2

Journal of Nephrology and

Renal Transplantation
(JNRT)
JNRT 5(1) 2013 : 2 10

HAEMATOLOGICAL PROFILE OF PATIENTS WITH

CHRONIC KIDNEY DISEASE IN NIGERIA
**
***
**
AO Shittu*, A
, AM Makusidi
* Chijioke , SA Biliaminu
***
*** , MA
Sanni , MB Abdul-Rahman , IM Abdul-Azeez
*

Department of Haematology and Blood Transfusion, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
**
Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
***
Department of Chemical Patholgy, University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Abstract

[Keywords]
Haematological
profiles, chronic
kidney disease,
Nigeria.

Chronic kidney disease (CKD) is a global public health problem, with

greater burden and very high cost of care especially in developing
countries like Nigeria. Hamatological profiles are commonly affected in
CKD and this becomes more apparent as the disease progresses. Few
literatures exist on haematological profiles of subjects with CKD in our
environment. The objective is to assess the haematological profile of our
subjects with CKD and compare the results with the ones found in other
parts and outside Nigeria. Seventy subjects with CKD at different stages
of the disease and 50 healthy adults were recruited into the study.
Haemoglobin concentration, PCV, total red cell count, MCV, MCH,
MCHC, total white cell count, platelet count and serum ferittin were
assessed for the subjects and controls. Results were analysed using SPSS
17.0 and comparison between subjects and control was made with
students t-test. All the measured parameters for the subjects were
significantly different from that of the control except MCV and MCH (ttest 0.000). Moderate anaemia was prevalent and the anaemias are
predominantly normocytic normochromic. Degree of anaemia worsened
with the progression of CKD. Our result is in keeping with that found in
Nigerian and other countries of the world.
2013 Journal of Nephrology and Renal Transplantation. All rights reserved

1. Introduction
Chronic Kidney Disease (CKD) is a major health problem throughout the
world [1]. It has a global public health problem, with greater burden and very

JNRT 5(1): 2013

high cost of care especially in developing countries. The exact prevalence rate of
Chronic Kidney Disease in Nigeria is not known. Hospital based data in Nigeria
have reported prevalence rates expressed as ratios of hospital admissions of
between 1.6 -8% [2,3]. CKD has been defined as either a level of glomerular
filtration rate (GFR) < 60ml/min per 1.73m2, which is accompanied in most
cases by signs and symptoms of uraemia, or a need for initiation of renal
replacement therapy [4].
Haematological parameters are commonly affected in CKD. Of all the
parameters, red cell indices are the ones commonly and severely affected. This is
because as high as 90% of erythropoietin is produced in the juxta glomerular
apparatus of the kidney while 10% are produced in the liver and other organs.
The severity of affectation depends on the stage of renal failure. Changes in red
cell indices are due to a number of factors aside erythropoietin productions.
Deficiencies of iron, vitamin B12 and folate as a result of nutritional
insufficiency or due to increased blood loss [5] are contributory factors.
Shortened red cell survival [6], hyper parathyroidism [7], mild chronic
inflammation [8] and aluminum toxicity [9] have also been implicated.
Anaemia is a consistent and severe complication of CKD [10] and its
occurrence as the disease progresses is well established [11]. The severity of
anaemia increases along with the progression of the disease [10]. Anaemia has
been shown to start appealing at GFR below 60ml/min [12], but more prevalent
when it falls below 30ml/min (or stages 4 and 5 of CKD) [13]. Severe anaemia is
a common feature in Nigerians with CKD and is strongly associated with severity
of CKD [16]. Haematocrit correlates inversely with the degree of renal failure as
assessed by serum creatinine [16].
Aside red cell indices, white blood cells, platelets and coagulation factors may
also be affected. Most authors reported total white cell count, platelet count and
bleeding time of normal ranges [15], but striking eosinophilia [16]. Prolonged
bleeding time has also been reported [16].
Literature on haematological profiles of patients with CKD in Ilorin, Nigeria
is sparse. Also no such study has been conducted in the North central region of
Nigeria so far, we therefore decided to evaluate the haematological profile of our
patients with chronic renal failure pre dialysis.

