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International Journal of Research in Biochemistry and Biophysics
Universal Research Publications. All rights reserved
ISSN 2249-8524
Original Article
“Role of Trace Elements and Lipid Peroxidation levels in pre and
post Hemodialysis of Chronic renal failure patients”.
Ramprasad. N *, Al- Ghonaim Mohammed I **
* Assistant Professor of Biochemistry, Medical Laboratory Science Department, College of
Applied Medical Sciences, Shaqra University, Al- Quwayiyah, Kingdom of Saudi Arabia.
** Dean of Medical Laboratory Science Department, College of Applied Medical Sciences, Shaqra University,
Al- Quwayiyah, Kingdom of Saudi Arabia.
Email: [email protected], Ph: +966 542768177
Received 10 December 2012; accepted 26 December 2012
Abstract
Background: Oxidative stress is related to several diseases, including chronic renal insufficiency. Trace elements
constitute a relatively small amount of total body tissues but these are essential for many vital processes. The lipid
Peroxidation in hemodialysis patients may be partly due to the trace element disturbances. It has been mentioned that
during dialysis some trace elements can accumulate while other may be removed from blood, leading to deficiency of some
trace elements. Aim: In the present study, our aim was to investigate the lipid Peroxidation and trace elements levels i.e.
Selenium (Se), Zinc (Zn), Copper (Cu), Manganese (Mn), Magnesium (Mg) and Aluminum (Al) in chronic renal failure
patients before and after hemodialysis. Materials and Methods: The study was carried out in 55 hemodialysis patients
compared with 70 healthy controls. The blood samples were collected before and after hemodialysis sessions. Parameters
like serum Malondialdehyde used as an index of oxidative stress and trace elements levels were measured in atomic
absorption spectrophotometry. Results: Increased levels of MDA and Al concentrations in dialysis patients compared to
controls. Trace elements such as Zn, Cu and Mn levels were significantly reduced in pre and post dialysis groups when
compared with the controls. On the other hand, no significant change in the values of Se and Mg between controls and post
dialysis process. Conclusion: The hypothesis of the current study indicates that decreased level of trace elements in pre
and post hemodialysis patients which is thought to be related to the loss of trace elements through the membrane leading to
the increased lipid peroxidation. Ongoing oxidative stress present in the patients of hemodialysis may play a
pathophysiological role in the development of cardiovascular disease.
©2013 Universal Research Publications. All rights reserved
Key words: Chronic renal failure, hemodialysis, Lipid Peroxidation, trace elements.
1. Introduction
Chronic renal failure (CRF) is a common clinical syndrome
characterized by decline in glomerular filtration
perturbation of extracellular fluid volume, electrolytes and
acid base homeostasis and retention of nitrogenous waste
from protein catabolism [1].
Chronic kidney disease (CKD) is emerging as an important
problem worldwide. However, data on the burden of CKD
in the Arab world remains poorly understood. The kingdom
of Saudi Arabia is the largest country in the Arabian
Peninsula in Southwest Asia. It has an estimated population
of 28 million, including approximately 5.5 million nonnationals. Data available on the exact incidence and
1
prevalence of chronic kidney disease is limited to patients
with end-stage renal disease. The incidence of dialysis in
the kingdom of Saudi Arabia was 136 new cases per
million populations (pmp). This compares to 360 pmp in
the United States, 585 pmp in Europe and to 163 pmp in
India [2].
CRF is often a complication of sepsis, trauma or multiple
organ dysfunctions. The primary event leading to renal
failure is a free radical medicated injury to the endothelial
cells in the outer medulla. During hemodialysis essential
kidney functions, such as the elimination of water and
metabolic wastes as well as the correction of the electrolyte
and acid/ base state are replaced by the artificial
purification systems [3]. In recent years hemodialysis has
International Journal of Research in Biochemistry and Biophysics 2013; 3(1): 1-6
been successful in extending life span of renal patients and
is effective in correcting the metabolic abnormalities
related to renal oxidative stress that contributes to
morbidity in hemodialysis patients. Dialysis patients are
subjected to an oxidative stress resulting from the dialysis
sessions [4].
Oxidative stress is defined as the interruption of balance
between oxidants and reductants within the body due to the
excess production of peroxides and free radicals. This
imbalance will cause damage to cellular components and
tissues in the body leading to oxidative stress and as well as
the decrease in total antioxidant capacity [5].
