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International Journal of Medicine and

Pharmaceutical Science (IJMPS)


ISSN (P): 2250-0049; ISSN (E): 2321-0095
Vol. 6, Issue 3, Jun 2016, 51-60
TJPRC Pvt. Ltd.

C-REACTIVE PROTEIN AND RENAL FUNCTION TESTS IN CHRONIC RENAL


FAILURE PATIENTS ON HEMODIALYSIS AND KIDNEY TRANSPLANTATION
AHMED METHAB ATHAB1, NABEEL K. M. ALI2 & LUMA T. AHMED3
1

Assistant Professor, Department of General Medicine, Medical College of Diyala University, Iraq
2

Baquba Teaching Hospital, Diyala, Iraq

Research Scholar, Department of Medical Mycology, Medical College of Diyala University, Iraq

ABSTRACT
Chronic renal failure refers to an irreversible deterioration in renal function which classically develops over
a period of months to years. Initially its manifest only as a biochemical abnormality. Eventually, loss of the excretory,
metabolic and endocrine functions of the kidney leads to the clinical symptoms and signs of renal failure, which are
referred to as uremia.
Chronic kidney failure is a worldwide disease especially in the last years, and this is indicated by World

In this study, we evaluated the c reactive protein and kidney functions in patients with end stage renal disease
on hemodialysis and kidney transplantation from: Measurement levels of urea, creatinine, and C-reactive protein, in
CRF patients and compared control.
This study was conducted in Baquba Teaching hospital/Department of dialysis, the period from 1st of Augast.
2015 to. 30 of April. 2016, from which to collect 80 blood samples, 40 samples hemodialysis patients including

Original Article

Health Organization, the incidence of chronic kidney failure in Iraq range from 100_130 case per million

(26 males, 14 females), 40 person Renal or Kidney transplant patients (32 males, 8 females) compared with 40 blood
samples for healthy people (control)(32 males,8 females), within the age range of (20-70 years).
The results of study revealed a significant increase of probability (p<0.001) in levels of urea and creatinine in
hemodialysis patients compared to control (21.9+_ 1.1 , 4.8 +_0.1 mmol/L)(413.4+_29.1,62.4+_1.1umol/L) respectively.
The result also indicate revealed a rise in the concentration of acute phase protein (C-reactive protein) by(50 %) in
hemodialysis patients, which reflected negatively increase the mortality rate in these patients, and low in glomerular
filtration rate in hemodialysis patients compared to control (16.2 +_1.4 , 126.3 +_ 2.02 ml/min) respectively. While still
this significant difference in these levels with the exception of urea and glomerular filtration, which continued at same
level in renal transplant patients.
KEYWORDS: CRP - CRF and Transplant-Diyala

Received: May 03, 2016; Accepted: May 31, 2016; Published: Jun 10, 2016; Paper Id.: IJMPSJUN201606

INTRODUCTION
The human kidneys are a pair of bean-shaped organs situated in the retroperitoneal space, positioned on
either side of the vertebral column at the level of the lower thoracic and upper lumbar vertebrae. Each adult kidney
weighs about 120 to 170 g and measures about 12 6 3 cm, Each human kidney contains approximately 1
million nephrons[1]

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Ahmed Methab Athab, Nabeel K. M. Ali & Luma T. Ahmed

Chronic renal failure refers to an irreversible deterioration in renal function which classically develops over a
period of years. Initially its manifest only as a biochemical abnormality. Eventually, loss of the excretory, metabolic and
endocrine functions of the kidney leads to the clinical symptoms and signs of renal failure, which are referred to as
uremia.[2]
Chronic kidney failure is a worldwide disease especially in the last years, and this is indicated by World Health
Organization, the incidence of chronic kidney failure in Iraq range from 100_130 case per million.[3]
The ninth main cause of death in United States of America and other developed countries is chronic kidney
failure.[4]
The recent studies referred that approximately 110000 Americans treated with hemodialysis and kidney
transplantation at 2007.[5]. And probably this number will be increase to 2.2 million at 2030.[6]
In Europe one of the studies referred that the incidence of kidney failure in children about 74.7 per million [7].
Where as in United state the incidence increase to 1700 case per million according to the last statistics [8]
The two main causes of chronic kidney disease are diabetes and high blood pressure, which are responsible for up
to two-thirds of the cases. Diabetes happens when your blood sugar is too high, causing damage to many organs in your
body, including the kidneys and heart, as well as blood vessels, nerves and eyes. High blood pressure, or hypertension,
occurs when the pressure of your blood against the walls of your blood vessels increases. If uncontrolled, or poorly
controlled, high blood pressure can be a leading cause of heart attacks, strokes and chronic kidney disease. Also, chronic
kidney disease can cause high blood pressure[9]
Symptoms of kidney failure include feeling tired, physical and mental fatigue, decrease appetite, dyspnea, itching,
frequent urination, anemia, hypertension, peripheral neuropathy, vitamin D deficiency [10]
Chronic renal failure treated with diet, medications, hemodialysis and lastly renal transplantation [11], As it
represents the optimal treatment for the patient, being improved patients' quality of life and increase the chances of
survival[12]
Chronic Kidney failure affects in a wide range of different tissues, organs and vital events of the body,
The other effects and biochemical changes include increase in urea and creatinine, metabolic acidosis
hypoglycemia and decrease in serum lipid [13]
C-reactive protein (CRP) is a well-known biochemical marker of inflammation, and has also been shown to be
involved in several immunological functions [14]. The usefulness of CRP measurements in the diagnosis of infection has
been studied previously in several clinical settings [15], and various studies have suggested that the CRP cut-off level for
infection diagnosis is between 5 and 10 mg/dL [16]
CRP is an acute phase reactant synthesized by the liver, level of CRP increase within 6 hr of an inflammatory
stimulus and may rise up to 1000 fold. Measurement of CRP provides a direct index of acute inflammation and because
plasma half life of CRP is 19 hrs, levels fall promptly once the stimulus is removed. Sequential measurement is useful in
monitoring disease. For reasons that remain unclear, some disease are associated with only minor elevation of CRP despite
unequivocal evidence of active inflammation.[17]

