Prevalence of anemia among hemodialysis patients treated with recombinant human erythropoietin

109 Pages·2016·3.18 MB·English

AL Azhar University- Gaza
Deanship of Postgraduate Studies
Faculty of Pharmacy
Pharmaceutical Sciences program

Prevalence of anemia among hemodialysis patients treated
with recombinant human erythropoietin (rhEPO) in Gaza
Strip

Submitted by:
Tasneem Basem Shaban

Supervisors:

Dr. Amin T. Hamed Dr. Marwan A. Arafat
Assoc. Professor of Pharmacology PhD in Nephrology
Faculty of Pharmacy Al Shiffa Hospital
Al- Azhar University- Gaza

A thesis submitted for master degree in Pharmaceutical Sciences

Gaza, 2016
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ا ا ا 

(٥٩ :مﺎﻌﻧﻷا)

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DECLARATION

I, the undersigned hereby, declare that the thesis titled: Prevalence of anemia
among hemodialysis patient treated with recombinant human erythropoietin
(rhEPO) in Gaza Strip.
Is my own research work and the work provided in this thesis, unless
otherwise referenced, is the researcher’s own work, and has never been
submitted elsewhere for any other degree qualification nor for any academic
titles, nor for any other academic or publishing institutions.
I, hereto, affirm that I will be completely responsible in academic and legal
terms if this work proves the opposite.

Student’s name: Tasneem Basem Sha’ban
Signature:
Date:
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Dedication
To my beloved parents, for the sacrifices that they had made
For their endless love
Support and encouragement.
To my beloved husband and son who helped me to accomplish this thesis
and for their patience and understanding.
To my brothers and sister for their great efforts and help.

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Acknowledgement
This research would not have been possible without the support of many people.
I would like to express my deepest gratitude and appreciation to my supervisors,
Dr. Amin T. Hamed and Dr. Marwan A. Arafat who were abundantly helpful
and offered me invaluable assistance, continuous support, encouragement and
guidance that led to the emergence of this work in its current form.
My gratitude and thanks to Al- Azhar University- Gaza, Palestine. My thanks
and appreciation goes to my teachers in Faculty of Pharmacy for their
encouragement and assistance.
Deep thanks and respects for my friends at Faculty of Pharmacy Al- Azhar
University- Gaza and my friends at Al- Shifa hospital for their high cooperation
and support.
Thanks and respects for my colleagues and all hemodialysis staff at Al- Shifa
hospital, Shohadaa Al Aqsa hospital and Nasir hospital for their high
cooperation.
I would like to thank Dr. Nibal Al Shawwa and my colleagues in the pharmacy
department at Al Shifa hospital, especially in the internal and central pharmacies
for their help and support.
Also, I would like to thank all the patients for their approval to participate in this
study, without their help, this study could not be accomplished.
Lastly, I offer my regards and blessings to all of those who supported me in any
respect during the completion of this thesis.

