IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 Levels of Trace and Essential Elements in Sera o f Chronic Renal FAilure Patients Before and After Dialysis A. H. Jawad*, A.A.AL-Mulla **,A. .S.A.Zardlek awee** * Departme nt of Chemistry,College of Sciences, AL-Nahrain Unive rsity **Departme nt of Chemistry, College of Education Ibn Al-Haitham, Unive rsity of Baghdad Abstract This st udy included a group of (15) chronic renal failure p atients (CRF), an addition group of (15) healthy individual was concluded in this st udy for control. Trace and essential elements ( Zn, Cu , Ca , K , Na) were measured by atomic absorp tion and flam analyzer in sera of CRF p atients p re and p ost dialysis and control group s. T he results showed a significant ( p < 0.05) increase in Zn and k+ concentration in sera of CRF p atients p re and p ost dialysis comp ared to the control group . While there is a significant decrease for copp er concentration in sera of CRF p atients p re and p ost dialysis compared to the control group . There was no significant alteration (p > 0.05) in Ca and Na+ concentration in sera of CRF p re and p ost dialysis compared to the control group . Introduction Chronic renal failure (CRF) is sy ndrome, which results it’s a st rong p rogressive and an irreversible dest ruction of nephrons [1]. The dest ruction lead to t he reduction of glomerulur filtration rate (GFR) [2] Uremia often occurs as a sy mptom and comp lication of CRF , though some patients may be asy mptomatic until the GFR falls below 5-10 ml /min, nephrous can regenerate and restore normal function after acute failure , but ( CRF) requires a kidney transp lant or hemodialysis [ 3] Hemodialy sis is not limited to the treatment of renal insufficiency it is also used in liver disease to remove wastes normally detoxified by the liver Zinc is an essential trace element and is a required component of many enzy mes [4] Zinc exists in high concentration in kidney among other organs zinc which influences many body sy st ems and function .Zinc as a cofactor for many metal enzy mes ,it is transp orted in p lasma mostly by albumin (60-70) %.Although serum or p lasma were the usual sp ecimen of assessment of zinc st atus, urine and leukocyte zinc level were also used .Cop p er is an essential element in biological sy st em. Cop p er is incorp orated into several enzy mes involved in hemoglobin formation, carbohy drate metabolism, catecholamine biosy nthesis, and cross- linking of collagen, elastin and hair keratin [5]. A 70 k gm human, adult body contains app roximately 80 mg of copp er. Following absorp tion copp er the main site of bounded Cu is cerrup lasmine and is mainly deposited in liver hepatocy tes with lesser amounts in the kidney . Biliary excretion is t he major route with small amounts secreted in the urine Elevated serum copp er level over 2.0 mg/l (31.5 mol/ l)can result from the use of oral contracep tive and estrogen therap y and are usual during the third trimester of p regnancy . Serum levels are also elevated in some p atients undergoing renal dialysis Calcium is essential for both the phy sical structure of bone and for normal phy siological function (e.g., nerve IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 conduction, muscle contraction, blood clotting membrane p ermeability , enzy me activation, and acety lcholine sy nthesis [6]. The average healthy adult body contains about 1200g of calcium 99%of which is found in bone and teeth, with remaining 1% in the extra cellular fluids, intracellular structures, and cell membranes Very large chronic intakes are associated with hy p ercalcemia and / or hy p ercalciuria. Ot her sy mptoms of calcium excess include renal failure and soft tissue calcification. High – calcium diets could increase the risk of kidney st ones in suscep tible individuals and reduce the bioavailability of zinc and iron which Oxidation