Ethnic prevalence of anemia and predictors of anemia among chronic kidney disease patients at a tertiary hospital in Johannesburg, South Africa

A New Artificial Intelligence Approach Using Extreme Learning Machine as the Potentially Effective Model to Predict and Analyze the Diagnosis of Anemia

The procedure to diagnose anemia is time-consuming and resource-intensive due to the existence of a multitude of symptoms that can be felt physically or seen visually. Anemia also has several forms, which can be distinguished based on several characteristics. It is possible to diagnose anemia through a quick, affordable, and easily accessible laboratory test known as the complete blood count (CBC), but the method cannot directly identify different kinds of anemia. Therefore, further tests are required to establish a gold standard for the type of anemia in a patient. These tests are uncommon in settings that offer healthcare on a smaller scale because they require expensive equipment. Moreover, it is also difficult to discern between beta thalassemia trait (BTT), iron deficiency anemia (IDA), hemoglobin E (HbE), and combination anemias despite the presence of multiple red blood cell (RBC) formulas and indices with differing optimal cutoff values. This is due to the existence of several varieties of anemia in individuals, making it difficult to distinguish between BTT, IDA, HbE, and combinations. Therefore, a more precise and automated prediction model is proposed to distinguish these four types to accelerate the identification process for doctors. Historical data were retrieved from the Laboratory of the Department of Clinical Pathology and Laboratory Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia for this purpose. Furthermore, the model was developed using the algorithm for the extreme learning machine (ELM). This was followed by the measurement of the performance using the confusion matrix and 190 data representing the four classes, and the results showed 99.21% accuracy, 98.44% sensitivity, 99.30% precision, and an F1 score of 98.84%.

Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa

BACKGROUND

Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting.

METHODS

A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests.

RESULTS

Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively.

CONCLUSIONS

HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.

Prevalence of anemia and its predictors among patients with chronic kidney disease admitted to a teaching hospital in Ethiopia: A hospital-based cross-sectional study

Anemia is a common complication of chronic kidney disease (CKD) and is associated with adverse patient outcomes. However, data on the prevalence of anemia in CKD patients is sparse, particularly in resource-limited settings. Therefore, this study aimed to assess the prevalence of anemia and its predictors among patients with CKD admitted to the Jimma medical center, southwest Ethiopia. A hospital-based prospective cross-sectional study was conducted from September 1 to November 30, 2020. All adult patients with CKD aged ≥18 years who fulfilled the inclusion criteria were consecutively recruited into the study. Data were entered into the Epi data manager version 4.4.1 and then exported to SPSS version 22 (IBM Corp., Armonk, NY) for analysis. The predictors of anemia were determined using multivariable logistic regression analysis. Statistical significance was set at P < .05. A total of 150 patients were included in this study. Of these, 64.67% were male, 56.67% had stage 5 CKD, 78% had a CKD duration of less than 1 year, and 74% had proteinuria. Hypertension (40.7%) and diabetes (14.7%) were the common causes of CKD. The prevalence of anemia was 85.33%. Of the patients, 28.67%, 40.67%, and 16% had mild, moderate, and severe anemia, respectively. On multivariate logistic regression, stage 4 CKD (adjusted odds ratio [AOR] 3.2, confidence interval [CI]: 1.78-12.91, P = .025), stage 5 CKD (AOR 4.03, CI: 1.17-13.73, P = .016), and CKD duration of less than 1 year (AOR 3, CI: 1.19-9.11, P = .007) were significantly associated with anemia. The prevalence of anemia among stage 3 to 5 CKD patients was very high. Anemia was significantly associated with the severity and duration of CKD. Therefore, serial follow-up of patients with a long duration and advanced stages of CKD may help prevent anemia and its adverse consequences.

Anemia and its predictors among chronic kidney disease patients in Sub-Saharan African countries: A systematic review and meta-analysis

INTRODUCTION

Anemia is a serious complication of chronic kidney disease (CKD) with a significant adverse outcome on the burden and progression of the disease. Hence, the study intended to assess the pooled prevalence of anemia and its predictors among CKD patients in Sub-Saharan African nations.

METHODS

To identify the relevant studies systematic searches were carried out in Medline, EMBASE, HINARI, Google Scholar, Science Direct, and Cochrane Library. From selected studies, data were taken out with a standardized data extraction format prepared in Microsoft Excel. Inverse variance (I2) tests were employed to evaluate the heterogeneity across the included studies. Due to substantial heterogeneity among the studies, a random-effects meta-analysis technique was employed to estimate the pooled prevalence of anemia. Subgroup analysis, sensitivity analysis, and meta-regression analysis were carried out to search the possible bases of heterogeneity. Funnel plot symmetry, Begg's test, and Egger's regression test were employed to assess the existence of publication bias. In addition, factors associated with anemia among CKD patients were examined. All statistical analyses were carried out with STATA™ Version 14 software.

