Co-Relation
between Anthropometry and Urinary Urea / Creatinine Ratio in Assessment of
Nutritional Status
Rathi H.B.1*, Kashyap Sashikala2, Bansal
A.K.3, Mohan R.S.1, Gopinath A.4, Kalita R.4
and Bansal Akash4
1Dept.
of Community Medicine, Govt. Medical College, Jagdalpur. 494001..
2Dept.
of Pathology, Govt. Medical College, Jagdalpur, 494001.
3Professor
and HOD, Department of Community Medicine, Govt. Medical College, Jagdalpur,
494001.
4Dept. of Biochemistry, Govt. Medical
College, Jagdalpur. 494001.
ABSTRACT:
On analysis of the collected data the
authors reached to the conclusion that on the basis of urinary Urea/Creatinine
ratio alone, nutritional grading of children would have been impossible. Thus
Urea/Creatinine ratio can be used only in conjunction with the anthropometric
and clinical methods, if used alone then
utility is of questionable nature.
KEYWORDS: PEM, Urinary
urea/ Creatinine ratio.
INTRODUCTION:
There
are several biochemical indicators of malnutrition, specific for different
nutritional deficiencies. In most instances, nutrient intakes are reflected in
their levels present in blood, serum or urine. These levels can at least in
part, be defined or related inadequate or high dietary intakes of the nutrient.
Protein Energy Malnutrition (PEM) is considered to represent the most common
nutritional problems of children in developing countries, unfortunately there
in no single biochemical procedure that can satisfactorily evaluate PEM in
early or sub-clinical states. However careful interpretation of some of the
biochemical measurements when used in conjunction with clinical and
anthropometric assessments, provide a reasonable evaluation of PEM status.
Urinary excretion of urea mainly depends upon protein intake. This is the basis
of urinary urea/ creatinine ratio in which creatinine was introduced so that
random urine samples could be used. Studies have shown that under normal
iso-caloric conditions average ratio falls with decrease of protein intake. The
urinary urea / creatinine ratio. The rational for this method is based upon the
observation that low intake of protein reduces the rate of protein turnover and
concomitantly the urinary excretion of urea. The urinary urea creatinine ratio
is easy to determine, that neither blood sample nor complicated conversion
systems are required, only a single morning sample is needed, makes it a
potentially useful technique for estimating individual protein intake under
field conditions. A direct correlation was observed between percentage of urea
nitrogen in urine and plasma albumin values before and after treatment. This
would suggest that the percentage of urea nitrogen may be as good an index as
the serum albumin level. In most instances nutrient intakes are reflected in
their levels present in blood serum or urine. In 1957 as per recommendation of
the study group of World Health Organization (WHO) has expressed the view that
in order to get a comprehensive picture of disease (any health problem) more
and more studies should be carried out, Garg Narendra K (1-2) and Bansal A.K.
(3-6). It was therefore decided to estimate urinary urea/ creatinine ratio and
correlate the findings with nutritional status assessed by anthropometry.
MATERIAL
AND METHODS:
Study
was conducted in a slum. Anthropometric examination of children was done by
taking in to consideration of weight for age as per Indian Academy of
Pediatrics Classification.
>
80 % Weight for age - Normal
71 –
80 % Weight for age - Grade – I
61 –
70 % Weight for age - Grade – II
51 –
60 % Weight for age - Grade – III
<
50 % Weight for age - Grade – IV
The
urine sample was collected next day of anthropometric examination of the child.
The laboratory techniques used for detection were Berthelot Method and Jaffe
reaction respectively. Microlab-200 of Merck semi auto analyzer has used for
the estimation of above biochemical parameters. The data was tabulated and analyzed.
The statistical tests used were Chi-square test and Z-test.
ESTIMATION OF URINARY UREA BY
BERHELOT METHOD:
Principle:
Urease breaks
down urea in to ammonia and carbon dioxide in alkaline medium. Ammonia
liberated
from
the breakdown of urea reacts with hypochlorite and salicylate to form
dicarboxylindophenol. This reaction is catalysed by the presence of
nitroprusside. The intensity of the colour produced by the reaction is directly
proportional to the concentration of urea present in the sample and it is
measured photometrically at 600nm.
Sample:
urine diluted 1:99 in normal saline and result multiplied by 100.
Procedure:
|
REAGENT |
BLANK |
STANDARD |
TEST |
|
Working reagent |
1ml |
1ml |
1ml |
|
Urea standard |
---- |
10ul |
---- |
|
sample |
---- |
----- |
10ul |
Mix
well and incubate at 37c for 5 minutes
|
Reagent -2 |
1ml |
1ml |
1ml |
Mix well and incubate at 37c for 5 minutes. Measure the
absorbance of standard and sample against the reagent blank at 600nm within 60
minutes.
