THE MINISTRY OF THE MINISRY OF DEFENCE EDUCATION AND TRAINING MILITARY MEDICAL UNIVERSITY PHAN THE CUONG STUDY THE CONCENTRATION OF SERUM ERYTHROPOIETIN, FERRITIN AND TRANSFERRIN IN PATIENTS WITH END-STAGE RENAL DISEASE UNDERGOING HEMODIALYSIS Speciality : Nephro-Urology Code : 62.72.01.46 MD-PhD THESIS SUMMARY HA NOI - 2016 The thesis was completed at: MILITARY MEDICAL UNIVERSITY Supervisors: Prof Dr Nguyen Anh Tri A Prof Dr Hoang Trung Vinh 1st reviewer: 2nd reviewer 3rd reviewer: The thesis will be upheld before the University Grade Thesis Examination Board At: hour on day month year 20161 The thesis can be found at: National library Military medical university’s library FOREWORDS The necessity of the topic Anemia is common in chronic kidney disease (CKD) patients especially in the end-stage and increases mortality, cardiovascular complications and reduces quality of life Main cause of anemia in these patients is the decrease in the excretion of erythropoietin (EPO) in the kidneys The invention of recombinant human erythropoietin (Rhu EPO) has opened a turning-point in the treatment of anemia for CKD patients However, the treatment of anemia for them especially dialysis patients so far remains challenging for clinicians because of expensive treatment costs and there are many factors that reduce the response to Rhu-EPO treatment Iron deficiency increases the severity of anemia and is one of the main causes of reduced effectiveness of Rhu-EPO treatment in CKD patients In fact, the results of the Rhu-EPO are different in various objects, including some cases even without using Rhu-EPO or treated with low doses still achieved target Hb This phenomenon may be related to the preservation of EPO secretion function and regulatory mechanisms in CKD patients Furthermore, the adequate intravenous iron supplement significantly affects the efficiency of the treatment of anemia Therefore, the study of the extent and the factors related to the decreased excretion of EPO and iron indices in CKD patients is very necessary, providing a scientific basis for determining the time, the most suitable dose of Rhu-EPO and intravenous iron to achieve high treatment efficiency and reduce the costs of treatment For this reason, we conducted this study with two following objectives: To investigate erythropoietin level, serum ferritin and transferrin saturation (TSAT) in patients with end-stage renal disease (ESRD) indicated chronic hemodialysis To assess the change of concentration of erythropoietin , ferritin and TSAT in patients with end-stage renal disease after the first months of chronic hemodialysis combined with some other treatment New contributions of the topic - Quantitatively determine the average serum erythropoietin levels in patients with end-stage renal disease indicated chronic hemodialysis and find out the difference of these values compared to normal people and anemia patients without renal failure Create equation calculating estimated erythropoietin levels from a linear correlation between erythropoietin and hemoglobin levels in anemia patients without renal failure from which to assess the EPO response in anemia patients with ESRD - Evaluate the results of iron deficiency treatment with bolus dose, iron deficiency prevention with maintenance dose as well as variations in the iron status of patients without iron supplementation through serum ferritin and TSAT in patients after the first months of chronic hemodialysis Structure of the thesis: The thesis includes 121 pages Forewords: pages; Overview: 30 pages; Subjects and methods: 20 pages; Results: 32 pages; Discussion: 33 pages; Conclusions and recommendations: pages The thesis contains 41 tables, 18 charts, figures It reffered 146 references including 18 Vietnamese and 128 English Chapter OVERVIEW 1.1 Erythropoietin levels in anemia patients with and without chronic renal failure 1.1.1 The role and regulatory mechanism of erythropoietin secretion * The role of erythropoietin in the process of red blood cell production in the bone marrow Erythropoietin is a glycoprotein with a molecular weight 30,4kDa and fold into a compact spherical structure consisting of four α helix bundle EPO stimulates red blood stem cells (Burst forrming units erythroid BFU – E, erythroid colony forming units - CFU - E) to produce, develop morphological structure to return into proerythroblast, erythroblast and reticulocyte * Regulatory mechanism of erythropoietin secretion In adults, EPO is primarily produced in the justaglomerular cells (90%), only a small amount (10 %) are produced in pericapillary cells of the liver interstitial The decrease of