|Year : 2015 | Volume
| Issue : 2 | Page : 571-577
Serum hepcidin level in children with chronic renal failure either on hemodialysis or on conservative therapy
Ali M El-Shafie1, Ghada M El-Mashad1, Hossam H Hegran1, Mohsen M El-Deeb MS 2
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
|Date of Submission||03-Jun-2014|
|Date of Acceptance||04-Jun-2014|
|Date of Web Publication||31-Aug-2015|
Mohsen M El-Deeb
Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta, Gharbia 31511
Source of Support: None, Conflict of Interest: None
To study serum hepcidin level in children with chronic renal failure (CRF), either on hemodialysis (HD) or on conservative therapy, and its role in anemia in chronic kidney disease (CKD) patients.
The role of hepcidin in the occurrence of anemia in children with CKD.
Patients and methods
Serum samples were obtained from 30 healthy individuals and from 10 patients with chronic renal diseases, and 20 patients with CRF. The levels of serum hepcidin, serum ferritin, and serum hemoglobin were determined and the correlation between them was studied.
There is a significant increase in the serum hepcidin levels in group I and group II than the control group. There was significant correlation between hepcidin and serum ferritin, and there was a negative correlation between serum hepcidin and hemoglobin and serum creatinine and clearance of serum hepcidin by HD.
CRF showed an increase in the serum hepcidin level that increased in severity with the increasing duration of HD, C-reactive protein, ferritin serum level and hemoglobin level. Hepcidin may serve as a marker for diagnosis and monitor anemia in CKD patients either on HD therapy or on conservative therapy. Standard dose of HD clear the serum hepcidin by about 35%.
Keywords: anemia, chronic renal failure, ferritin, hepcidin
|How to cite this article:|
El-Shafie AM, El-Mashad GM, Hegran HH, El-Deeb MM. Serum hepcidin level in children with chronic renal failure either on hemodialysis or on conservative therapy. Menoufia Med J 2015;28:571-7
|How to cite this URL:|
El-Shafie AM, El-Mashad GM, Hegran HH, El-Deeb MM. Serum hepcidin level in children with chronic renal failure either on hemodialysis or on conservative therapy. Menoufia Med J [serial online] 2015 [cited 2021 Mar 8];28:571-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/571/163920
| Introduction|| |
End-stage renal disease (ESRD), the terminal stage of chronic kidney disease (CKD), when treated with renal replacement therapy (dialysis or transplantation), becomes necessary to sustain life  .
Chronic renal impairment is defined as a reduction in glomerular filtration rate (GFR) below the normal values of ~120-130 ml/min/1.73 m 2 , developing over months to years. Its incidence has increased significantly over the last several years, but this probably reflects more accurate estimations of GFR  .
Many disorders can cause chronic renal failure (CRF). Two congenital abnormalities, posterior urethral valves and hypoplastic/dysplastic kidneys, and a third disorder, focal segmental glomerulosclerosis, are the primary causes of long-term kidney failure in children  .
Anemia is a frequent and serious complication of CKD and a risk factor for early death. Anemia conveys significant risk for cardiovascular disease, faster progression of renal failure, and decreased quality of life. Patients with CKD can have anemia for many reasons, with the severity being proportional to the degree of renal insufficiency. Anemia develops when the creatinine clearance has decreased to 30-40 ml/min/1.73 m 2  .
These patients require a thorough evaluation to identify and correct causes of anemia other than erythropoietin (EPO) deficiency. The mainstay of treatment of anemia secondary to CKD has become erythropoiesis-stimulating agents (ESAs). ESA therapy produces a dose-dependent increase in hemoglobin (Hb) levels and can restore Hb to normal levels if sufficient ESAs are administered. Iron deficiency is a frequent complication in patients with CKD. Iron deficiency blunts the response to ESA agents. Iron losses cumulating to 2 g/year are typical in the hemodialysis (HD) patients and exceed normal total body stores. The gastrointestinal iron absorption is less than ongoing iron losses in the majority of HD patients. Functional iron deficiency develops in most patients, leading to iron-limited erythropoiesis  .