SYSTEM PARAMETERS:
Reaction type : End point
Wave length : 600nm
Temperature : 370c
Incubation : 5 minutes and 5 minutes
Sample volume : 10ul
Working reagent 1 :
1.0 ml
Working reagent 2 : 1.0
ml
Standard concentration :
40 mg/dl
Zero setting : Reagent blank
Light path : 1.0
cm
ESTIMATION OF URINARY
CREATININE BY JAFFE’S METHOD: (Alkaline
picrate method):
Principle: creatinine reacts with picric
acid in an alkaline medium to form an orange coloured complex and the rate of
change in absorbance is measured at 505nm at pre determined interval of time.
The concentration of picric acid and sodium hydroxide as well as reaction time
has been optimized in this method to avoid interference from CLIFS (creatinine
like interfering factors) in sample.
Sample:
urine diluted 1:99 in normal saline and the result multiply by 100
Working
reagent preparation: working reagent is prepared by combining equal volumes of
picrate and sodium hydroxide reagent.
Procedure:
|
REAGENT |
STANDARD |
TEST |
|
Working reagent |
1.0ml |
1.0ml |
|
Creatinine standard |
50ul |
------ |
|
sample |
------- |
50ul |
Mix
well and measure the absorbance at 505nm.
SYSTEM PARAMETERS:
Reaction type : Fixed
time (increasing)
Wave length : 505nm
Temperature : 370c
Delay time : 30
sec
Interval : 120 sec
Sample volume : 50ul
Reagent volume : 1.0ml
Standard concentration:
2.0mg/dl
Zero setting : Deionised
water
Light path : 1 cm
OBSERVATIONS AND DISCUSSIONS:
On
analysis of the collected data it has been observed that 43 (15.6 %) out of 276
children were in normal grade and 87 (31.5 %), 100 (36.2 %), 39 (14.2 %), 07
(2.5 %) Grade-I, Grade-II, Grade-III and Grade- IV respectively (Table - I).
Table – I reveals that out of 276 children 127 (46.01 %) were males and 149
(53.98 %) females. Table further reveals that there were higher percentages of
female (16.8 %) in comparison to their counterparts males (14.2 %) belong to
normal grade of nutrition. But the difference was not found statistically
significant. (X2 = 0.35, d. f. = 1, P
> 0.05). (Table-II) reveals that for normal grade, children
the mean urea estimates was 296.0 ranging between 192 to 612 mg / 100ml, For
grade I, II and severely malnourished (Grade-III and IV) children, the mean
values were less than those of normal grade children i.e.262.0, 251.3, 222.3 mg
per 100 ml and the range were 166 – 518, 166 – 518, and 178 – 316 mg per 100 ml
respectively.
Table – I: Nutritional Status
of Children up to five years of Age as per IAP Classification N=276
|
Age Groups
(months) |
Normal |
Nutritional
Grade |
Total Malnourished |
|||
|
Grade-I |
Grade-II |
Grade-III |
Grade- IV |
(5+6) |
||
|
(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
|
0 < 6 |
10 (45.5) |
6 (27.31) |
1 (0.45) |
3 (13.6) |
2 (9.11) |
12 (54.5) |
|
6 < 12 |
9 (30.0) |
10 (33.3) |
8 (26.7) |
3 (10.1) |
- |
21 (70.0) |
|
12 < 24 |
5 (7.2) |
22 (31.4) |
29 (41.4) |
11 (15.7) |
3 (6.3) |
65 (92.8) |
|
24 < 36 |
8 (14.6) |
24 (43.6) |
14 (25.5) |
8 (14.5) |
1 (1.8) |
47 (85.4) |
|
36 < 48 |
9 (15.3) |
15 (25.4) |
27 (45.8) |
7 (11.9) |
1 (1.7) |
50 (84.7) |
|
48 <_60 |
2 (5.0) |
10 (25.0) |
21 (52.5) |
7 (17.5) |
- |
38 (95.0) |
Figures
Parenthesis indicates percentage.
