JOURNAL
Current Issue
Journal Archive
.............................................................
September 2019 -
Volume 17, Issue 9

View this issue in pdf format

........................................................
From the Editor

........................................................

 

Original Contribution

Assessment of patient safety culture in tertiary health care settings in Taif City, Saudi Arabia
[pdf]
Dalia El-Sayed Desouky , Atheer Alraqi , Rabeah Alsofyani , Najla Alghamdi
DOI: 10.5742MEWFM.2019.93673

The Development of a Primary Health Care system in the State of Qatar
[pdf]
Asan Ali Qasim Al Nyazee, Sarab K. Abedalrahman, Zeena N. Abdulrahman, Islam A.R. Zadawy
DOI: 10.5742MEWFM.2019.93667

Hypoglycemia: Its effect on patients with diabetes
[pdf]
Bilal Ahmed, Muhammed Naeem Khan
DOI: 10.5742MEWFM.2019.93675

Extracorporeal shock wave lithotripsy and ureterorenoscopy procedures of ureteric stone disease inpatients with a solitary kidney in Aden
[pdf]
Ali Ahmed Salem Hatroom
DOI: 10.5742MEWFM.2019.93681

Population and Community Studies

Symptomatic Knee Osteoarthritis and Dyslipidemia. A study from Kurdistan of Iraq
[pdf]
Asso Amin, Raof Merza, Mohammed J. Baban, Hawar Khan, Khalid A. Hama-ghareeb, Mohammed IM Gubari, Soran Noori, Saman Sadeq, Alan Saeed
DOI: 10.5742MEWFM.2019.93682

Smoking-induced endothelial damage may increase plasma triglycerides
[pdf]
Mehmet Rami Helvaci, Abdulrazak Abyad, Lesley Pocock
DOI: 10.5742MEWFM.2019.93676

 



Middle East Quality Improvement Program
(MEQUIP QI&CPD)

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

.........................................................

Publisher -
Lesley Pocock
medi+WORLD International
AUSTRALIA
Email
: lesleypocock@mediworld.com.au
.........................................................

Editorial Enquiries -
abyad@cyberia.net.lb
.........................................................

Advertising Enquiries -
lesleypocock@mediworld.com.au
.........................................................

While all efforts have been made to ensure the accuracy of the information in this journal, opinions expressed are those of the authors and do not necessarily reflect the views of The Publishers, Editor or the Editorial Board. The publishers, Editor and Editorial Board cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; or the views and opinions expressed. Publication of any advertisements does not constitute any endorsement by the Publishers and Editors of the product advertised.

The contents of this journal are copyright. Apart from any fair dealing for purposes of private study, research, criticism or review, as permitted under the Australian Copyright Act, no part of this program may be reproduced without the permission of the publisher.

September 2019 - Volume 17, Issue 9

Symptomatic Knee Osteoarthritis and Dyslipidemia.
A study from Kurdistan of Iraq

Asso Amin (1)
Raof Merza
(1)
Mohammed J. Baban
(2)
Hawar Khan
(2)
Khalid A. Hama-ghareeb
(1)
Mohammed IM Gubari
(1)
Soran Noori
(3)
Saman Sadeq
(3)
Alan Saeed
(4)


(1) Department of Medicine, College of Medicine, Ministry of Higher Education, Kurdistan Regional Government, Iraq.
(2) Department of Rheumatology, Sulaimany General Medical Teaching Hospital, Sulaimany, Iraq.
(3) Department of Orthopedic, Sulaimany Surgical Teaching Hospital, Sulaimany, Iraq.
(4) Department of Family Physician, PHCC-Qatar, Doha, Qatar.