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Prevalence of anemia among hemodialysis patients treated with
recombinant human erythropoietin (rhEPO) in Gaza Strip
Abstract (English)
Background: Anemia is a major complication of chronic kidney disease
(CKD), it is common in all stages but is more pronounced at the end stage renal
disease (ESRD). Anemia in CKD has multifactorial etiology. However,
erythropoietin deficiency is the most significant cause of anemia in ESRD.
Despite use of recombinant human erythropoietin (rhEPO), anemia is a frequent
finding in hemodialysis patients in Gaza Strip
Objectives: The present study was undertaken to assess the prevalence of
anemia among patients on regular hemodialysis treated with recombinant human
erythropoietin (rhEPO) in Gaza Strip; to determine the dose of rhEPO; to
identify iron status of hemodialysis patient; and to study some of the modifiable
factors that affect anemia and response to rhEPO as vascular access type;
compliance to hemodialysis sessions; hospitalization and albumin level as
indicator for inflammation and malnutrition.
Methodology: To achieve this purpose, seventy four hemodialysis patients from
both genders aged between 18-60 years, diagnosed as an ESRD on hemodialysis
for more than two years and treated with rhEPO at Al Shifaa hospital, Shohadaa
Al Aqsa hospital and Nasir hospital, Gaza Strip-Palestine, were enrolled in this
retrospective, cross sectional study, in the period between Jan 2013 to Dec 2014.
A questionnaire interview was used to collect the different socio-demographic
factors as, age, gender, other comorbidities, duration and number of
hemodialysis sessions/week.
Data concerning the medical history as, primary cause of ESRD, exact time for
initiation hemodialysis, hospitalization and laboratory tests as hemoglobin (Hb),
platelet count, serum albumin, transferrin saturation, serum iron, calcium,
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phosphate and alkaline phosphatase, were collected by reviewing the medical
record of each patient.
Results: Anemia is a major finding among hemodialysis patients in Gaza Strip,
Most hemodialysis patients (85%) had mean Hb values below 11.0 g/dl, mean
differences of hemoglobin values decreased throughout the study period with
statistically significant value, the mean dose of erythropoietin used was 5702±71
IU/week (93.34 ±33.7 IU/kg/week). There was a variability in response to
erythropoietin among HD patients, transferrin saturation increased throughout
the study period with statistically significant value, 62% of hemodialysis
patients had transferrin saturation more than 20% and there was a statistically
significant decrease in the mean albumin level during the study period.
Factors that may contribute to progression of anemia among HD patients in
Gaza Strip include, unstable supply of rhEPO, dependence on central venous
catheters to maintain regular hemodialysis, increase hospitalization rate among
HD patients, 37% of patients dialyzed less than four hours, 63% had albumin
level less than normal (3.5g\dl), and 52% of patients had hyperphosphatemia.
Conclusions & Recommendations: The prevalence of anemia is high in HD
patients in Gaza Strip. Anemia management needs more attention, rhEPO should
be continuously available for HD patients, and its cost must be weighed against
the cost of anemia complication, strategies should be put in place to improve
patient adherence to erythropoiesis stimulating agents (ESAs), iron and dialysis,
regular periodic monitoring of hemoglobin, iron status and renal function tests
should be done for HD patients.
Keywords: End Stage Renal Disease (ESRD), Hemodialysis, anemia,
recombinant human erythropoietin (rhEPO), Gaza Strip.