2. Materials and Methods

This was a cross-sectional study conducted at University of Ilorin Teaching
Hospital, a tertiary hospital in North Central region of Nigeria. Seventy (70) adult
patients with CKD at different stages of the disease were recruited consecutively
from Nephrology clinic of the hospital for the study. Fifty apparently healthy
adults who are mainly staff of the hospital were also recruited into the study as
controls. Verbal consent from the patients and controls and hospital ethical
approval were obtained before commencing the study. Patient already on

dialysis, those with active infections, those with haemoglobinopathies and those
with anaemia not related to CKD were excluded from the study.
5ml of venous blood sample was collected into tri-potassium ethylene
diamine tetraacetic acid (K3EDTA) from each patient and controls. The samples
were analysed for haemoglobin concentration, packed cell volume( PCV), total
red cell (RBC) count, mean corpuscular volume (MCV), mean corpuscular
haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC),
total WBC count, platelet counts and serum ferittin using KX 21N sysmex
automated machine.
The results were analyzed statistically using SPSS 17.0. Mean and standard
deviation of every parameter were calculated. The results of subjects and controls
were compared using students t-test.
s/no

Table 1 Age and haematological profile of the subjects and controls.

Parameters
Subject
Control
T-test
MeanSD

MeanSDH

Age

41.3 + 16.4

41.0 + 13.3

0.75

Hb (g/dL)

7.6 + 2.6

13.1 + 1.4

0.000

PCV %

24.41 + 8.4

40.1 + 4.4

0.000

12

RBC (x10 /L)

2.82 + 1.0

4.6 + 0.4

0.000

MCV(fl)

79.3 + 6.6

87.3 + 5.0

0.000

MCH (pg)

27.6 + 2.3

28.4 + 1.4

0.020

MCHC(g/dL)

33.3 + 1.4

32. + 0.6

0.020

8.3 + 4.5

2.9 + 0.6

0.000

112.11+84.4

190.3+97.5

0.000

167.4 + 165.0

16.6 + 13.9

0.000

TWBC (x10 /L)

9

Platelet (x 10 /L)
9

Serum

ferritin

(g/L)
10

3. Results
70 subjects and 50 controls were recruited for the study. The mean age of the
subjects and controls were 41.316.4 and 41.013.3 respectively. For the
subjects the haemoglobin concentration, PCV, total RBC count, MCV, MCH,
MCHC, total WBC count, platelet count and serum ferritin were 7.62.6 g/dl,
24.418.4%, 2.821.0 x1012/l, 79.36.6fl, 27.62.3pg, 33.31.4g/dl,
8.34.5x109/l, 112.184.4x109/l and 167.4165.0g/l respectively, Table 1. For
the controls the corresponding results were 13.11.4g/dl, 40.14.4%,

JNRT 5(1): 2013

4.60.4x109/l,
87.35.0fl,
28.41.4pg,
32.70.6g/dl,
2.90.6x109/l,
190.397.5x109/l and 16.613.9g/l respectively, Table 1. T-test shows a
significant difference in the values of all the profiles except for MCH and
MCHC.
Table 2 Age, Sex and haematological profiles of the subjects at different stages of CKD.
s/no
Parameters
Mild CKD
Moderate
Severe CKD
CKD
1

Total

number

13

40

40.98 16.6

41.58

17

of subjects.
2

Mean age

39.35 15.38

16.07
3

M.F

2:1

1:1.1

1:1.3

Mean

9.24 2.68

8.32 2.61

5.49 2.40

29.04 8.63

26.20 8.37

17.93 2.40,

3.65 0.98

3.08 0.95

1.73 0.83

MCV

79.06 6.47

78.97 6.36

79.86 6.96

MCH

27.27 2.19

28.32 2.17

27.41 1.38

Mean MCHC

34.09 1.36

32.00 1.31

33.78 1.38

5.86 4.65

5.72 4.33

13.40 4.19

143.94 8.38

104.50

Hb

conc(g/dl)
5

Mean

PCV

(%)
6

Mean RBC (x
109/l)

