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Prevalence of pernicious anemia in healthy consenting adults -- a report from northwestern India

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https://www.eduzhai.net Public Health Research 2014, 4(4): 117-119 DOI: 10.5923/j.phr.20140404.02 Prevalence of Pernicious Anaemia among Voluntarily Consenting Healthy Adults - A Report from North-west India Sunil Kumar Raina1,*, Jagjit Singh Chahal2, Krishan Kumar Sharma2, Navjot Kaur3, Satyabushan Sharma2 1Department of Community Medicine, Dr. RP Govt. Medical College, Tanda (Himachal Pradesh), India 2Department of Biochemistry, Dr. RP Govt. Medical College, Tanda (Himachal Pradesh), India 3Department of Pathology, Dr. RP Govt. Medical College, Tanda (Himachal Pradesh), India Abstract Introduction: Pernicious anaemia is an autoimmune atrophic gastritis that causes a deficiency in vitamin B12 due to its malabsorption. Presence of intrinsic factor antibodies (AIFAb) is viewed as a diagnostic marker for pernicious anaemia. Materials and methods: This was an observational study carried out among healthy adults (students and employees) of in a medical college setting in north-west India. Results: By using reference range given by the manufacturer of the diagnostic kit, none of the participants enrolled for study was found to be positive for anti intrinsic factor antibodies (AIFAb) because all had serum level less than 25 EU/ml. Discussion: The study emphasises the need for further research in understanding the cause for vitamin b12 deficiency. Keywords Prevalence, Pernicious, Healthy adults 1. Introduction Serum vitamin B12, has usually been seen to be lower among Indian toddlers and in adults, indicating hypovitaminosis. [1, 2] Chronic vitamin B12 depletion (i.e prolonged low intake or intestinal malabsorption) results in a state of negative vitamin B12 balance. Although the depletion process may take years to become clinically evident, early and reliable diagnosis of deficiency is crucial, owing to the latent nature of the disorder and the resulting possible irreversible neurologic damage. [3, 4] Megaloblastic anaemia is the usual culmination of deficiency of vitamin B12 or folate. Intrinsic factor (IF), a 60kD glycoprotein produced by the parietal cells of the stomach lining is required for the absorption of vitamin B12. [5, 6] Pernicious anemia is an autoimmune atrophic gastritis that causes a deficiency in vitamin B12 due to its malabsorption. Presence of intrinsic factor antibodies (AIFAb) is viewed as a diagnostic marker for pernicious anaemia. These are basically of Ig G isotype and occur in about 70% of patients of pernicious anaemia. [7] The study was planned with the aim to assess the prevalence of pernicious anemia among voluntarily consenting healthy adults using intrinsic factor * Corresponding author: ojasrainasunil@yahoo.co.in (Sunil Kumar Raina) Published online at https://www.eduzhai.net Copyright © 2014 Scientific & Academic Publishing. All Rights Reserved antibodies (AIFAb) as a marker. 2. Material and Methods This was an observational study carried out among healthy adults (students and employees) of in a medical college setting in north-west India. The protocol and plan of study was approved by the institutional Ethics Committee. Voluntarily willing students and employees were recruited for the study after obtaining informed written consent. A total of 153 study units were picked by stratified random sampling method from the sampling frame that comprised of all students and employees of the medical college. Study plan and procedure was explained to the recruited participants. Blood sample was collected by following standardized procedure for the collection of blood sample. Inclusion Criteria: i) Any adult voluntarily consenting student or employee, aged 18 to 62 Years of the medical college. Exclusion Criteria i) Subject’s refusal. ii) Subjects who were taking methylcobalamin or vitamin B12 or folic acid or IFA or have taken the same for more than 15 days during last 3 months. iii) Subjects who had received vitamin B12 or iron formulations as injectables during last one year. iv) Subjects on medication for hypertension or diabetes or on lipid lowering drugs. v) Those with chronic illness like tuberculosis, cancer 118 Sunil Kumar Raina et al.: Prevalence of Pernicious Anaemia among Voluntarily Consenting Healthy Adults - A Report from North-west India or immunocompromised subjects. vi) Pregnant or lactating mothers. vii) Anyone who had either donated or received blood in last three months. General Procedure for assay of AIFAb: 1:101 dilution of patient sample was prepared by mixing 10 μl sample and 1000 μl serum diluents.100 μl each of diluted sample, calibrator and control was pipetted into each microwell and microplate was incubated for 30 minutes. Plate was washed four times with wash buffer and 100 μl of conjugate was pipetted into each microwell. Plate incubated for 30 minutes at room temperature followed by washing for four times with wash buffer. 