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ﻲﻓ ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا جﻼﻋ نﻮﻘﻠﺘﯾ ﻦﯾﺬﻟا يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﻰﺿﺮﻣ ﻦﯿﺑ مﺪﻟا ﺮﻘﻓ رﺎﺸﺘﻧا
ةﺰﻏ عﺎﻄﻗ
ﺔﺳارﺪﻟا ﺺﺨﻠﻣ
ﻊﯿﻤﺟ ﻲﻓ ﻊﺋﺎﺷ ﻮھو ،ﻦﻣﺰﻤﻟا يﻮﻠﻜﻟا رﻮﺼﻘﻟا ضﺮﻤﻟ ﺔﯿﺴﯿﺋﺮﻟا تﺎﻔﻋﺎﻀﻤﻟا ﺪﺣأ ﻮھ مﺪﻟا ﺮﻘﻓ :ﺔﻣﺪﻘﻤﻟا
،ةدﺪﻌﺘﻣ مﺪﻟا ﺮﻘﻓ بﺎﺒﺳأ .مﺪﻘﺘﻤﻟا يﻮﻠﻜﻟا رﻮﺼﻘﻟا ﻲﻓ ﺎﻋﻮﯿﺷ ﺮﺜﻛأ ﮫﻨﻜﻟ ،ﻦﻣﺰﻤﻟا يﻮﻠﻜﻟا رﻮﺼﻘﻟا ﻞﺣاﺮﻣ
ﻰﺿﺮﻤﻟا ءﺎﻄﻋإ ﻚﻟﺬﻟ، ﮫﺼﻘﻧ ﻰﻟإ يدﺆﯾ ﺎﻤﻣ ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا نﻮﻣﺮھ ﻊﯿﻨﺼﺗ ﻲﻓ ﺔﯿﻠﻜﻟا ﻞﺸﻓ ﺎﮭﻤھأ ﻦﻜﻟ
.ﻦﯿﺑﻮﻠﺟﻮﻤﯿﮭﻠﻟ لﻮﺒﻘﻣ ىﻮﺘﺴﻣ ﻰﻠﻋ ظﺎﻔﺤﻠﻟ ﺔﻟﺎﺤﻟا هﺬھ ﻲﻓ ﻲﺳﺎﺳأ ﻮھ ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا
.مﺪﻟا ﺮﻘﻓ ﻦﻣ نﻮﻧﺎﻌﯾ ﻰﺿﺮﻤﻟا ﻦﻣ ةﺮﯿﺒﻛ ﺔﺒﺴﻧ ﺖﻟاز ﺎﻣ ،ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا ماﺪﺨﺘﺳا ﻦﻣ ﻢﻏﺮﻟﺎﺑ ﻦﻜﻟو
جﻼﻋ نﻮﻘﻠﺘﯾ ﻦﯾﺬﻟا يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﻰﺿﺮﻣ ﻦﯿﺑ مﺪﻟا ﺮﻘﻓ رﺎﺸﺘﻧا ىﺪﻣ مﯾﯾﻘﺗﻟ ﺔﺳاردﻟا هذھ تﯾرﺟأ :فﺪﮭﻟا
ىﻮﺘﺴﻣ ﻢﯿﯿﻘﺗ ،ﺎﮭﺘﯾﺎﻔﻛو ﺾﯾﺮﻤﻟا ﻰﻠﻋ ةﺎﻄﻌﻤﻟا ﺔﻋﺮﺠﻟا ﺮﯿﺛﺄﺗ ىﺪﻣ ﻢﯿﯿﻘﺗ ، ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا
ﻰﻠﻋ ﺮﺛﺆﺗ ﻲﺘﻟاو ﻞﯾﺪﻌﺘﻠﻟ ﺔﻠﺑﺎﻘﻟا ﻞﻣاﻮﻌﻟا ﻦﻣ ﺔﻋﻮﻤﺠﻣ ﺔﺳاردو ،ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا ﻰﻠﻋ هﺮﯿﺛﺄﺗو ﺪﯾﺪﺤﻟا
تﺎﺴﻠﺠﺑ ﺾﯾﺮﻤﻟا ماﺰﺘﻟا ىﺪﻣ ،ﺔﻣﺪﺨﺘﺴﻤﻟا ﺔﯿﻧﺎﯾﺮﺸﻟا -ﺔﯾﺪﯾرﻮﻟا ﺔﻠﺻﻮﻟا عﻮﻧ :ﻞﺜﻣ جﻼﻌﻠﻟ ﻰﺿﺮﻤﻟا ﺔﺑﺎﺠﺘﺳا
