Common Chronic Disease Patterns in Arabian Gulf, Saudi Arabia & YemenDr. O. P. Kapoor
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Blood Chemistry and SMA 12 Reports

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Multiple test profiles have become a fashion in the medical circles. SMA 12/60 or SMA 18 or SMA 26 or any form of SMA you ask for and it is available with Pathologists or private hospitals and laboratories.

Since the Arabs, in addition to a specific illness, often come for a routine health check up, such tests are being asked for very frequently. Fifteen years back when I saw my first Arab patient, this facility was not available. In the last ten years, however, I must have asked for these tests in more than two thousand five hundred Arabs. There is a tendency amongst the doctors to label their patients as suffering from a disease, diagnosed, by the presence of an abnormal SMA 12 report. In many of such patients, a lot of undesired anxiety and mental trauma have been caused.

Following are the factors which can alter the readings of SMA 12 reports

(1) Many Arabs do not give their blood sample "fasting" as required for the laboratory procedure. This is either due to language problem or more often because the patient does not realise the importance of total fasting. A 'non-fasting' specimen often shows raised 'levels' of the following:

  • Glucose
  • B.U.N.
  • Albumin
  • Alkaline phosphatase
  • Triglycerides

Thus when they are labelled as "abnormal" on a number of occasions, the patient can be helped to get rid of his anxiety by coaxing him to repeat the blood test (which many Arab patients, specially females, grumble to do) on a 'proper' empty stomach.

Remember that usually an Arab does not like to re-visit the same laboratory.

(2) A number of pathological laboratories are located on fifth or sixth stored and facilities for the use of the elevator are not adequate. Many a times, the Arabs do not mind climbing the steps. Off and on, these patients' blood reports will show elevated C.P.K. levels after visiting such a laboratory. Strenuous exercise not only elevates blood levels of C.P.K. but can also raise creatinine or uric acid levels of blood.

(3) Haemolysis in blood can occur from a venepuncture or an improper collection of blood and the blood report mav show the following high levels of—

  • L.D.H.
  • B.U.N.
  • S.G.O.T.
  • Bilirubin
  • Potassium
  • Phosphorous

(4) "Alcoholic liver" is over-diagnosed in Arabs because of the reports of abnormal levels of liver function tests. These patients are afraid of the harmful effects of the alcohol. Thus, the anxiety created by this diagnosis often compels such a patient to have a second opinion. Very often I find that he has had a heavy bout of alcohol the previous night but he is not an alcoholic.

Raised levels of the following blood constituents can occur after a heavy alcoholic bout:—

  • S.G.O.T.
  • Bilirubin
  • Alkaline phosphatase
  • C.P.K.
  • L.D.H.
  • Uric acid
  • Calcium
  • Phosphorous
  • Total proteins
  • E.S.R.
  • Triglycerides

Often the Arab patients go to more than one laboratory. When they see the conflicting reports, they fly into a rage. They have to be convinced that no two laboratories give the same report.

The following are the additional factors which will help in calming down the Arab patient while interpreting SMA 12 reports.

Serum Alkaline Phosphatase

So sensitive is this test that in a patient suspected to have secondary deposits in the liver even if all imaging tests like isotope liver scan, sonography and computerized tomography of the liver are found normal. a raised alkaline phosphatase would call for a liver biopsy.

Similarly in an obstruction of the common bile duct, I have off and on seen this enzyme rising without elevated serum bilirubin.

Sometimes the reason for the elevation of serum alkaline phosphatase can be suspected, to be due to any of the following:

Some of them are on injection therapy of Androgens.

Use of chlorpropamide for control of diabetes. This is the most popular therapy for diabetes in Arab population. (It should not be forgotten that diabetes itself can cause elevated levels of serum alkaline phosphatase).

Many Arab patients, especially from Bahrain, Saudi and Qatar have been consuming Methyldopa, which is a popular drug for long-term treatment of hypertension.

Many Yemeni patients have been consuming tablets containing phenothiazine derivatives.

Finally, serum alkaline phosphatase is one of the most notorious tests, known for being reported as "high" for "no obvious reason". I have found this in about ten to fifteen percent patients of mine.

L.D.H.

