INTRODUCTION:

Chronic renal failure (CRF) is correlated with skeletal anomalies recognized as renal osteodystrophy (ROD), which included several types of bone tissue oddities when estimated by histomorphometric¹. Osteoporosis is a repeated feature that may lead to late friable fractures in the route of ROD². Moderate to mild levels of CRF patients have rarely clinical symptoms. Whilst, the recent years studies revealed that about more than 50% of moderate renal failure patients only have abnormal bone histology^1,3, signalize that skeletal alterations may be commenced before the symptoms originate from years, and at minimum in some patients at very early stages of CRF⁴.

Different studies on bone mineral density (BMD) to renal failure patients were published recently, and performed to patients on dialysis stage. So, more of investigators were documented reduction of bone mass^{5, 6}. The researches on moderate to mild CRF patients with BMD are few and limited. Furthermore, most of the patients groups are little, and the conclusion standards are different in the severity and implied renal diseases terms on renal ailments⁷.

An attempt to estimate ROD clinically, and generally was implemented by collecting the results of serum assessments to ionized calcium (Ca⁺²), thyroid hormones (T₃, T₄), and vitamin D situation. Presently, biochemical parameters of bone turnover were showed significant in metabolic bone diseases when monitoring bone matrix to patients on CRF pre-dialysis^8,9.

The target of study was to investigate the role of Vit.D and Ca⁺² as a biochemical parameter of bone formation and effectiveness of advanced renal failure in chronic renal failure patients pre-dialysis on bone matrix, and to study the relation between other associated hormones (T₃,T₄) and bone resorption in patients with chronic renal failure.

Subjects and samples:

Patients and control:

The population samples were collected from Al-Hussein Medical City/Kerbala/Iraq, after the diagnosis by urology unit, and transported to dialysis unit through the duration of November 2017 to February 2018, seventy patients with chronic renal failure with ages ranging between (20 to 50) year were taken.

Healthy group were 50 subjects who were free from symptoms and signs of renal failure, and don’t have history of kidney failure, their ages were matched with the patients.

Specimens Collection:

Five milliliters of venous blood were drawn from pre-dialysis patients and control in the early morning after an overnight fasting. The samples were centrifuged at 3000 xg for 15 minute, then serum was separated and stored at -70 ̊C (deep-freeze) until analysis.

Vit. D Assay:

Serum Vit.D was detected by miniVIDAS automated immunoassay analyzer by using Vit. D kit (VIDAS^® 25 OH Vitamin D Total)

T₃and T₄ Assay:

Serum T_3, and T₄ were determined by using COBAS c311 system and human T₃, and T₄ kit.

Calcium (Ca⁺²) Assay:

Serum Ca⁺² concentration was measured by spectrophotometer method by using (Spinreact (7) E-17176 Sant Estevede bas (GI), Spain) kit.

Statistics:

In our data, was used the statistical package for social sciences (SPSS) version 22 to statistical analysis. Student t-test was used to results analysis. All of data were expressed as mean ± standard deviation (S.D). P-value ≤ 0.05 was considered a significant.

RESULTS:

The results showed that patients with pre-dialysis chronic renal failure have significantly higher Vit.D, and Ca⁺² levels (P=0.001) and significantly lower T₃, T₄ levels (P=0.001) than healthy group (Table 1).

Table 1: The levels of parameters under study to pre-dialysis chronic renal failure patients and control group

P-value	Control n=50 Mean ± S.D	Patients n=70 Mean ± S.D	Parameters
0.001	39.87±8.13	165.78±53.34	Vit. D (ng/ml)
0.001	2.10±0.28	0.71±0.34	T₃(nmol/L)
0.001	91.43±17.05	51.14±10.80	T₄(nmol/L)
0.001	0.82±0.16	21.87±2.82	Ca^²⁺)mg/dl)

In this study, the pre-dialysis chronic renal failure patients were classified according to their age into two groups. Group 1 which included of 24 patients (34%) their ages from (20 to 35) years old and group 2 which included of 46 patients (66%) their ages from (36 to 50) years old (Figure 1). The results revealed that patients with CRF (group 1) have significantly higher T₃ and lower Ca⁺² level (P=001) (P=0.04) than group 2 whereas there was no significant variations in the concentrations of their vit.D and T₄levels (P˃0.05) (Table 2). In addition, the CRF patients were classified according to their gender into two groups (sexual categories). Group 1 which included of 40 male patients (57%); and group 2 which included of 30 female patients (43%) (Figure 3). The results showed that female patients have lower T₃ level (P=001) than male, whereas there was no significant differences in the concentrations of other parameters (P˃0.05) (Table 3)

(36-50 yrs.) (20-35 yrs.)

