Gnogbo Alexis Bahi1,2*, A.
Bamba2,
G.M. M'Boh1, A.
Aké-Edjeme1,3, S. Méité1,
A.P. Bidié2, A.J.
Djaman1,2
1Department of Clinical and Fundamental Biochemistry, Institute
Pasteur of Côte D’Ivoire (IPCI), Ivory Coast
2Laboratory of Biochemical Pharmacodynamics, University
Félix Houphouët-Boigny (UFHB), Ivory Coast
3Laboratory of Biochemistry and Molecular Biology, University
Félix Houphouët-Boigny (UFHB), Ivory Coast
*Corresponding
author: Gnogbo Alexis Bahi, Department of Clinical
and Fundamental Biochemistry, Pasteur Institute of Côte D’Ivoire (IPCI),
Ivory Coast. Tel: +22501106725;
Email: alexisbahi@yahoo.fr
Medical management of Multidrug-Resistant Tuberculosis (MDR-TB) has become a major public health issue. The outbreak of this form of tuberculosis is partly due to anemia observed in patients with (MDR-TB). In order to improve the medical management of these patients, it is therefore necessary to define the characteristics of this anemia. The main objective of this study was to investigate the biochemical and haematological parameters related to the anemia observed in patients with Multi-Drug Resistant Tuberculosis (MDR-TB). Thus, 100 (MDR-TB) patients and 100 non-tuberculous patients as many women than men and between 18 and 55 years of age were selected. The hematological markers were assayed with the Sysmex Kobe automate, Japan, while the biochemical parameters such as ferritin and transferrin were performed using Cobas C311 from Roche Diagnostic, France and as for the serum iron, an Atomic Absorption Spectrometer (AAS) of the Varian Spectr AA-20 Victoria® type, Australia was used.
Results showed that 32% of women and 18% of men had mixed (iron deficiency and inflammatory) anemia, while the remaining 68% of women and 82% of men had inflammatory anemia.
Keywords: Abidjan; Anemia; MDR-TB; Micronutrients
Abbreviations: MCV: Mean Cell Volume; MCHC: Mean Corpuscular
Hemoglobin Concentration; RMCH: Rates of Mean Corpuscular Hemoglobin; TBC: Total Iron Binding
Capacity; TSC: Transferrin
Saturation Coefficient
1. Introduction
Multidrug-Resistant Tuberculosis (MDR-TB) is a disease caused
by Mycobacterium tuberculosis which is at least resistant to
two major TB drugs in first-line therapy, such as Isoniazid and Rifampicin [1].
The outbreak of this kind of tuberculosis is a real threat against all efforts
made recently to control and eradicate tuberculosis [2].
According to the World Health Organization (WHO) 480,000 people have contracted Multidrug-Resistant Tuberculosis (MDR-TB) and 190,000 deaths was recorded worldwide [3]. The prevalence rate in Africa and Côte d'Ivoire are respectively 14% [4] and 2.5% [5]. The medical management of this form of tuberculosis is not easy on account of the high rates of therapeutic failures leading to the selection of mycobacterial bacilli with new resistance to second-generation anti-tuberculosis drugs. These therapeutic failures stand for a threat to the Sustainable Development Goals (MDGs) which aims at eradicating any kinds of TB in 2030 [6]. According to WHO report [3], the rate of treatment failures in the cohort of MDR-TB cases detected in 2010 was more than 50% and that about 9.6% of these MDR-TB evolved to a form of Ultra-Drug-Resistant Tuberculosis (UDRTB) in 2012. One of the main findings generally brought back by studies carried out on tuberculosis studies and particularly on MDR-TB is anemia [7,8]. Anemia is multifactorial: it can be of infectious origin or due to a micro-nutritional deficiency. Thus, an effective management of this form of tuberculosis requires to specify the origins of anemia. The aim of this study was to investigate the biochemical and haematological parameters related to the observed anemia in people with Multidrug-Resistant Tuberculosis (MDR-TB).
This study consisted in:
2. Materials and Methods
This study was conducted at the Institute Pasteur of Côte d'Ivoire (IPCI). It
involved blood samples of MDR-TB patients. These samples were collected from
five Anti-Tuberculosis Centers (ATC) of Abidjan from
January 2014 to December 2015. One hundred (100) Multidrug-Resistant Tuberculosis Patients
(MDR-TB) as many men as women and one hundred (100) non-tuberculous volunteers
used as control with 50 men and 50 women were selected for this study. The age
of patients and control ranged from 18 to 55 years. Blood samples were
performed at different stages of patients follow-up:
·The
M0 stage involved initial assessment after the GenXpert® MTB
/ RIF test to confirm multidrug resistance before starting any
treatment [9].
