Jurnal Anemia in Diabetes

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Anemia in diabetic patients at aninternal medicine ward: Clinicalcorrelates and prognostic significance

Presentan : Rahma Yuantari

Pembimbing : dr. Haryono, Sp.PK-K

Pembahas : dr. Anny Maryani

D Almoznino-Sarafian, M Shteinshnaider , Irma Tzur, AB Chaim,

E Iskhakov, Sylvia Berman, et al

European Journal of Internal Medicine;21;2010;9196


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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


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Reliable predictors :

CKD severity,

Transferrin saturation, sex,

albumin excretion ratio

HbA1c

Anemia in diabetes

progression of cardiovascular

disease, nephropathy,hospitalization and mortality

Etiology :

erythropoietin deficiency or

ineffectiveness of the latter,

nutritional deficiencies, systemic inflammation,

medications

autoimmune disorders


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Most of the information available from data in anambulatory setting, from that admitted to the internalhospital 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 areinstitutionalized with nutritional problems not included instudies performed in an ambulatory setting

Comprehensive information on etiology, clinical profile andprognostic significance of anemia in the in-patients unavailable


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define the prevalence of anemia in diabetic patientsthat were hospitalized in a medical department

etiology of anemia

its association with relevant clinical and laboratoryvariables, and

the impact of anemia and its associated conditions onsurvival

The aim of the present study


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Materials and methods

July 2005August 2006, patient from Emergency

Department due to a variety of internal disorders, ortransferred 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.


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Patient from ED with DM type 1 & 2

Anemic Non Anemic

Obvious case Unknown etiology

Included : hematological disorders, active malignant diseases acute severe bleeding multiple organ failure

chronic dialysis declined further

hospitalization

Evaluated duringhospitalization

Survival& causes

of death


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Data

Demographic and clinical data registered only at firsthospitalization

complete blood count hemoglobin

HbA1c & fasting serum glucose,

albumin excretion in a spot urine sample and/or 24-hour urine collection,

erythrocyte sedimentation rate (ESR), serum C-reactiveprotein (CRP), urea, creatinine, iron, transferrin,

transferrin saturation, ferritin, vitaminB12, folic acid and erythropoietin.


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Definition

microalbuminuria /overt proteinuria.

persistent fasting hyperglycemia >7 mmol/l(126mg/dl), with or without referring to theprevious medical charts and/or history ofchronic anti-hyperglycemic treatment

Cr 133 mol/l (1,5 mg/dl) and eGFR < 60ml/min/1.73m2 (using MDRD equation)


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Symptoms shortness of breath, orthopnea or paroxysmalnocturnal dyspnea

data from previous and/or presenthospitalization(s) and/or outpatient facilityrecords.

Physical signs edema, pulmonary rales, gallop rhythm ordisplaced left ventricular apical impulse

Radiographic evidence of pulmonary congestion, pulmonaryvenous redistribution, basal or perihilar vascular blurring, Kerley Blines, pulmonary edema or pleural effusions


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WHO)

ferritin 100 g/l

ferritin 16 g/l & sTf20%

ferritin


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2.5 year follow-up period both diabetic anemic and non-anemic patients.

mortality incidence, cause of death, was registered.

Survival

Information about death and cause of death the registry ofthe Internal Affairs Ministry, hospital records, patients'families or outpatient death certificates.


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statistical comparison patients with and without anemia, andbetween the various anemic subgroups

Statistical analysis

Pearson's Chi-square or Fisher's exact test comparison of

qualitative variables

Analysis of Variance (ANOVA) or Mann-Whitney non-parametric U-test 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


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Result

Non Anemic Anemic

age 64.4 + 13 years 71.4 + 11 P = 0.001Gender 44.4% 52.4% P = 0.02

Hospital stay 5.7 + 13.8 7.2 + 12.1 P=0.1


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38%

54%12%

39%

47%22%


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44 patients three or more etiologic or aggravating factors ofanemia 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 (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


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Discussion

The present study observational, cross-sectional andprospective investigation, although part of the data still hadto be collected retrospectively

The patients randomly referred to the two InternalMedicine Departments inclusion bias

Patients admitted to the rest of the departments notincluded in the present investigation

The 1st study aiming to evaluate relevant aspect of anemiain uncelected diabetic patients hospitalized in IMD


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Three main issues :

prevalence and characteristics of anemia,

cause of anemia and association of anemia with variousrelevant comorbidities,

and prognostic significance of anemia.

Large epidemiologic study on general population of olderpersons with anemia only part of whom were diabetic1/3 nutritional deficiency , 1/3 anemia of chronic disease orCKD or both 1/3 unexplained anemia. This study iincludeinstituzionalized patients.


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In this study :

Iron deficiency : 38%

Vitamin B12/folat deficiency : 12%

Anemia of chronic disease : 54%

RD : 39%

HF : 47%

Diabetic foot : 22%

Multifactorialcause ofanemia

> patient has 2 concomitan conditions:

o Inflamatory disease

o Medication (metformin/thiazolidirfendiones, ACE inhibitor,sulfonylurea)

o Hemolysis

o Mild untreated hypothyroidsm 2 case


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Other literature

Anemia & RD risk of death in HF

Prev. iron def. varies, 43% anemic patients insufficient ironstores, 58% reduced iron availability

Study on pts. (-) nephropathy (-) iron def.

In this study38% 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


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Anemia in diabetes

survival

infection

DMHFRF

AlbuminuriaHF

Male

Marker of theconcurrent disease

>>died in 1st year

follow up & tx infection prevention


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The assumption that anemia improvement mightprolong survival, especially in males with albuminuriaor HF need future investigations.

The mortality rate in complex nursing care patients

and those with diabetic foot higher suggestingthat continuous medical control may be beneficial.


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Learning points

The frequency of anemia in diabetic patients admitted toInternal Medicine departments, compared to the studiesperformed on ambulatory patient populations.

Anemia in diabetic in-patients

caused by a variety ofetiologic factors

Anemia in diabetes ~ higher post-discharge mortality VSdiabetic patients free of anemia.

Infection main cause of death in anemic diabetic in-patients.

Within the group of anemic diabetic in-patients, , albuminuriaand HF ~ higher risk of death.


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Telaah Kritis


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Jurnal Anemia in Diabetes

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