Mean
(fl)

Mean
(pg)

(g/dl)
10

Mean

TWBC

count (x 109/l)
11

Mean Platelet
count (x 109/l)

12

Mean

Serum

ferritin (g/l)

87.90 82.52

216.01 153.99

84.4
192.13
164.46

94.00
62.88

Table 2 shows the age, sex and haematological profiles of the subjects at
different stages of CKD. The total number of subjects with mild, moderate and
severe CKD was 13, 40 and 17 respectively. The mean age SD of the subjects

with mild, moderate and severe CKD were 40.9816.6, 41.5816.07 and
39.3515.38 respectively. Male to female ratio for mild, moderate and severe
CKD was 2:1, 1:1.1 and 1:1.3 respectively. The meanSD of haematological
profile for subjects with mild CKD was 9.242.68g/dl, 29.048.63%, 3.650.98
x 1012/l, 79.066.47fl, 27.272.19pg, 34.091.36g/dl, 5.864.65 x 109/l,
143.948.38 x 109/l and 192.13164.46g/l respectively. For subjects with
moderate CKD the corresponding values were 8.322.61g/dl, 26.208.37%,
3.080.95 x 1012/l, 78.976.36fl, 28.322.17pg, 32.001.31g/dl, 5.724.33 x
109/l, 104.5084.4 x 109/l and 94.0062.8g/l respectively. For subjects with
severe CKD the corresponding values were 5.492.40g/dl, 17.932.40%,
1.730.83 x 1012/l, 79.806.96fl, 27.411.38pg, 33.781.38g/dl, 13.404.19 x
109/l, 87.9082.52 x 109/l and 216.01153.99g/l respectively.
Table 3 shows the comparison of the haematological profiles of the subjects at
different stages of CKD with that of the control. The haemoglobin concentration
and total red cells count were significantly different from that of the control only
at the severe stage with p-value <0.05 but PCV was significantly different from
that of the control throughout the stages with p-value <0.05. MCV, MCH and
MCHC were not significantly different from the control throughout the stages
indicating the presence of normocytic normochromic anaemia throughout the
course of CKD. Total white cell count was consistently on the high sides as the
disease progresses and is significantly different from the control with p-value
<0.05. Platelet count was also on the decline as the disease progresses with
significant difference from the control (p-value<0.05). Serum ferritin although
with a very wide range of normal values (15-300g/l) was also significantly
different from that of the control with p-value <0.05.
Table 3 Haematological profiles of the controls compared with those of mild, moderate
and severe CKD subjects.
Parameters Controls Mild
PModerate
PSevere
PCKD
Total no of

50

value

CKD

Value

CKD

13

40

40.98

41.58

13.3

16.6

16.07

15.38

M:F

2:1

1:1.1

1:1.3

MeanSD

13.1

Hb

1.4

Value

17

Pts
Mean age

conc

41.0

9.24
2.68

>0.05

8.32
2.61

39.35

>0.05

5.49
2.40

<0.05

JNRT 5(1): 2013

(g/dl)
Mean SD

40.1

of

4.4

8.63

4.6 0.4

3.65

PCV

29.04

<0.05

26.20

<0.05

8.37

17.93

<0.05

2.40

(%)
Mean SD
RBC count

>0.05

0.98

3.08

>0.05

0.95

1.73

<0.05

79.86

>0.05

0.83

(x 109/l)
Mean SDs

87.3

79.06

MCV (fl)

5.0

Mean SD

28.4

MCH (pg)

1.4

Mean SD

32.7

MCHC

0.6

1.36

2.9 0.6

5.86

>0.05

6.47

>0.05

6.36

27.27

>0.05

2.19

78.97

28.32

6.96

>0.05

2.17

34.09

>0.05

32.00

27.41

>0.05

1.38

>0.05

1.31

33.78

>0.05

1.38

(g/dl)
Mean SD
TWBC

(x

<0.05

4.65

5.72

<0.05

4.33

13.40 +

<0.05

4.19

109/l)
Mean SD

190.3

143.94

Platelet

97.5

83.8

Count
109/l)