Correspondence:
Dr Asso Amin,
Department of Medicine, College of Medicine, Ministry of Higher Education,
Kurdistan Regional Government, Iraq.
Email: delanamin@hotmail.com

Received: July 2019; Accepted: August 2019; Published: September 1, 2019. Citation: Asso Amin. et al. Symptomatic Knee Osteoarthritis and Dyslipidemia. A study from Kurdistan of Iraq. World Family Medicine. 2019; 17(9): 30-35. DOI: 10.5742MEWFM.2019.93682

Abstract


Background:
As a complex multifactorial condition, knee osteoarthritis has been considered as a leading cause of disabilities. Dyslipidemia is a metabolic component that can probably play a role in knee osteoarthritis development and comorbidities; however, this relationship is still debated. The present study was carried out in order to figure out the prevalence of dyslipidemia among knee osteoarthritis patients and to compare their abnormal serum lipid components with non-exposed individuals.

Patients and methods: A total of 60 patients with knee osteoarthritis and 60 non-exposed (without knee osteoarthritis) individuals were studied in a prospective cohort study that was conducted from March 2018 to May 2019. The patients were chosen from those who referred to the Rheumatology Division in Sulaymaniyah, the Kurdistan Region of Iraq. EULAR and ACR diagnostic and classification criteria and radiographic confirmation for definite osteophyte were utilized to diagnose the primary knee osteoarthritis. Required data were collected using a questionnaire, taking blood samples and by conducting several laboratory tests.

Results: The mean age of the patients with knee osteoarthritis was 51.8 years. Female-to-male ratio was 2.1:1. It was seen that dyslipidemia increased two folds among patients with knee osteoarthritis than the non-exposed subjects. Patients and non-exposed subjects were significantly different in terms of dyslipidemia prevalence (p<0.013). Furthermore, all the lipid components were significantly abnormal in those with knee osteoarthritis.

Conclusion: Dyslipidemia is prevalent among knee osteoarthritis patients, and there is a significant association between knee osteoarthritis and high-density lipoprotein, total cholesterol, low-density lipoprotein, and triglyceride. Dyslipidemia prevention may reduce the development of knee osteoarthritis and cardiovascular comorbidities.

Key words: knee osteoarthritis, dyslipidemia, serum lipid components, radiography


INTRODUCTION

As the most common chronic, heterogeneous, and debilitating arthritic disorder, osteoarthritis (OA) mainly impacts diarthrodial joints [1-5]. Quality of life can be negatively affected by osteoarthritis, which in turn raises the healthcare and social costs [6]. The prevalence of OA ranges from 3.8-70% depending on different regions of the world [7], and it has been reported to affect 1 million people in Iraq, Yemen, Saudi Arabia, and Syria [8]. In addition, it has been indicated that OA was more prevalent among men than women. However, studies demonstrated that beyond 50 women are more likely to have OA than same age men [9].

The most common type of OA is knee osteoarthritis (KOA) [10]. The prevalence of KOA has been reported to be 12% in those over the age of 55 years [11].

OA is associated with pain and functional limitations [12] and is typically believed to be the result of obesity and aging [13]. In addition to age and obesity, metabolic syndrome (MetS) has been referred to as a major risk factor for OA development [14]. Association between OA and MetS is referred to as metabolic OA, indicating the association between OA and obesity, dyslipidemia, and hypertension [15].

Due to the high prevalence of knee osteoarthritis (KOA) particularly in the middle-aged individuals, the debilitating effect of osteoarthritis and consequently has a negative impact on quality of life. Moreover, due to the reported association between OA and dyslipidemia, the present investigation was carried out in order to study the prevalence of dyslipidemia among individuals with symptomatic KOA.

MATERIALS AND METHODS

Study design and sample: The present investigation was a prospective cohort study which was carried out in the Rheumatology Division in Sulaymaniyah, Iraqi Kurdistan from March 2018 to May 2019. For this purpose, 60 patients with symptomatic KOA (41 females and 19 males) were chosen as the exposed for the study. Following both ACR classification of OA of the knee [27] and EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis [28], 60 non-exposed (no symptomatic KOA) with the same age range were selected in order to be compared to the exposed.

Selection of the target sample was based on some inclusion and exclusion criteria. The inclusion criteria involved patient consent, age, duration of knee pain not exceeding 2 years, presence of definite osteophyte in at least one joint, and normal body mass index (BMI). Patients with possible secondary causes of dyslipidemia were excluded.