·Stages
M3 and M6 for the follow-up assessment at respectively
3 and 6 months for second-line anti-tuberculosis treatment.
Two samples of MDR-TB were collected at each follow up stage (M0,
M3 and M6) and two (2) samples from each
non-tuberculosis control patients in a non-anticoagulant tube (red cap tube)
and in an EDTA tube (Ethylene Diamine Tetra-acetic Acid), 5 mL of blood was
collected in each tube. 600 MDR-TB samples (300 tubes without anticoagulant and
300 EDTA tubes) and 200 samples as control (100 tubes without anticoagulant and
100 EDTA tubes) were selected for this study. The samples of tubes without
anticoagulant were then centrifuged at 3000 rpm for 5 minutes using a horizon
642 VES centrifuge, THE DRUCKER CO., USA. The serum was then collected for
analysis of the biochemical markers. As for the EDTA tube, it was used for the
determination of haematological markers of iron metabolism. Hematological
markers such as hemoglobin, mean cell volume, rate of mean corpuscular
hemoglobin was
measured using Sysmex XN-1000i Kobe Japan [10]. Analysis of iron in serum was assayed by atomic absorption
spectrometer (SAA) of Varian Spectr AA-Victoria® type,
Australia [11]. As for ferritin and transferrin, different assays were performed
with Cobas C311 from Roche Diagnostic, France [12,13].
3. Results
The results of this study showed a significant decrease in
hematic markers of iron metabolism at the onset of the experiment compared to
the non-tuberculosis controls groups P <0.05. During anti-tuberculosis
treatment, only the rate of hemoglobin (Hb) remained significantly lower
compared to non-tuberculosis control groups P <0.05.
On the other hand, this hemoglobin level increased significantly
during anti-tuberculosis treatment compared to the initial analysis (M0)
P <0.05. However, it should be noted that, apart from the hemoglobin level
and total iron binding capacity (TBC) which showed a
significant increase during treatment P <0.05, the other haematological
markers did not undergo any significant change (Figures 1-4).
Hemoglobin rate for MDR-TB patients and non-tuberculosis control
groups. M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values.
*: significant Difference between MDR-TB and non-tuberculosis control groups P
< 0.05. Significant difference
between the various stages of the follow-up, P < 0.05.
Mean cell volume (MCV) for Multidrug-Resistant Tuberculosis
(MDR-TB) and non-tuberculosis control groups. M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values. *: significant Difference
between MDR-TB and non-tuberculosis control groups P < 0.05.
Mean corpuscular hemoglobin concentration for
Multidrug-Resistant Tuberculosis (MDR-TB) and non-tuberculosis control groups.
M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values. *: significant Difference
between MDR-TB and non-tuberculosis control groups P < 0.05.
Rates of mean corpuscular hemoglobin (RMCH) for
multidrug-resistant tuberculosis (MDR-TB) and non-tuberculosis control groups.
M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values. *: significant Difference
between MDR-TB and non-tuberculosis control groups P < 0.05.
This study also showed a significant decrease in serum iron
concentrations and Total Iron Binding Capacity (TBC) in patients with
multidrug-resistant tuberculosis, notwithstanding the follow up stage of
patients compared to controls (P ˂ 0.0001) (Figures 5,6). In contrast to
serum iron that did not undergo any significant change, TBC increased
significantly during anti-TB treatment compared to baseline (P ˂
0.0001) (Figure 6).
Serum iron concentration for Multidrug-Resistant Tuberculosis
(MDR-TB) and non-tuberculosis control groups. M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values. *: significant Difference
between MDR-TB and non-tuberculosis control groups P < 0.05.
Total Iron Binding Capacity (TBC): Rate of bound iron when
transferrin is saturated at 100%. MDR-TB: multidrug resistant Tuberculosis. M0: initial assessment.
M3, M6: follow-up assessment
at 3 and 6 months of treatment. NV: Normal values. *: significative difference
between MDR-TB and non-tuberculosis control groups, P ˂ 0.0001. º: significative
difference between initial assessment and MDR-TB follow up assessment, P ˂
0.0001.
It should be noted that despite increases in iron concentrations
and TBC values during treatment, reduction percentages of these markers
remained high after six months of treatment (M6) (Figures 7,8).
Iron reduction percentage in MDR-TB at the follow up different
stages compared to non-tuberculosis control group.
Total Iron binding capacity (TBC) in MDR-TB at the follow
up different stages compared to non-tuberculosis control group.