blood oxygen levels due to anemia or arterial oxygen pressure (who resides in a high altitude ) will stimulate renal EPO synthesis and secretion into the bloodstream 1.1.2 Change in serum EPO levels of anemic patients without renal failure When patients with intact renal function suffer from anemia due to any other cause, such as decreased production of red blood cells in the bone marrow (Myelodysplasic syndromes or lack of material to produce red blood cells), bleeding or hemolysis, the oxygen in tissues reduced, stimulating EPO synthesis in the kidneys and secretion into the bloodstream to increase red blood cell production in the bone marrow In this case, levels of EPO increase by up to tens or even hundreds of times higher than normal The studies showed that serum EPO levels correlate closely and conversely with Hb levels but inversely and closely correlated with the production of red blood stem cells (CFU - E) 1.1.3 Change in serum EPO levels of patients with ESRD Initially, it is expected that serum EPO levels in anemic patients with ESRD were lower than normal In fact , serum EPO levels in most patients with ESRD are equal to or higher than normal and this led scientists to assume the presence of bone marrow inhibitors in patients with ESRD This also showed that the reductions of EPO response in patients with ESRD can not be assessed through testing serum EPO levels When the glomerular filtration rate falls below 40ml / min, there is no linear correlation between serum EPO and Hb levels or Hct The observations then showed that serum EPO levels in anemic patients without kidney failure many times higher than those in ESRD patients with the same degree of anemia This is the basis for the scientists to demonstrate the decrease of EPO secretion in patients with ESRD When glomerular filtration rate decreases, the EPO response will decrease However , there was no linear correlation between serum EPO with glomerular filtration rate or serum creatinine To assess the EPO response in anemic patients with ESRD, their serum EPO levels are compared with estimated serum EPO levels based on EPO response in chronic anemic patients without renal failur The EPO response in CKD patients decreases with degree of renal failure, as CKD progressed to stage , and , the EPO response also decreased respectively: 15 %; % and % The decrease in the EPO response in CKD patients is the real cause of anemia when the glomerular filtration rate < 30ml/ 1.2 The changes of serum ferritin and TSAT in patients with ESRD 1.2.1 Features of iron metabolism in patients with ESRD In normal individuals, the daily cycle of iron metabolism of the body almost formed "closed recycling" Transferrin obtain iron mainly from reticuloendothelial system, where macrophages destruct "old" RBC and release iron into the blood Then, transferrin carries iron to the bone marrow to produce new red blood cells Only a small amount of iron (about 1-2 mg) daily loss and is compensated by the absorption of iron in the gastrointestinal tract In hemodialysis patients, daily cycle of iron metabolism has no longer feature "closed recycling" The characteristics of the change in iron metabolism in hemodialysis patients include: - Increased amount of supplemented intravenous iron - Increased the amount of iron transported to the bone marrow due to Rhu-EPO treatment - Increased iron liberation from the destroyed red blood cells into blood due to decreased erythrocyte life by about a third compared with normal people - Increased iron loss due to blood loss (blood samples taken periodically, blood loss during dialysis, bleeding from fistula needle positions after the hemodialysis sessions, gastrointestinal bleeding ) - Inflammation, malnutrition in hemodialysis patients increase the rate of functional iron deficiency 1.2.2 Evaluate iron status in patients with ESRD * Diagnosis of iron deficiency Iron deficiency includes types: “absolute iron deficiency"when iron stores are not enough to supply the bone marrow with iron to produce red blood cells and “functional iron deficiency"when the iron stores in the body are not lacking, but iron is not transported enough to the bone marrow to produce red blood cells International Society of Nephrology recommends testing ferritin and TSAT levels for monitoring and diagnosis of iron deficiency + Absolute iron deficiency: - Non-dialysed CKD patients: serum ferritin < 100ng/ml and or TSAT < 20% - Hemodialysed patients: serum ferritin < 200ng/ml and or TSAT < 20% + Functional iron deficiency: serum ferritin ≥ 200ng/ml and TSAT < 20% * Diagnosis of iron overload in patients with ESRD The applied diagnostic