31.8.14 Glucose-6-Phosphate Dehydrogenase Deficiency in Icteric Neonates with indirect Hyperbilirubinemia

Original Article

 

G6PD in Icteric Neonates

Glucose-6-Phosphate Dehydrogenase Deficiency in Icteric Neonates with indirect Hyperbilirubinemia

Nathumal Maheshwari1, Ashok Kumar1, Adnan Bashir3, Shakeel Ahmed4, Bilawal Hingorjo5 and Anjum Rehman2

ABSTRACT

Objective: Determining the Glucose-6-phosphate dehydrogenase (G6PD) deficiency in icteric neonates with indirect hyperbilirubinemia reporting at a tertiary care hospital of Sindh.

Study Design: Cross Sectional study.

Place and Duration of Study: This study was conducted at the Department of Paediatrics, SMBB Medical College Layari General Hospital, Karachi, Sindh from January 2017 to May 2019.

Materials and Methods: A sample of 311 icteric neonates was selected by convenient probability sampling through inclusion and exclusion criteria. Complete blood counts and reticulocyte counts were analyzed on Sysmex KX-21 hematology analyzer. Serum bilirubin and glucose- 6-phosphate dehydrogenase were estimated by diazo method and color decolorization method (Sigma assay kit). Statistical analysis was performed at 95% confidence interval (P≤ 0.05) using SPSS software 21.0 (IBM, Inc USA).

Results: Of 311 sample size, 23 (7.39%) revealed G6PD deficiency and 288 (92.6%) neonates revealed normal G6PD concentrations. Age, Gestational age and hemoglobin were similar in both G6PD normal and deficient neonates. Anemia, reticulocyte counts, direct, indirect and total bilirubin revealed significant differences in G6PD deficient and normal neonates (P=0.0001).

Conclusion: The present study reports 7.39% frequency of Glucose-6-phosphate dehydrogenase deficiency in icteric neonates with indirect hyperbilirubinemia.

Key Words: Icteric Neonates, G6PD Deficiency, Indirect Hyperbilirubinemia.

Citation of article: Maheshwari N, Kumar A, Bashir A, Ahmed S, Hingorjo B, Rehman A. Glucose-6-Phosphate Dehydrogenase Deficiency in Icteric Neonates with indirect Hyperbilirubinemia. Med Forum 2020;31(8):58-62.

 

 

INTRODUCTION

Glucose-6-Phosphate-Dehydrogenase (G6PD) is the most important enzyme of hexose monophosphate (HMP) pathway of glucose metabolism. It catalyzes the first biochemical reaction of HMP glucose pathway; converting glucose 6 phosphates to 6-phosphogluconate.

 

 

1. Department of Paediatrics / Obstet & Gynae2, Shaheed Muhtrama Benazir Bhutto Medical College, Layari General Hospital Karachi, Sindh.

3. Department of Paediatrics, Hamdard College of Medicine and Dentistry Hamdard University Hospital, Karachi.

4. NICH, JPMC, Sindh, Karachi.

5. Department of Paediatrics, Dow University of Health Sciences/ Civil Hospital Karachi.

 

 

Correspondence: Dr. Nathumal Maheshwari, Assistant Professor of Paediatrics / Obstet & Gynae2, Shaheed Muhtrama Benazir Bhutto Medical College, Layari General Hospital Karachi, Sindh.

Contact No: 03333622316

Email: drnathumal@gmail.com

 

 

Received:    April, 2020

Accepted:    May, 2020

Printed:        August, 2020

 

G6PD deficiency is the most common enzymopathy that manifests clinically.1,2 G6PD deficiency is a congenital inherited enzymopathy affecting many organs but the red blood cells (RBCs) are adversely affected at the most. HMP pathway generates NADPH from glucose that is essential for maintaining the RBC cell membrane integrity. NADPH is proton donor to the glutathione system of RBCs keeping it ready for scavenging the free radicals. Glutathione system maintains the vital functions of RBC by removing the oxygen free radicals that may alter cell structure.1,2 Current estimates show the G6PD deficiency affects 400 million people over the Globe. G6PD deficiency is an X linked disorder.3,4 G6PD deficiency was discovered 50 years age. G6PD deficiency is of clinical importance because of its severe effects on RBCs. One of the clinical manifestations of G6PD enzymopathy is the neonatal hyperbilirubinemia without hemolysis. Deficiency may be serious causing kernicterus leading to death. Neonatal infections are increased by G6PD deficiency.4-6 G6PD deficiency was reported in 10% of black neonates in the United States without severe neonatal jaundice.  Incidence of G6PD enzymopathy varies from country to country. Its incidence is reported as 40% in Nigeria, 18.4% in Saudi Arabia, 12.2% in India, 1.62% in Singapore, 1.57% in Jamaica, 3.5% in Malaysia and 0.1% in Japan and Europe, 10% in Iran and 14% in Bengal in neonatal hyperbilirubinemia without hemolysis.1,3 Prevalence of G6PD deficiency is 32.5% in Africa and Arabian Peninsula. Prevalence of 62% is reported in Kurdish Jews. In Pakistan, the G6PD deficiency ranges between 3 to 6.9% similar to the Southern China and Russia.1,3 The high and low prevalence of G6PD deficiency may be due to the consanguine marriages and homozygous female add more to enzymopathy. Other studies from Pakistan revealed 16%6 and 30.1%7deficiency of G6PD in neonates with hyperbilirubinemia without hemolysis. Increasing neonatal hyperbilirubinemia in many geographical areas is linked with the co-occurrence of G6PD deficiency. However, currently, few empirical studies are reported from Pakistan, hence there is need of conducting more studies. The present prospective study was conducted to determine the frequency of Glucose-6-phosphate dehydrogenase (G6PD) deficiency in icteric neonates without hemolysis at a tertiary care hospital of Sindh.