on the surface of the metal may form highly reactive sup eroxides , which can detonate the bulk causing sp att ering and skin and eye penetration . The main trace element is K in the intracellular fluid, accumulating to a concentration about 30 times higher than in p lasma. Pot assium in p lasma is involved in nerve transmission, muscle contraction and blood p ressure homeost asis. The gastrointest inal absorp tion of p otassium is nearly comp lete: p lasma concentrations are kept within a narrow range by regulation of urinary excretion and by depletion of body st ores in cases of low p otassium intake [4]. Pot assium app ears to moderate the effect of increased sodium intake on elevating p ressure p robably by affecting renal sodium excretion. Sodium is the main element of extra cellular fluid and the p rimary regulator of extra cellular fluid volume [7]. Sodium also regulates osmolarity , acid –base balance and membrane p otential and p articip ates in active transp ort across cell membranes. Renal excretion of sodium maintains homeost asis over a wide range of intakes and losses, via aldost erone control of tubular excretion [6]. The aim of this st udy included the measurement of the trace elements (zinc, copp er) and essentially elements (p otassium, sodium and calcium) for p re and p ost dialysis chronic renal failure by using atomic absorp tion and flame analyzer. S ampling The samples were collected from (AL-kadhmeia teaching hosp ital and sp ecialized surgical hosp ital) They were classified into two group s as t he following: 1.Control group : included [15] healthy individual from both sexes, with no p revious disease, which may interfere with the parameters analyzed in this st udy . 2.Patients group : include [15] Chronic Renal Failure patients (CRF) (p re and p ost ) dialysis S amples and methods Col lection of blood Ten ml venous blood was taken from the above group s , p lace in p lane tube ( no anti coagulant ) left for ( 15 min ) at room temp erature , then centrifuged ( at 300 rp m ) for (20 min ) to get serum ,which is stored at ( -20 C) unless used immediately . Experimental Determination of (Zinc, Cop p er, Calcium, Sodium, & Pot assium)Concentration in serum was p erformed by using atomic absorp tion sp ectrop hotometer shchimadzu AA 670 ( Japan ) (, while the concentrations of ( Na+ & K+) in serum samples were determined by flame analyzer ( Gallen Kamp).[8] S tatisti cal analysi s Statist ical analyses were p erformed by using M icrosoft excel 2003. Data p resented were the means and standard deviations. Analy sis of student - t - test was also made to compare the significance of difference in the mean values of any tow group s (P< 0.05) was considered st atist ically significant [9]. IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 Re sult and Discussion Serum zinc, copp er concentration ( mol/ l) and serum calcium concentration ( mmol/ l ) of chronic renal failure and control group s were shown in table (1) and figure (1) . From table (1) and fig (1) zinc and copp er concentration shows a significant decrease in sera of (p re and p ost ) dialysis in CRF group comp ared to normal control no significant alteration in serum calcium level (p re and p ost ) dialysis in CRF group comp ared to normal control [10]. Zinc deficiency was first described in human in the early 1960s research which has elucidated many of its sp ecific metabolic interaction moreover the discovery of a variety of zinc –related clinical disorders has directly demonst rated the importance of Zn in human nutrition .The zinc metabolism is altered in chronic uremia, and it is not corrected by maintenance dialysis therap y [11].The cause of zinc deficiency associated with chronic uremia has not been elucidated increased the urinary zinc losses or decreased intestinal zinc absorp tion which may contribute to the p resence of zinc deficiency in uremia. Previous