RENAL DATA FROM THE ARAB WORLD
Year : 2008 | Volume
: 19 | Issue : 2 | Page : 274--279
Hematological Changes Post-Hemo and Peritoneal Dialysis Among Renal Failure Patients in Sudan
Mohamed Siddig Mohamed Ali1, Muna Abbas Babiker2, Leena Babiker Merghani1, Fadl Aljabbar Al Taib Ali3, Mekki Hamad Abdulmajeed3,
1 Department of Hematology, Faculty of Medical Laboratory Sciences, AI Neelain University, Sudan
2 College of Medicine, Juba University, Sudan
3 Medical Laboratory, Ministry of Health, Khartoum, Sudan
Mohamed Siddig Mohamed Ali
Faculty of Medical Laboratory Sciences, Al Neelain University, P.O. Box 12702, Khartoum
The objective of the study was to assess the changes that occur in various hematological parameters that may occur in renal failure patients after hemo and peritoneal dialysis sessions. The study was carried out at the AI Neelain University, Khartoum, Sudan. Blood samples were collected from 180 renal failure patients undergoing hemo and peritoneal dialysis (90 each) before and after dialysis sessions. The samples were tested for complete blood count, prothrombin time and activated partial thromboplastin time by the manual calibrated techniques. The study demonstrated an increase of hemoglobin, hematocrit and red cell count after both hemo and peritoneal dialysis. The mean corpuscular hemoglobin and hemoglobin concentration showed mild increase after peritoneal dialysis and slight decrease after hemodialysis. Leukocyte and platelet counts also showed mild increase after hemodialysis, while the prothrombin and activated partial thromboplastin times were significantly prolonged. Our study shows that most of the hematological parameters as well as prothrombin and partial thromboplastin times increased after a dialysis session. Therefore, it is recommended that all patients be screened appropriately before and after dialysis to avoid complications.
|How to cite this article:|
Mohamed Ali MS, Babiker MA, Merghani LB, Ali FA, Abdulmajeed MH. Hematological Changes Post-Hemo and Peritoneal Dialysis Among Renal Failure Patients in Sudan.Saudi J Kidney Dis Transpl 2008;19:274-279
|How to cite this URL:|
Mohamed Ali MS, Babiker MA, Merghani LB, Ali FA, Abdulmajeed MH. Hematological Changes Post-Hemo and Peritoneal Dialysis Among Renal Failure Patients in Sudan. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2021 Sep 21 ];19:274-279
Available from: https://www.sjkdt.org/text.asp?2008/19/2/274/39045
Dialysis involves the removal of urea and other toxic substances from the plasma as well as the correction of electrolyte imbalance. Of the two methods of dialysis, hemodialysis (HD) is the most commonly used method in which, blood is passed through an extra corporeal circuit and pumped across an artificial semi permeable membrane to bring the blood into contact with the dialysate. ,
The second method is the intermittent and continuous ambulatory peritoneal dialysis (PD). This method utilizes the peritoneal membrane, as the semi permeable membrane, with capillaries on one side and high osmotic fluid infused into the peritoneal cavity on the other side. The peritoneal cavity is drained and the cycle is repeated after a suitable time to allow the equilibration of diffusible substances. ,
Both types of dialysis are known to have side effects on the variable blood components. These effects vary with several physiological and non-physiological factors such as age, gender, race, muscular activity, position of patient during dialysis as well as the duration and type of dialysis. It has been reported that dialysis lowers the hemoglobin (Hb) level and red blood cell (RBC) count; this is more pronounced in females than males, and in patients in advanced age because of the reduced erythropoietin concentration in these patients. ,
Data concerning platelet count before and after dialysis, suggest that there may be other factors affecting platelets during dialysis.  However, recent studies have shown that HD decreases the percentage of RNA-rich platelets through elimination of the younger and more active platelets  while it dose not affect apoptosis of neutrophils  or monocytes. 
Dialysis remains the most common form of renal replacement therapy worldwide due to the high cost associated with transplantation and difficulty in finding a compatible organ donor. Approximately, 100 white individuals per million population (pmp) require renal replacement therapy in the United Kingdom each year. The corresponding figure among people of African and Asian origin in the U.K is 300-400 pmp  with 70-80 new patients pmp accepted for long-term dialysis annually. 
In Sudan, according to ministry of health records, the prevalence of renal failure is increasing through the few past years; approximately 70 to 140 new patients pmp undergo dialysis each year. This high frequency is thought to be due to epidemic malarial infection, which is well known to cause glome rulonephritis. 