MATERIALS AND METHODS

The present cross sectional study was conducted at the Neonatology unit, Department of Paediatrics, Shaheed Muhtrama Benazir Bhutto (SMBB) Medical College Layari General Hospital, Karachi Sindh. Research protocol was applied for ethical review committee approval. The study was conducted over duration of >2 years (January 2017 to May 2019). Sample size for the research protocol was calculated by ‘sampling for proportions’. Sample size was calculated to be 311 (at 5% α-level of significance, 90% Power (test) at an expected % of G6PD deficiency in neonates as 16.2%.1 A sample of 311 icteric neonates (hyperbilirubinemia) were selected by convenient probability sampling by the inclusion and exclusion criteria. A Performa was generated for the present research proposal for the collection of biodata, clinical presentation and laboratory findings of neonates. Jaundiced (icteric) neonates (neonatal unconjugated hyperbilirubinemia) were examined for the criteria of inclusion. Full term neonates, gestation age ≥38 weeks, neonatal age 2- 28 days, total bilirubin ≥12 mg/dl and predominantly unconjugated hyperbilirubinemia otherwise healthy, negative direct Coomb’s test and C-reactive protein (CRP) within normal limits were included. Preterm neonates, term neonates (Total bilirubin <12 mg /dL), sepsis, septic neonates with renal failure or signs of disseminated intravascular clotting, toxoplasmosis, birth asphyxia, ABO and Rh incompatibility and direct hyperbilirubinemia were exclusion criteria. After clinical history, the neonates were examined by Pediatric consultant. The venesection was performed under strict aseptic measures and venous blood was collected in plain and EDTA bottles.  1 ml blood of EDTA tubes was processed for complete blood counts and reticulocyte counts on Sysmex KX-21 hematology analyzer. 2 ml blood was centrifuged to get sera for the detection of serum bilirubin and glucose- 6-phosphate dehydrogenase. Diazo method (Diazotized sulphanilic test) was used for the estimation of serum bilirubin. Commercial Sigma assay kits were used for G6PD estimation by the colour decolorization (qualitative) method. Study variables were saved in Microsoft Excel sheet. Data was analyzed by Statistical software (SPSS software 21.0, IBM, Inc USA). Quantitative variables were analyzed and interpreted by Student`s t-test and qualitative variables by Chi- square test. Statistical analysis was performed at 95% confidence interval
(P≤ 0.05).

RESULTS

Of 311 sample size, 23 (7.39%) revealed G6PD deficiency and 288 (92.6%) neonates revealed normal G6PD concentrations (Table 1, Graph-1).

Table No.1: Demographic features, blood and biochemical findings

Parameter

G6PD Deficiency

G6PD Normal

P-value

Age (days)

5.61±2.10

5.86±2.12

0.57

Gestational age (weeks)

38.73±0.41

38.7±0.39

0.79

Hemoglobin

16.97±1.65

17.47±1.54

0.14

Reticulocyte counts

2.43±0.89

4.06±1.17

0.0001

Direct Bilirubin (mg/dL)

2.63±0.80

4.09±1.18

0.0001

Indirect Bilirubin (mg/dL)

22.17±1.95

19.11±1.59

0.0001

Total Bilirubin (mg/dL)

23.97±2.37

19.23±1.63

0.0001

G6PD Deficiency 

23 (7.39%)

288(92.6%)

0.0001

Anemia

7 (30.4%)

57(19.79%)

0.0001

Total

23

288

311

Graph No.1: Bar graph showing frequency of normal and deficiency of Glucose 6 phosphate dehydrogenase

Graph No.2: Bar graph showing serum direct bilirubin in neonates with normal and deficient Glucose 6 phosphate dehydrogenase levels

Graph No.3: Bar graph showing serum indirect bilirubin in neonates with normal and deficient Glucose 6 phosphate dehydrogenase levels

Graph No.4: Bar graph showing serum total bilirubin in neonates with normal and deficient Glucose 6 phosphate dehydrogenase levels

 

Of 311 sample; 215 (69%) were male and 96 (31%) were female. Male to female ratio was 2.29:1. Of 23 (7.39%) G6PD deficient neonates; 17 (73.9%) were male and 6 (26.08%) (P=0.0001). Age of G6PD normal and deficient neonates was 5.61±2.10 days and 5.86±2.12 days respectively (P=0.57). Gestational age was 38.73±0.41 weeks in G6PD deficient and 38.7±0.39 weeks G6PD normal neonates (P=0.79). Hemoglobin 16.97±1.65 and 17.47±1.54 g/dl in G6PD deficient and normal neonates respectively (P=0.14). Anemia was noted in 7 of 23 (30.4%) in G6PD deficient and 57 of 288 (19.79%) of normal G6PD neonates (P=0.0001). Reticulocyte counts, direct (Bar graph-2), indirect (Bar graph- 3) and total bilirubin (Bar graph- 4) showed statistically significant different in G6PD deficient and normal neonates (P=0.0001).