(x

<0.05

104.50
84.4

<0.05

87.90
82.52

<0.05

Mean SD

16.6

Serum

13.9

192.13
164.46

<0.05

94.00
162.88

<0.05

216.01

<0.05

153.99

ferritin
(g/l)

4. Discussion
Our study shows a significant difference in all the haematological parameters
measured between our subjects and controls except MCV, MCH and MCHC.
Moderate anaemia with meanSD of haemoglobin concentration of 7.6 2.6g/dl
was recorded for all our subjects. This is in keeping with the findings of other
researchers in Nigeria [15,16,17,18]. The pattern of anaemia in this study was
predominantly normocytic and normochromic as reported in other studies also.
Total WBC count, platelet count and serum ferritin were all within normal
limits as found by other authors [15,16,17,18] at the mild and moderate stages
but there was leukocytosis and thrombocytopenia at the severe stage.
A progressive decline in haemoglobin concentration, PCV and total red cell
count was noted among our subjects as the disease progresses. This can be
explained by a corresponding reduction in the synthesis and serum levels of
erythropoietin which is a major drive for erythropoiesis in the bone marrow.
Other factors may contribute to this in our subjects especially the associated
malnutrition noted in them.
With the progression of the disease, MCV, MCH and MCHC remain within
normal limits. Total WBC count remained normal at the mild and moderate
stages but was elevated above normal at the severe stage. Total platelet count
also remained within normal range at the mild and moderate stages but mild
thrombocytopenia was noticed at the severe stage. Serum ferritin remains within
normal limits throughout the disease progression.
The degree and pattern of anaemia in chronic kidney has been studied by
several authors. Prevalence of anaemia generally, as high as 94% has been
reported [14] as in our study. In other studies 13% of subjects were found not to
be anaemic [16]. The mean haemoglobin concentration has been found to range
between 7.4mg/dl [17] to 24.1mg/dl [16]. Mild to moderate anaemia was found
in up to 69% [16] and 1 00% [17] of subjects and severe anaemia in about 18%
[16] of subjects. Normochromic normocytic blood picture is commonly seen in
CKD as in other chronic disorders. It is seen virtually in all patients in Nigeria
[15,16,17,18] as in our study, but a figure as low as 30% was reported in
India[14]. Microcytic hypochromic blood picture is also common, seen in up to
65% of subjects [14] while macrocytic blood picture is seen only in 5% of
subjects [14].

JNRT 5(1): 2013

Other haematological findings in CKD were high reticulocyte counts in up to

46% of subjects[14], erythroid hyperplasia in 75% of subjects[14], normal bone
marrow cellularity in 61% of subjects[14], depleted bone marrow iron stores in
30%17-57%[14] of subjects, normal bone marrow iron stores in 37%[14] and
increased iron stores in 6%[14] and 50%[17] of subjects, low serum ferritin in
62%[14] of subjects and megaloblastic changes in bone marrow of 40%
subjects[17].
Total white blood cell (WBC) and its differentials, platelet count, bleeding
time, prothrombin time and partial thromboplastin time in Kaolin may also
affected in CKD. As in our results normal ranges of total WBC, platelet count
and bleeding time has been reported in CKD subjects [15]. Similar observation
but striking eosinophilia and prolonged bleeding time was made with no
significant correlation between platelet count and bleeding time (r = 0.21, p =
0.34), and none also between bleeding time and serum creatinine (r = 0.09, P
>0.05) [16] . Thrombocytopaenia in 52% of subjects and eosinophilia in 32% of
subjects are also common findings [14].
The normal WBC count may be due to the fact that uraemia affects the
function of leukocytes rather than granulopoiesis and this is the reason why there
is poor leukocytes response to infection in CKD patients [19]. Bleeding
tendencies is attributed to platelet dysfunction due to abnormal platelet
aggregation and adhesiveness [20]. Reduction in natural killer cells has also been
reported [21] while erythrocyte sedimentation rate has not been shown to
correlate with anaemia despite being elevated in up to 48% of patients [22].

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