Table
– II: Urinary Urea, Creatinine and U/C Ratio According to Nutritional Status
|
Nutritional Status |
Urinary Urea (mg./100ml.) |
Creatinine (mg./100ml.) |
U/C Ratio |
SD |
|||
|
Mean |
Range |
Mean |
Range |
Mean |
Range |
||
|
Normal |
296.0 |
192 to 612 |
22.5 |
5.1 to 42.4 |
12.6 |
9.8 to 19.8 |
2.2 |
|
Grade – I |
262.0 |
166 to 518 |
21.6 |
14.7 to 34.7 |
12.3 |
7.4 to 21.2 |
2.2 |
|
Grade – II |
251.3 |
166 to 518 |
21.7 |
15.4 to 36.2 |
11.4 |
8.4 to 19.4 |
1.8 |
|
Grade – III + IV |
222.3 |
178 to 316 |
21.5 |
16.4 to 36.4 |
10.0 |
7.4 to 16.3 |
1.3 |
Table – III: Urinary
Urea/Creatinine Ratio of Children by Age and Nutritional Status
|
Age Groups
(months) |
Normal |
Grade-I |
Grade-II |
Grade-II + IV |
Total |
||||||||||
|
No. |
Mean |
S.D. |
No. |
Mean |
S.D. |
No. |
Mean |
S.D. |
No. |
Mean |
S.D. |
No. |
Mean |
S.D. |
|
|
0 < 6 |
10 |
11.6 |
1.6 |
6 |
11.8 |
1.6 |
1 |
10.9 |
- |
5 |
9.5 |
0.7 |
22 |
10.9 |
0.9 |
|
6 < 12 |
9 |
12.6 |
2.9 |
10 |
12.9 |
1.3 |
8 |
12.5 |
1.5 |
3 |
10 |
0.9 |
30 |
12 |
1.6 |
|
12 < 24 |
5 |
11.8 |
2.6 |
22 |
10.7 |
1.5 |
29 |
10.7 |
1.6 |
14 |
10.1 |
1.5 |
70 |
10.8 |
1.8 |
|
24 < 36 |
8 |
13.1 |
1.6 |
24 |
11.7 |
1.5 |
14 |
11 |
1.3 |
9 |
9.3 |
0.6 |
55 |
11.2 |
1.2 |
|
36 < 48 |
9 |
13.4 |
2.6 |
15 |
14 |
3.4 |
27 |
11.9 |
2.3 |
8 |
10.7 |
2.3 |
59 |
12.5 |
2.6 |
|
48 <_60 |
2 |
13.6 |
0.5 |
10 |
12.8 |
1.5 |
21 |
11.9 |
1.7 |
7 |
10.4 |
1.2 |
40 |
12.1 |
1.2 |
|
Total |
43 |
12.6 |
2.2 |
87 |
12.2 |
2.2 |
100 |
11.4 |
1.8 |
46 |
10 |
1.3 |
276 |
11.5 |
1.5 |
Henry
et al (9) observed the range of urea values in all five grades of nutrition
status between 202 to 1240 mg per 100 ml. Similarly Fawcett et al (10) got the
range of males from 210 to 812 mg / 100 ml which is more or less similar to the
findings of the present study. (Table-I) further reveals that mean values for
creatinine for normal grade children was 22.5 and raging between 15.1 to 42.4
mg / 100 ml. while for malnourished children were 21.6, 21.7 and 21.5 mg / 100
ml range from 14.7 – 34.7, 15.4 – 36.2, 16.4– 36.4ml/100 mg. for grade-I, II
and III + IV children respectively.
As
there is no definite standard for creatinine values and large variations were
observed from region to region, it is felt that the creatinine value alone
can’t be of much use in determining the grades of nutritional status. In
longitudinal studies in which Estimations for the some individual are made from
time to time, this index can prove useful, but the utility in a cross sectional
study likes the present one is limited. Therefore also urinary Urea/Creatinine
ratio was studied.
The
mean value of urinary urea/creatinine ratio for the normal subjects was 12.6
ranging between 9.8 to 19.8 for grade-I, II and severely malnourished (III and
IV) the mean values were 12.3, 11.4 and 10 respectively and ranges from 7.4 –
21.2, 8.4 – 19.4 and 7.2 to 16.3. The overall range (all range combined) for undernourished
was from 7.4 to 21.2. The observed urinary urea/creatinine ratio for normal Vs.
various grades of malnutrition was analyzed statistically by applying ‘Z’ test.
Normal
Vs. grade-I Z = 0.73, P > 0.05 (N.S.)
Normal
Vs. grade-II Z = 3.53, P < 0.01 (H.S.)
Normal
Vs. grade III + IV Z = 7.03, P < 0.01 (H.S.).
The
mean values of the ratios show a declining tendency with declining of the
nutritional status.
Aaron
et al (7) noted the mean U/C ratio of 9.25 with standard deviation of 3.81,
Ratio ranged between 0.46 to
31.25.
Raju
P.V. et al (8) observed the mean ratio as highest for the normal preschoolers
viz 13.4 and lowest for grade IV viz 9.03. These findings were more or less
similar to the findings of the present study. (Table-III) reveals that mean
values of the ratios for 43 normal subjects was 12.6 with a standard deviation
2.2, the mean value of ration for 87 grade – I subjects was 12.2 with deviation
2.2, 100 grade – II children 11.4 with standard deviation 1.8 and grade – III +
IV, 46 subjects the ratio 10.0 with standard deviation 1.3. The mean values of
ratio in grade – II, III and IV are significantly below the level of normal
values. The U/C ratio did not show any variable trend with age.
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Received on 10.04.2010
Accepted on 10.07.2010
© A&V Publication all right reserved
Research J. Pharmacology and
Pharmacodynamics. 2(6): Nov. –Dec. 2010, 414-417