The
production of reactive oxygen species (ROS) which has the
ability to react with all biological molecules like lipids,
proteins, carbohydrates, DNA etc and exert cytotoxic
effects on cellular components. Thus as increased ROS and
impaired antioxidant defense contribute for the initiation
and progression of micro and macro vascular complications
in chronic renal failure disease [6].
Lipid peroxidation (LPO) is a free radical related process,
which is potentially harmful because its uncontrolled, selfenhancing process causes disruption of membranes, lipids
and other cell components. A lot of oxygenated
compounds,
particularly
aldehydes
such
as
Malondialdehyde (MDA) are produced during the attack of
free
radicals
to
membranes,
lipoprotein
and
polyunsaturated fatty acids [7]. MDA, a water soluble low
molecular weight LPO product, is partially excreted via
urine under normal conditions. However, it is not known
exactly what proportion of MDA formed in the body is
eliminated by the kidney [8]. Thus LPO in the blood
provides useful information for the prognosis of renal
failure disease in which secondary disorders are often fatal.
Trace elements play an important role in the structure of
proteins, enzymes and complex carbohydrates to participate
in biochemical reactions. Essential trace elements are
involved in a number of metabolic activities, including
neuroconduction, transport, excretory processes and
serving as cofactors for enzymes [9]. Some of the trace
elements like Selenium, Zinc, Manganese, Magnesium and
Copper are cofactors or structural components of
antioxidant enzymes. Morever, selenium and glutathione
peroxidase play an important role in protecting cell
membranes from oxidative damage and decreased blood
selenium and are common in chronic renal failure patients.
Zinc and Copper are the intensively and metabolically
important trace metal for nutrients [10].
In recent years, intermittent hemodialysis has been
successful in extending the life span of chronic renal failure
patients. However, chronic renal failure may result in
impaired renal excretion and accumulation of some trace
elements in the body. During dialysis some trace elements
can accumulate in the body because of dialysis fluid
impurities and others may remove from blood to dialysate
leading to deficiency of some trace elements in the body
[11].
The main purpose of this study was carried out to
investigate the lipid peroxidation marker i.e. MDA, which
is widely used as an index of the extent of oxidative
2
damage and trace elements levels like Selenium (Se), Zinc
(Zn), Copper (Cu), Manganese (Mn), Magnesium (Mg) and
Aluminium (Al) were measured in patients with chronic
renal failure before and after hemodialysis and compared
with normal healthy control subjects.
2. Materials and Methods:
The study was case controlled in design. We have selected
the patients as they are presented. Patients included in the
present study were all admitted to the Nephrology unit or
attending the Out Patient Department (OPD) of medicine
and some patients were admitted to the Nephrology and
Dialysis ward of Al- Quwayiyah Government General
Hospitals, Shaqra University, Kingdom of Saudi Arabia.
The study group consisted of fifty five Hemodialysis
patients of both the sexes in the age ranging from 40—65
years and they were admitted to hospital. All patients were
dialyzed for 4 ± 1 hour with average 2 ± 1 times of a week.
Blood samples were obtained from the concerned subjects
before dialysis (Group 1) and after dialysis (Group 2) for
the study. The diagnosis was based on history, detailed
clinical examination and relevant laboratory investigations.
Seventy healthy subjects, age and gender matched, having
normal kidney functions (urea, creatinine) were included as
a controls.
Subjects suffering from diabetes, acute renal failure,
cardiovascular disease, hepatic disease, pregnancy and any
chronic or acute inflammatory illness were excluded from
the study. All participants gave written informed consent
and this protocol was approved by the ethical and human
research committee.
The blood samples were drawn for routine hematological
parameters like haemoglobin, haematocrit and MCV was
measured by ERBA Sysmax cell counter. The biochemical
parameter such as urea, creatinine, albumin and uric acid
was done by fully automated analyzer Cobas Integra 400
from ROCHE diagnostics, Germany.
Serum levels of
MDA, a marker of lipid peroxidation were measured by
thiobarbutric acid (TBA) method [12]. We measured Six
trace element levels; Selenium (Se), Zinc (Zn), Copper
(Cu), Magnesium (Mg), Manganese (Mn) and Aluminum
(Al) in serum were determined by flame atomic absorption
spectrophotometer with deuterium background correction
(Perkin- Elmer model 5000) [13].