criteria: - Blood tests : TSAT ≥ 50 % and or serum ferritin ≥ 500ng/ml (caution is advised when treating intravenous iron supplementation ) - Liver biopsy : Liver iron concentration - LIC > mg/g dry weight liver 1.3 Studies of erythropoietin levels and iron status in CKD patients 1.3.1 Research world-wide * Studies of EPO levels in CKD patients Most of the research was to evaluate the role of reduced EPO excretion leading to anemia in CKD patients or to assess the decreased EPO secretion in various stages of CKD in relation to the degree of anemia Early studies only showed that serum EPO to be equal or higher than healthy people (Radtke H.W et al (1979), McGonigle R.J et al (1984), Fukushima Y Et al (1986) From these results, the authors concluded that in CKD patients and even hemodialysis patients EPO excretory function of the kidneys still remained Then, Seguchi C et al (1992) found that, in anemia patients with CKD serum EPO is much lower than that in anemic patients without renal failure having the same degree of anemia Fehr T et al (2004) showed that glomerular filtration rate the more decreased the inverse correlation between the serum EPO and Hb levels the more decreased and when the glomerular filtration rate falls below 40 ml/min, this correlation did not exist as in anemic patients without renal failure, this negative correlation is very strong Artunc F et al (2007) conducted a study comparing serum EPO levels in CKD patients with estimated serum EPO calculated from the linear regression equation in anemic patients without renal failure and found that the EPO response in patients with CKD stages 3,4 and decreased gradually 15%; 4% and 3% respectively Differences in the treatment of anemia, particularly in hemodialysis patients also make researchers more interested in understanding and assessment of EPO secretion function and its regulatory mechanism in circumstance of hypoxia due to anemia A Kato et al have found that when Hb levels decreased from 8,9 g /dl to 5,8 g/dl in 11 hemodialysis patients, the serum EPO increased 52.2 times higher than normal This shows that the ability of EPO secretion was partly preserved in patients with ESRD Ifudu O et al studied the changes of EPO lavels in hemodialysis patients treated with Rhu-EPO After a 6-week dialysis dose increase, hematocrit levels increased and EPO levels decreased from 9,1 mU/ ml to 6,1 mU/ ml The author commented: negative feedback phenomenon regulating EPO secretion still remained in dialysis patients 1.3.1.2 Studies of serum ferritin and TSAT in CKD patients The research on iron status in patients can be divided into several groups such as research evaluating iron status, studies assessing the effectiveness of treatment of iron deficiency and iron maintenance therapy, … The typical multinational studies evaluating iron status may be listed such as studies NHANES (National Health and Nutrition Examination Survey) of Hsu C Y et al conducted in the US (2002), ESAM 2003 (European Survey on Anemia Management 2003) carried out by Jacob C et al in Europe (2005) and GSAM in 2005 (The Gulf Survey on Anemia Management) conducted by Alsuwaida A et al in the Arab countries (2007) These studies have shown a panorama of anemia, iron deficiency and the related factors in CKD patients The studies of effectiveness of treatment of iron deficiency in hemodialysis patients showed that the majority of patients achieve adequate iron with intravenous iron loading dose (Van Wyck D.B et al (1989), Sunder -Plassmann G et al (1995), Park L et al (1998), Maintenance dose 100-200 mg/month can prevent iron deficiency and improve the effectiveness of treatment of anemia in CKD patients (MacDougall I.C et al (1996), Kosch M et al (2001), Harmankaya O.va et al (2002), 1.3.2 Studies in Vietnam Until now, in Vietnam no research of serum EPO levels in CKD patients published Studies on serum iron levels, ferritin and TSAT in non-hemodialysis and hemodialysis patients were conducted by a lot of authors during about recent 10 years such as Hoang Thi Oanh (2004), Tran Thi Thuan (2010), Ngo Quan Vu (2011), Nguyen Thi Huong (2006) and Nguyen Van Hung et al (2011) Most of the studies assessed the relationship between iron indicies and clinical, laboratory parameters There were some follow-up studies, but they did not show the change of the iron indicies in subjects treated with intravenous iron with different treatment regimes as well as did not evaluate the effectiveness of iron deficiency therapy or prevention of iron deficiency iron deficiency when combined Rhu-EPO treatment in hemodialysis patients who have high risk of iron loss Chapter