الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Pro-oxidants, commonly referred to as reactive species, include reactive oxygen species and reactive nitrogen species. Some reactive species are free radicals while others are non-radicals. These highly reactive dangerous substances can be responsible for tissue injury. Unsaturated lipid molecules of cell membranes, RNA, DNA, and enzymes are susceptible to their oxidative damage. Antioxidants (enzymatic and non-enzymatic) prevent free radical induced tissue damage by preventing the formation of radicals, scavenging them, or by promoting their decomposition.
When the production of free radicals is beyond the protective capability of the antioxidant defenses, OS occurs, where excess reactive species react with carbohydrates, lipids, proteins, and nucleic acids, thus altering their structure and function, resulting in cellular damage and pathologic processes.
ESRD refers to permanent serious damage to the kidney function. The annual mortality of ESRD patients is about 10-20 fold higher than the general population. Approximately 50% of these deaths are due to CVD. High cardiovascular risk associated with ESRD is partly due to OS.
Micronutrients in diet play a major role in the antioxidant status of HD patients and their deficiency might elevate the OS of the body. Usually, antioxidant-rich food intake is significantly lower in all CKD patients. Many patients on dialysis tend to eliminate eating even allowed fruits, in an effort to decrease potassium levels and many of them are diabetic and do not eat fruits for fear of increasing their blood sugar levels. Moreover, some patients do not eat fruits at all even if their potassium and sugar levels are within the range. Since HD patients live under pro-oxidative conditions, they may require an increased level of antioxidant protection. Educating HD patients regarding all aspects of nutrition, especially antioxidant-rich foods safe to consume, plays an integral role in their management and may improve the CVD morbidity and mortality of HD patients. Thus, this study was designed to assess the impact of educating HD patients regarding aspects of nutrition and value of antioxidant-rich food through dietary counseling.
The general aim of the present study was to assess the impact of dietary intervention on OS control among adult patients attending Alexandria University Students Hospital for HD; while the specific objectives were to assess the nutritional status and the OS among those patients, to develop and implement an individualized renal diet plan and an individualized nutritional education program for them with emphasis on antioxidant-rich food safe for ESRD, and to evaluate the effect of antioxidant-rich food consumption on control of OS and the nutritional status of those patients in terms of dietary intake, laboratory findings, and anthropometric measurements.
A one group pretest-posttest intervention study was conducted in the hemodialysis unit of Alexandria University Students Hospital. Twenty five adult patients attending Alexandria University Students Hospital for HD were included in the study from November, 2018 to April, 2019.
The study involved the following 3 phases:
1 - Phase 1: preliminary assessment.
All participants were interviewed to answer a pre-designed questionnaire which included sociodemographic characteristics, smoking habits, medical history, and history concerning CKD.
All patients were interviewed to answer a predesigned food frequency questionnaire. Patients were asked about the frequency of consumption of different food items, focusing on antioxidant-rich fruits and vegetables, during the previous month. Each participant completed three 24-hour dietary recalls (the day before HD, the day of HD, and the day following HD). Every patient was asked to recall the types and quantities of foods and beverages that he or she consumed on the 3 days.
Data of the 24-hour dietary recalls were analyzed to get the mean daily intake of energy, protein, phosphorus, potassium, and sodium. Dietary density of protein and dietary adequacy for energy and for protein were calculated.
SGA was assigned to each patient. Patients were classified into well-nourished, mild malnutrition, moderate malnutrition, and severe malnutrition.
Height, dry body weight, MUAC, and TSF thickness were measured, and BMI and MAMA were calculated.
Fasting blood samples were collected from the patients to estimate total antioxidant capacity, complete blood count, serum albumin, kidney function tests, parameters of lipid profile, blood electrolytes, and serum calcium and phosphorus levels.
2 - Phase 2: nutritional intervention and education.
Every patient was given an individualized meal plan using renal exchange list (according to his anthropometric measurements, clinical condition, and laboratory findings). All patients were given a written nutritional education program, which was discussed thoroughly with them.
3 - Phase 3: final assessment and evaluation of the outcome.
Dietary intake using 24-hour recall method, SGA components, anthropometric measurements, and laboratory findings were re-assessed after 3 months of nutritional intervention program.
Statistical analysis was performed using the appropriate computer programs and statistical methods. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. Statistical significance of the obtained results was set at p-value ≤ 5%. Qualitative data were described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation, median and interquartile range. Paired t-test, Wilcoxon signed-rank test, McNemar test, and marginal homogeneity test were used to analyze the data.
6.2. Conclusion
A- Before applying the intervention program:
• A high percentage of patients consumed less protein and calories than their dietary requirements. Dietary phosphorus intake was high in almost half of the patients while dietary potassium intake was normal in the majority of patients.
• Most of the patients showed some degree of malnutrition. Mild malnutrition was prevalent among the majority of HD patients.
• All patients had total antioxidant capacity value within normal range.
• Anemia was observed in almost half of HD patients, the highest percentage of patients had a low absolute lymphocytic count, while hypoalbuminemia was observed in only 12% of patients.
• Hypocholesterolemia and low HDL-C levels were observed in the majority of the patients.
• Serum potassium and phosphorus levels were high in about half of the patients.
B-After applying the intervention program:
• There was an increase in protein and energy adequacy among patients whose protein and energy consumption were not adequate. On the other hand, there was a significant reduction in protein and energy adequacy among patients whose protein and energy consumption were more than their dietary requirements.
• There was a significant reduction in dietary intake of potassium and phosphorus and the percentage of patients who had high dietary phosphorus intake was significantly lower.
• There was a significant decrease in the SGA score, indicating improvement in the SGA variables and in the nutritional status of the patients.
• Total antioxidant capacity was almost the same before and after applying the intervention program.
• Serum albumin levels were higher and the serum HDL-C levels increased significantly.
• There was a significant DROP in serum creatinine after nutritional counseling, which was in parallel with reduction in blood urea.
• The serum potassium and phosphorus levels decreased significantly and the percentage of patients with hyperkalemia and that of patients with hyperphosphatemia were significantly lower.
6.3. Recommendations
from the present study, we came to the following recommendations:
1- Since the current study results show that individualized nutritional counseling is effective in improving parameters that have been associated with nutritional status and adverse outcomes in patients with ESRD, implementation of a nutritional education program and individualized dietary counseling are highly recommended for all HD patients.
2- Diet modifications should be recommended without dramatic changes in the patient’s dietary habits or in his lifestyle in order to gain a better chance of patient compliance.
3- Periodic evaluation of nutritional status of patients regardless their weight and BMI is recommended for early detection of malnourished cases.
4- A multidisciplinary approach including nephrologists and nutritional specialists is preferred to reduce morbidity and mortality.
5- To evaluate the effect of nutritional counseling more objectively:
• Further long-term studies are needed to assess the effects of nutritional education on changes in body composition, biochemical parameters, nutritional status, and OS in HD patients.
• Adding additional markers of inflammation would provide a clearer picture of the inflammatory profile of HD patients.
• Future studies assessing multiple OS biomarkers are recommended.
• Studies including a control group that is not receiving nutritional counseling are required.
• Studies involving a larger number of patients are needed.