Impact Factor (JCC): 5.4638

NAAS Rating: 3.54

C-Reactive Protein and Renal Function Tests in Chronic Renal


Failure Patients on Hemodialysis and Kidney Transplantation

53

Objectives

Study the effect of treatment with hemodialysis and renal transplantation on levels of urea, creatinine, C-reactive
protein, glomerular filtration rate and body weight among two groups of patients.

Measurement of C-reactive protein levels in patients treated with hemodialysis and renal transplantation and be
compared to control

MATERIALS AND METHODS


The study relied on its way to collect samples style of non-random selection based on simple variables, including
the name, age, sex, height, weight, the incidence of chronic diseases, type of treatment and duration of treatment.
I collect 40 sample of blood from kidney transplants patients (32 males, 8 females), and 40 sample of blood
chronic kidney failure patients who are on regular hemodialysis (26 males, 14 females) from Baquba Teaching hospital/
Department of renal dialysis, patients age range between 20-70 year
The two groups of patients divided into another groups depending on duration of treatment, the hemodialysis
patients groups divided into two groups:

On regular hemodialysis less than one year

On regular hemodialysis more than one year


Where as kidney transplants patients groups divided into

Duration of transplant less than one year

Duration of transplant more than one year

Control Group
40 blood samples(32 males, 8 females) was collected from healthy persons, who not have signs and symptoms of
kidney disease or diabetes mellitus from Baquba city, patients age range between 20-70 years.

RESULTS
Table 1: Body Weight, Glomerular Filtration Rate, and Some Chemo Biological Values in Serum
Blood of Hemodialysis Patients and Kidney Transplant Patients Compared with Control
Control Arithmetic
Mean+_The
standard Error

Hemodialysis
Arithmetic Mean+_the
Standard Error

Number

40

40

Kidney Transplant
Arithmetic Me
And+_The
Standard Error
40

Age

1.4+_39.7

2.2+_51.2

1.7+_45.4

Body mass index (kg/m2)

0.7+_23.9

Glomerular filtration rate


(ml/minute)

2.02+_126.3

Urea(mmol/l)

0.1+_4.8

Creatinine (micromol/l)

1.1+_62.4

0.6+_21.4
a*
1.4+_16.2
a***
1.1+_21.9
a***
29.1+_413.4
a***

0.8+_24.3
b**
4.5+_88.5
a*** b***
0.7+_8.8
a*** b***
5.4+_88.7
b***

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Ahmed Methab Athab, Nabeel K. M. Ali & Luma T. Ahmed

a = difference between control group and others groups


b =difference between patients groups
*p<0.05 **p<0.01 ***p<0.001
Table 2: Body Weight, Glomerular Filtration Rate, and Chemo Biological Values in
Serum Blood of Hemodialysis Patients according to Duration of Hemodialysis

Number

On Hemodialysis <
1 year, Arithmetic
Mean +_
Standared Error
22

On Hemodialysis >1
Year, Arithmetic
Mean +_Standared
Error
18

Body mass index (kg /m2)

0.9+_21.1

0.9 +_21.7

Glomerular filtration rate


(ml/minute)

1.7+_15.9

2.3+_16.5

Urea (mmol/l)

1.5+_21.4

1.5+_22.5

Creatinine (micromol/l)