DISCUSSION

The present study is the first research study being reported from our tertiary care hospital reporting on frequency of Glucose 6 Phosphate Dehydrogenase (G6PD) in icteric neonates with indirect hyperbilirubinemia. The findings are of utmost clinical importance for better management of neonatal hyperbilirubinemia. We think G6PD assay should be performed for all those presenting with icterus and neonatal hyperbilirubinemia. The present study found   frequency of 7.39% G6PD deficiency in icteric neonates with indirect hyperbilirubinemia. G6PD deficiency predominated in the male neonates. The findings are in agreement with previous studies.1,8,10-14 G6PD deficiency is an X- linked recessive disease. Its deficiency causes neonatal jaundice, chronic hemolytic anemia, increased infections, favism and drug-induced hemolysis.9 Of 311 sample; 215 (69%) were male and 96 (31%) were female. Male to female ratio was 2.29:1. Of 23 (7.39%) G6PD deficient neonates; 17 (73.9%) were male and 6 (26.08%) (P=0.0001). These findings are also in keeping with previous studies.1,8,11-14 Munir et al8 conducted study at the Children Hospital, PIMS, Islamabad, analyzed 160 icteric neonates and reported 6.7% frequency of G6PD deficiency and male neonates predominated. The findings of above study in line with the present study. Siddiqui et al10 reported 5.4% frequency of G6PD deficiency that is inconsistent with present study, reason is clear that the sample size of above study was small compared to the present study. Alvi et al11 reported 10% G6PD deficiency in neonates with indirect hyperbilirubinemia. Frequency of 10% G6PD deficiency is higher than the present study.  However, another previous study12 reported 8.2% of neonates were G6PD deficient that approximates to our present observations of 7.39% G6PD deficiency in icteric neonates. Another previous study13 reported 8.2% of neonates were G6PD deficient. Above findings is in keeping with the present study. A previous study14 showed 12% of adults patients having G6PD enzyme deficiency. In present study, significant differences were observed in reticulocyte counts, direct, indirect and total bilirubin in G6PD deficient neonates. The findings are in agreement with previous studies.1,15-17 However, Munir et al8 reported no difference in reticulocyte counts and hemoglobin in G6PD-deficient neonates compared to G6PD normal neonates. This is inconsistent to present and other previous studies.15-17 We observed hyperbilirubinemia and icterus in >90% of neonates that is supported by a previous studies11,12 that observed similar 80%- 90% neonates revealed jaundice within first 7 days of life respectively.  Daliri et al18 analyzed 284 neonates and reported 12.1% frequency of G6PD deficiency of sample. A recent study19 published results of screening of 5652 neonates, and reported 12.4% prevalence of G6PD deficiency. Male predominated for the G6PD deficiency. The findings of above study are in support to observations of the present study. A study1 from Pakistan analyzed 400 male children. They reported overall prevalence of 10% G6PD deficiency the findings are in keeping with the present study. Another recent study20 analyzed G6PD in 100 neonates with icterus and reported 6% frequency of G6PD deficiency. Jan et al21 analyzed 1695 neonates with jaundice and found 152(9%) deficiency of G6PD. They further added the most of the neonates presented with icterus in the first 4 days of life, this is in agreement with the present study. Evidence based findings of present prospective in light of published literature from Pakistan points towards the need of screening of glucose-6-phosphate dehydrogenase for the icteric neonates with indirect hyperbilirubinemia. This will help prevent the hemolytic crises, hyperbilirubinemia and associated complications like kernicterus in neonates. Timely measures to combat the morbidities of G6PD deficiency will help better management and outcome of neonates. One of the limitations of present study is small sample size hence results cannot be generalized to other settings. But the strength of study lays in its prospective study design and inclusion criteria of research protocol.

CONCLUSION

The present study reports 7.39% frequency of Glucose-6-phosphate dehydrogenase deficiency in icteric neonates with indirect hyperbilirubinemia. We recommend performing G6PD assay for all those icteric neonates presenting with indirect hyperbilirubinemia to prevent hemolytic crisis, kernicterus and other complications. Timely measures to combat the morbidities of G6PD deficiency will help better management and outcome of suffering neonates.

Author’s Contribution:

Concept & Design of Study:

Nathumal Maheshwari

Drafting:

Ashok Kumar, Adnan Bashir

Data Analysis:

Shakeel Ahmed, Bilawal Hingorjo, Anjum Rehman

Revisiting Critically:

Nathumal Maheshwari, Ashok Kumar

Final Approval of version:

Nathumal Maheshwari

Conflict of Interest: The study has no conflict of interest to declare by any author.

 

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