International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 05 Issue 17, September, 2013

Pages: 10-15

Date of Publication: 12-Sep-2013


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SERUM AMYLASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Author: Bindu C. M., Vidya Shankar. P., H. V. Shetty, Deepti Gupta

Category: Healthcare

Abstract:Introduction: Chronic kidney disease is a progressive loss in renal function over period of many months or years. There is decline in nephron function and number generally quantitated as reduction in glomerular filtration rate. As the GFR declines there is accumulation of metabolic end products excreted by Kidney. Amylase is one of enzyme that is rapidly excreted by kidney, thus patients in chronic kidney disease have elevated serum pancreatic enzymes. Aims and Objectives: The aim of present study was to determine changes in serum total amylase levels in patients with end stage renal disease on hemodialysis and non dialysed chronic kidney disease patients. Material and Method: Fifty patients with end stage renal disease coming for hemodialysis and fifty non dialysed chronic kidney diseases on outpatient follow up were included in this study. Fifty age and gender matched healthy individuals were included as control group. Blood samples were collected from patients as well as controls and were analysed for amylase, urea and creatinine using a fully automated analyzer. The results were analyzed statistically using student \"t\" test. Result: Present study has showed that serum total amylase levels were significantly higher in end stage renal disease and chronic kidney disease patients as compared to healthy controls (p value < 0.001). Serum total amylase levels was above the upper limit in sixty percent of patient and more than twice of upper limit in ten percent of patients. Conclusion: From our study it was concluded that in end stage renal disease and chronic disease patients, serum total amylase levels was found to be elevated .Serum amylase alone as a diagnostic tool in recognising acute pancreatitis leads to false positive results. Hence interpretation of elevated amylase in chronic kidney patients has to be supported by other laboratory and clinical evidence.

Keywords: End stage renal disease, chronic kidney disease, serum amylase

Full Text:

INTRODUCTION

Chronic kidney disease (CKD) is associated with the decreased glomerular filtration rate over period of months to years. In the later stages of CKD, the glomerular filtration falls drastically eliding to the accumulation of metabolic end products. There is decline in nephron function and number generally quantitated as reduction in glomerular filtration rate (1)

Chronic kidney disease is identified by blood tests, creatinine and urea are two such substances routinely measured. 

The National kidney foundation proposed a new classification system to classify chronic kidney disease in five stages, this system is known as Kidney disease outcome quality initiative (KDOQI)

Stage 1 being mildest with GFR 60 to 90 ml/min, Stage II is with GFR between 45 to 59 ml/min, Stage III patients having GFR of 30 to 44 ml/min, Stage IV are patients with GFR of 15 to 29 ml/min and stage 5 are patients with GFR of less than 15 ml/min. Patients with advanced CKD (Stage III, IV and V) have profound impaired GFR and accumulation of metabolic end products. End stage renal disease (ESRD) is group of patients on maintenance hemodialysis for CKD and requires dialysis to sustain life (2)

Amylase is one of the enzyme that is produced by exocrine pancreas and salivary gland that hydrolyses starch is rapidly cleared by kidney .Twenty percent of pancreatic enzymes is  excreted by the kidney thus patients with end stage renal disease have elevated levels of serum  pancreatic enzymes. The serum amylase and lipase are elevated in patients with end stage renal disease in absence of pancreatitis (3,4,5). The highest levels of amylase and lipase are noted in advanced CKD patients but marked elevations can also be seen in patients undergoing peritoneal dialysis (6,7).In one of study by Montalto  et al found increase in serum pancreatic enzyme during chronic renal pathology is slight but frequently occurs(8).

The purpose of this study was to evaluate the changes of serum amylase levels in patients with end stage disease on hemodialysis and non dialysed chronic kidney disease patients in the Indian subcontinent.

METHODS

Study subjects

100 patients of age group between 18 to 70 years of either gender were enrolled in the study.

They were divided in to two groups as follows

(1) 50 patients with ESRD coming for maintenance hemodialysis to the department of nephrology.

(2) 50 nondialysed Chronic Kidney Disease patients on outpatient follow up.

Study controls

Control group comprised of 50 healthy voluntary adults in the Rajarajeswari medical college.

All patients and subjects showed no evidence of pancreatitis, alcoholic liver disease, acute infections and patients with HbsAg/Hcv positive and they were not on medications which may lead to pancreatitis.

Informed consent was obtained from these subjects. The study was approved by the institutional human ethical committee

SAMPLING

Blood samples (4ml) were drawn with proper aseptic precautions from these subjects using vacutainers containing clot activators. The blood was allowed to clot, centrifuged and serum was used to perform biochemical analysis on the same day.

ANALYSIS

  1. Serum creatinine levels were estimated using modified Jaffes method.
  2.  Blood urea was estimated using Urease –GLDH (Glutamate Dehydrogenase) method.