Data collection: The exposed and non-exposed individuals randomly visited the Rheumatology Division, and the required data were collected by conducting face-to-face interviews using a researcher-designed questionnaire.

Statistical analysis: In order to analyze the collected data, Statistical Package for Social Sciences version 25 was used. The descriptive results were expressed as mean ± standard deviation (SD). Normality of the data was verified using Kolmogorov Smirnov test. The categorical variables were analyzed through Chi-square test, and Fisher’s exact test was used when more than 20% of the cells were less than five. Pearson’s and Spearman’s tests were used for the correlation between the variables. Level of significance probability value (p-value) was set at 0.05.

RESULTS

A total of 60 patients with KOA were studied. Analyzing the collected data revealed that their mean age was 51.8 (±3.745) years. Regarding their sex, there were 41 (68.3%) females and 19 (31.7%) males, and the female-to-male ratio was 2.1:1 (See Table 1).

Table 1: Demographic characteristics of KOA cases

The results obtained from analyzing the data collected from the 60 non-exposed subjects indicated that their mean age was 50.95 (±5.077) years. In terms of their sex distribution, 41 (68.3%) females and 19 (31.7%) males were in the control group, with a female-to-male ratio of 2.1:1.

The study demonstrated that 34 cases (56.7%) had bilateral KOA and 26 (43.3%) unilateral KOA. Out of the unilateral cases, 14 had right-side while 12 had left-side KOA, respectively (See Table 2).

Table 2: Type and site of KOA pattern distribution

The results showed that KOA pain duration ranged from 3 to 18 months, with 47 cases (78.3%) having a disease span of less than 12 months, and 13 (21.7%) more than 12 months (See Figure 1).

Click here for Figure 1: Duration of KOA pain (months)

Comparing the cases and controls through t-test, revealed that levels of serum lipid had a significant increase in the KOA patients compared to the controls. There was a significant difference between the two groups in terms of all lipid variables including high-density lipoprotein (HDL) at a p-value of 0.001, total cholesterol (TC) at a p-value of 0.001, low-density lipoprotein (LDL) at a p-value of 0.019, and triglyceride (TG) at a p-value of 0.002 (See Table 3).


Table 3. Analyzing and comparing means with Independent sample T-test

P- Value {Sig (2-Tailed)}is significant whenever it is less than or equal to .05

According to the results obtained from the Chi-square test, the cases had significantly higher levels of abnormal TC, TG, LDL, and HDL compared to the control. Based on these results, it was concluded that KOA had a significant relationship with elevated level of TC (p-value=0.024), TG (p-value=0.016), LDL (p-value=0.018), and HDL (p-value=0.032) (See Table 4).

Click here for Table 4. Significant ratio of normal and abnormal percentage and distribution of lipids among exposed and non-exposed

Compared to the 15 controls (12.5%), 28 cases with KOA (23.3%) had different types of dyslipidemia, and this difference was significant, showing a significant relationship between KOA and dyslipidemia at a p-value of 0.013 (See Figure 2).

Click here for Figure 2: Dyslipidemia among KOA exposed and non-exposed

The results revealed that there was no statistically significant association between sex and age in patients with KAA in terms of dyslipidemia (See Table 5).

Click here for Table 5. Correlation of dyslipidemia with gender and age

The study revealed, that there was a significant relationship between dyslipidemia and pain duration in KOA patients (p<0.0001). Dyslipidemia was more common among patients with knee pain of more than 10 months. Also, dyslipidemia was significantly correlated with bilateral knee joint involvement at a p-value of 0.001 (See Table 6).

Table 6. Correlation of dyslipidemia with duration and joint pattern

Finally, there was a significant connection between pain duration of either 9 or 10 months and the site of knee joint involvement (p=0.004). The study revealed that bilateral involvement was more prevalent in patients with knee pain duration of 10 months (See Table 7).