st udies p erformed in laboratory have shown a decreased renal tubular re –absorp tion of zinc both in chronic uremia p atients and rat model of chronic uremia [12]. The low level of serum zinc concentration found in the p resent st udy consists with the reports of other invest igators Ongajooth et al. (1996) [13] observed that p lasma Zn was significantly lower in the hemodialy sis (HD) p atients than in the controls. Some factors that may count for low serum Zn levels in CRF p atients are restriction of p rotein diet , low dietary Zn intake, a sp ecific Zn transp ort defect, and absence of intest inal Zn ligand. Zn sup p lementation was recommended when p rotein is restricted in CRF p atients. The cause of zinc deficiency is not well known in uremic p atients but malnutrition and malabsop tion are most common, decreased bioavailability of zinc in the diet, dietary habits drug intra zinc and increased urinary excretion of zinc as factor underly ing zinc deficiency was observed that z inc urea is directly connected to p rotein urea in patients with nephrotic has reported that they observed a relationship between zinc deficiency with CRF [14]. In some st udies, serum Cu levels were higher in HD p atients while in others, the serum cu levels in p atients with CRF were within normal ranges or lower . Serum Cu levels were significantly lower in the HD p atients than in the controls. Our results are comp atible with that reported value in CRF,. Although, this may seem to be and inconsist ency with other st udy claimed that , t he serum levels were also within normal ranges. Also st udy by , Krachler reported elevated p lasma Cu content before and after HD and invest igated kinetics of p lasma cu during HD sensation revealed that p lasma Cu is st eadily increasing. Similarly , it was showed a higher concentration Cu in HD p atients while showed no change during the dialy sis t reatment Calcium is an imp ortant ion in the normal functioning and survival of animal cells. The human body is equip p ed with an efficient p rotection sy st em against hy p ocalcaemia. This sy st em is comp osed of p arathy roid glands bone, kidney , and intestine By app rop riate action of p arathy roid hormone (PT H) and active vitamin-D, a small fall of extra cellular calcium ion concentration is instantly corrected. Thus, a defect of any st ep in this sy st em results in the development of hy p ocalcaemia [16] Overloaded calcium either from bone or intest ine is efficiency excreted into urine IBN AL- HAITHAM J . FO R PURE & APPL. SC I VO L.22 (4) 2009 Thus hy p ercemia develops almost exclusively when a greater amount of calcium than the kidney can excrete is loaded . In chronic dialysis p atients, either hy p ocalcaemia or hy p ercalcemia may develop because of defects in these two defense sy st ems against calcium imbalance . Calcium accumulations in erythrocytes were associated with a wide range of toxic factors. Increased in intracellular ,calcium concentration of ery throcytes may cause decreased deformability and observed erythrocytes [17]. M any reports indicate that Ca p re- and p ost – HD remain higher than control The suggestion is that many factors, such as comp lement activation, shearing st ress, and p eroxidative damage of the membrane’s lip id-may increase the erythrocytes membrane p ermeability during HD and favor calcium influx [18]. The p otassium and sodium concentration ( meq/l) in sera of st udied group s were p resented in table ( 2) and fig ( 2) .The results of p otassium for p re and p ost –dialysis in CRF were ( 6.8429 ±1.506) meq / l (6.0 ± 1.600) meq /l resp ectively comp ared to the normal control (4.729 ± 0.6887) Pot assium concentration was significantly increased for p re and p ost – dialysis comp ared to control Pot assium (K) is the major determinate for the rest ing membrane p otential of excitable cells [19]. The concentrations of p