Often one can pick up the disease of haemolytic anaemia from raised levels of L.D.H. After the other causes of elevated L.D.H. mentioned above are ruled out, tests like sickle cell test, Haemoglobin electrophoresis and G6PD levels should always,be asked for specially if the reticulocyte count is high.

Albumin

Low albumin levels are found so commonly in elderly Arabs and are a normal phenomenon at this age. Also, because of the dietetic habits, these levels are lower in Yemenis.

S.G .O.T.

Elevated S.G.O.T. levels can often be seen in Arabs because of the following—

  1. Use of injections of androgens for sex weakness.
  2. After investigations have been done where radioopaque contrast media have been used. The most common investigation in such patients is intravenous pyelography.
  3. Patients who have been on Methyldopa therapy for hypertension .
  4. Patients who have been consuming sedatives like chlordiazopoxide .

Finally in a number of patients, I found the levels of S.G.O.T. slightly elevated for no reason at all. If all other tests are normal, I am not disturbed by a reading of S.G.O.T. upto 50 units.

Creatinine

On two occasions I picked up patients with raised creatinine levels and labelled as chronic renal failure, consuming clofibrate for hyperlipedemia. Once in a while use of methyldopa can also elevate creatinine levels.

C.P.K.

Apart from the factors mentioned above, one of the common causes of an elevated reading of C.P.K. is the intramuscular injections (of tonics etc.), which these patients have been on, and which the Arab population is very fond of.

Gamma G.T.

Although a very sensitive test for diagnosis of an "alcoholic", off and on, I find it elevated in many others and often in young Arab women who have never tasted alcohol. Also, a single heavy bout of alcohol can cause its elevation by "enzyme induction".

Glucose

This subject has been discussed in detail in the chapter on Diabetes.

Suffices to say here that I have often found readings of blood glucose elevated in SMA 12 reports upto 130 mg in patients, whose full blood sugar curve done later, showed no evidence of diabetes.

B.U.N.

Peptic ulcer syndrome is extremely common in this population. Also most of them consume a lot of antacids and one may be tempted to blame the antacids for an incidentally raised B.U.N.

It is important to realise that you would over-diagnose this condition unless the following levels are also found elevated:

  • Calcium
  • Phosphorus
  • Uric acid.

Since this population, as mentioned elsewhere, does not believe in taking "long-term treatment" the above situation is rare.

A few Arabs would be seen where the mildly elevated B.U.N. is due to one of the following:

  1. Investigations where radio opaque contrast media were used (e.g. I.V.P.)
  2. Patients on methyldopa therapy
  3. Patients on long-term thiazide therapy (Nephril-popular at Bahrain) for hypertension.

Finally, if all the above factors are absent and the blood creatinine levels are normal, levels of B.U.N. upto 25 mg can be passed off as normal. Of course, it will be worthwhile asking for creatinine clearance levels in these patients, to make doubly sure of the diagnosis.

Bilirubin

In addition to causes mentioned above, increased bilirubin levels are a common indication of presence of haemolytic anaemias in Arab population. Off and on I have investigated these patients thoroughly—and detected the following causes resulting in rise of bilirubin—

  1. Patient on injections of Androgens.
  2. Patients having had investigations where radio opaque contrast media were used.
  3. Patients who were on Nitrofurantoin or chlordiazopoxide, or methyldopa therapy.

Finally if all the above causes have been excluded, bilirubin levels upto 1.2 mg can be accepted as normal in these patients.

Uric acid

Although drugs like methyldopa, thiazide or other diuretics, which these patients are consuming, off and on can raise uric acid levels, I find levels upto 8 or 8.5 mg. in this population as normal.

Calcium

Apart from the variations discussed above, occasionally you would spot a patient where the level of serum calcium was more than 11 mg. and he is on high doses of "Androgenic steroid" therapy which is known to raise serum calcium. Also after seeing and investigating hundreds of patients with renal stones (to exclude hyperparathyroidism), I have come to the conclusion that in a thoroughly investigated case (including blood P.T.H levels), one should not mind accepting levels of serum calcium upto 11.2 or 11.3 mgm as normal, in this population.

Finally I would stress that the problems of blood chemistry and SMA 12 reports are more in Arab population, because they are fond of investigations. Moment they find a laboratory reporting more number of tests, they would like to visit the same.

 

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