2.1 Statistical Analysis
All values are expressed as mean ±SD. Student t- test was
used to estimate the significant difference between the
groups. The level of statistical significant was set at
p<0.001. SPSS for windows 13.0 was used for statistical
analysis.
3. Results:
As shown in Table 1, the average and standard deviation of
serum urea, creatinine and uric acid showed significantly
increased in pre and post hemodialysis patients when
compared to controls (p<0.001). Whereas deceased
albumin (p<0.001) levels in pre and post dialysis patients
compared to controls. While the values of urea, creatinine,
uric acid and albumin were not significant difference
between the pre dialysis and post dialysis patients.
The pathological parameter like hemoglobin, hematocrite
International Journal of Research in Biochemistry and Biophysics 2013; 3(1): 1-6
Table 1: Laboratory parameters of patients and controls
Controls (n=70)
Pre dialysis (Group 1)
Post dialysis (Group 2)
Parameters
Mean ±SD
(n= 55) Mean ±SD
(n= 55) Mean ±SD
25.5 ± 5.7
132.2 ± 17.1*
128.0 ± 16.8**
Urea (mg/dl)
0.7 ± 0.9
9.8 ± 3.2*
8.5 ± 3.0**
Creatinine (mg/dl)
4.5 ± 0.8
2.9 ± 1.0*
3.1 ± 0.9**
Albumin (gm/dl)
3.9 ± 1.1
8.6 ± 2.1*
8.4 ± 2.0**
Uric acid (mg/dl)
13.8 ± 1.4
8.9 ± 2.7*
9.1 ± 2.9**
Hemoglobin (g/dl)
42.0 ± 6.1
26.3 ± 8.1*
28.1 ± 7.8**
Hematocrite (%)
89.6 ± 7.9
99.6 ± 10.4*
95.8 ± 9.9**
MCV (fl)
*P<0.001, and **p<0.001, highly statistically significantly compared to controls.
MCV; Mean Corpulsor value
Table 2: Serum Trace elements levels and MDA Concentration in study subjects.
Controls
Pre dialysis (Group 1)
Post dialysis (Group 2)
Parameters
(n=70) Mean ±SD
(n= 55) Mean ±SD
(n= 55) Mean ±SD
90.5 ± 11.1
88.2 ± 9.1 NS
89.1 ± 10.1 NS
Se (µg/dl)
80.2 ± 7.9
60.1 ± 6.8*
62.8 ± 7.0**
Zn (µg/dl)
105.8 ± 12.1
73.8 ± 10.1*
75.9 ± 11.1**
Cu (µg/dl)
18.5 ± 1.9
12.0 ± 1.3*
10.6 ± 0.6**
Mn (mg/dl)
22.1 ± 2.8
19.9 ± 1.9 NS
21.0 ± 2.0 NS
Mg (mg/L)
25.0 ± 2.7
38.3 ± 4.1*
36.1 ± 3.9**
Al (µg/dl)
3.8 ± 0.7
6.1 ± 0.5*
8.9 ± 1.7**
MDA (nmoles/ml)
*P<0.001 and **p<0.001, Highly statistically significantly compared to controls.
Se=Selenium, Zn= Zinc, Cu= Copper, Mn= Manganese, Mg= Magnesium, Al= Aluminum, MDA= Malondialdehyde.
showed decreased levels in both the hemodialysis groups
when compared to controls (p<0.001), but increased levels
of MCV as seen in pre and post dialysis groups when
compare to normal controls (p<0.001).
The mean serum levels of MDA and trace elements levels
in all groups and standard deviation are shown in Table 2.
Serum levels of MDA showed significant difference
between pre-dialysis and control group (p<0.001). It was
significantly increased in the post dialysis group when
compared with pre-dialysis and control group (p<0.001).
This table shows there was no significant difference in Se
and Mg levels between controls and the pre and post
dialysis values. On the other hand, the mean levels of Zn,
Cu and Mn were significantly decreased in pre and post
dialysis patients compared to control group (p<0.001).
Whereas, the mean serum Al levels in the pre-dialysis
group showed a significant elevation when compared to
controls (p<0.001), but no significant changes occurred
between groups before and after dialysis process. After
hemodialysis, the levels of Zn, Cu and Mn were highly
statistically significant decreased compared to control
groups. No significant changes were observed in the levels
of the studied trace elements in pre-hemodialysis compared
to their levels after hemodialysis patients.