Thus, despite the use of ESAs, anemia in CKD patients can be resistant to therapy. Both absolute and functional iron deficiency along with inflammation can contribute to ESA resistance and can be difficult to identify with current-day markers of iron storage  . Hepcidin, a 25-amino-acid peptide (hormone), is made primarily of hepatocytes in response to liver iron levels. Increased iron inflammation leads to increase in hepcidin; however, hypoxia, anemia, and decrease in iron stores leads to decrease in hepcidin. Hepcidin is the main iron regulatory hormone. Once secreted into the circulation, hepcidin binds to ferroportin (iron transporter) on enterocytes and macrophages, which trigger its internalization and lysosomal degradation. Thus, in chronic inflammation, the excess of hepcidin decreases iron absorption and prevents iron recycling, which results in hypoferremia and iron-restricted erythropoiesis, despite normal iron stores (functional ID), and anemia of chronic disease, which can evolve to anemia of chronic disease plus true ID. In contrast, low hepcidin expression may lead to iron overload, and vice-versa  .
Clearance of hepcidin by HD suggests a therapeutic intervention in patients with anemia  .
| Patients and methods|| |
The present study was carried out in the Department of Pediatrics, Menoufia University Hospital, during the period from January 2013 to January 2014, after getting acceptance from the ethical committee of the Faculty of Medicine and getting written consents from patients. The present study was carried out on 40 children divided into three groups:
The participants were classified into the following groups:
included 20 patients with CRF on regular HD. They were 12 boys and eight girls. Their ages ranged from 5 to 16 years.
Patients with ESRD of different causes on regular HD therapy three times/week, with each dialysis session lasting for 3-4 h, were included in this study. Their ages ranged from 5 to 16 years. They have been free from acute dialysis-related complications for at least 30 days before recruitment.
Dialysis was started when GFR was equal or less than 15 ml/min/1.73 m 2 .
included 10 patients with chronic renal insufficiency on conservative therapy. They were six boys and four girls. Their ages ranged from 5 to 16 years.
Patients' chronic renal insufficiency (stages 2-4 CKD) of different causes on conservative therapy, who did not require dialysis before, were included in this study. Their ages ranged from 5 to 16 years.
included 30 apparently healthy children with age and sex matched were chosen as control group. All patients received (before and during the study) supportive therapy in the form of subcutaneous EPO in a dose of 50 IU/kg/setting, intravenous iron dextran 100 mg/week, oral folic acid 1 mg/day, oral calcium 1000 mg/day, oral vitamin D (1α) in a dose of 0.01-0.05 μg/kg/day, and oral antihypertensive medications for hypertensive patients.
The following patients were excluded from this study.
All investigations were carried out before starting the HD session.
- Patients previously diagnosed with nonrenal cause of anemia other than iron deficiency.
- Patients with evidence of active or occult bleeding.
- Blood transfusion within the past 4 months.
- History of malignancy, end-stage liver disease, or chronic hypoxia.
- Recent hospitalization or infection requiring antibiotics within the past 4 weeks.
- Patients with ESRD and older than 18 years or younger than 2 years in age were excluded from the study. Patients were dialyzed on Fresenius 4008B dialysis machine (Bad Homburg, Germany) at blood flow rate = 2.5 × weight (kg) + 100 ml/min, using polysulfone hollow fiber dialyzers suitable for the surface area of the patients (Fresenius F3 = 0.4 m 2 , F4 = 0.7 m 2 , F5 = 1.0 m 2 , and F6 = 1.2 m 2 ). Bicarbonate dialysis solutions were used.
All patients and controls were subjected to the following:
Measurement of serum hepcidin
- Full history taking: including age, sex, residence, socioeconomic status, full nutritional history, duration of dialysis, and regular drug taking doses.
- Clinical examination:
- Anthropometric measures including weight and height.
- Systemic examination including chest, heart, abdominal, and neurological examination.
- Laboratory investigations: routine investigations including complete blood count, serum ferritin level, C-reactive protein (CRP), blood urea, and serum creatinine. Specific investigations: serum hepcidin levels with enzyme-linked immunosorbent assay (ELISA)  .
Quantitative measurement of bioactive hepcidin in serum was carried out using ELISA , .
Hepcidin reduction ratio
Serum hepcidin measurements were obtained immediately before HD initiation. A final sample was obtained immediately after the dialysis was completed. The average blood flow was 320 ± 52 ng/ml in pediatric patients.