Concerning serum ferritin and Transferrin
Saturation Coefficient (TSC), 16 women out of 50, or 32% of women and 9 men out of
50, or 18% of men, had a significantly lower serum ferritin concentration and
TSC compared to controls and the usual values (P ˂ 0.05) (Tables 1,2). The remaining 68% of
women and 82% of men had ferritinemia and TSC in the normal range (Table 1,2).
Ferritin concentration in multidrug resistant tuberculosis
(MDR-TB) at initial assessments (M0) and follow-up assessment at 3 and 6 months of treatment (M3 and M6) with those of
non-tuberculosis volunteer control groups. *: Significative difference, P ˂
0.05.
Transferrin Saturation Coefficient (TSC): percentage of transferin iron binding. MDR-TB: Multidrug resistant tuberculosis. M0: initial assessment. M3, M6: follow-up assessment at 3 and 6 months of treatment. *: Significative difference, P ˂ 0.05. Serum ferritin concentrations and Transferrin Saturation Coefficient (TSC).
4. Discussion
This study showed a significant decrease in haematological
markers such as Hemoglobin (Hb), Mean Cell Volume (MCV), Mean Cell and
Hemoglobin Concentrations (MCH and MCHC) in Multidrug-Resistant TB Patients
(MDR-TB) compared to non-tuberculosis control groups. These results define the
microcytic and hypochromic character of anemia found in these MDR-TB. Several
authors have reported anemia in tuberculosis treating patients, though these
studies are not precise on the type of anemia [8]. These results could
highlight a lack of iron supply to the erythropoietic process.
Furthermore, analysis of the biochemical parameters of this
study showed a significant decrease in serum iron concentrations and Total Iron
Binding Capacity (TBC) in Multidrug-Resistant Tuberculosis (MDR-TB) compared to
non-tuberculosis control group and to normal values. Serum ferritin
concentrations and Transferrin Saturation Coefficient (TSC) decreased
significantly in 32% of women with MDR-TB and in 18% of men with MDR-TB, while they
remained within the range of normal values in the rest of patients. These
results are characteristics of inflammatory anemia or anemia of chronic
diseases on the one hand (ferritin and normal TSC) and a mixed anemia (iron
deficiency and inflammatory anemia) on the other hand (ferritin and low TSC) as
reported by several studies [14,15] The inflammatory anemia is due not to an iron deficiency but
rather to a functional deficiency of iron. Indeed, the normal ferritin values
representing the reserve pool reflecting an absence of iron deficiency, while
the low values of TBC, which is the functional iron pool, might characterize
a functional deficit of available iron [16]. These results are in agreement with those of Lovey et al. [17] who showed that ferritin
levels above 100 μg / L exclude the hypothesis of iron deficiency and that the
transferrin saturation coefficient only decreases when iron reserves are
completely depleted. On the other hand, low serum iron concentrations and
decreased Total Iron Binding Capacity (TBC) could be explained by a high
retention of iron in macrophages and a decrease in the iron supply to
erythropoiesis during chronic inflammation induced by Mycobacterial
infection [18].
The mechanisms leading to the introduction of this type of
anemia involve the production of various cytokines including interferon-γ,
TNF-α and interleukins 1 and 10 which could lead to the sequestration of
iron resulting from the degradation of red blood cells by macrophages and
repression of the synthesis of erythropoietin. This process could be amplified
by an excessive synthesis of hepcidin. A pro-inflammatory protein mostly
produced by the hepatocyte and excreted in the bloodstream. This protein would
interact with ferroportin which is the exporter of iron present in enterocytes
and macrophages causing degradation of the latter. This leads to a decrease in
intestinal iron absorption and iron retention in macrophages and hepatocytes,
the two main routes of iron supply to the body [14]. This set of mechanisms
would lead to decreased serum iron concentration and iron binding capacity to
transferrin [16]. This difficulty of mobilizing iron from the reserves
might lead to a decrease in the synthesis of hemoglobin, hence the hypochromic
character of anemia (low hemoglobin concentration).
At the same time, there is a reactionary increase in the number
of mitoses resulting in a production of small red blood cells, which is
reflected by the Microcytic Character of the Anemia (low MCV). In addition, the
decrease in Total Iron Binding Capacity (TBC) is due to a decrease in plasma of
transferrin levels.
