Estimation of incidence of iron deficiency anemia and correlation of iron profile, serum cholesterol and serum albumin in children with idiopathic nephrotic syndrome

Introduction::

Nephrotic syndrome is seen more often in children. 9 Glomerular filtration barrier becomes defective which is responsible for loss of protein in urine. 1

Heavy proteinuria (>40 mg/m2/day), hypoalbuminemia (albumin<3 g/dl) and edema are the characteristics of NS in children.

There is significant urinary loss of various molecular weights plasma proteins which leads to mortality in NS. 9

Risk of CVS disease is increased in children with NS due to hyperlipidemia. Hyperlipidemia is not always connected with NS but in some cases like frequent relapsing NS, persistence of hyperlipidemia for longer period is seen. 8

Iron is crucial for erythropoiesis. Normally iron is recycled from aged erythrocytes and it is the major source for erythropoiesis. Enterocytes regulate the absorption of whole-body iron and the major organs for storing iron in the form of ferritin are liver and spleen. Storage cells release iron into the plasma through ferroprotein which is a transmembrane protein located on surface of storage cells. Hepcidin is the regulator for transport of iron in the body. 7

Anemia is seen in patients with NS as a complication. Exaggerated urinary losses of iron, transferrin, erythropoietin and transcobalamin in NS may lead to anemia. 7

Although cause of anemia in patient with CKD are well established, the reason of anemia in NS with normal renal function are complex and not understood completely. 7

Very small number of studies are done in India and none in south west Bihar on iron deficiency and IDA in NS.

Objectives

⮚ To estimate the incidence of iron deficiency anemia in children with NS.

⮚ To study the correlation between iron profile, serum cholesterol and serum albumin in children with NS.

Materials and Methods :

Study design-Hospital based prospective observational study

Place of study:

The study will be conducted in Department of Pediatrics, Narayan Medical College & Hospital, Jamuhar, Sasaram. The duration of study 18 months (November 2022 to April 2024).

Study population:

All Children attending pediatrics OPD/ Emergency with laboratory confirmed diagnosis of Idiopathic Nephrotic Syndrome.

Inclusion criteria:

Children with well-established Idiopathic Nephrotic Syndrome with preserved renal function and under regular follow up.

Exclusion criteria:

1. Children with impaired renal function.

2. Children with manifestations of any systemic disease.

3. Patients with secondary nephrotic syndrome.

4. Children who will be already on iron supplements

Follow up: All cases were followed as per the protocol of nephrotic syndrome.

Statistical analysis:

Appropriate statistical method were applied for analysis of data. Statistical significance was taken if p value is < 0.05. Standard statistical methods will be used for calculating statistical

Results:

15 patients participated in the study. 66.7% (N=10) were female and 33.3%(N=5) male. Mean age of presentation of the patients who were diagnosed case of idiopathic NS is 5 years.

Chart 1

Age wise distribution

26.7%(N=4) of the patients enrolled, were of 2 years of age. 26.7%(N=4) were between 2 years and 5 years of age. 46.6%(N=7) of the patients in this study are between 6 years and 10 years of age.

Chart 2

46.7%(N=7) patients were anaemic of which 28.6%(N=2) were male and 71.4%(N=5) of them are female.

Chart 3

Of all anaemic patients, as per RBC indices 57.1%(N=4) patients were microcytic hypochromic, 14.3% (N=1) patients were macrocytic hyperchromic and remaining 28.6%(N=2) patients were normocytic normochromic.

Chart 4

Among those, who were having microcytic hypochromic anaemia (N=4), all were having low s. iron, while s. ferritin was reduced in 50%(N=2) of them. Transferrin saturation was low in 50%(N=2) of them. TIBC was not raised in any of them.

Correlation between serum albumin and serum cholesterol.

The result of Pearson correlation revealed a negligible, not significant inverse correlation between serum albumin and serum cholesterol.

