D Almoznino-Sarafian, M Shteinshnaider , Irma Tzur, AB Chaim, E Iskhakov, Sylvia Berman, et al European Journal of Internal Medicine;21;2010;9196 Presentan : Rahma Yuantari Pembimbing : dr. Haryono, Sp.PK-K Pembahas : dr. Anny Maryani
Introduction
Anemia in diabetes
common & frequently unrecognized complication of diabetes. prevalence varies 8% through 23% in large studies prevalence ~ chronic kidney disease (CKD) more severe at any level of Glomerular Filtration Rate (GFR) compared to non diabetic patients
Anemia in diabetes
Etiology : erythropoietin deficiency or ineffectiveness of the latter, nutritional deficiencies, systemic inflammation, medications autoimmune disorders
Reliable predictors : CKD severity, Transferrin saturation, sex, albumin excretion ratio HbA1c
Most of the information available from data in an ambulatory setting, from that admitted to the internal hospital units ( in demographic parameters and clinical profile)
Diabetic patients might suffer from diabetic complications (diabetic foot, CKD and HF which may aggravate anemia, and vice versa ) in need nursing care or are institutionalized with nutritional problems not included in studies performed in an ambulatory setting
Comprehensive information on etiology, clinical profile and prognostic significance of anemia in the in-patients unavailable
define the prevalence of anemia in diabetic patients that were hospitalized in a medical department etiology of anemia its association with relevant clinical and laboratory variables, and the impact of anemia and its associated conditions on survival
July 2005August 2006, patient from Emergency Department due to a variety of internal disorders, or transferred from the Intensive Care units, or hospitalized for elective investigative purposes. Included all patients with type 1 or 2 diabetes.
Conducted principles of the Declaration of Helsinki & approved by the Local Ethics Committee.
Obvious case
Unknown etiology
Included : hematological disorders, active malignant diseases acute severe bleeding multiple organ failure chronic dialysis declined further hospitalization
Data
Demographic and clinical data registered only at first hospitalization complete blood count hemoglobin HbA1c & fasting serum glucose, albumin excretion in a spot urine sample and/or 24hour urine collection, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), urea, creatinine, iron, transferrin, transferrin saturation, ferritin, vitamin
Definition
persistent fasting hyperglycemia >7 mmol/l (126mg/dl), with or without referring to the previous medical charts and/or history of chronic anti-hyperglycemic treatment
Cr 133 mol/l (1,5 mg/dl) and eGFR < 60 ml/min/1.73m2 (using MDRD equation)
data from previous and/or present hospitalization(s) and/or outpatient facility records.
Physical signs edema, pulmonary rales, gallop rhythm or displaced left ventricular apical impulse
Radiographic evidence of pulmonary congestion, pulmonary venous redistribution, basal or perihilar vascular blurring, Kerley B lines, pulmonary edema or pleural effusions
WHO)
Survival
2.5 year follow-up period both diabetic anemic and nonanemic patients. mortality incidence, cause of death, was registered.
Information about death and cause of death the registry of the Internal Affairs Ministry, hospital records, patients' families or outpatient death certificates.
Statistical analysis
statistical comparison patients with and without anemia, and between the various anemic subgroups Pearson's Chi-square or Fisher's exact test comparison of qualitative variables Analysis of Variance (ANOVA) or Mann-Whitney non-parametric Utest quantitative variables Kaplan-Meier Survival curves Mantel-Cox and Breslow tests evaluate the differences between the curves Cox proportional hazards model identify those variables most significantly associated with mortality A P-value 0.05 was considered significant. The data were analyzed using BMDP Statistical Software
Result
44 patients three or more etiologic or aggravating factors of anemia were identified. In other 81 patients two factor.
An association between HF and RD the most significant 66 (56.4%) of 117 patients with HF suffered of RD, P< 0.001
Follow-up for all patients (range of 0.3 27.1 months), the median value for survivors of the first hospital admission being 19.2 months. 50 from 58 (86%) in the anemic population & 12 from 60 (60%) in non anemic died in 1st year after discharge
Gambar 1
Most common cause infection, 26/58 (45%) in anemic and 6/20 (30%) in non anemic
Mortality rate in anemic patients: > (20.3% vs. 10.4%, P=0.03), (+) vs (-) albuminuria (20.7% vs. 9.2%,P=.01) HF vs. non-HF borderline significant (19.7% vs. 10.8%, P=0.06).
No significant differences inmortality rates between : subgroups aged <70 vs 70 years Hb<10 vs 10 g/dl HbA1c < 7.5% vs 7.5% nutritional def anemia vs anemia of chronic disease RD vs non-RD, nursing care or diabetic foot vs their counterparts
The Cox proportional hazards model male gender ~ lower survival (P=.03, OR 2.02, 95% CI 1.044.00).
Discussion
The present study observational, cross-sectional and prospective investigation, although part of the data still had to be collected retrospectively
The patients randomly referred to the two Internal Medicine Departments inclusion bias Patients admitted to the rest of the departments not included in the present investigation
The 1st study aiming to evaluate relevant aspect of anemia in uncelected diabetic patients hospitalized in IMD
Three main issues : prevalence and characteristics of anemia, cause of anemia and association of anemia with various relevant comorbidities, and prognostic significance of anemia.
Large epidemiologic study on general population of older persons with anemia only part of whom were diabetic 1/3 nutritional deficiency , 1/3 anemia of chronic disease or CKD or both 1/3 unexplained anemia. This study iinclude instituzionalized patients.
In this study :
Iron deficiency : 38% Vitamin B12/folat deficiency : 12% Anemia of chronic disease : 54% RD : 39% HF : 47% Diabetic foot : 22%
> patient has 2 concomitan conditions: o Inflamatory disease o Medication (metformin/thiazolidirfendiones, ACE inhibitor, sulfonylurea) o Hemolysis o Mild untreated hypothyroidsm 2 case
Other literature
Anemia & RD risk of death in HF Prev. iron def. varies, 43% anemic patients insufficient iron stores, 58% reduced iron availability Study on pts. (-) nephropathy (-) iron def. In this study 38% pts anemia with insufficient iron stores, > 12% patients vit B12/folat inappropriate nutrition, gastritis, malabsorbtion, metformin.
Def vit B12/folat neuropathy, + erythropoietin production & eventual orhtostatic hypotension life span
infection
Albuminuria HF Male
DM HF RF
Anemia in diabetes
survival
The mortality rate in complex nursing care patients and those with diabetic foot higher suggesting that continuous medical control may be beneficial.
The assumption that anemia improvement might prolong survival, especially in males with albuminuria or HF need future investigations.
Learning points
The frequency of anemia in diabetic patients admitted to Internal Medicine departments, compared to the studies performed on ambulatory patient populations.
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