4. Discussion:
In healthy persons the kidney is a regulatory organ that
allows for variations in dietary intake by causing
corresponding alternations in excretion. Hemodialysis
patients are at risk for deficiency of essential trace elements
and excess of toxic trace elements, both of which can affect
health. Though trace elements occur in very low
concentrations in the body, their role in the maintenance of
undisturbed biological functions is nonetheless highly
important [14]. In CRF, the concentrations of trace
3
elements are modified as a consequence of endogenous
toxicities and of impaired renal function, partly due to
dietary restriction and therapeutic measures [15].
MDA is a natural product of lipid peroxidation and reflects
the oxidant status of the biological systems. It has been
well documented that even a single session of hemodialysis
significantly increases lipid peroxides and decreases
antioxidants [16]. Results with regard to MDA levels in
hemodialysis are conflicting with some studies showing an
increase [17, 18] while others reporting a decrease in MDA
levels to normal after dialysis due to its clearance [19, 20].
Our study showed that there is a significant increase of
serum MDA levels in the post dialysis group when
compared with pre- dialysis group. There was also a
significant difference between the dialysis groups (pre and
post) compared to controls. These finding are in agreement
with the previous studies which have reported on elevation
of LPO in CRF patients and together with dialysis was
associated with an impairment of antioxidant defense and
overproduction of oxidative stress [21].
Trace elements are being increasingly recognized as
essential mediators of the development and progression of
kidney disease. On theoretical grounds, trace elements may
be protective against oxygen free radicals in the
development of chronic renal failure disease. Selenium (Se)
is a part of Glutathione peroxidase in the cytosol and
mitochondria, which protects biomembranes against
destruction. Se is also a central enzyme for eliminating
oxygen free radical and peroxidase [22]. Se is one of the
elements whose clinical importance for patients on
hemodialysis has not been clearly evaluated. Bogye et al
[23] revealed that Se levels in controls and post
hemodialysis patients are consistent with the results.
Zachara et al [24] who founded there was no significant
International Journal of Research in Biochemistry and Biophysics 2013; 3(1): 1-6
difference between serum Se concentration before and after
dialysis session. Similarly, in the present study also we did
not find any significant difference between serum Se in pre
and post dialysis. But we observed decreased Se levels in
hemodialysis patients when compared to controls. The low
Se level may be one of the factors responsible for the
increased incidence of malignancy in patients with CRF.
Zinc (Zn) is the essential trace element present in the body.
It takes part in the various important body functions
including protein synthesis, DNA synthesis, and cellular
growth. It is found almost in every cell and plays a vital
role in body’s immune system affecting innate and acquired
immunity. In renal failure, patients have disturbances in
acid- base balance and blood pH is acidic, therefore low Zn
levels in these patients are believed to be due to the shift of
zinc into red cells under acidic conditions [25]. In this
study, we found significantly decreased levels of Zn in pre
and post dialysis patients compared to controls. Our results
are in accordance with previous studies in which they
documented significantly lower Zn levels in hemodialysis
patients when compared to controls [26, 27]. Tetiker et al
[28] says that there was no significance difference between
Zn levels in pre and post in chronic hemodialysis patients.
However, in a study performed by Paydas et al [29] Zn
levels found to be normal in chronic hemodialysis patients.
Low concentration of plasma Zn levels in hemodialysis
patients may be possible because of restricted food intake,
diet with limited protein content, loss of appetite, loose
motions, negative nitrogen balance, skin manifestations,
impotency and decreased gastrointestinal absorption of Zn.
In addition, possible cause of decreased serum Zn levels in
these patients may be excessive loss of trace elements in
the dialysate.
Copper (Cu) plays an essential role in the function of some
enzymes like lysyl oxidase which helps in maintaining the
integrity of connective tissue in the heart and blood vessels.
It also plays a part in the bone formation and teeth. Clinical
characteristic of Cu deficiency are leucopaenia,
hypochromic microcytic anemia and osteopenia [30].
Alarcon et al [31] and Ghoreshi et al [32] revealed that
there is a significantly increased serum Cu level in pre and
post hemodialysis patients compared to controls. However
other studies have reported that there is no difference Cu
levels in the hemodialysis patients and control subjects
[33]. In a present study, we observed serum Cu level is
significantly decreased in pre and post dialysis when
compared to healthy controls. There was also significant
difference between the pre and post dialysis patients.