RESULTS

A total of 25 studies with 5042 study participants were considered in this study. The pooled prevalence of anemia among CKD patients was estimated to be 59.15% (95% CI, 50.02-68.27) with a substantial level of heterogeneity as evidenced by I2 statistics (I2 = 98.1%; p < 0.001). Stage of CKD (3-5) (pooled odds ratio (POR) = 5.33, 95% CI:4.20-6.76), presence of diabetes mellitus (POR = 1.75, 95% CI: 1.10-2.78), hemodialysis history (POR = 3.06, 95% CI: 1.63-5.73), and female sex (POR = 2.50, 95% CI: 1.76-3.55) were significantly related with anemia.

CONCLUSIONS

More than half of CKD patients were suffering from anemia. Stage of CKD, presence of DM, hemodialysis history, and being female sex were factors associated with anemia among CKD patients.

Situation analysis on the regulation of nanomedicines in Southern Africa

Background

Medical products incorporating nanoparticle drug delivery systems (nanomedicines) are therapeutic or imaging agents, which comprise a delivery system within the nanometer size range (1 - 1000 nm). As medical products, nanomedicines meet definitions of medicines according to various national legislations for regulation of medicines. However, for the regulation of nanomedicines, additional assessments including toxicological issues have to be considered. These complexities require extra regulatory effort. In the resource-limited context of low- and middle-income countries, many National Medicines Regulatory Authorities (NMRAs) lack resources and capacities to effectively assure the quality of medicinal products in their countries. With emerging trends in innovative technologies, including nanotechnology, this burden is worsened. The need to overcome regulatory challenges drove the formation of a work sharing initiative in the Southern African Development Community (SADC), ZaZiBoNA in 2013. Regulatory agencies participating in this initiative cooperate in the assessment of applications for registration of medicines.

Methods

A cross-sectional exploratory study design with qualitative techniques was used to investigate the status of the regulation of nanomedicines in Southern African countries in particular those participating in the ZaZiBoNA initiative.

Results

The study found that in general, NMRAs are aware of the existence of nanomedicines and they apply legislation applicable to other medical products. The NMRAs however neither have specific definition for nanomedicines and technical guidance documents, nor technical committees specific for consideration of nanomedicines. Collaboration with external experts or organisations in the regulation of nanomedicines was also found to be lacking.

Discussion

Capacity building and collaboration in the area of regulation of nanomedicines is strongly encouraged.

Demographic and clinical profile of black patients with chronic kidney disease attending a tertiary hospital in Johannesburg, South Africa

Background

The prevalence of chronic kidney disease (CKD) is increasing worldwide; black patients have an increased risk of developing CKD and end stage kidney disease (ESKD) at significantly higher rates than other races.

Methods

A cross sectional study was carried out on black patients with CKD attending the kidney outpatient clinic at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa, between September 2019 to March 2020. Demographic and clinical data were extracted from the ongoing kidney outpatient clinic records and interviews, and were filled in a questionnaire. Patients provided blood and urine for laboratory investigations as standard of care, and data were descriptively and inferentially entered into REDcap and analysed using STATA version 17. Multivariable logistic regression analysis was used to identify demographic and clinical variables associated with advanced CKD.

Results

A total of 312 black patients with CKD were enrolled in the study with a median age of 58 (IQR 46–67) years; 58% patients had advanced CKD, 31.5% of whom had grossly increased proteinuria, 96.7% had hypertension, 38.7% had diabetes mellitus and 38.1% had both hypertension and diabetes mellitus. In patients with advanced CKD, the median age was 61 (IQR 51–69) years, eGFR 33 (30–39) mL/min/1.73 m2, serum bicarbonate 22 (IQR 20–24), haemoglobin 12.9 (IQR 11.5–14.0) g/dl and serum uric acid 0.43 (IQR 0.37–0.53). The prevalence of metabolic acidosis was 62.4%, anemia 46.4% and gout 30.9% among those with advanced CKD, while the prevalence of metabolic acidosis and anaemia was 46.6% and 25.9% respectively in those with early CKD. Variables with higher odds for advanced CKD after multivariable logistic regression analysis were hypertension (OR 3.3, 95% CI 1.2–9.2, P = 0.020), diabetes mellitus (OR 1.8, 95% CI 1.1–3.3, P = 0.024), severe proteinuria (OR 3.5, 95% CI 1.9–6.5, P = 0.001), angina (OR 2.5, 95% CI 1.2–5.1, P = 0.008), anaemia (OR 2.9, 95% CI 1.7–4.9, P = 0.001), hyperuricemia (OR 2.4, 95% CI 1.4–4.1, P = 0.001), and metabolic acidosis (OR 2.0, 95% CI 1.2–3.1, P = 0.005). Other associations with advanced CKD were loss of spouse (widow/widower) (OR 3.2, 95% CI 1.4–7.4, P = 0.006), low transferrin (OR 2.4, 95% CI 1.1–5.1, P = 0.028), hyperkalemia (OR 5.4, 95% CI 1.2–24.1, P = 0.029), use of allopurinol (OR 2.4, 95% CI 1.4–4.3, P = 0.005) and doxazosin (OR 1.9, 95% CI 1.2–3.1, P = 0.006).