Table 7. Correlation between joint pain pattern with duration of pain

DISCUSSION


Knee osteoarthritis (KOA) has been defined by the European League against Rheumatism as a condition in which the patients experience functional limitation and/or usage-related pain in their knee(s).[17].Studies has shown that KOA is quite common among middle-aged adults particularly those who are over the age of 55 [11]. In line with this report, the results of the present analysis revealed that the patients’ mean age was 51.8 years, with most patients (61.7%) belonging to the age groups 50-54 and 55-59 years. Similarly, Silverwood et al. (2015) reported age of over 50 years to be a risk factor for knee pain/OA [18].

Furthermore, the current results highlighted that most of the patients with KOA (68.3%) were females. In the same way, results from a study carried out by Corti and Rigon (2003) pointed out that women are more likely to develop KOA [9].

According to the current study, more than half of the KOA cases (56.7%) were bilateral, compared to 43.3% unilateral. Similarly, Fathi (2018) studied unilateral versus bilateral primary knee osteoarthritis in Egyptian patients and reported that 65% of the patients had bilateral KOA and 35% unilateral [19].

Comparing patients with KOA and the non-exposed subjects in terms of their serum lipid variables (i.e. high-density lipoprotein, total cholesterol, low-density lipoprotein, and triglyceride) they were significantly higher in the KOA patients (p<0.05). Likewise, Garcia-Gil et al. (2017) who studied serum lipid levels and risk of hand osteoarthritis (HOA) concluded that the patients with HOA had a significantly higher level of total cholesterol (TC) and triglyceride (TG), but not high-density lipoprotein (HDL) and low-density lipoprotein (LDL) [20].

The analysis of this study revealed that abnormal lipid levels, were significantly higher in the cases than the controls, leading to the conclusion that KOA is significantly correlated with increased levels of TC, TG, LDL, and HDL (p<0.05). Correspondingly, Gandhi et al. (2010) noticed a significant relationship between etiopathogenesis of osteoarthritis and hyperlipidemia [21], highlighting the significance of keeping lipid levels within the normal limit. In the same way, Velasques et al. (2010) demonstrated that OA initiation and progression are significantly affected by various interrelated lipids, metabolic and humoral mediators; therefore, they reported a strong relationship between OA and metabolic factors including dyslipidemia [22].

This study unveiled that dyslipidemia prevalence was found in 23.3% of the KOA patients. This finding agrees with the outcome of a meta-analysis carried out by Baudart et al. (2017) who reported that 30% of the studied KOA patients had dyslipidemia [23]. Moreover, Farnaghi (2014) reported an association between high serum TC and OA. In justifying this association, it was stated that mitochondrial DNA oxidative damage is caused by, and cell dysfunction happens as, a result of high cholesterol-challenged articular cartilage, leading to further apoptosis and overproduction of reactive oxygen species, which in turn leads to development of abnormalities similar to characteristic features associated with OA [24].

Moreover, our study has revealed that serum lipid levels, and KOA duration were significantly correlated (p<0.0001). This finding was not established in any previous research. Additionally, we found a significant relationship between bilateral knee involvement and dyslipidemia with p-value of 0.001. Similarly, Irshad et al (2014) and Al-arfaj (2003) reported a significant relationship between hypercholesterolemia and involvement of both right and left joints in KOA patients [40, 43].

CONCLUSION


Knee osteoarthritis was found to be more prevalent among middle-aged patients and women. Compared to non-exposed individuals, patients with KOA have a higher mean level of serum lipids including total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein. Dyslipidemia is two-fold higher in patients with knee osteoarthritis than non-exposed individuals. Development and progression of KOA might be restricted and controlled by preventing and controlling dyslipidemia.

REFERENCES


1. Wittenauer R, Smith L, Aden K. Update on 2004 Background Paper, BP 6.12 Osteoarthritis. Geneva: World Health Organization, 2013.
2. Deveza LA, Loeser RF. Is osteoarthritis one disease or a collection of many? Rheumatology (Oxford, England). 2018; 57(suppl_4):iv34-iv42.
3. Kotlarz H, Gunnarsson CL, Fang H, Rizzo JA. Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data. Arthritis and rheumatism. 2009; 60(12):3546-53.
4. Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Annals of internal medicine. 2000; 133(8):635-46.
5. Martel-Pelletier J, Barr AJ, Cicuttini FM, Conaghan PG, Cooper C, Goldring MB, et al. Osteoarthritis. Nature reviews Disease primers. 2016; 2:16072.