Above parameters were estimated in hospital laboratory using fully automated analyser.

ESTIMATION OF AMYLASE

The method used to estimate amylase concentration in serum is by CNPG (2-chloro-4-nitrophenol   β -1-4 galactopyranosylmaltotrioside) method .It is a direct substrate for determination of amylase activity .The rate of 2-chloro-4-nitrophenol formation can be monitored at 415 nm and is proportional to amylase activity.

Calculation of Glomerular Filteration Rate

GFR was estimated by CKD EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. 

CKD EPI Equation for Estimating GFR Expressed for Specified Race, Sex and Serum Creatinine in mg/dl (9)

EQUATION

GFR = 141 × min (Scr /κ, 1) α × max(Scr /κ, 1)-1.209 × 0.993Age × 1.018 [if female] × 1.159 [if black] where Scr is serum creatinine in mg/dl, κ is 0.7 for females and 0.9 for males, α is -0.329 for females and -0.411 for males.

Values for serum creatinine, Age in years were inserted in equation to give values of glomerular filtration rate.

STATISTICAL ANALYSIS

The comparison of mean and SD between two groups was done using students “t” test using Minitab software for windows. A p value of <0.05 was considered to be statistically significant. Pearson correlation coefficient was also calculated.

RESULTS

The patients with Chronic kidney Disease showed positive correlation trends with serum amylase levels and eGFR (r=.206) but was not statistically significant.

It was noted that as the GFR declines below 50 ml/min the serum amylase levels showed deviation from the normal cut off values.

Serum total amylase together with serum creatinine and blood urea values for end stage renal disease patients, chronic kidney disease patients and controls are given in Table 1.The age and sex distribution in patients are given in Table 2. 

Serum total amylase levels was similar and above the upper limit of normal in both, end stage renal disease patients and chronic kidney disease patients. While it was higher in chronic kidney disease than end stage renal disease, the difference was not statistically significant (p=2.1).

Normal range for total amylase is 80 IU/L and there are differences from laboratory to laboratory. 50 control subjects were compared with 50 end stage renal disease it was significantly higher in patients (p<0.001) as shown in Figure1.

50 control subjects were compared with chronic kidney disease patients it was significantly higher in patients (p<0.001) as shown in Figure 1. Serum total amylase levels was above upper limit of normal in sixty percent of patients and markedly abnormal (more than twice upper limit of normal) in ten percent of patients

The glomerular filtration rates as measured by CKD EPI (Chronic Kidney Disease Epidemiology Collaboration) are given in Table3

In End stage renal disease patients glomerular filtration rate range is 4.1 ml/min to 15.3 ml/min and in chronic kidney disease range is from 9.0ml/min to 50.4 ml/min and there were 32 patients with glomerular filtration rate <30 ml /min and there were 18 patients with >30ml/min.

In 50 chronic kidney disease patients 24 patients had blood urea level between 43 to 100 mg/dl and 26 patients had   blood urea level >100mg/dl. Serum creatinine levels in 13 patients were more than 10 mg/dl and 27 Patients serum creatinine ranged from2.1-10 mg/dl.

In  50 end stage renal disease patients 12 patients  had blood urea levels between 43-100mg/dl ,38 patients had blood urea levels >100mg/dl. Serum creatinine levels in 14 patients were more than 10mg/dl and in 26 patients serum creatinine levels ranged from 4-10 mg/dl.

Three patients with end stage renal disease had more than two fold elevations of serum total amylase and in these patients blood urea and serum creatinine were very high.

Three patients with chronic kidney disease had more than three fold increase in serum total amylase levels and their blood urea and serum creatinine levels were also abnormal.

DISCUSSION

The present study has demonstrated that serum total amylase levels were elevated in patients  with end stage renal disease and chronic kidney disease  when compared with healthy controls it was statistically significant (p<0.001).Chronic kidney patients had higher total amylase levels ( mean 94.3+86.2SD) than end stage renal disease (mean 84.3+22.7 SD). It would appear that high levels of serum total amylase in patients need not indicate pancreatic disease since our patients had no clinical evidence of exocrine pancreatic disease and were not on drugs which would cause hyperamylasia

Elevations in serum total amylase among patients with chronic kidney disease or  end stage renal disease are most likely due to impaired renal clearance (10).In one study serum amylase began to rise only when the creatinine clearance dropped below 50 ml/min(11)

The highest levels of amylase are noted in hemodialysis patients but marked elevations can also be seen in patients with chronic renal failure and those undergoing peritoneal dialysis. A three fold to five fold increase in amylase levels is most commonly observed but the absolute values do not exceed three times the upper limit of normal. The degree of elevation is roughly proportional to the degree of renal dysfunction (7,12).