otassium should be kept 3-5 mmol/L. Severe hy p okalemia leads to p ronounced hy p er p olarization of the cell membrane which causes ventricular arrhynias. Plasma K + levels higher than 7 mmol/L cause life-threatening cardiac events as well as blood p ressure decreases. M ichael and Hermiann (1999) reported that elevated p lasma K concentration in HD p atients decreased st eadily during HD to level of healthy adult. Documented to the rapid fall ectop y in serum p otassium concentration during dialysis ,our results are in an agreement with the rep orted value [20]. The development of intracellular acidosis in kidney from p otassium deplete rats was demonst rated by 31 P NM R st udies. T he 31 P NM R st udy also showed that an infusion of KCl led to a rapid (30 minute) returned to normal p H in kidney from p otassium deplete rats, suggesting the p ossibility of an interchange of (H + ) and (K + ) within an intracellular comp artment. While severe p otassium depletion induces an intracellular acidosis in muscle. Early st udies associated with more modest st udy of p otassium dep letion failed to demonstrate an intracellular acidosis The decrease of p lasma p otassium concentration was p revented by the increase of K + concentration in the dialysis according to its p redialy sis p lasma level One of the goals of p eriodic dialsate is the removal of K from the body that has accumulated over the two to three days between blood and dialy sis p otassium concentration [21]. Na is the representative of the extra cellular electrolytes that are subst antial for maintaining the osmotic balance between extra-and intra cellular sp ace. M oreover, Na is an imp ortant determinant in blood p ressure control, and the p lasma level of Na should be kep t in the range of 135-145 mmol/L . High p lasma Na concentrations (hy p ernatermia) give rise to elevated blood pressure, and consequently , lead to an increased p reload of the heart. Table (2) and fig (2) showed the results of sodium in sera of p re – dialysis , p ost -dialysis were ( 138.363 ± 4.148) ( 137.03 ± 3.448) resp ectively comp ared to control group ( 137.58 ± 7.858) On along run, high p lasma Na level leads to cardiovascular disease and hence adequate Na balance during dialysis is of major imp ortance for the p revention of comp lication (20) . To keep the Na balance in patients, the required range was 135-145 meq/L. Our results (134-144) m mol/L is compatible with the rep orted value in HD for chronic renal failure. This balance IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 was established by an app rop riate selection of the Na + concentration in the dialsate, and no ionic flow across the membrane occurred. Low sodium concentration (hy p onatremia) possible causes of sodium deficiencies include p rolong sweating, renal disease in which sodium is reabsorbed inadequately , adrenal cortex disorders in which aldost erone secretion is insufficient to p romote the reabsorp tion of sodium and drink too much water. Possible effect of hy p onatremia include the development of extra cellular fluid that is accomp anied by Osmosis , the concentration of Na in p lasma and dialysis fluid were almost identical and did not change during hemodialysis(21 ) . Re ferences 1.Cerpts, E.X.(1991): Am. Kidney.J.;Renal Data Sy st em: 18(Sup p 12), college of medicine , department of chemistry and biochemist ry , laboratory manul , second y ear ,p art t wo p p .(980-980 2.Internet (2004) , human p hy siology , htt// www.egy p t.com ,files all in htm. 3. Hakim, R.M ., (1999) Assessing the Adequacy of dialysis kidney ; 12:17 4.National research council, (1989) Recommended Dietary Allowances, 10 th ed. National academy p ress, Washington, DC. 5.Agency for toxic substances and disease registry (AT SDR) (1990) : Toxicologicalp rofile for cop p er .Atlanta,GA. 6.internet (2004) , kidney function inter , . www.kager.com,journals,nef 7.Krenzelok , E.P. (1992) : sodium and potassium in : Hazardous materials toxicology , edited by J.B. Sulliran Jr ., and G.R. Krieger, pp . 