Thus, both HD and PD are widely used worldwide but the effects of these types of dialysis on patients' blood have not been investigated thoroughly in Sudan. This study is aimed at providing essential data concerning evaluation of the dialysis process, and the precautions to be taken before and after a dialysis session in order to reduce patient morbidity and mortality.
Material and Methods
The study design is a descriptive comparative type. This study was conducted in Khartoum State in the following medical centres: Dr. Salma Dialysis Centre, Khartoum Teaching Hospital Dialysis Unit and Military Hospital Centre which are popular special centres with experienced consultants and specialists. Patients with chronic renal failure undergoing renal replacement therapy (HD and PD) in these medical centres were included in the study.
A total of 360 blood samples were collected randomly; 180 samples each were collected from 90 patients on HD and PD, prior to, and after a dialysis session. All samples were analyzed within two hours of collection.
Pre-testing (validity) with a set of normal blood samples was done by automatic cell counter "Sysmex" for various hematological parameters and by the coagulometer for prothrombin time (PT) and activated partial thromboplastin time (APTT) in each batch.
The results were accepted only when the difference between the two values was less than 2 SD.
Venous blood samples were collected in dipotassium EDTA containers, labelled and tested within six hours for complete hemogram and platelet count while, for performing PT and APTT, samples were collected in blood containers containing tri-sodium citrate anticoagulant (9:1).
Hemoglobin-cyanide (HiCN) method, globally considered as the standard method, was used to measure Hb concentration colorimetrically by using HiCN reference solution.
Micro-Hematocrit method, described by Dacie & Lewis  , was adopted to measure the packed cell volume (PCV) using microHematocrit centrifuge (10000 g for 5 minutes), and the standard capillary tubes.
Total and differential leukocyte count (WBC) was performed by manual methods. For counting the WBC, blood samples were diluted 1 in 20 using 2% glacial acetic acid solution as a diluent, which lyses the red cells and stains white cells. They were counted microscopically using improved neubauer chamber as described by Bernadette F. Rodack. 
Differential leukocyte count was performed manually using thin blood films. Blood films were prepared, stained with leishman's stain and examined under the microscope to evaluate the morphological features of blood cells.
Red blood cell count was used to assess the numerical variation of patients' blood and performed by manual 1% formal citrate method using improved neubauer chamber and, red cell indices (MCV, MCH & MCHC) were calculated according to the formula described by Cheesbrough. 
For counting platelets, blood samples were diluted 1 in 20 using 1% ammonium oxalate solution as a diluent, which lyses the red cells. Platelets were counted manually using improved neubauer chamber as described by Bernadette F. Rodack. 
The PT measures the time taken by plasma to clot in the presence of an optimal concentration of tissue extract (thromboplastin), and indicates the overall efficiency of the extrinsic clotting system, i.e. factor VII, X, V, prothrombin and fibrinogen. The APTT, also known as the partial thromboplastin time with kaolin (PTTK) and the kaolin cephalin clotting time (KCCT), is a screening test for the intrinsic clotting system, i.e. factor XII, XI, IX, VIII, X, V, prothrombin and fibrinogen. It measures the clotting time of plasma after the activation of contact factors but without adding tissue thromboplastin.
The prothrombin and activated partial thromboplastin times were performed as described by Dacie & Lewis using the Thromboplastin of DiaMed Company.
The data of this study were analyzed using the SPSS software (non-parametric statistical tests).
A total of 360 venous blood samples, collected from 180 renal failure patients before and after a dialysis session, were analyzed. There were 90 patients on HD and 90 others on PD. There were 78 patients (43.3%) aged more than 50 years, 48 patients (26.7%) between 40 and 50 years, 30 patients (16.7%) between 30 and 40 years, and 24 patients (13.3%) were between 20 and 30 years. Seventy-eight patients (43.3%) were females. The duration on dialysis was between six and 10 years in 12 patients (6.7%), one and five years in 150 patients (83.3%) and less than one year in 18 patients (10%).
There was slight increase in Hb concentration, PCV, MCV and red cell count after both HD and PD [Table 1].
[Table 2] illustrates the significant statistical correlation between the increase of the Hb concentration, PCV, MCV and red cell count and the duration on HD. Also, there was significant correlation between the decrease of mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration and the duration on HD.
[Table 3] shows the statistically insignificant increase in the number of platelets before and after HD and PD.
[Table 4] shows the statistically significant increase of PT and highly significant increase of APTT after HD.
Chronic Renal failure is a major health problem and greatly affects the economic and social status of affected patients. Its incidence in Sudan is about 70-140 cases pmp per year and the problem is expected to increase unless greater efforts are directed towards its prevention.