Average time is 3.0 ± 0.4 h in the pediatric patients. Average ultrafiltration was 1.6 ± 1.1 l in pediatric patients. The hepcidin reduction ratio was calculated as (hepcidin at start of dialysis-hepcidin at end of dialysis)/hepcidin at the start of dialysis.
| Results|| |
The present study was conducted on 40 children who were divided into three groups.
included 20 patients with ESRD under HD therapy, and serum hepcidin levels were measured before and after HD.
included 10 patients with CKD under conservative treatment.
included 30 apparently healthy children as control group.
There was no significant difference between age and sex in the studied groups.
The causes of CRF of the patients in group I were chronic glomerulonephritis in eight patients (40%), polycystic in three patients (15%), obstructive uropathy in three patients (15%), reflux in three patients (15%), toxic drugs in two patients (10%), and hypertension in one patient (5%) (total 20 patients). In group II, glomerulonephritis in six patients (60%), toxic drugs in one patient (10%), obstructive uropathy in one patient (10%), hypertension in one patient (10%) and reflux in one patient (10%) were the causes of CRF. The duration of HD ranged from 1 to 7 years, with mean duration of 2.75 ± 1.65 years. There was a significant decrease in body weight and height of the patient groups compared with controls (P < 0.05). There was a highly significant decrease in Hb of group I and group II than in group III (P < 0.05). There was a highly significant increase in the serum ferritin levels in group I and group II as compared with the control group III (P < 0.001). There was a highly significant increase in the serum creatinine levels in group I and group II as compared with group III (P < 0.001).
There was a significant positive correlation between serum hepcidin and CRP both in group I and group II.
There was a positive correlation between hepcidin level and serum creatinine in group I. There was no significant correlation between serum hepcidin level and serum creatinine in group II. There was a significant positive correlation between serum hepcidin level and serum ferritin in group I. There was also a significant positive correlation between serum hepcidin level and serum ferritin in group II. There was a negative correlation between serum hepcidin level and Hb level both in group I and group II.
| Discussion|| |
ESRD is the terminal stage of CKD when treatment with renal replacement therapy (dialysis or transplantation) becomes necessary to sustain life  .
Chronic renal impairment is defined as a reduction in GFR below the normal value of ~120-130 ml/1.73 m 2 , developing over months to years  .
Anemia is a frequent and serious complication of CKD, and it is a risk factor for early death. Anemia conveys significant risk for cardiovascular disease, faster progression of renal failure, and decreased quality of life. Patients with CKD can have anemia for many reasons  .
The present study was conducted to evaluate serum hepcidin level (using a ELISA assay) in pediatric patients with ESRD under regular HD therapy and patients with CKD under conservative treatment, and its possible role in the pathogenesis of anemia in those patients and the impact of HD on serum hepcidin level, which could be used therapeutically to reduce the serum hepcidin level, and thereby improve ESA responsiveness.
The introduction of ESAs, such as EPO, has allowed effective treatment of anemia in patients with CKD. However, rhEPO resistance often associated with iron deficiency and inflammation remains a challenging problem  .
Most patients with CKD and anemia can be effectively treated with ESAs  .
Drueke and Locatelli, showed that 10% of the patients are hyporesponsive or nonresponsive to ESA. Several cohort studies have reported an association between higher doses of ESA and mortality. The important role of ESA resistance is stressed by the results of randomized controlled trials that reported an increased mortality or morbidity in patients who were targeted to high Hb levels. However, in this study, there is hyporesponsiveness to ESAs about 40%.
Hepcidin, an acute phase reactant released from the liver, is a negative regulator of iron entry to plasma  . High hepcidin levels are expected in CKD and ESRD and may be correlated with the inability to utilize iron and be hyporesponsive to ESA therapy  .
Hepcidin concentration were reported to be increased in patients with CKD, although this could be caused by inflammation that frequently accompanied CKD and that progressively increased with the increasing severity of CKD  .
Renal excretion is a major route of hepcidin clearance. Loss of kidney function decreases hepcidin clearance, and leads to the accumulation of hepcidin and the development of iron-restrictive anemia. Some studies have reported inverse correlation between GFR and serum hepcidin  .