6. Pereira D, Ramos E, Branco J. Osteoarthritis. Acta medica portuguesa. 2015; 28(1):99-106.
7. Sowers M, Lanchance L, Hochberg M et al. Radiographically defined osteoarthritis of the hand and knee in young and middle aged African American and Caucasian women. Osteoarthritis Cartilage. 2000; 8: 69-77.
8. Halter J, Ouslander J, Tinetti M et al. Hazzard’s geriatric medicine and gerontology Jeffrey B Halter Hazzard’s geriatric medicine and gerontology et al McGraw-Hill Medical pound154. Nursing older people. 2010; 22(6):10.
9. Corti MC, Rigon C. Epidemiology of osteoarthritis: prevalence, risk factors and functional impact. Aging clinical and experimental research. 2003; 15(5):359-63.
10. Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand, hip and knee osteoarthritis among patients in a health maintenance organization. Arthritis and rheumatism. 1995; 38(8):1134-41.
11. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001; 60(2):91-7.
14. Lane NE, Schnitzer TJ. 270 - Osteoarthritis. In: Goldman L, Schafer AI, editors. Goldman’s Cecil Medicine (Twenty Fourth Edition). Philadelphia: W.B. Saunders; 2012. p. 1672-6.
13. Wallace IJ, Worthington S, Felson DT, Jurmain RD, Wren KT, Maijanen H, et al. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A. 2017; 114(35):9332-6.
14. Aspden RM, Scheven BA, Hutchison JD. Osteoarthritis as a systemic disorder including stromal cell differentiation and lipid metabolism. Lancet (London, England). 2001; 357(9262):1118-20.
15. Mertens I, Van Gaal LF. New International Diabetes Federation (IDF) and National Cholesterol Education Program adult treatment panel III (NCEP-ATPIII) criteria and the involvement of hemostasis and fibrinolysis in the metabolic syndrome. J Thromb Haemost 2006; 4:1164–6.
16. Altman RD. Classification of disease: osteoarthritis. Seminars in arthritis and rheumatism. 1991; 20(6 Suppl 2):40-7.
17. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010; 69(3):483-9.
18. Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP. Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2015; 23:507–15.
19. Fathi, H.M. Unilateral versus bilateral primary knee osteoarthritis: Relation to the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), C-reactive protein and radiological assessment in Egyptian patients. The Egyptian Rheumatologist. 2018; 10.1016/j.ejr.2018.12.003.
20. Garcia-Gil M, Reyes C, Ramos R, et al. Serum Lipid Levels and Risk of Hand Osteoarthritis: The Chingford Prospective Cohort Study. Sci Rep. 2017;7(1):3147. Published 2017 Jun 9. doi:10.1038/s41598-017-03317-4
21. Gandhi R, Razak F, Tso P, Davey JR, Mahomed NN. Asian ethnicity and the prevalence of metabolic syndrome in the osteoarthritic total knee arthroplasty population. The Journal of arthroplasty. 2010; 25(3):416-9.
22. Velasquez MT, Katz JD. Osteoarthritis: another component of metabolic syndrome? Metabolic syndrome and related disorders. 2010; 8(4):295-305.
23. Baudart P, Louati K, Marcelli C, Berenbaum F, Sellam J. Association between osteoarthritis and dyslipidaemia: a systematic literature review and meta-analysis. RMD Open. 2017; 3(2):e000442.
24. Farnaghi S. Hypercholesterolemia is a metabolic risk factor for osteoarthritis. 2014, Inst. of Hlth. and bioMed. P. 158 innovation, Brisbane, Australia.
25. Irshad K, Afzal MN. Comparison of serum lipid levels among patients suffering from osteoarthritis in Pakistan. Rawal Med J 2014; 39:6–9.
26. Al-Arfaj AS. Radiographic osteoarthritis and serum cholesterol. Saudi Med J 2003; 24:745-7.

 

 


 

.................................................................................................................