.ﻰﺿﺮﻤﻟا ءﻻﺆھ ﺪﻨﻋ مﻮﯿﺴﻟﺎﻜﻟاو ،تﺎﻔﺳﻮﻔﻟا ،ﻦﯿﻣﻮﯿﺒﻟﻻا ىﻮﺘﺴﻣ ،ﻞﯿﺴﻐﻟا
حواﺮﺘﺗ ، مﺪﻘﺘﻤﻟا يﻮﻠﻜﻟا ﻞﺸﻔﻟﺎﺑ بﺎﺼﻣ ﺾﯾﺮﻣ نﻮﻌﺒﺳو ﺔﻌﺑرأ ،ضﺮﻐﻟا اﺬھ ﻖﯿﻘﺤﺘﻟ :ﺔﺳارﺪﻟا ﺔﯿﺠﮭﻨﻣ
ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا جﻼﻋ اﻮﻘﻠﺗ و ﻞﻗﻷا ﻰﻠﻋ ﻦﯿﻣﺎﻌﻟ يﻮﻠﻜﻟا ﻞﯿﺴﻐﻠﻟ اﻮﻌﻀﺧ ،ﺎﻣﺎﻋ ٦٠-١٨ ﻦﯿﺑ ﻢھرﺎﻤﻋأ
ﻰﻔﺸﺘﺴﻣ ﻲﻓ ٢٠١٤ ﺮﺒﻤﺴﯾد ﻰﻟإ ٢٠١٣ ﺮﯾﺎﻨﯾ ﻦﯿﺑ ﺎﻣ ةﺮﺘﻔﻟا ﻲﻓ ﻲﻌﺟر ﺮﺛﺄﺑ ﻢﮭﺘﺳارد ﻢﺗ ، ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا
.ﻦﯿﻄﺴﻠﻓ /ةﺰﻏ عﺎﻄﻗ ،ﺮﺻﺎﻧ ﻰﻔﺸﺘﺴﻣو ﻰﺼﻗﻷا ءاﺪﮭﺷ ﻰﻔﺸﺘﺴﻣ ،ءﺎﻔﺸﻟا
،ﻞﻤﻌﻟا ﺔﻌﯿﺒط ،ﺲﻨﺠﻟا ،ﺮﻤﻌﻟا :ﻞﺜﻣ ﺔﯿﻧﺎﻜﺴﻟاو ﺔﯿﻋﺎﻤﺘﺟﻻا ﻞﻣاﻮﻌﻟا ﻊﻤﺠﻟ نﺎﯿﺒﺘﺳا ماﺪﺨﺘﺳﺎﺑ ﻚﻟذ ﻢﺗ ﺪﻗو
ﺐﺒﺴﻟا :ﻞﺜﻣ ﺾﯾﺮﻤﻠﻟ ﻲﺒﻄﻟا ﺦﯾرﺎﺘﻟﺎﺑ ﺔﻘﻠﻌﺘﻤﻟا تﺎﻧﺎﯿﺒﻟا ﺎﻣأ .ىﺮﺧﻵا ضاﺮﻣﻷا و ﻲﻤﯿﻠﻌﺘﻟا ىﻮﺘﺴﻤﻟا
ﺢﺋﺎﻔﺼﻟا ،ﻦﯿﺑﻮﻠﺟﻮﻤﯿﮭﻟا ﻞﺜﻣ ﺔﯾﺮﺒﺨﻤﻟا تﺎﺻﻮﺤﻔﻟاو ،يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ءﺪﺑ ﺖﻗوو ،يﻮﻠﻜﻟا ﻞﺸﻔﻠﻟ ﻲﺴﯿﺋﺮﻟا
.ﺾﯾﺮﻣ ﻞﻜﻟ ﻲﺒﻄﻟا ﻞﺠﺴﻟا ﺔﻌﺟاﺮﻤﺑ ﺖﻌﻤﺟ ﺪﻘﻓ تﺎﻔﺳﻮﻔﻟاو مﻮﯿﺴﻟﺎﻜﻟا، ﻦﯿﻣﻮﺒﻟﻷا ،ﺔﯾﻮﻣﺪﻟا
ﻞﯿﺴﻐﻟا ﻰﺿﺮﻣ ﻢﻈﻌﻣ ،ةﺰﻏ عﺎﻄﻗ ﻲﻓ ﻰﻠﻜﻟا ﻞﯿﺴﻏ ﻰﺿﺮﻣ ﻦﯿﺑ ﺔﻈﺣﻼﻣ ﺔﺠﯿﺘﻧ ﻮھ مﺪﻟا ﺮﻘﻓ :ﺞﺋﺎﺘﻨﻟا
لﻼﺧ ﻦﯿﺑﻮﻠﺟﻮﻤﯿﮭﻠﻟ قوﺮﻔﻟا ﻂﺳﻮﺘﻣ ﺾﻔﺨﻧا ،لد/ج ١١ ﻦﻣ ﻞﻗأ ﻢﮭﯾﺪﻟ ﻦﯿﺑﻮﻠﺟﻮﻤﯿﮭﻟا نﺎﻛ (٪٨٥) يﻮﻠﻜﻟا
ةﺪﺣو ٧١ ± ٥٧٠٢ ﺖﻧﺎﻛ ﺔﻣﺪﺨﺘﺴﻤﻟا ﻦﯿﺘﯾﻮﺑوﺮﺜﯾرﻹا ﺔﻋﺮﺟ ، ﺔﯿﺋﺎﺼﺣإ ﺔﻟﻻد تاذ ﺔﻤﯿﻘﺑ ﺔﺳارﺪﻟا ةﺮﺘﻓ
ﻰﺿﺮﻣ ﺔﺑﺎﺠﺘﺳا ﻲﻓ توﺎﻔﺗ كﺎﻨھ نﺎﻛ ،(عﻮﺒﺳأ / ﻢﺠﻛ / ﺔﯿﻟود ةﺪﺣو ٣٣.٧ ± ٩٣.٣٤) عﻮﺒﺳﻷا/ﺔﯿﻟود
،ﺔﯿﺋﺎﺼﺣإ ﺔﻟﻻد تاذ ﺔﻤﯿﻘﺑ ﺔﺳارﺪﻟا ةﺮﺘﻓ لﻼﺧ ﺪﯾﺪﺤﻟا ﻊﺒﺸﺗ ﺔﻤﯿﻗ تداز ، ﻦﯿﺘﯾﻮﺑوﺮﺜﯾرﻺﻠﻟ يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا
ﺔﻤﯿﻘﺑ ضﺎﻔﺨﻧا ﺎﻀﯾا ﺔﺳارﺪﻟا تﺮﮭظا ،٪٢٠ ﻦﻣ ﺮﺜﻛأ ﻢﮭﯾﺪﻟ ﺪﯾﺪﺤﻟا ﻊﺒﺸﺗ ﺔﺒﺴﻧ ﺖﻧﺎﻛ ﻰﺿﺮﻤﻟا ﻦﻣ %٦٢
.ﺔﺳارﺪﻟا ةﺮﺘﻓ لﻼﺧ ﻰﺿﺮﻤﻟا ﺪﻨﻋ ﻦﯿﻣﻮﺒﻟﻷا ىﻮﺘﺴﻣ ﻲﻓ ﺔﯿﺋﺎﺼﺣإ ﺔﻟﻻد تاذ
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ﻲﻓ يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﻰﺿﺮﻣ ﻦﯿﺑ مﺪﻟا ﺮﻘﻓ رﻮﻄﺗ ﻲﻓ ﻢﮭﺴﺗ ﻞﻣاﻮﻌﻟا ﻦﻣ ﺪﯾﺪﻌﻟا نأ ﻰﻟإ ﺔﺳارﺪﻟا ﺖﻠﺻﻮﺗ
ﻰﻠﻋ ظﺎﻔﺤﻠﻟ ﺔﯾﺰﻛﺮﻤﻟا ﺔﯾﺪﯾرﻮﻟا ةﺮﻄﺴﻘﻟا ﻰﻠﻋ دﺎﻤﺘﻋﻻا ،ﻢﻈﻨﻣو ﻢﺋاد ﻞﻜﺸﺑ ءاوﺪﻟا ﺮﻓﻮﺗ مﺪﻌﻛ ،ةﺰﻏ عﺎﻄﻗ
ﻦﻣ ةﺮﯿﺒﻛ ﺔﺒﺴﻧ ،يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﻰﺿﺮﻤﻟ ﻰﻔﺸﺘﺴﻤﻟا لﻮﺧد لﺪﻌﻣ ةدﺎﯾز ،يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﺔﯾراﺮﻤﺘﺳا
ﻲﻓ ةدﺎﯾز ﻢﮭﯾﺪﻟ نﺎﻛ ﻰﺿﺮﻤﻟا ﻦﻣ 52% و ﻦﯿﻣﻮﯿﺒﻟﻻا ىﻮﺘﺴﻣ ﻲﻓ ضﺎﻔﺨﻧا ﻢﮭﯾﺪﻟ نﺎﻛ (%٦٣) ﻰﺿﺮﻤﻟا
.تﺎﻔﺳﻮﻔﻟا ىﻮﺘﺴﻣ
ةﺎﻋﺪﻣ اﺬھو ،ةﺰﻏ عﺎﻄﻗ ﻲﻓ يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ﻰﺿﺮﻣ ىﺪﻟ ﻊﻔﺗﺮﻣ مﺪﻟا ﺮﻘﻓ رﺎﺸﺘﻧا لﺪﻌﻣ :تﺎﯿﺻﻮﺘﻟا و ﺞﺋﺎﺘﻨﻟا
، ﻰﺿﺮﻤﻟا ءﻻﺆﮭﻟ راﺮﻤﺘﺳﺎﺑ ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا ﺮﯿﻓﻮﺗ ﺚﯿﺣ ﻦﻣ ﻦﯿﻟوﺆﺴﻤﻟا ﻞﺒﻗ ﻦﻣ مﺎﻤﺘھﻼﻟ
ﻢﻈﺘﻨﻣ و يرود ﻢﯿﯿﻘﺗ ﻞﻤﻋو ، جﻼﻌﻟﺎﺑ ﺾﯾﺮﻤﻟا ماﺰﺘﻟا ﻦﯿﺴﺤﺘﻟ ﺔﻣزﻼﻟا تﺎﯿﺠﯿﺗاﺮﺘﺳﻻا ﻊﺿﻮﻟ ﻲﻌﺴﻟاو
. ﻰﻠﻜﻟا ﻒﺋﺎظوو ﺪﯾﺪﺤﻟا ،ﻦﯿﺑﻮﻠﺟﻮﻤﯿﮭﻠﻟ
،مﺪﻟا ﺮﻘﻓ ،ﻊﻨﺼﻤﻟا يﺮﺸﺒﻟا ﻦﯿﺗﻮﯿﺑوﺮﺜﯾرﻻا ، يﻮﻠﻜﻟا ﻞﯿﺴﻐﻟا ،مﺪﻘﺘﻤﻟا يﻮﻠﻜﻟا رﻮﺼﻘﻟا :ﺔﯿﺣﺎﺘﻔﻣ تﺎﻤﻠﻛ
.ةﺰﻏ عﺎﻄﻗ

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