Growth failure was well documented in our patients by significantly low weight, height in group I and group II patients compared with the control group. Inflammation is closely related to protein energy wasted in CKD and HD patients  , and the simultaneous combination of these two conditions, also referred to as malnutrition inflammation cachexia syndrome, is observed frequently in CKD and HD patients  .
In the present study, serum hepcidin levels were significantly higher in patients in group I, before HD, than in CKD in group II and controls, and the hepcidin level was decreased after HD in group I. The results in this study are in agreement with the study by Ashby et al.  and Tomosugi et al.  .
As expected, the elevation of serum hepcidin seems multifactorial in this particular population, with hepcidin correlation with markers of both iron storage and inflammation, and it slows the reduction in serum hepcidin by nearly 50% after standard HD treatment. However, in our study, the reduction is nearly 35%. Because hepcidin is a small molecule of 2.8 kDa, similar to the size of vitamin B 12 , it was cleared by HD  .
Kuragano et al.  also found that the serum hepcidin levels decreased by only 27% after a single HD session, but returned to the basal level before the next HD session.
There was a significant positive correlation between the serum hepcidin level and serum ferritin in group I and group II.
There was negative correlation between the serum hepcidin level and Hb level in group I and group II.
Zaritsky et al.  measured serum hepcidin in 26 pediatric HD patients and found elevated serum hepcidin level median (652.4 ng/ml). This level was much higher than our results (213.7 ng/ml), and this can be explained by high Hb levels in patients of his study (13.3 g/dl) compared with our patients Hb (8.95 g/dl in group I and 9.69 g/dl in group II)  . In addition, HD is an effective method for the removal of hepcidin, decreasing its serum concentration compared with peritoneal dialysis (PD). Our patients suffer from anemia, despite regular EPO and iron administration. Elevated levels of serum hepcidin in patients of this study reveled the truth regarding unresponsiveness of anemia to oral iron supplementation that makes unconfident that oral iron therapy in HD patients is of no value. Hepcidin inhibits iron absorption from the intestine  and intravenous iron administration by passing the intestinal barriers.
In the present study, there was a highly significant decrease in Hb of group I and group II than of group III (P < 0.05). Moreover, there were a negative correlation between the serum hepcidin levels and Hb levels in group I and group II.
There was a highly significant increase in the serum ferritin levels in group I and group II compared with the control group III (P < 0.001). The serum ferritin levels were significantly elevated in group I and group II. This may be explained by intravenous iron administration. Despite their high levels of iron, our patients still suffer from anemia. The bioavailability of this iron for erythropoiesis may by impaired by the elevated hepcidin levels, as hepcidin blocks iron released by the liver and macrophages interrupting iron recycling between old senescence red cells and reticuloendothelial system lead to a state of functional iron deficiency  .
In this study, elevated serum ferritin confirms the state of functional iron deficiency. ESRD patients on ESAs are at a high risk of developing iron-restricted erythropoiesis, because the rate at which iron is released from stores and delivered to the bone marrow fails to match the increase iron demand. This limited availability of iron to the bone marrow can be corrected effectively by intravenous iron, which improves Hb level  .
Serum ferritin is the most commonly used laboratory indicator in the diagnosis and management of iron deficiency anemia in CKD and ESRD patients. In the present study, the serum hepcidin levels were correlated with serum ferritin; this may suggest to use hepcidin as a novel biomarker of iron status. Numerous studies documented a positive correlation between serum levels of hepcidin and ferritin , .
The results in this study are 35%; however, Peters et al.  stated 50% clearance of hepcidin by HD. Therefore, with standard dose HD, there was a significant decrease in the weekly dose of erythropoietin-stimulating agents (ESA) in patients in group I [Figure 1] [Figure 2] [Figure 3] [Figure 4] and [Table 1] [Table 2] [Table 3] [Table 4].
|Figure 1: Correlation between serum hepcidin level and serum ferritin in group I|
Click here to view
|Figure 2: Correlation between serum hepcidin level and serum ferritin in group II|
Click here to view
|Figure 3: Correlation between serum hepcidin level and hemoglobin level in group I. Hb, hemoglobin|
Click here to view
|Figure 4: Correlation between serum hepcidin and hemoglobin level in group II. Hb, hemoglobin|
Click here to view
| Conclusion|| |
- Children with CRF show increase in serum hepcidin level; its level increases with increase in the years of HD, CRP levels, and serum ferritin levels, and decrease in the Hb level.
