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8/3/2019 Jurnal Anemia in Diabetes
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Anemia in diabetic patients at aninternal medicine ward: Clinicalcorrelates and prognostic significance
Presentan : Rahma Yuantari
Pembimbing : dr. Haryono, Sp.PK-K
Pembahas : dr. Anny Maryani
D Almoznino-Sarafian, M Shteinshnaider , Irma Tzur, AB Chaim,
E Iskhakov, Sylvia Berman, et al
European Journal of Internal Medicine;21;2010;9196
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Introduction
Anemia in diabetes
common & frequently unrecognized complication
of diabetes.prevalence varies 8% through 23% in large
studies
prevalence ~ chronic kidney disease (CKD)
more severe at any level of Glomerular Filtration
Rate (GFR) compared to non diabetic patients
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Reliable predictors :
CKD severity,
Transferrin saturation, sex,
albumin excretion ratio
HbA1c
Anemia in diabetes
progression of cardiovascular
disease, nephropathy,hospitalization and mortality
Etiology :
erythropoietin deficiency or
ineffectiveness of the latter,
nutritional deficiencies, systemic inflammation,
medications
autoimmune disorders
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Most of the information available from data in anambulatory setting, from that admitted to the internalhospital units ( in demographic parameters and clinical
profile)
Diabetic patients might suffer from diabetic complications(diabetic foot, CKD and HF which may aggravate anemia,and vice versa ) in need nursing care or areinstitutionalized with nutritional problems not included instudies performed in an ambulatory setting
Comprehensive information on etiology, clinical profile andprognostic significance of anemia in the in-patients unavailable
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define the prevalence of anemia in diabetic patientsthat were hospitalized in a medical department
etiology of anemia
its association with relevant clinical and laboratoryvariables, and
the impact of anemia and its associated conditions onsurvival
The aim of the present study
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Materials and methods
July 2005August 2006, patient from Emergency
Department due to a variety of internal disorders, ortransferred from the Intensive Care units, or
hospitalized for elective investigative purposes. Included all patients with type 1 or 2 diabetes.
Conducted principles of the Declaration of Helsinki &approved by the Local Ethics Committee.
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Patient from ED with DM type 1 & 2
Anemic Non Anemic
Obvious case Unknown etiology
Included : hematological disorders, active malignant diseases acute severe bleeding multiple organ failure
chronic dialysis declined further
hospitalization
Evaluated duringhospitalization
Survival& causes
of death
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Data
Demographic and clinical data registered only at firsthospitalization
complete blood count hemoglobin
HbA1c & fasting serum glucose,
albumin excretion in a spot urine sample and/or 24-hour urine collection,
erythrocyte sedimentation rate (ESR), serum C-reactiveprotein (CRP), urea, creatinine, iron, transferrin,
transferrin saturation, ferritin, vitaminB12, folic acid and erythropoietin.
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Definition
microalbuminuria /overt proteinuria.
persistent fasting hyperglycemia >7 mmol/l(126mg/dl), with or without referring to theprevious medical charts and/or history ofchronic anti-hyperglycemic treatment
Cr 133 mol/l (1,5 mg/dl) and eGFR < 60ml/min/1.73m2 (using MDRD equation)
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Symptoms shortness of breath, orthopnea or paroxysmalnocturnal dyspnea
data from previous and/or presenthospitalization(s) and/or outpatient facilityrecords.
Physical signs edema, pulmonary rales, gallop rhythm ordisplaced left ventricular apical impulse
Radiographic evidence of pulmonary congestion, pulmonaryvenous redistribution, basal or perihilar vascular blurring, Kerley Blines, pulmonary edema or pleural effusions
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WHO)
ferritin 100 g/l
ferritin 16 g/l & sTf20%
ferritin
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2.5 year follow-up period both diabetic anemic and non-anemic patients.
mortality incidence, cause of death, was registered.
Survival
Information about death and cause of death the registry ofthe Internal Affairs Ministry, hospital records, patients'families or outpatient death certificates.