797-799. Williams &wilkins , Baltimore , M .D. 8.Aclock,W.N, (1987) copp er. In : methods in clinical chemistry p esce A.M . and Kap lan L.A(eaitors) , M osby , Co;USA 9.Degroot, M .H. (1986) :Probability and statist ics; 2 nd Edition , Adison Wesley p ublishing comp any , 5: 20-22. 10.Burtis , C.A. and Ashwod. (1994) clinical chemist ry , 2 nd Edition , Philadelphia , 11.Iotovap, Ionnova,D.; Kuleva, and Ant or, (1997) Nep hron Dail Transp lant 12: 370- 371. 12.Young, T.K.; Wang, S.C.; Chen, S.M . and Shice, (1996) clin p hy siol 39: 43-48.. 13.Ongajooth, Likidlilid, A. ;Chantachum,Y.; Shayakui, C.N.and Warangkur, S. (1996) J.M ed Assoc. thai, 791-800. 14.Prehn, B. ( 1991) Urol. Nep hro., 17: 66. 15.Gallient , M .; Bracaccio, D.;Cozz olino, M . and Sabbioni, (1996): Nep hroldial Transp lant, 11: 1232-1235 16. Al-deeb ,H. M . internet(2004):evaluation of educational program from hemodialysis p atients at p rincess Basmal hosp ital 17. Gardner, D.G(2001):Am.M ed.15:736-737 18.Luciak M . and Trendelk, (1991): Nephron Dial Transp lant; 6: 66-70 19.Tannen, R. L.; Davsion, A.W.; Grunfeld, D. P. and Kerr Diritz, E. (ed.), (1992): Hy p er Kalamia in came- 1ons: "Oxford textbook of clinical Nephrology " Oxford university p ress, p p .895- 917. 20.M ichael and Hermiann (1999): Jt race element in exp erimental medicine; 2:297 21.Radaelli B., (1996): Nephron Dial. Transp ort; 39:41. 16.Hussein M ust afa Al- deeb , internet 2004: evaluation of educational program from hemodialysis p atients at p rincess Basmal hosp ital . 17.Gardner D.G(2001): Am. M ed: 15: 736- 737. IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 Table (1) :Concentration of Zn, Cu and Ca in sera of patient and control groups p Ca (mmol/l) p Cu ( mol/l) p Zn ( mol/l) No. 2.52 ± 0.3545 26.34 ± 7.558 10.102 ± 3.068 15 Control p >0.05 3.1813 ± 0.163 P < 0.05 23.329 ± 8.744 P < 0.05 16.54 ± 7.36 15 Pre- dialysis p >0.05 2.9330 ± 0.328 P < 0.05 22.00 ± 9.565 P < 0.05 17.075 ± 7.726 15 Post- dialysis Table (2): Concentration of K+, and Na+ in sera of patient and control groups p Na+ (M eq/l) p +K (M eq/l) No. 137.58 ± 7.858 4.729 ± 0.6887 15 Control p >0.05 138.363 ± 4.148 P < 0.05 6.8429 ± 1.506 15 Pre- dialysis p >0.05 137.03 ± 3.448 P < 0.05 6.0 ± 1.600 15 Post-dialysis IBN AL- HAITHAM J. FO R PURE & APPL. SC I VO L.22 (4) 2009 0 10 20 30 Zn&Cu (umol/l), Ca(mmol/l) control pre-dialysis post-dialysis control 10.102 26.34 2.52 pre-dialysis 16.54 23.329 3.1813 post-dialysis 17.075 22.004 2.933 Zn Cu Ca Fig. (1): Concentration of Zn, Cu and Ca in se ra of patient and control g 0 2 4 6 8 k+(meq/l) K+ 4.729 6.8429 6 Control pre- post- Fig. (2): Concentration of K+ in se ra of patient and control groups 136 137 138 139 Na+(meq/l) Na+ 137.58 138.368 137.03 Control pre- post- Fig. (3): Concentration of Na+ in sera of patient and control groups 2009) 4 (22مجلة ابن الهیثم للعلوم الصرفة والتطبیقیة المجلد عناصر النزرة واالساسیة في مصل دم مرضى الفشل الكلوي المزمن مستویات ال قبل وبعد الدیلزة **،اواز صالح الدین عبد اللة الزردلیكاوي **،ازهار عباس اسماعیل المال * عالء حسین جواد جامعة النهرین ،كلیة العلوم قسم الكیمیاء ، * جامعة بغداد، كلیة التربیة ابن الهیثم،قسم الكیمیاء ** الخالصة العناصـر .ًفـردا مـن االصـحاء) 15( ال عـن ضفـًمریضا من مرضى الفـشل الكلـوي المـزمن ) 15( تضمنت هذة الدراسة ي فـي مـصل دم مرضـى الفـشل تـم قیاسـها بواسـطة االمتـصاص الـذري والمحلـل اللهبـ) Zn, Cu, Ca ,K, Na(االساسـیة والنـزرة p( وفـي مجموعـة الـسیطرة اظهـرت النتـائج الزیـادة المعنویـة . الكلوي المزمن قبل وبعـد عملیـة الـدیلزة Zn فـي تركیـز ) 0.05 > بینمــا كــان هنالــك ،مرضــى الفــشل الكلـوي المــزمن قبــل وبعــد عملیـة الــدیلزة بالمقارنــة مــع مجموعـة الــسیطرة فـي مــصل دمK+و .في تركیزالنحاس في مصل دم مرضى الفشل الكلوي قبل وبعد عملیة الدیلزة بالمقارنة مع مجموعة السیطرة نقصان معنوي