBC, packed cell volume (PCV), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), total leukocyte count (TLC), differential leukocyte count (DLC)—neutrophil and lymphocyte blood, platelet count, platelet distribution width (PDW), platelet large cell ratio (P-LCR), respectively.
Creatinine and blood urea levels were also assessed to check for improvement in dialysis. All measurements were recorded before and after dialysis.
Statistical Analysis
Paired t-test was used to analyze statistical data. All tests were two-tailed and the significance level was p < 0.05.
RESULTS
The age of the patients enrolled ranged from 24 to 72 years with a mean age of 47 years.
Out of 51 patients 20 were males and 31 were females.
Red Blood Cell Parameters
The following values were observed for various red cell-related indices Hb, RBC, and PCV (Table 1).
| Mean Hb ± SD (gm/dL) | p-value | Mean RBC ± SD (mL/m3) | p-value | Mean PCV ± SD (%) | p-value | |
|---|---|---|---|---|---|---|
| Predialysis | 9.10 ± 1.91 | 0.006 | 3.10 ± 0.78 | 0.017 | 29.38 ± 5.80 | 0.013 |
| Postdialysis | 9.68 ± 2.04 | 3.33 ± 0.69 | 30.82 ± 6.04 |
Hb: The patients are mostly anemic with prehemodialysis Hb varying from 5.5 to 13.5 gm/dL. The mean levels of Hb were significantly higher with p-value = 0.006 in postdialysis samples compared to predialysis.
RBC count: The mean levels of the RBC count were significantly increased inpatient samples postdialysis compared to predialysis with a p-value = 0.017.
PCV: The mean levels of the PCV were significantly higher inpatient samples postdialysis compared to predialysis with a p-value = 0.013 (Table 2).
| Mean MCV (fL) ± SD | p-value | Mean MCH (pg) ± SD | p-value | |
|---|---|---|---|---|
| Predialysis | 93.64 ± 6.35 | 0.041 | 28.77 ± 2.271 | 0.062 |
| Postdialysis | 92.72 ± 5.72 | 29.24 ± 2.243 |
There is a significant decrease in the MCV of patients after dialysis with p-value = 0.041, whereas the difference in the MCH in patients pre- and postdialysis is not significant. p-value = 0.062.
The MCHC is significantly increased in the patients postdialysis samples p-value = 0.014. RDW does not vary significantly in postdialysis samples compared to predialysis samples p-value = 0.569 (Table 3).
| Mean MCHC (gm/dL) ± SD | p-value | Mean RDW (fL) ± SD | p-value | |
|---|---|---|---|---|
| Predialysis | 30.72 ± 1.41 | 0.014 | 51.24 ± 4.90 | 0.569 |
| Postdialysis | 31.25 ± 1.35 | 51.01 ± 4.31 |
White Blood Cell Parameters
Difference in the values of total leukocyte count pre- and postdialysis are not significantly different p-value = 0.562 (Table 4).
| Mean TLC (×103/μL) ± SD | p-value | Mean neutrophil (%) ± SD | p-value | Mean lymphocyte (%) ± SD | p-value | |
|---|---|---|---|---|---|---|
| Predialysis | 6.4196 ± 1.49 | 0.562 | 63.73 ± 11.47 | 0.00 | 27.37 ± 9.77 | 0.00 |
| Postdialysis | 6.2412 ± 2.66 | 71.65 ± 13.96 | 21.06 ± 10.95 |
The difference in the percentage of neutrophils and percentage of lymphocytes is statistically significant with a p-value = 0.000 each, with the percentage being significantly increased after dialysis compared to predialysis samples.
Platelet Parameters
The difference in the platelet count and MPV between pre- and postdialysis samples is not significant p-value = 0.882 (Table 5).
| Mean Plt ± SD (×103/μL) | p-value | Mean MPV ± SD (fL) | p-value | |
|---|---|---|---|---|
| Predialysis | 170.00 ± 51.89 | 0.882 | 11.19 ± 1.23 | 0.264 |
| Postdialysis | 170.88 ± 59.73 | 11.03 ± 1.36 |
Plt, platelet count
Difference in mean PDW is not significant (p = 0.562), whereas mean value for P-LCR is significantly decreased postdialysis p = 0.036 (Table 6).
| Mean PDW ± SD (fL) | p-value | Mean P-LCR ± SD (%) | p-value | |
|---|---|---|---|---|
| Predialysis | 15.05 ± 2.51 | 0.562 | 34.31 ± 9.09 | 0.036 |
| Postdialysis | 14.84 ± 3.44 | 32.33 ± 9.05 |
Biochemical Parameters
The mean levels of blood urea and serum creatinine are significantly lower in postdialysis samples compared to predialysis p-value = 0.000 each (Table 7).
| Mean B. urea (mg/dL) ± SD | p-value | S. creat (mg/dL) ± SD | p-value | |
|---|---|---|---|---|
| Predialysis | 131.70 ± 43.92 | 0.000 | 10.2969 ± 4.92 | 0.000 |
| Postdialysis | 50.29 ± 29.61 | 4.2853 ± 2.74 |
B. urea, blood urea nitrogen; S. creat, serum creatinine
DISCUSSION
The results of this study show that there are many differences in the changes in hematological parameters in kidney patients receiving hemodialysis.
The RBC count, Hb levels, PCV, MCHC, and percentage neutrophils show significant elevation (p-value < 0.05) in samples obtained after dialysis compared to those obtained before dialysis.