Conclusion

Hypertension and diabetes mellitus were strongly associated with advanced CKD, suggesting a need for primary and secondary population-based prevention measures. Metabolic acidosis, anemia with low transferrin levels, hyperuricemia and hyperkalemia were highly prevalent in our patients, including those with early CKD, and they were strongly associated with advanced CKD, requiring clinicians and dietitians to be proactive in supporting the needs of CKD patients in meeting their daily dietary requirements towards preventing and slowing the progression of CKD.

Risk Factors for Anemia in Patients with Chronic Renal Failure: A Systematic Review and Meta-Analysis

Background

Anemia in patients with chronic kidney disease presents significant impacts on patients, the health-care system and financial resources. There is a significant variation in the primary studies on risk factors of anemia in this patient population across the globe. Therefore, this study aimed to identify the risk factors of anemia among chronic kidney disease patients at the global level.

Methods

PubMed, Scopus, African Journals Online, Web of Science and Google Scholar were searched and complemented by manual searches. A Funnel plot and Egger's regression test were used to determine publication bias. DerSimonian and Laird random-effects modes were applied to estimate pooled effect sizes, odds ratios, and 95% confidence interval across studies. Analysis was performed using STATA™ Version 14 software.

Result

A total of 28 studies with 24,008 study participants were included in this study. Female sex (AOR= 1.36; 95% CI 1.11, 1.67), stage 5 CKD (AOR = 13.66; 95% CI: 5.19, 35.92), body mass index ≥ 30 kg/m² (AOR = 0.51; 95% CI: 0.29, 0.91), comorbidities (AOR = 2.90; 95% CI: 1.68, 5.0), proteinuria 3⁺(AOR = 3.57; 95% CI: 1.03, 12.93), hypocalcemia (AOR=3.61, 95%CI: 1.56–8.36), and iron therapy (AOR: 0.59; 95% CI:0.31, 0.98) were significantly associated with anemia of chronic kidney disease.

Conclusion

Female sex, stage 5 CKD, body mass index ≥ 30 kg/m², comorbidity, and hypocalcemia were found to be significantly associated with anemia of chronic kidney disease. Therefore, situation-based interventions and country context-specific preventive strategies should be developed to reduce the risk factors of anemia in patients with chronic renal failure.

Prevalence of anemia and associated factors among the elderly population in South Khorasan, Birjand, 2019

Background: Anemia is a multifactorial and common public health problem in geriatric age groups, especially in developing countries. Therefore, this study was designed to study the prevalence of anemia and associated factors among the elderly population in Birjand, Iran, in 2019. Methods: This was a cross-sectional approach to the baseline data of the Birjand longitudinal aging study (BLAS) in which 1396 people aged ≥ 60 years were screened for the presence of anemia based on the World Health Organization (WHO) criteria. For each participant, a standard questionnaire was administered. Furthermore, the height, weight, and body mass index (BMI) were calculated. Blood samples were obtained from each participant for hematological examination. Hemoglobin, hematocrit, and other indices of cell blood count were measured using an automatic cell counter. The prevalence rates were estimated using survey analysis with the weight of Birjand county older population. Univariate and multivariable logistic regression analyses were applied to detect the associated factor with anemia. Results: The mean age of the participants was 69.73±7.66 years. The crude prevalence of anemia was 11.10%, and the age-standardized prevalence based on the standard WHO population 2000-2025 was equal to 16.78% (12.81%-21.66%) (15.95% [10.41%-23.69%] in women and 17.32% (12.65%-23.25%) in men. Mild and normocytic anemia were the predominant types. The mean hemoglobin, hematocrit, mean cell volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were lower in women than in men and the mean platelet count in women was higher (p<0.001). In the final multivariate logistic regression model, only age groups, BMI, fish consumption, and chronic kidney disease (CKD) were related to anemia. Conclusion: In conclusion, our findings showed the association of anemia with some risk factors and diseases. Anemia in geriatric age groups is often underdiagnosed; hence, identification of subgroups at risk for anemia and its associated risk factors in geriatric groups has a paramount importance in preventing adverse outcomes.