In one study by bastani et al 22 peritoneal dialysis patients were compared with 43 hemodialysis patient and 22 non dialysed chronic renal patients, mean total amylase activity was similar and above the upper limit  of normal in all 3 groups it was abnormal in 75% and above twice upper limit of normal in 24% of all patients(13)

We found 60% of patients increase in serum amylase activity and in 10 patients it was more than twice upper limit of normal .The precise mechanism of amylase transfer within the kidney have not yet been clarified. It was earlier concluded that amylase clearance was essential a function of glomerular filtration without significant tubular reabsorption(14).

In our study it was noted, patients with advanced CKD had higher level of serum amylase (mean 94.4+86.2SD) in comparison to ESRD patients (Mean84.2+22.7SD). It could be due to clearance of amylase during dialysis and malnutrition associated with dialysis.

Recent work by Johnson et al provides strong evidence in favour of tubular absorption of amylase in man(15). This has been shown experimentally in the rat(16). Loss of this preferential clearance of amylase is evident in renal insufficiency and is undoubtedly related to accompanying renal tubular atrophy(17).  Acute and chronic renal failure is accompanied by retention of both amylase and lipase(18)  hence rise in serum total amylase levels.

CONCLUSION

Serum total amylase was found to be elevated in both end stage renal disease and chronic kidney disease patients when compared to controls .Serum amylase as a diagnostic tool in recognising acute pancreatitis leads to false positive results. Hence interpretation of elevated amylase in chronic kidney disease patients has to be supported by other laboratory and clinical evidence.

ACKNOWLEDGEMENTS

The authors are indebted to all nurses in nephrology unit, dialysis centre of Rajarajeswari medical college and hospital for their support. We also thank Mr Shivanna for excellent co-operation and support.

References:

  1. National kidney foundation 2002), K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am j kidney dis.2002;39 (suppl 1):S1-S266.
  2. National institute for health and clinical excellence.clinical guidelines 73: chronic kidney disease.London, 2008.
  3. Royes VL, Jensen DM, Corwin HL. Pancreatic enzymes in chronic renal failure. Arch Intern Med 1987; 147: 537.
  4. Vaziri ND, Chang D, Malekpour A, Radaht S. Pancreatic enzymes in patients with end stage renal disease maintained on hemodialysis. Am J Gastroentrerol.1988; 83:410.
  5. Lin XZ, Chen TW, Wang SS, et al. Pancreatic enzymes in uremic patients with or without dialysis.Clin Biochem .1988;21:189
  6. Kimmel PL, Tenner S, Habwe VQ, et al.Trypsinogen and other pancreatic enzymes in patients with renal disease a comparision of high efficiency hemodialysis and continuous ambulatory peritoneal dialysis.Pancreas.1995;10:325
  7. Caruana RJ, Altman R, Fowler B, et al. Correlates of amylase and lipase levels in chronic dialysis patients.Int J Artif Organs.1988;11:454.   
  8. Montalto G, Carroccio A, SparacinoV, et al. Pancreatic enzymes in chronic failure and transplant patients.Eur J ClinChemClinBiochem .1997;35:237
  9. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2000;150;604-6
  10. Collen MJ, Ansher AF, Chapman AB, et al. Serum amylase in patients in patients with renal insufficiency and renal failure. Am J Gastroentrerol.1990;85:1377
  11. Aderstam B, Gracia-Lopez E, Heimburger O, Lindholm B. Determination of alpha amylase activity in serum and dialysate from patients using icodextrin based peritonial dialysis fluid.Perit Dial Int .2003; 23:146.
  12. MasoeroG, Bruno M, GalloL, etal. Increased serum pancreatic enzymes in uraemia relation with treatment modality and pancreatic involvement .Pancreas.1996; 13:350-355.
  13. Bastani B, MifflinTE, Lovell MA, Westervelt FB.Serum amylases in chronic and end stage renal failure: effects of mode of therapy, race, diabetes and peritonitis. Am J Nephro.1987; 7:292-299.
  14. McGeachin RL, Hargan LA. Renal clearance of amylase in man .Journal of applied physiology.1956; 9:129-131.
  15. Johnson SG, Ellis CJ, Levitt MD. Mechanism of increased renal clearance of amylase/creatinine in acute pancreatitis. New England Journal of Medicine.1976; 295:1214-1217. 
  16. Noda A.Renal handling of amylase: Evidence for reabsorption by stop flow analysis.Metabolism.1972; 21:351-355.
  17. Hegarty JE, O’Donnell MD, Mcgeeney KF,Fitzgerald O.Pancreatic and salivary amylase /creatinine clearance ratios in normal subjects and in patients with chronic pancreatitis.Gut.1978;19:350-354.
  18. Meroney WH, Lawson NL, Rubini ME, Carbone JV.Some observations of the behaviour of amylase in relation to acute renal insufficiency. New England Journal of Medicine.1956;255:315-

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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Best Article Award

A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Leow Jun Xian and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh et al. entitled "Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


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