SUBJECTS AND METHODS 2.1 Subjects We studied 222 subjects and divided into groups: - Study group: 105 patients with ESRD indicated hemodialysis Patients were studied at the beginning and after first months of hemodialysis treatment combined other treatment measures - Anemia control group: 51 anemic patients without renal failure suffering from Myelodysplasic syndromes - Refractory anemia treated at National Hematology and Blood Transfusion Institute from 10/2008 to 12/2011 - Healthy control group: 66 staff members of Hemodialysis Department of Bachmai Hospital and the Bank for Agriculture and Rural Development 2.1.1 Selection criteria * Healthy control group - 66 healthy people including both genders - Age ≥ 18 The age and gender distribution is equivalent to the study group 10 - The test of blood count, serum urea and creatinine are within normal limits - Voluntarily participated in the research * Anemia control group - 51 anemic patients without renal failure suffering from Myelodysplasic syndromes - Refractory anemia Age ≥ 18, the age and gender distribution is equivalent to the study group - Serum urea and creatinine are within normal limits - Voluntarily participated in the research * Study group - Patients with ESRD starting hemodialysis trearment - Age ≥ 18 - The causes of renal failure: chronic glomerulonephritis, chronic pyelonephritis, hypertention, diabetes melitus, lupus nephritis - Voluntarily participated in the research - Patients were followed-up for the first months of hemodialysis with the coordinated measures: dialysed under a unified regime, use of Rhu-EPO, iron supplementation as recommended by K/DOQI, antihypertensive medications and symptomatic treatment 2.1.2 Exclusion criteria * Healthy control group and anemia control group - Had blood transfusions, acute blood loss, surgical interventions or invasive procedures in the previous months - Who is pregnant or had given birth within the previous months - Suffer from polycystic kidneys and liver, chronic hepatitis, cirrhosis, chronic cardio-pulmonary disease, peptic ulcer, acute or chronic colitis, malignant blood diseases or cancer, cognitive disorders or mental disorders, HIV infection - Refuse to participate in research * Study group - Had blood transfusions, iron intravenous supplementaion, acute blood loss, surgical interventions or invasive procedures in the previous months 13 Indication: serum ferritin < 200 ng/ml or 200ng/ml ≤ serum ferritin < 500 ng/ml and TSAT < 20% Dose: 1000 mg iron sucrose (Venofer) divided into 10 injections in 10 consecutive dialysis sessions then maintained: 200 mg iron sucrose/ month, divided into equally spaced injections o Maintenance dose: Indication: 200 ng/ml ≤ serum ferritin < 500 ng/ml and TSAT ≥ 20% or serum ferritin > 500ng/ml and TSAT < 20% Dose: 200 mg iron sucrose/month, divided into equally spaced injections o No treatment: Serum ferritin ≥ 500 ng/ml and TSAT ≥ 20% - rHu-EPO: Neo-recormon 2000UI x syringes/week; subcutaneously (intravenously if there are adverse events) after each dialysis session Stop injecting when anaphylaxis happened; Increased dose by 25% every weeks if Hb level did not increase by 10-20 g/l / month or reduced dose by 25% while Hb level increased more than 1020 g/l / month or achieved target Hb (100-120 g/l) + Step 6: Evaluation after months of treatment - RBC, hemoglobin, hematocrit - Ure, creatinin, protein, albumin, hs-CRP, serum iron, serum ferritin, transferrin, EPO level 2.2.2 The diagnostic criteria and classifications, formulas used in the study - Criteria for diagnosis of stages of CKD according to the NKF / KDOQI 2003 - Evaluate iron status according to American Society of Nephrology Table 2.2 Criteria for assessing the serum ferritin and TSAT Level Serum ferritin (ng/ml) TSAT (%) Low [...]... with increased hepcidin synthesis (hepcidin prevents the liberation of iron from reticuloendothelial system into the bloodstream and reduces iron absorption from the gastrointestinal tract into the bloodstream) in liver leading to reduced TSAT and increased serum ferritin Evaluating the relationship between hs-CRP levels and serum ferritin in 72 patiets with serum ferritin ≥ 200 ng/ml, we found that there... between serum EPO with iron status we found that serum EPO was inversely and moderately correlated with serum ferritin (r = -0,312; p < 0,01) The results of this study showed that there was a relationship between the body's iron stores and the serum EPO in patients with ESRD 4.2.2 Serum iron, ferritin and TSAT in patients with ESRD and their relations with some clinical and laboratory parameters * Serum. .. treatment (27.6%) with p