Indeed, during inflammation, the reduction level of this plasma
iron transport protein is linked to its hyper catabolism in the inflammatory
zone and on the other hand to the reduction of its synthesis due to the
reserves in full iron, as shown by the normal serum ferritin
concentrations [17]. Mix Anemia (iron deficiency and inflammation anemia)
could be explained by an insufficient iron intake in addition to the inflammatory
process. However, the slight increase in serum iron concentrations during
second-line therapy in MDR-TB was not in agreement with the study of Edem et
al. [19], which showed a progressive decrease in iron concentrations in
tuberculosis patients during First-line treatment. This observation is due to
the fact that second-line antituberculosis molecules have no haemolytic action
in MDR-TB compared to first-generation anti-tuberculosis drugs such as
Rifampicin [20]. Moreover, despite the significant increase in iron
concentrations and TBC values during treatment, the percentages of reduction
of these markers remained high after six months of treatment (M6). This may
suggest inaction of the second generation anti-tuberculosis molecules on the
inflammatory process caused by the Mycobacterium tuberculosis bacillus.
5. Conclusion
The management of multidrug-resistant tuberculosis has become a
major public health issue. The outbreak of this form of tuberculosis is partly
due to the anemia observed in these people with a MDR-TB. In order to improve
the medical management of these patients, it is important to define the origin
of this anemia observed in these patients. Thus, our study on the profile of
hematological and biochemical markers of iron metabolism made it possible to
specify the inflammatory and mixed characteristics of anemia observed in these
multidrug resistant tuberculosis (MDR-TB). The persistence of these metabolic
disorders after six months of the intensive phase of second-line
anti-tuberculosis treatment advocates additive measures such as the effective
management of inflammation in parallel with anti-tuberculosis treatment.
6. Acknowledgements
We thank all of the participants and healthy volonteers who
consented to take part in this present study. We do not forget to thank the
head of Institut Pasteur of Côte
d’Ivoire, Prof. DOSSO Mireille, who provided us with the Atomic
Absorption Spectrometer machine she gave her support to the project. We also
want to thank ATTEMENE Serge David, PhD for his help in the english version of
the current manuscrit.
Figure 1: Hemoglobin rate of
MDR-TB and controls.
Figure 2: Mean cell volume
of MDR-TB and controls.
Figure 3: Mean corpuscular
hemoglobin concentration.
Figure 4: Rate of mean
corpuscular hemoglobin in MDR-TB and controls.
Figure 5: Serum iron concentration
for MDR-TB and controls.
Figure 6: total iron binding capacity
(TBC) for MDR-TB and controls.
Figure 7: Iron reduction
percentage in MDR-TB.
Figure 8: Reduction percentage of TBC.
|
MDR-TB with low
ferritin (μg/L) |
MDR-TB with normal
ferritin (μg/L) |
Non tuberculosis
control group (μg/L) |
|||
|
Men (9) or (18%) |
Women (16) or (32%) |
Men (41) or (82%) |
Women (34) or (68%) |
Men (50) or (100%) |
Women (50) or (100%) |
M0 |
14,9 ± 7,3* |
12,2 ± 5,7* |
211,6 ± 21,5 |
166,5 ± 10,0 |
164,4 ± 18,2 |
96,6 ± 13,1 |
M3 |
18,7 ± 5,5* |
14,9 ± 4,3* |
151,3 ± 11,9 |
163,4 ± 11,6 |
||
M6 |
21,6 ± 6,4* |
17,5 ± 3,2* |
154,6 ± 9,8 |
117,6 ± 11,6 |
Table 1: Values of serum ferritin
concentrations in MRD-TB and controls.
|
MDR-TB with low TSC (%) |
MDR-TB with normal TSC
(%) |
Non tuberculosis
control group (%) |
|||
|
Men (9) or (18%) |
Women (16) or (32%) |
Men (41) or (82%) |
Women (34) or (68%) |
Men (50) or (100%) |
Women (50) or (100%) |
M0 |
10,9 ± 3,1* |
09,4 ± 2,1* |
21,9 ± 1,4 |
27,3 ± 1,7 |
28,6 ± 2,3 |
26,9 ± 1,8 |
M3 |
11,7 ± 2,1* |
11,1 ± 1,3* |
22,7 ± 1,1 |
23,8 ± 1,4 |
||
M6 |
12,3 ± 2,3* |
12,3 ± 1,2* |
23,8 ± 1,3 |
22,6 ± 2,2 |
Table 2: Values of Transferrin Saturation Coefficient (TSC) in MDR-TB and the controls.
Citation: Bahi GA, Bamba A, M'Boh GM, Aké-Edjeme A, Méité S, et al. (2018) Evaluation of The Hematological and Biochemical Markers of Iron Metabolism in Pulmonary Multidrug-Resistant Tuberculosis (MDR-TB). J Trop Med Health: JTMH-132. DOI: 10.29011/JTMH-132. 000032