Similar observation was made by Sen et al [34]. A rich
source of the Cu is organ meat, and legumes. When the
patient develops chronic kidney disease, the diet containing
these foods are restricted which leads to deficiency of these
trace elements in the patients on hemodialysis and also may
be excessive loss of Cu in the dialysate.
Magnesium (Mg) is another trace element which is
essential for maintaining proper body functions. It is vital
for body’s immune system, cardiovascular and
musculoskeletal systems. Deficiency of this element will
lead to HTN, diabetes, kidney disease and cardiovascular
4
diseases [35]. In general serum Mg concentrations have
been reported to elevate in hemodialysis patients because of
decrease of the Mg excretion in a kidney. Yoshinori Miura
et al [36] and Tetiker et al [28] reported that the pre and
post hemodialysis patients did not show any significant
elevation of serum Mg compared to controls. Similarly in
our study also there is no significance difference between
the hemodialysis (pre and Post) groups when compared to
controls.
The Manganese (Mn) is rich in liver and kidney. Mn serves
as a cofactor for several enzymes and required for the
formation of bone, proper reproduction and normal
functioning of nervous system and it inhibits lipid
peroxidation. Conflicting results have been reported
regarding serum levels of Mn in hemodialysis patients.
There are reports of low, normal and high levels of Mn in
chronic dialysis patients [37, 38, 39]. Morever, this study
showed that there is a significant decreased level of Mn in
pre and post dialysis group when compared to controls
which are in agreement to finding of Pietrzak et al [40].
The deficiency of Mn cause impaired growth, abnormal
metabolism of glucose and lipids.
In hemodialysis patients, accumulation of Aluminum (Al)
has been reported. Al encephalopathy and aluminumrelated bone disease are important trace element related
complications. Dialysis itself might be an important cause
of Al accumulation [36]. In the present study we observed
Al levels in pre and post dialysis patients are significantly
higher compared to controls. Lee et al [41] reported that
serum Al concentration is higher in dialysis patients than
the controls. Some authors did not find any significant
difference between serum Al concentrations in
hemodialysis patients and normal controls [14]. The
accumulation of high Al levels in hemodialysis patients is
the use of Al containing drugs e.g. aluminum hydroxide.
Therefore most of the patients are bound to take this drug
and develop high level because use large amount of Al are
absorbed in the gastrointestinal tract. Molony et al [42]
made same observation that Al based phosphate binders
result in accumulation of Al in dialysis patients. Another
reason for Al accumulation in hemodialysis is the
decreased excretion of Al in urine and formation of uremic
compounds [43]. Moreover, according to the current results
of Al are statistically different between groups which point
out that it may be important to analyze this element. The
abnormal metabolism of Al may contribute to a part of
hemodialysis. It is very important that Al based phosphate
binders should be used very cautiously to avoid its toxicity
and non Al based phosphate binders need to be used.
Thus the results of our study shows that significant
difference of trace elements levels between pre and post
dialysis group is thought to be related with the loss of trace
elements through the membrane and the decreased
antioxidant enzymes and trace element levels may be
related to increase of lipid peroxidation in hemodialysis
patient. Morever, measurement of the trace elements should
be done before starting dialysis and at regular intervals
during dialysis.
There were some limitations in the present study, sample
International Journal of Research in Biochemistry and Biophysics 2013; 3(1): 1-6
size was small and it was a hospital based study, so can’t
represent whole population. There is need to perform such
studies on larger and community based population.
Conclusion:
Our results suggest that in CRF patients undergoing
hemodialysis, oxidant and antioxidants play a vital role in
the pathogenesis of disease. The result shows increased
reactive oxygen species accompanied by decreased
antioxidant defense in CRF patients on hemodialysis and
increased lipid peroxidation in erythrocyte membranes.
New approaches in dialysis membranes, hemodialysis
technique
and
usage
of
different
exogenous
supplementation of antioxidants and trace elements, for
removal of reactive oxygen species are important in
improvement of life qualities of hemodialysis patients. To
prevent some complications in hemodialysis patients, it is
important to regulate levels of trace elements. Otherwise,
ongoing oxidative stress present in the patients of
hemodialysis may play a pathophysiological role in the
development of cardiovascular disease.
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Source of support: Nil; Conflict of interest: None declared
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