40.9+_418.4

42.2+_407.3

Table 3: Body Weight, Glomerular Filtration Rate, and Some Chemo Biological Values in
Serum Blood of Kidney Transplant Patients According to Duration of Transplant

Number

Transplant <5
Year Arithmetic
Mean +_Standard
Error
23

17

Body weight (kg/m2)

1.2 +_24.9

1.2+_23.6

Glomerular filtration rate (ml/minute)

6.7+_90.8

5.6+_85.3

Urea(mmol/l)

0.8+_8.2

1.298+_9.7

Creatinine (micromol/l)

8.7+_90.9

5.3+_85.6
b*

Transplant >5 Year


Arithmetic Mean
+_Standard Error

*p<0.05
b =difference between patients groups
Table 4: C-reactive Protein Levels in Hemodialysis Patients

CRP Positive
CRP Negative

Males

Females

9
15

11
5

Duration of
hemodialysin
(Month)
14
10

Fistula

Catheter

7
15

13
5

Mortality
Rate after
6month
20%
0%

Table 5: Body Weight, Glomerular Filtration Rate, and Some Chemo Biological Values in
Serum Blood of Hemodialysis Patients According to C-reactive Protein Level

Number
Body mass index (kg/m2)
Glomerular filtration rate
(ml/minute)
Urea(mmol/l)
Creatinine (micromol/l)

Impact Factor (JCC): 5.4638

Hemodialysis Group
CRP Negative
Arithmetic Mean
+_Standard Error
20
0.5+_20.5

CRP Positive
Arithmetic Mean
+_Standard Error
20
1.1+_22.5

1.9 +_16.8

2.1+_15.6

1.0+_22.7
33.6+_387.5

1.9+_21.7
47.6+_440.6

NAAS Rating: 3.54

C-Reactive Protein and Renal Function Tests in Chronic Renal


Failure Patients on Hemodialysis and Kidney Transplantation

55

DISCUSSIONS
Body Mass Index among the Groups under Study
Although the average body mass of all the values of the three study groups were within normal limits, but noted
the emergence of a significant decrease among hemodialysis patients, This decline is due to several reasons including:

Infections are one of the main causes of loss of appetite and hypoalbuminemia in hemodialysis patients[18]

Malnutrition resulting from heart disease, blood vessels, blood albumin deficiency, anemia, causing weight loss
[19]
It is noted improvement in body mass index levels in patients with renal transplantation compared to dialysis

patients may be due to:

The weight gain is of the main problems experienced by patients with kidney transplant because of steroid
treatment and lack of exercise with increased daily caloric intake[20]

The high level of cortisone in the blood helps to benefit from the protein to produce heat and power and lead to
weight gain[21]
Our study agree with Uliviera study in Indian patients who continue to take steroids by 10 mg or less, they've got

overweight so it may be contributing factors in obesity[22]


Urea levels in the blood serum of groups under study:
In this study I found an increase in urea levels in the blood serum with the hemodialysis group than controls, it is
due to high urea concentration in the blood of patients with chronic dialysis to the fact that urea is an article of nitrogenous
basic metabolic waste, which consist mainly in the liver and put outside the body through the urine and in the case of
kidney failure there is insufficiency of kidney functions and lead to a lack of urea to put out of the body, leading to urea
accumulation in the blood.[23]
The researchers Gottschalk and Schrier (1997) pointed out, that the increase in urea levels reflect the insufficiency
of filtration of kidney, this increase depends on the severity and progress of renal failure and the amount of protein intake
and the rate of its catabolism[24]
Alain and others (2010) pointed that the increase the urea concentration in the blood serum depends not only on
renal function, but due to other factors, such as increasing the amount of protein intake by patients, an increase in catabolic
rate of proteins, dehydration, muscle damage (as in starvation) and in some cases of chronic liver disease. In all cases of
prerenal above, the level of creatinine concentration in serum is normal, therefore (urea) does not reflect the renal function,
But in case of postrenal (kidney failure) both urea and creatinine levels rise in serum as a result of blocking the flow of
urine[25]
Also Mustafa and Khalaf (2012) pointed that the rise in urea concentration reflects occurrence of uremia in these
patients, which represent the final stage of chronic renal failure[26]
this study showed an increase in urea levels in patients treated with kidney transplant than controls, the rise in
urea levels in patients with kidney transplants may be due to renal transplant patients who suffer from high blood pressure,
which leads to a failure of excretion of urea due to stimulation of angiotensin 2 which causes an increase in the growth of
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Ahmed Methab Athab, Nabeel K. M. Ali & Luma T. Ahmed