	R	p
S. albumin and S. Cholesterol	-0.07	.813

Graph 1

Correlation between serum albumin and serum iron

The result of Pearson correlation revealed a low, not significant inverse correlation between serum albumin and serum iron.

	r	p
S. albumin and S. iron	-0.29	.286

Graph 2

Graph 3

Correlation between serum albumin and TIBC

The result of Pearson correlation revealed a high, significant positive relationship between serum albumin and TIBC.

	r	p
S. albumin and TIBC	0.71	.003

Graph 4

Correlation between serum albumin and transferrin saturation

The result of the Pearson correlation revealed moderate, not significant inverse correlation between serum albumin and transferrin saturation.

	R	p
S. albumin and transferrin saturation	-0.33	.224

Graph 5

Correlation between serum cholesterol and serum iron

The result of Pearson correlation revealed negligible, not significant direct correlation between serum cholesterol and serum iron.

	r	p
S. cholesterol and S. iron	0.03	.916

Graph 6

Correlation between serum cholesterol and serum ferritin

The result of Pearson correlation revealed high, significant direct correlation between serum cholesterol and serum ferritin.

	R	p
S. cholesterol and S. ferritin	0.61	.016

Graph 7

Correlation between serum cholesterol and TIBC

The result of Pearson correlation revealed negligible, not significant direct correlation between serum cholesterol and TIBC.

	r	P
S. cholesterol and TIBC	0.02	.953

Graph 8

Correlation between serum cholesterol and transferrin saturation

The outcome of Pearson correlation revealed negligible, not significant direct correlation between serum cholesterol and transferrin saturation.

	r	P
S. cholesterol and Transferrin saturation	0.02	.955

Graph 9

Findings:

1. Commonest age group found in the study was between 6 and 10 years. (Chart 2)

2. Out of 15 patients who were included in the study, 7 patients were anaemic. (Chart 3)

3. As per RBC indices, out of those 7 patients who were anaemic, 4 were having microcytic hypochromic anaemia (chart 4) and all 4 were having low serum iron while serum ferritin was low in 2 of them.

4. Pearson correlation between s. albumin and s. cholesterol, serum iron, s. ferritin and transferrin saturation were negative and it was not significant. (Graph 1, 2, 3 and 5 respectively)

5. There was direct significant correlation between serum albumin and TIBC. (Graph 4)

6. Pearson correlation between s. cholesterol and s. iron, TIBC and transferrin saturation were positive and it was not significant. (Graph 6, 8 and 9 respectively)

7. There was positive significant correlation between s. cholesterol and s. ferritin. (Graph 7)

Discussion :

In my study there was low and inverse correlation between s. albumin and serum iron which was not significant. (r=-0.29, p= 0.286). There was moderate inverse correlation between s. albumin and transferrin saturation which was not significant. (r= -0.33, p=0.224) There is high direct correlation between s. albumin and TIBC which was significant (r= 0.71, p=0.003), however it could not be explained. Significant weak inverse correlation was seen between s. albumin and s. ferritin (r= - 0.368, P= 0.019). There was moderate negative correlation between serum albumin and serum ferritin (r= -0.45, p= 0.93).

Mayada Kadhim et. al.1 in their study in 2022 found iron deficiency as the most possible complications of NS and it can be as severe to cause IDA. However, they found more frequency of iron deficiency anaemia in steroid resistant NS as it was very difficult to control proteinuria and loss of iron in them. Significant moderate direct correlation was seen between s. albumin and s. iron (r = 0.426, P= 0.006) and s. albumin and transferrin saturation (r = 0.463, P= 0.003).

Sreekanth et. Al2. in their cross-sectional study in 2021 found that iron deficiency and iron deficiency anaemia were very common in nephrotic syndrome. They also suggested that all cases whether newly diagnosed or follow ups should be routinely (3-6 monthly) assessed for this deficiency.

Moftah Mohamed Rabeea et. al.3 in their study in 2019 concluded that evidence of IDA in NS is more during the active stage of disease. In children with active NS, the reliable parameter for prediction of iron deficiency anaemia is urinary transferrin. Urinary transferrin was not done in my study.

