Hemolysis and Renal Dysfunction in Hemodialysis A Bilirubin-Based Study with Hepatic Confounding

Abstract Background: Hemolysis is a common complication in patients with renal failure undergoing hemodialysis, resulting from mechanical, metabolic, and oxidative stress. In resource-limited settings, bilirubin is often used as a surrogate marker of hemolysis; however, its interpretation in adults may be confounded by hepatocellular conditions such as hepatitis C virus (HCV) infection. Objective: To evaluate hemolysis-associated hematological parameters in patients with acute and chronic renal failure undergoing hemodialysis and to assess the impact of HCV infection on the interpretation of bilirubin as a hemolysis marker. Methods: A retrospective analytical study was conducted on 52 hemodialysis patients. Hematological parameters (hemoglobin, hematocrit, MCHC) and biochemical markers (serum creatinine, total bilirubin) were analyzed. Hemolysis percentage was estimated using a bilirubin-based equation. Subgroup analysis based on HCV status and multivariate linear regression were performed to control for confounding. Results: CRF patients showed significantly higher creatinine, bilirubin, and hemolysis levels compared to ARF patients (p < 0.05). In HCV-positive patients, bilirubin was markedly elevated but weakly correlated with hemolysis (r ≈ 0.21, p > 0.05), suggesting hepatic contribution. In contrast, HCV-negative patients showed a strong correlation (r ≈ 0.64, p < 0.01). Regression analysis identified creatinine as an independent predictor of hemolysis (β ≈ 2.35, p < 0.01), while HCV influenced bilirubin without directly affecting hemolysis. The model explained ~ 51% of variability. Conclusion: Hemolysis is elevated in CRF patients; however, bilirubin is a non-specific marker influenced by liver function. Its interpretation should consider HCV status. Combining hepatic and hematological indicators improves diagnostic accuracy in hemodialysis patients.