Abstract
Anemia is an early complication of chronic kidney disease (CKD). The iron deficiency is an important contributor, more so in the Pakistani population. As routine standalone iron tests do not accurately reflect the actual status in the complex environment of CKD, there is a need to study better indicators. Serum iron, ferritin, total iron-binding capacity (TIBC), and serum transferrin receptor (sTfR) levels were estimated in 100 primary iron deficiency anemia (IDA) patients (controls-Group 1) and 68 newly diagnosed CKD cases. The CKD patients were divided into two groups: Serum ferritin 100 μg/L (Group 3). The values of percentage saturation, log of ferritin (log_ferritin), and the ratio of sTfR to log ferritin (sTfR/log_f or sTfR index) were calculated. The CKD cases were further divided depending on ferritin cut-offs of 30, 50, 70, and 100 μg/L and statistically analyzed including ROC and AUC, to choose the best diagnostic parameter for accurate assessment of iron status in CKD cases. The mean serum ferritin was 11.34 μg/L, 28.70 μg/L, and 281.81 μg/L, and the mean sTfR was 2.34 μg/ml, 1.82 μg/ml, and 1.28 μg/ml in Groups 1, 2, and 3. Among all groups, the difference was found to be significant for serum iron, log_ferritin, and sTfR/log_f. The sTfR and sTfR/log_f showed good discrimination between IDA and Anemia of chronic disease in CKD cases, but sTfR/log_f gave the best discrimination at all cut-off levels of ferritin. At a ferritin cut-off of 50 μg/L, the sTfR/log_f value of 0.83 had a sensitivity of 93.5% and specificity of 95.45%, and at a ferritin cut-off 100 μg/L, the same value of 0.83 had a sensitivity of 95.5% and specificity of 86.5%. The ratio of sTfR/log_f is the best indicator for assessing iron status in CKD. Keywords: Anemia, chronic kidney disease, ferritin, transferrin receptor DOI : 10.7176/JMPB/57-03 Publication date : July 31 st 2019
Highlights
Anemia is an early complication of chronic kidney disease (CKD) and causes increased morbidity and mortality.[1]
A wide range of reference limits for serum ferritin have been suggested to diagnose iron deficiency in patients with chronic inflammation.[7],[8] Traditional laboratory indices of iron status such as serum iron, total iron-binding capacity (TIBC), and serum ferritin do not always distinguish anemia of chronic disease (ACD) from iron deficiency anemia (IDA) as both serum ferritin and transferrin can be affected by chronic inflammation
STfR is unaffected by inflammation and rise in serum transferrin receptor (sTfR) level may be the first detectable response noted after erythropoiesis stimulating agents (ESA) therapy in CKD patients.[10] sTfR has been shown to be of value in differentiating IDA from ACD, but in the setting of CKD, it is more reflective of erythroid proliferation
Summary
Anemia is an early complication of chronic kidney disease (CKD) and causes increased morbidity and mortality.[1]. The cause of anemia is varied and includes nutritional deficiency, increased pro-inflammatory cytokines, chronic blood loss, and relative erythropoietin (EPO) deficiency. This decrease in EPO matches the decline in kidney function and is the main determinant of anemia in CKD stage 4-5.[2] This rationale forms the basis for treating CKD with erythropoiesis stimulating agents (ESA). The aim of the study was to evaluate the iron status in newly diagnosed CKD cases, and to determine the most suitable indicator, which would reflect the true iron status in these patients
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