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statistical comparison patients with and without anemia, andbetween the various anemic subgroups
Statistical analysis
Pearson's Chi-square or Fisher's exact test comparison of
qualitative variables
Analysis of Variance (ANOVA) or Mann-Whitney non-parametric U-test quantitative variables
Kaplan-Meier Survival curves
Mantel-Cox and Breslow tests evaluate the differences between
the curves
Cox proportional hazards model identify those variables most
significantly associated with mortality
A P-value 0.05 was considered significant.
The data were analyzed using BMDP Statistical Software
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Result
Non Anemic Anemic
age 64.4 + 13 years 71.4 + 11 P = 0.001Gender 44.4% 52.4% P = 0.02
Hospital stay 5.7 + 13.8 7.2 + 12.1 P=0.1
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38%
54%12%
39%
47%22%
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44 patients three or more etiologic or aggravating factors ofanemia were identified.
In other 81 patients two factor.
An association between HF and RD the most significant 66 (56.4%) of 117 patients with HF suffered of RD, P (20.3% vs. 10.4%, P=0.03),(+) vs (-) albuminuria (20.7% vs. 9.2%,P=.01)HF vs. non-HF borderline significant (19.7% vs. 10.8%,
P=0.06).
No significant differences inmortality rates between :subgroups aged
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Discussion
The present study observational, cross-sectional andprospective investigation, although part of the data still hadto be collected retrospectively
The patients randomly referred to the two InternalMedicine Departments inclusion bias
Patients admitted to the rest of the departments notincluded in the present investigation
The 1st study aiming to evaluate relevant aspect of anemiain uncelected diabetic patients hospitalized in IMD
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Three main issues :
prevalence and characteristics of anemia,
cause of anemia and association of anemia with variousrelevant comorbidities,
and prognostic significance of anemia.
Large epidemiologic study on general population of olderpersons with anemia only part of whom were diabetic1/3 nutritional deficiency , 1/3 anemia of chronic disease orCKD or both 1/3 unexplained anemia. This study iincludeinstituzionalized patients.
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In this study :
Iron deficiency : 38%
Vitamin B12/folat deficiency : 12%
Anemia of chronic disease : 54%
RD : 39%
HF : 47%
Diabetic foot : 22%
Multifactorialcause ofanemia
> patient has 2 concomitan conditions:
o Inflamatory disease
o Medication (metformin/thiazolidirfendiones, ACE inhibitor,sulfonylurea)
o Hemolysis
o Mild untreated hypothyroidsm 2 case
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Other literature
Anemia & RD risk of death in HF
Prev. iron def. varies, 43% anemic patients insufficient ironstores, 58% reduced iron availability
Study on pts. (-) nephropathy (-) iron def.
In this study38% pts anemia with insufficient iron stores, >
12% patients vit B12/folat inappropriate nutrition, gastritis,
malabsorbtion, metformin.
Def vit B12/folat neuropathy, + erythropoietin production &eventual orhtostatic hypotension life span
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Anemia in diabetes
survival
infection
DMHFRF
AlbuminuriaHF
Male
Marker of theconcurrent disease
>>died in 1st year
follow up & tx infection prevention
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The assumption that anemia improvement mightprolong survival, especially in males with albuminuriaor HF need future investigations.
The mortality rate in complex nursing care patients
and those with diabetic foot higher suggestingthat continuous medical control may be beneficial.
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Learning points
The frequency of anemia in diabetic patients admitted toInternal Medicine departments, compared to the studiesperformed on ambulatory patient populations.
Anemia in diabetic in-patients
caused by a variety ofetiologic factors
Anemia in diabetes ~ higher post-discharge mortality VSdiabetic patients free of anemia.
Infection main cause of death in anemic diabetic in-patients.
Within the group of anemic diabetic in-patients, , albuminuriaand HF ~ higher risk of death.
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Telaah Kritis
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Kesimpulan
Jurnal ini :
Cukup valid
pentingdapat diaplikasikan
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