Figure 1: Percentage of CRF patients according to age groups

Table 2: The levels of parameters under study to patients on pre-dialysis CRF according to age groups

P-value	Age(36-50) n=46 Mean ± S.D	Age(20-35) n=24 Mean±S.D	Parameters
0.671	170.26±54.54	160.92±53.97	Vit. D(ng/ml)
0.001	0.51±0.33	0.93±0.19	T₃(nmol/L)
0.363	53.08±10.33	49.05±11.36	T₄(nmol/L)
0.043	22.95±3.00	20.70±2.16	Ca^²⁺)mg/dl)

Figure 3: Percentage of CRF patients according to genders

Table 3: The levels of parameters under study to patients on pre-dialysis CRF according to genders

P-value	Female n=30 Mean ± S.D	Male n=40 Mean ± S.D	Parameter
0.724	160.23±51.44	163.38±55.56	Vit. D(ng/ml)
0.001	0.40±0.28	0.86±0.27	T₃(nmol/L)
0.068	56.32±7.99	48.70±11.29	T₄(nmol/L)
0.128	23.13±3.15	21.28±2.54	Ca^²⁺)mg/dl)

In our study, Person^'s correlation coefficient was used to mean the correlation between the markers. The results showed a strong positive correlations between vit.D with Ca⁺²; and T₃ with T₄ (r = 0.859, r = 0.767) respectively. Also the results revealed a strong negative correlations between vit.D with T₃; vit.D with T₄; T₃ with Ca⁺²; and T₄ with Ca⁺² (-0.813, -0.691, -0.878, -0.774) respectively (Table 4).

Table 4: The correlations between parameters under study to pre-dialysis chronic renal failure patients

Parameter1	Parameter2	n	(r)	P-value
Vit. D	T₃	70	-0.813	0.001
Vit. D	T₄	70	-0.691^**	0.001
Vit. D	Ca²⁺	70	0.859^**	0.001
T₃	Ca²⁺	70	-0.878^**	0.001
T₄	Ca²⁺	70	-0.774^**	0.001
T₄	T₃	70	0.767^**	0.001

**Correlation is significant at the 0.01 level

DISCUSSION:

In previous decade, the specific biochemical indicators of bone turnover were studied widely, than the actual notion of bone research ﬁeld is that those biochemical indicators, the results didn’t found certain diagnostic use to the single patient, than may be some uses in the following results of clinical attempts¹⁰. The causes of limitation in the daily clinical uses are a substantial intra-individual variability¹¹, then a strong association between parameters and rate of bone loss¹².

Little of researches subsist on use a biochemical bone markers in pre-dialysis CRF patients, and were concluded that the bone markers osteocalcin and bone resorption are caused by renal clearance reduction¹³.

The results of this study are associated with returns of histomorphometric studies, which commence with bony changes, at an early stage of kidney failure¹⁴. Malluche et al (2013) documented that pre-dialysis CRF patients have decreased levels of BMD, which associate with the GFR reduction¹⁵. Although, they revealed that only bone cortex was affected, which dispute with the current results, it is explained that complexity with bone cortex was evenly affected in those uremic patients. The reasons for this conflict may be attributed to difference of patient's categories or to difference of scanning techniques.

There was significant variation in patients with low T₃ level depended on the advanced stages of CRF patients. As well, was found positive association between GFR and serum T₃ in male and female groups; and in all control group¹⁶. Sang et al (2009) demonstrated that decreased T₃ syndrome was highly common in CRF patients and was noticeable results in early stage of CRF patients^16,17. Furthermore, Fan, et al (2016) documented that a highly common of decreased T₃ syndrome was monitored in pre-dialysis CRF patients, until in early stages (stage 1; and 2) of CRF. The prevalence increasing of low T₃ level in CRF patients indicate to finding a predictor to worst cases of CRF patients¹⁸.

Increase and decrease Ca⁺²levels jointly have dangerous effects in CRF patients. Increased levels of Ca⁺² may elevate the risks of cardiovascular diseases or vascular calcinations, but decreased levels of Ca⁺² may elevate the risks of fractures or osteoporosis^19,20. In addition, Moscovici, et al (2010) demonstrated that in mostly CRF patients with early stage, Ca⁺² and PO₄^-3 disturbances were not apparent until the advanced stages (stage 4). Subsequently, the elevated risks of cardiovascular diseases in those CRF patients were not attributed to those mineral disorders solely²¹.

Dhanwal, (2011) showed the possibility of bone resorption is prospective in the patients with chronic renal failure (CRF). Serum Vit.D and Ca⁺² results with the assay of thyroid hormones (T₃, T₄) may be provide a valuable indicators to bone turnover, or bone resorption in untreated patients with osteoporosis, and to therapy monitoring²².

CONCLUSION:

A high state of bone resorption result in reduced bone density, and its present in early stage of chronic renal failure (CRF) [GFR 5 to 60 ml/min], by assessment of elevated serum thyroid hormones (T₃, T₄), and elevated of biochemical markers (vitamin D and Ca⁺²) levels. We recommend to study some drugs which described to CRF patients, and that associated with bone matrix and cause osteoporosis like cortisone derivatives or non-steroidal drugs as a future studies.

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Received on 15.02.2019 Modified on 10.03.2019

Research J. Pharm. and Tech 2019; 12(10):4909-4912.

DOI: 10.5958/0974-360X.2019.00850.3