smooth muscle lining of blood vessels, thus reducing the rate of filtration [27].
The scientists Fink and Weir (1999) refer that the use of a drug cyclosporine cause an increase in urea in the blood
of more than 85% of patients, through its effect on the absorption of urea through the renal tubule, and also affects the
kidney functions and cause a rise in blood pressure [28]
Creatinine levels and glomerular filtration rate in the blood serum of groups under study:
The results of this study showed increased creatinine levels in the blood serum with the dialysis group, compared
to control, and low levels of glomerular filtration rate in both dialysis and kidney transplant patients compared to control.
Attributed reason for the high concentration of creatinine in the serum blood of patients with chronic renal failure
to the fact that creatinine is a metabolic waste product that excrete naturally through the urine and in the case of renal
failure this lead to renal insufficiency and affect filtration and waste products excretion outside the body, leading to high
concentration of creatinine in the serum, and it's concentration inversely related with the speed of glomerular filtration, that
any slight decrease in the glomerular filtration lead to an increase in the concentration of creatinine in the blood [29]
Jonathon (2004) refers that the increase in urea and creatinine levels in the serum of patients with renal failure
undergoing hemodialysis to be due to a decline in the number of nephrons, which in turn reduces the glomerular filtration
rate, causing a significant decrease in kidney excretions of water and solutes[30]
C -Reactive Protein Levels in the Blood Serum of Groups under Study
Results of the current study showed a rise in levels of C reactive protein among dialysis patients with the progress
of the treatment period compared to kidney transplants patients and control, and this is due to the presence of infections
among chronic kidney disease patients, as it is a strong predictor of mortality due to heart and blood vessels diseases
among hemodialysis patients [31]
Nand and others (2009) mention the high levels of a C reactive protein closely linked to the bad situation for
patients and the interaction of several factors together with a number of mechanisms including low hemoglobin, high
cardiovascular disease rates, malnutrition as caused by low serum albumin and low body mass index, as well as frequent
and early hospitalization dialysis (along the treatment period of hemodialysis), this is consistent with my study[32]
The researchers Chertow and Lazarus (1997) refer that there is an inverse relationship between high concentration
of C reactive protein in the serum of patients with chronic renal failure and lower concentration of albumin, it found that
the lower the concentration of albumin is an important indicator of the presence of the disease and the high mortality rate
in patients with chronic renal failure and attributed the causes of the decline, to poor nutrition, as well as the presence of
systemic inflammation.[33]
Hasan and others (2009) refer that the activation of inflammatory cytokines in hemodialysis patients is associated
with a deficiency of kidney function and range of other factors induced infections in dialysis patients (such as permanent
contact or repeated with membranes of dialysis machine (period of dialysis), grafts connected to the blood vessels,
catheters, all of these may lead to inflammation, as the increased secretion or activate inflammatory cytokines such as IL -6
or TNF, may cause appetite suppression causing proteolysis in muscle and hypoalbuminaemia which lead to
atherosclerosis and this is consistent with the current study [34]

Impact Factor (JCC): 5.4638

NAAS Rating: 3.54

C-Reactive Protein and Renal Function Tests in Chronic Renal


Failure Patients on Hemodialysis and Kidney Transplantation

57

Hayashi and others (2006) refers that the use of central venous catheters is associated with high rates of
complications such as infections and thrombosis. While the use of AV fistula has many benefits compared to other
modalities for vascular access in terms of its stay for a long period and associated with lower rates of
complications(infections and thrombosis) [35]
This consistent with the current study, which showed that 65% of patients who suffer from the high levels of C
reactive protein connect them to hemodialysis through a central venous catheters in the neck or groin.
The researchers Azar and Hamid (2005), Effat and others (2008) mention that the high C-reactive protein levels in
the blood serum of patients with hemodialysis is a sign of the presence of inflammation and increase mortality rate in these
patients, and this is consistent with the current study, as it found that the mortality rate was (4 patients, a rate of 20%) of
patients [36]
In a study done by a Saudi researcher Al Saran and others (2012) on 70 patients suffering from kidney failure and
are regular on hemodialysis, 35 patients used AV fistula and other 35 patients using central venous catheter, 80% of them
are male and 20% female with an average age of (15.61 + _50.09) [37]
The results indicated

The emergence of the close correlation between the use of central venous catheters and the incidence of infections
causing an increase in C-reactive protein levels, which shows that the catheter may be an important factor to
increase the inflammatory response.

There is no relationship between a high level of C-reactive protein, age and gender.
This is consistent with the current study.

CONCLUSIONS
Through what has been presented above, the study has reached a set of conclusions can be summarized as follows:

The study recorded a decline in glomerular filtration rate, in both hemodialysis patients group and kidney
transplant group.

The study showed that both the duration of treatment with (hemodialysis and kidney transplant) don't affect on
chemo biological values except CRP which its level rise with progress of treatment period with hemodialysis.

The study showed that the treatment with kidney transplant lead to improved chemo biological values

The study found that high Protein CRP due to infections among hemodialysis patients.

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