In my study, there is negligible negative correlation between s. albumin level and s. cholesterol level which was not significant. (r= -0.07, p= 0.813). Sabyasachi Som and Abhishek Roy4 in 2018 concluded analytically significant inverse correlation between s. cholesterol and s. albumin level.

P Anil Kiran and B Deeva Kumar5 in their study in 2017 found male predominance of childhood nephrotic syndrome and commonest age group included in study were between 2 to 8 years old.

There was female predominance but commonest age group was same.

Sofia Feinstein et al6 in their in 2001 concluded anaemia as common manifestation of persistent NS, prolonged transferrin and iron losses lead to the depletion of iron loss and anaemia

Conclusion:

Commonest age group of presentation of idiopathic NS is between 2 to 8 years of age.

Microcytic hypochromic anaemia is commonly seen in idiopathic NS and iron deficiency may be a reason.

High serum Ferritin may be due to coexisting infections.

Prevalence of iron deficiency anaemia is very difficult to conclude as sample size is less.

References :

1. Mayada K. Kadhim, Faliha Obaid Hassan. Iron Deficiency Anemia in Children with Idiopathic Nephrotic Syndrome. Kirkuk Journal of Medical Sciences(2022); Vol 10 Issue 2: 18-30

2. Sreekanth S, Bhatia P, Meena J, Dawman L, Tiewsoh K. Iron deficiency in proteinuric children with nephrotic syndrome: A cross-sectional pilot study. Archives de Pédiatrie. 2021 Aug;28(6):485-487.

3. MM Rabeea, NM Al-Akkad, GZ El-Morsi Evaluation of Serum Iron and Transferrin in Idiopathic Nephrotic Syndrome Patients Attending Al-Hussein Pediatric Nephrology Clinic. The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), 1036- 1046

4. Som, Sabyasachi & Roy, Abhishek. (2018). Correlation between Serum Cholesterol and Serum Albumin Levels in Idiopathic Nephrotic Syndrome in Children. Annals of International medical and Dental Research. 4. 10.21276/aimdr.2018.4.4.PE1

5. P. Anil Kiran, B. Deeva Kumar. Clinico-Biochemical Evaluation of Nephrotic Syndrome in children, International Journal of Contemporary Medical Research (October 2017), ISSN (online): 2393-915X; (print): 2454-7379, Volume-4, Issue 10(2214-2217).

6. Feinstein S, Becker-Cohen R, Algur N, Raveh D, Shalev H, Shvil Y et al. Erythropoietin deficiency causes anemia in nephrotic children with normal kidney function. American Journal of Kidney Diseases. 2001 Jan 1;37(4):736-742. doi: 10.1016/S0272-6386(01)80122-0

7. Iorember F, Aviles D. Anemia in nephrotic syndrome: approach to evaluation and treatment. Pediatr Nephrol. 2017 Aug;32(8):1323-1330. doi: 10.1007/s00467-016-3555-6. Epub 2016 Dec 21. PMID: 27999949.

8. Ksiazek J, Ciechanowicz A, Wierzbicka A, Syczewska M, Grenda R. Is dyslipidemia sustained during remission of nephrotic syndrome genetically determined? Evaluation of genetic polymorphisms of proteins involved in lipoprotein metabolism in children and adolescents with nephrotic syndrome. Pol Arch Med Wewn. 2009 Jan-Feb;119(1-2):11-6. PMID: 19341173

9. Priyadarshani Paik, Saroj Shekhar Rath, Swapna Mahapatra, Narendra Behera. Etiologic diagnosis of anemia in children admitted with nephrotic syndrome in a tertiary care hospital of Odisha, India. Journal of cardiovascular disease research(2022); Vol. 13, Issue 4:304-311

Estimation of incidence of iron deficiency anemia and correlation of iron profile, serum cholesterol and serum albumin in children with idiopathic nephrotic syndrome

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Introduction::

Materials and Methods :

Results:

Discussion :

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References :

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