Under the supervision
Prof. Dr. Hassan Abd EL-Halim Amer
Professor of Biochemistry and Chemistry of Nutrition.
Faculty of Veterinary Medicine, Cairo University
Adel M. El-Behairy Mohamad Ali Warda
Professor of Biochemistry and Professor of Biochemistry and
Chemistry of Nutrition. Chemistry of Nutrition.
Faculty of Vet. Medicine, Cairo Univ. Faculty of Vet. Medicine, Cairo Univ.
Dr. Mohamed Hassan Shaheen
Head of Laboratory Medicine Dept.
Maadi Armed Forces Hospital
Chronic Renal Failure (CRF):
Is defined as the renal injury of more prolonged nature which
often leads to progressive and irreversible destruction of nephron
mass, causing permanent reduction in glomerular filtration rate
sufficient to produce detectable alterations in well-being and
Several comorbidities occur in CRF including:
1-Biochemical alterations in blood parameters:
(uremia, hyperuricemia, hypoalbuminemia, electrolytes
imbalance, metabolic acidosis, disorders in calcium and
phosphorus metabolism, dyslipidemia)
4- Development of cardiovascular diseases.
5- Oxidative stress.
Anemia is defined as a decrease in the number of circulating
red blood cells (RBCs), reduction in the amount of hemoglobin
(Hb) in the RBCs, or combination of both.
Despite new therapeutic options and treatment strategies,
anemia remains one of the major complications of CKD,
especially in patients undergoing chronic hemodialysis (HD).
Anemia of Chronic diseases
The average normal ranges of Hb varies by age and gender, in
adults are 14 to 18 g/dl in males, and 12 to 16 g/dl in females .
The presence of anemia in these patients reduces quality of life
and contributes to symptoms of advanced renal failure, such as
fatigue, reduced exercise tolerance, depression and dyspnea.
Anemia is associated with worsening of cardiovascular
morbidity and accelerated rate of kidney damage, and it is an
independent predictor of mortality in CKD patients
Anemia is universal in end stage renal disease (ESRD)
Renal anemia is defined as an Hb concentration of < 11.5
g/dl in women, and < 13.5 g/dl in men.
Primary cause of renal anemia is relative lack of
erythropoietin hormone (EPO).
Various secondary causes can contribute to renal anemia,
Deficiency of iron
Active blood loss
Inflammatory conditions (acute and chronic inflammations
which suppress erythropoiesis in the bone marrow)
Shortened red blood cell survival due to uremia
Deficiencies of folate and vitamin B12
Inflammation and oxidative stress
Inflammation and oxidative stress causes anemia in patients
with CKD by several mechanisms include:
The depletion of redox capacity and oxidation of membrane
phospholipids in erythrocytes, both of which lead to a
shortened life span of these cells.
Increased production of hepcidin hormone, that inhibits both
intestinal absorption and mobilization of iron stores and
induction of erythropoietin resistance.
Treatment of Anemia
Anemia is corrected with the administration of erythropoiesis
stimulating agents (ESAs), the therapeutic goal is to reach a Hb
concentration between 11.0 and 12.0 g/dl.
Correction of anemia in CKD patients, especially
undergoing HD yields numerous benefits:
1) Higher tolerance for physical activity.
2) Improvement of cardiovascular functions.
3) Reduced the need for blood transfusions.
4) Better quality of life.
5) Reduced hospitalization.
6) Lower mortality.
ESA resistance has been defined by the European Renal
Association-European Dialysis and Transplant Association
(ERA-EDTA) as being present when patients do not achieve
the recommended Hb target level (11–12 g/dl), despite a
treatment with ESAs over several months with maintained
doses of rhEPO higher than 300 IU/Kg/ week of epoetin.
Main factors causing EPO - resistant anemia:
It is a relative common complication in chronic HD patients
and may lead to EPO-resistant anemia.
Secondary hyperparathyroidism is associated with bone
marrow fibrosis, increased hemolysis, decreased
erythropoiesis, reduce RBCs production and survival.
As well as, reduce release and impaired response to EPO.
3- Iron deficiency
In HD patients iron deficiency can be :
Absolute (eg, chronic blood retention in the dialysis
circuit, malnutrition, gastrointestinal bleeding, and frequent
Functional (i.e., limitation of bone marrow erythropoietic
activity by inability to mobilize sufficient iron from body
storage sites); in this situation the body’s total iron stores
may be normal.
There is a clear interconnection between inflammation and
oxidative stress in ESRD patients on maintenance HD.
Oxidative stress forms part of the inflammation mechanism.
HD is associated with an oxidative imbalance, in which
oxidation of different lipids and proteins are predominant.
As well as, loss of some antioxidants during HD may contribute
to this disorder
4- Inflammation and oxidative stress
Aim of the work
The study was designed to :
1) Correlate the hemodialysis process in ESRD with the inflammatory
markers on cellular level.
2) To address the potential coherent relation between hemodialysis and
global inflammatory response in the form of C-reactive protein.
3) To screen the immune status by measuring serum immunoglobulin
fractions and plasma protein foot-printing together with fluctuation
in interlukin6 level that shades patient’s immune status.
4) All the previous changes will be judged together with
plasma osmolality and other blood chemistry parameters
(including: Blood urea , serum creatinine, uric acid, total iron,
calcium, phosphorus, total proteins, albumin, total bilirubin,
alanine aminotransferase, aspartate aminotransferase, alkaline
phosphatase, total cholesterol, triacylglycerol, and blood
The correlation of the hemodialysis process in ESRD with the
inflammatory markers on cellular level will be performed in
the form of:
1. Modulation of antioxidant enzyme (superoxide dismutase)
2. Expected cell membrane deterioration (malondialdehyde level).
3. Accelerated apoptosis in the form of DNA-fragmentation.
From 200 ESRD outpatients , the study was focused on
80 ESRD categorized into 2 groups:
10 ml blood were taken just before and after the HD session
Blood collected in three types of vacutainer tubes
containing sodium citrate without anticoagulant
Citrated Plasma Estimation of plasma
Detection of leucocytic
Complete blood count