- Hepcidin may serve as a marker for diagnosis and monitor anemia in CKD either on HD therapy or on conservative therapy.
- Standard dose of HD clear the serum hepcidin by about 35%.
- In future, antihepcidin and gene therapy may play a role in the treatment of anemia.
| Acknowledgements|| |
Conflicts of interests
There are no conflicts of interest.
| References|| |
Warady BA, Chadha V. Chronic kidney disease in children: the global perspective. Pediatr Nephro 2007; 22
Kraut JA. Disturbances of acid-base balance and bone disease in end-stage renal disease. Semin Dial 2006; 13
Warady BA. End-stage renal disease in children: what causes? RENALIFE 2002; 17
Lankhorst CE, Wish JP. Anemia in renal disease: diagnosis and management. Blood Rev 2010; 24
Hayat A. Safety issues with intravenous iron products in the management of anemia in chronic kidney disease. Clin Med Res 2008; 6
Babitt JL, Lin HY. Molecular mechanisms of hepcidin regulation: implications for the anemia of CKD. Am J Kidney Dis 2010; 55
Gisbert JP, Gomollon F. An update on iron physiology. World J Gastroenterol 2009; 15
Kato A, Tsuji T, Luo J, Sakao Y, Yasuda H, Hishida A. Association of prohepcidin and hepcidin-25 with erythropoietin response and ferritin n hemodialysis patents. Am J Nephrol 2008; 28
Locatelli F, Martin-Malo A, Hannedouche T. Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 2009; 28
Ganz T, Nemeth E. Iron imports: IV. Hepcidin and regulation of body iron metabolism. Am J Physiol Gastrointest Liver Physiol 2009; 290
Nicolardi S, Palmblad M, Dalebout H, Bladergroen M, Tollenaar RA, Deelder AM, et al.
Quality control based on isotopic distributions for high-throughput MALDI-TOF and MALDI-FTICR serum peptide profiling. J Am Soc Mass Spectrom 2010; 21
Swinkels DW, Girelli D, Laarakkers C, Kroot J, Campostrini N, Kemna EH, et al.
Advances in quantitative hepcidin measurements by time-of-flight mass spectrometry. PLoS One 2008; 3
Drueke TB, Locatelli F, Clyne N. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006; 335
Zaritsky I, Young B, Wang HJ, Westerman M, Olbina G, Nemeth E, et al.
Hepcidin: a potential novel biomarker for iron status in chronic kidney disease. Clin J Am Soc Nephrol 2010; 4
Ashby DR, Gale DP, Busbridge M, Murphy KG, Duncan ND, Cairns TD, et al.
Plasma hepcidin levels are elevated but responsive to erythropoietin therapy in renal disease. Kidney Int 2009; 75
Fouque D, Kalantar-Zadeh K, Kopple J. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008; 73
El Shafie, AM, Bahbah MH, Khattab AA, El Mash GM. Evaluation of nutritional status of children with chronic renal disease before and after nutrition therapy. Jpc 2009; 9:8.
Tomosugi, N, Kawabato, H, Wakatabe, R, Higuchi M, Yamaya H, Umehara H, et al.
Detection of serum hepcidin in renal failure and inflammation by using protein chip system. Blood 2009; 108
Ganz T. Molecular control of iron transport. J Am Soc Nephrol 2007; 18
Kuragano T, Shimonaka Y, Kida A. Determinants of hepcidin in patients on maintenance hemodialysis: role of inflammation. Am J Nephrol 2010; 31
Young B, Zaristsky J. Hepcidin for clinicians. CJASN 2009; 4
Hugman A. Hepcidin; an important new regulator of iron homeostasis. J Biol Chem 2009; 276
Barany P. Inflammation, serum C-reactive protein, and erythropoietin resistance. Nephrol Dial Transplant 16
Peters HP, Laarakkers CM, Swinkels DW, Wetzels JF. Serum hepcidin-25 levels in patients with chronic kidney disease are independent of glomerular filtration rate. Nephrol Dial Transplant 2009; 2:848-853.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]