On the other hand, there is significant decrease in MCV, lymphocyte percentage, and P-LCR in postdialysis samples compared to predialysis samples.
Biochemical results showed that there was a decrease in blood urea and blood creatinine levels after dialysis, which is a possible and ideal situation for people with kidney disease.
The present study showed a significant elevation in many red cell parameters. However, this contradicts the report of Inagaki et al.,10 who reported a decrease in hematocrit and white blood cells in patients accepting hemodialysis. They explained that the decrease in various hematological parameters in hemodialysis may not be entirely due to hemodialysis, but may be due to hemodilution due to the supine position and the redistribution of water from the extravascular space to the intravascular space.11,12
Pandian et al.13 found that there was moderate degree of anemia in both pre- and postdialysis patients, and there was an increase in the severity of anemia after hemodialysis in many patients. The anemia was normocytic normochromic type.
Total white blood cell count and platelet count were noted to be decreased (p < 0.05). This change was also seen in differential counts with decreases in neutrophil and monocyte counts and increases in lymphocyte and eosinophil counts.
In a study by Algythan et al.,11 the observations indicated that the mean of each RBC count, Hb, HCT, MCH, MCHC, and RDW levels show a statistically significant increase in renal failure patients posthemodialysis when compared to prehemodialysis levels. The increase of RBCs count, Hb, and hematocrit levels posthemodialysis was explained by the fact that before hemodialysis, due to fluid retention, volume is high which leads to dilution and hence the RBC count, Hb, and HCT to be low. These observations to an extent correlate with the findings of our study with regard to parameters of RBC, Hb, MCHC, and PCV which showed a significant increase after dialysis.
They also observed an increase in leukocytes counts and the mean count of each except basophils after hemodialysis. This was explained by the same fact as above. On the other hand, we noted that neutrophil percentage in our study also increased significantly but not the other parameters. In addition, the lymphocytes showed a significant decrease after dialysis.13
Mohammed Ali et al. undertook a study with 90 patients each, undergoing hemodialysis and peritoneal dialysis. They noted that all the hematological parameters were found to increase insignificantly after hemodialysis sessions and concluded hemodilution before dialysis being the reason for the same. These findings were in cohesion with our study as well.14,15
In a study by Mohammed DK et al.,12 the Hb, RBC, PCV, blood sugar, serum calcium, and serum electrolytes like sodium and potassium were significantly increased in patients in renal failure after hemodialysis in comparison to before hemodialysis, while blood urea significantly decreased. They enrolled 52 patients of ESRD undergoing dialysis out of which 26 were undergoing hemodialysis and the rest were on peritoneal dialysis. The findings of this study were mostly in conjunction with observations of our study.
The authors discuss that the increase in hematocrit and hemoglobin was due to an increase in RBC counts. They also discussed that angiotensin II could activate erythropoiesis indirectly via adrenal cortical cells to secrete androgenic hormones. Similar to our study, they also observed that serum creatinine and urea were significantly reduced after dialysis.
Decreased urinary excretion leads to retention of metabolites like creatinine and urea as well as electrolytes and water. The increased formation of metabolites through catabolic processes and other metabolic pathways also contributes further; this problem in excretion compounded by constant release of creatinine from muscle, results in accumulation of creatinine and thus an elevation in patients with ESRD for which the patient is required to undergo procedure of dialysis.16
There have been authors who have studied comparison of platelet parameters before and after dialysis.
Our study revealed that P-LCR was significantly reduced after dialysis.
Daugirdas et al.17 extensively reviewed literature to study the effect of dialysis on platelets. They observed that the platelet count decreases to a small extent during dialysis, but this decrease tends to peak at 15–30 minutes into dialysis, and usually resolves by the end of the procedure. Even in our study, the mean values of the platelet count did decrease after dialysis but this difference was not significant.
Studies indicate that dialysis causes platelet activation during passage of blood through membrane filters often seen in the form of increased reticulated platelets. This refutes the findings in our study considering there is decrease in the P-LCR. This may be due to prolonged duration since the patient is on dialysis; there is reduction in the degree of activation with each dialysis.
CONCLUSION
After analyzing the available data and comparing our findings with those of other studies that also evaluated similar parameters, we observe that the hematological parameters can greatly vary due to the procedure of hemodialysis.
The procedure can have a variable effect on different parameters, but it is important to remember that there can be other factors that may have influence on the values of these parameters that may have not been taken into account.
The effects of dialysis on Hb and RBC parameters have been studied in many studies, but that also have conflicting reports.
Hemoglobin in individuals with chronic kidney disease (CKD) varies frequently above or below the recommended levels within short intervals of time even though the calculated mean Hb remains within the target range of 11–12 gm/dL. Management of anemia and maintenance of stable Hb levels using erythropoiesis-stimulating agents like recombinant EPO is an important part of disease management.
Thrombocytopenia is a documented potential adverse effect of hemodialysis; however, it is not observed frequently in patients who undergo hemodialysis using biocompatible membranes.
In conclusion, the results of this study indicate that most of the hematological parameters measured in hemodialysis patients, pre-or posthemodialysis were either elevated or lowered. Many factors can have an impact on them which need to be kept in mind during postdialysis management and care.
ORCID
Shubham S Chauhan https://orcid.org/0000-0002-7788-3978
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