Perfluoroalkyl acids and their isomers, diabetes, anemia, and albuminuria: Variabilities with deteriorating kidney function

Data for US adults aged ≥20 years from National Health and Nutrition Examination Survey for the years 2003-2014 were analyzed to evaluate how adjusted (N = 8481) and unadjusted (N = 9080) levels of selected perfluoroalkyl acids (PFAA) vary across the different stages of glomerular function (GF) among those who did not have diabetes, anemia, or albuminuria as compared to those who had diabetes only, anemia only, and albuminuria only. PFAAs selected for analyses were: perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorodecanoic acid (PFDA), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA). Irrespective of GF stage, there was no noticeable evidence to suggest that adjusted levels of PFAA for those with diabetes only are any lower than those with no diabetes, no anemia, and no albuminuria. Those who had anemia only were found to have lower adjusted levels of at least PFOA, PFOS, PFDA, and PFHxS than those who had no diabetes, no anemia, and no albuminuria. These results were seen in the presence (eGFR < 60 mL/min/1.73 m²) as well as the absence of chronic kidney disease. For GF-1 (eGFR > 90 mL/min/1.73 m²), GF-2 (60 ≤ eGFR ≤ 90 mL/min/1.73 m²), and GF-3B/4 (15 < eGFR ≤ 45 mL/min/1.73 m²), those who had albuminuria only had lower adjusted levels of PFOA, PFOS, and PFHxS than those who had no diabetes, no anemia, and no albuminuria. In general, adjusted levels of those who had albuminuria only were lower than those who had anemia only at GF-3 and more often than not at GF-1 and GF-2. Rise in adjusted levels of PFAA from GF-1 to GF-3A (45 < eGFR < 60 mL/min/1.73 m²) was faster for those with anemia only than any other comparison group for the total population and females.

Hepcidin and GDF-15 are potential biomarkers of iron deficiency anaemia in chronic kidney disease patients in South Africa

BACKGROUND

Anaemia is a common presenting feature among patients with chronic kidney disease (CKD) and it is associated with poor clinical outcomes and quality of life. It is not clear if growth differentiation factor-15 (GDF-15) or hepcidin are useful as early markers of iron deficiency anaemia (IDA) among non-dialysis CKD patients. We therefore evaluated the diagnostic validity of GDF-15 and hepcidin as biomarkers of IDA among non-dialysis CKD patients in Johannesburg, South Africa.

METHOD

An analytic cross-sectional study was conducted among non-dialysis CKD patients (n = 312) and apparently healthy controls (n = 184) from June to December 2016 at an Academic Hospital, in Johannesburg, South Africa. An interviewer administered proforma was used to obtain the socio-biological and clinical characteristics of the participants. Serum levels of GDF-15 and hepcidin were determined. Predictive logistic regression models were built and post estimation receiver operator characteristics were determined to evaluate diagnostic validity of hepcidin and GDF-15 for absolute and functional iron deficiency anaemia.

RESULTS

About half (50.6%) of the participants were female while the participants' mean age was 49.7 ± 15.8 years. The predictive value of diagnosing absolute IDA among CKD patients using GDF-15 was 74.02% (95% CI: 67.62-80.42%) while the predictive value of diagnosing functional IDA among CKD patients using hepcidin was 70.1% (95% CI: 62.79-77.49%).There was a weak negative correlation between hepcidin levels and GFR (r = - 0.19, p = 0.04) in anaemic CKD patients, and between serum GDF-15 and haemoglobin (r = - 0.34, p = 0.001). Serum ferritin (β = 0.00389, P-value< 0.001), was a predictor of log hepcidin. MCHC (β = - 0.0220, P-value 0.005) and CKD stage (β = 0.4761, P-value < 0.001), race (β = 0.3429, P-value = 0.018) were predictors of log GDF-15. Both GDF-15 (adj OR: 1.0003, 95%CI: 1.0001-1.0005, P = 0.017) and hepcidin (adj OR: 1.003, 95%CI: 1.0004-1.0055, P = 0.023) were associated with iron deficiency anaemia after multiple linear regression modelling.

CONCLUSION

Serum GDF-15 is a potential biomarker of absolute IDA, while hepcidin levels can predict functional IDA among CKD patients.