100 μl of enzyme substrate was pipetted into each microwell and microplate was again incubated for 30 minutes at room temperature. Reading was taken at 450 nm on BIO-RAD micro plate reader 550 after adding 100 μl of stop solution into each microwell. female students and 70.6% of female employees), while 16.3% of study population was severely deficient having serum vitamin B12 level below150 pg/ml. Table 1. AIFAb distribution amongst participants (N=153) Participants <15 EU/ml Number (%) >15 EU/ml Number % Total Employee Students Male Female Vegetarian Non-vegetarian 14 (20.29) 13 (15.48) 15 (17.45) 12 (17.91) 14 (18.67) 13 (16.67) 55 (79.71) 71 (84.52) 71 (82.55) 55 (82.09) 61 (81.33) 65 (83.33) 69 (100) 84 (100) 86 (100) 67 (100) 75 (100) 78 (100) 3. Results We analyzed the serum samples of participants for the estimation of anti intrinsic factor antibodies (AIFAb). More than 80% of all participants enrolled for study had serum AIFAb level higher than 15 EU/ml (table 1). This analyte (AIFAb) in serum showed even distribution across all groups of study population and did not show any significant inter-group variation based upon occupation, gender or dietary habits. By using reference range given by the manufacturer of the diagnostic kit [8], none of the participants enrolled for study was found to be positive for anti intrinsic factor antibodies (AIFAb) because all had serum level less than 25 EU/ml. However, the test result was indeterminate for 126 participants who had a bit higher titre of AIFAb (more than 15 EU/ml but less than 25 EU/ml). Remaining participants (N=27) were tested to be negative for this analyte (<15 EU/ml). Though not significant, same pattern of inverse relationship existed between vitamin B12 and serum AIFAb. We observed some degree of age associated increase in the serum level of AIFAb. Interestingly though mean serum vitamin B12 in both the groups of employees as well as students, was low (group I N 69: 241.56 ± 101.88 pg/ml; group II N 84: 217.98 ± 92.78 pg/ml)(table 2). Using 200 pg/ml as threshold, 53.6% of total participants had low vitamin B12 concentration (66.6% of 4. Discussion Hypovitaminosis B12 is common among adults and elderly with a prevalence ranging from 15%–40% used. [9] . Hypovitaminosis B12 is represented by classic pernicious anemia (PA). [10] It accounts for 20%–50% of the documented causes of vitamin B12 (cobalamin) deficiency in adults according to a recent series. [11] In the general population, the prevalence of PA is 0.1%; in subjects over the age of 60, it reaches 1.9%. [12, 13]. However, none of our enrolled volunteers showed a positive test result (>25EU/ml) for AIFAb. Of particular note was the occurrence of indeterminate test result for AIFAb in vast majority (N=126, 82.4%) of our study participants who had AIFAb titer between 15-20 EU/ml, whereas remaining participants (N=27, 17.6%) turned out to be negative for this test (AIFAb <15 EU/ml). Interestingly, though the results of our study showed a high frequency of suboptimal serum vitamin B12 in our study population. A total of 82 participants which makes 53.60% of the enrolled subjects, were having suboptimal level of vitamin B12. Of note was an observation that mean serum vitamin B12 level in younger age group (students) was lower than that in older group (employees). More of younger age group (58.34%) was in the suboptimal group, compared to older ones (47.82%). The study emphasises the need for further research in understanding the cause for vitamin b12 deficiency. Table 2. Intergroup distribution of hematological and hematopoietic variables along with their deficiency markers amongst participants of study population (N=153) Group Occupation wise Gender wise Variables Hb (g/dl) Employees Gp I (n=69) 12.63 ± 1.0 p value 0.011 Students Gp II (n=84) 12.20 ± 1.04 Male Gp III (n=86) 12.87 ± 0.95 p value 0.000 Female Gp IV (n= 67) 11.78 ± 0.79 Vitamin B (pg/ml) 241.56 ± 101.88 0.137 217.98 ± 92.78 248.36 ± 98.72 0.004 203.28 ± 90.16 AIFAb (EU/ml) 20.06 ± 7.04 0 .582 20.64 ± 5.8 19.85 ± 5.49 0.244 21.06 ± 7.3 Public Health Research 2014, 4(4): 117-119 119 REFERENCES [1] Hanumante NM, Wadia RS, Deshpande SS, Sanwalka NJ, Vaidya MV, Khadilkar AV. Vitamin B12 and Homocysteine Status in Asymptomatic Indian Toddlers. Indian J Pediatr 2008; 75(7): 751-53. [2] Banerjee DK, Chatterjea JB. Serum vitamin B12 in vegetarians. Br Med J 1960; 2: 992-4. [3] Herrmann W, Schorr H, Obeid R, Geisel J. Vitamin B-12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr 2003; 78: 131-6. [4] Khanduri U, Sharma A, Joshi A. Occult cobalamin and folate deficiency in Indians. Natl Med J India 2005; 18: 182-3. [5] Klee GG. Cobalamin and Folate Evaluation: Measurement of Methylmalonic Acid and Homocysteine vs Vitamin B12 and Folate. Clin Chem 2000; 46: 8(B): 1277-83. [6] Mayes PA. Structure and function of the water-soluble vitamins. In: Murray RK, Granner DK, Mayes PA, Rodwell VW (edi). Harper’s Biochemistry. 25th ed. Stamford, Appleton & Lange Publishers; 2000: 635-7. [7] Carmel R. Reassessment of the relative prevalences of antibodies to gastric parietal cell and to intrinsic factor in patients with pernicious anaemia: influence of patient age and race. Clin Exp Immunol 1992; 89: 74-7. [8] Product Insert of Immco diagnostics Anti-Intrinsic Factor (IF)-Antibody ELISA. [9] Andres E, Loukili NH, Noel E, et al. Vitamin B12 (cobalamin) deficiency in elderly patients. CMAJ.2004;171(3):251–259. [10] Andres E, Affenberger S, Vinzio S, Noel E, Kaltenbach G, Schlienger JL. Cobalamin deficiencies in adults: update of etiologies, clinical manifestations and treatment. Rev Med Interne. 2005;26(12):938–946. French. [11] Loukili NH, Noel E, Blaison G, et al. Update of pernicious anemia. A retrospective study of 49 cases.Rev Med Interne. 2004;25(8):556–561. French. [12] Carmel R. Pernicious anemia. In: Johnson LR, editor. Encyclopedia of Gastroenterology. Waltham, MA: Academic Press; 2004. pp. 170–171. [13] Toh BH, van Driel IR, Gleeson PA. Pernicious anemia. N Eng J Med. 1997;337(20):1441–1448.

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