Dialysis treatment (HD and PD) remains the principal method of treatment for correcting the renal dysfunction. However, dialysis has limitations chiefly in the form of lack of adequate dialysis facilities and well-trained personnel. Also, financial constrains prevent hospitals from performing dialysis in the right way, i.e. three sessions per week (5-6 hours per session). 
Globally, the dialysis-monitoring strategy is principally based on measurement of chemical substances before and after each session of dialysis. Thus, monitoring various hematological parameters, especially before dialysis, may help in preventing complications and, consequently, the mortality rate.
In the present study, all the hematological parameters were found to increase insignificantly after HD sessions; this is in contrast to the report of Inagaki H et al, who reported a significant decrease in the hematocrit and leukocyte count in patients undergoing HD. Thus, the reduction in the various hematological parameters during the HD session may not be attributable entirely to the HD procedure, but rather caused by the supine position and consequent hemodilution caused by redistribution of water from the extra-to intravascular space.  Further, the duration of HD and PD did not affect the hematological parameters with the exception of the PCV and red cell count, which were significantly increased by the increase of the duration of HD.
On the other hand, the PT and APTT were significantly increased after HD. This finding is in contrast to the study reported by Malyszko J et al  and could be explained by the difference in the dose of heparin as well as the reduction of the number of HD sessions. Additionally, the platelet count increased after HD and decreased after PD, although without statistical significance. This is in contrast to the study of Knudsen F et al,  who reported a decrease in the number of platelets after HD. This could also be explained by the reduction of the number of HD sessions in our study.
It can be concluded that complete hematological parameters as well as the PT and APTT were found to increase after both types of dialysis. Therefore, it is recommended that patients on dialysis should be investigated before and after dialysis to control the risk of anemia, bleeding or thrombosis.
|1||Bishop ML, Janet D, Edward PF. Clinical Chemistry: 4th edn. 1996:440-61.|
|2||Livolsi VA, Merino MJ, Books JJ. The National Medical Series of Independent Study. 3 rd ed. Pathology 1994:305-28.|
|3||Mayne PD, Mayne ZP. Clinical chemistry in diagnosis and treatment. 6th edn, 1994:20-1. |
|4||Fischbach F. A Manual of laboratory and diagnostic tests. 6 th ed, 2000:34-71.|
|5||Dacie JV, Lewis SM. Practical hematology. 9 th ed. Churchill Livingstone: Edinburgh; 2001:453.|
|6||Woo KT, Wei SS, Lee EJ, Lau YK, Lim CH. Effects of hemodialysis and peritoneal dialysis on antithrombin III and platelets. Nephron 1985;40(1):25-8.|
|7||Tassies D, Reverter JC, Cases A, et al. Reticulated platelets in uremic patients: Effect of hemodialysis and CAPD. Am J Hematol 1995;50(3):161-6.|
|8||Majweska E, Baj Z, Sulowska Z, Rysz J, Luciak M. Effects of uraemia and hemodialysis on neutrophil apoptosis and expression of apoptosis related proteins. Nephrol Dial Transplant 2003;18(12):2582-8.|
|9||Andrikos E, Buoncristiani E, D'Intini V, et al. Effect of daily hemodialysis on monocytes apoptosis. Blood Purification 2005;23(1):79-82.|
|10||Kumar P, Clark M. Clinical medicine, 4 th edn, 2002:484-5.|
|11||Edwards CR, Bouchier IA, Haslett C, Chilvers ER. International Student Edition Davidson's: Principles and Practice of Medicine, 18 th edn. 1999:631.|
|12||Abboud OL, Osman EM, Musa AR. The Etiology of chronic renal failure in adult sudanese patients. Ann Trop Med Parasitol 1989;83(4):411-4.|
|13||Rodack BF. Diagnostic hematology. Routine laboratory investigations of blood cells and bone marrow. 1st edn, 1993:125.|
|14||Cheesbrough M. Medical laboratory manual for tropical countries. 2 nd edn, Oxford. Butterworth, 1987:602.|
|15||Inagaki H, Kuroda M, Watanabe S, Hamazaki T. Changes in major blood components after adopting the supine position during haemodialysis. Nephrol Dial Transplant 2001;16 (4):798-802.|
|16||Malyszko J, Malyszko JS, Myliwiec M. Comparison of hemostatic disturbances between patients on CAPD and patients on HD. Perit Dial Int 2001;21(2):158-65.|
|17||Knudsen F, Dyerberg J. Platelets and antithrombin III in uraemia: The acute effect of haemodialysis. Scand J Clin Lab Invest 1985;45(4):341-7.|