الفهرس 
Chronic Kidney DiseaseOnly 14 pages are availabe for public view
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Abstract
Chronic kidney disease (CKD) is recognized as a major health problem. It describes abnormal kidney function and/or structure. It is common, frequently unrecognized and often exists together with other conditions (for example, cardiovascular disease and diabetes). When advanced, it also carries a higher risk of mortality. The risk of developing CKD increases with increasing age, and some conditions that coexist with CKD become more severe as kidney dysfunction advances. CKD can progress to established renal failure in a small but significant percentage of people.
The progression of chronic kidney disease usually occurs in four stages: diminished renal reserve, renal insufficiency, renal failure, and end-stage renal disease.
Diminished renal reserve occurs when the glomerular filtration rate (GFR) drops to approximately 50% of normal. Renal insufficiency represents a reduction in the GFR to 20% to 50% of normal. Renal failure develops when the GFR is less than 20% of normal. End-stage renal disease (ESRD) occurs when the GFR is less than 5% of normal.
Dialysis or renal replacement therapy is indicated when advanced uremia or serious electrolyte imbalances are present. The choice between dialysis and transplantation is dictated by age, related health problems, donor availability, and personal preference. Serum creatinine levels of > 6 mg/dL in males (4 mg/dL in females) and a GFR < 4 mL/min are the laboratory thresholds that are often used to indicate the need for dialysis therapy. Although transplantation often is the treatment preference, dialysis plays a critical role as a treatment method for ESRD. It is life sustaining for persons who are not candidates for transplantation or who are awaiting transplantation. There are two broad categories of dialysis: hemodialysis and peritoneal dialysis.
Removal of fluid to maintain the patient euvolemic, or slightly hypovolemic, after dialysis is often desirable. Normalization of serum electrolytes is obviously important. Guidelines for removal of other uremic toxins are, however more difficult to establish. Urea has been widely used as a marker to guide dialysis, since its removal by conventional hemodialysis appears to correlate with clinical outcome. Some have simply used the decrease in BUN during dialysis as an alternative guide.
Protein-energy malnutrition (PEM) is very common among patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis therapy. Owing to different definitions of PEM and different patient populations, the prevalence of PEM in the ESRD population varies between 18–70%. Most importantly, the presence of PEM is one of the strongest predictors of mortality and morbidity in this population and thus has been a target of intense interest for clinicians.
About 20–50% of patients on maintenance hemodialysis or peritoneal dialysis suffer from PEM. In the majority of dialysis patients, malnutrition is mild to moderate, only in approximately 10% of patients severe PEM can be found during the course of CKD.
CKD stages 3 and 5 are associated with a spontaneous reduction of the mean protein intake from 1.0 g/kg body weight/day to about 0.5 g/kg body weight/day. Accompanied by a reduction in energy intake. The presence of protein–energy malnutrition at the initiation of dialysis therapy is associated with higher risks of mortality and morbidity.
Enteral nutrition (EN) is the feeding route of choice. It is physiological, associated with less serious complications than parenteral feeding and is cheaper. So, in all clinical situations, if the gut is functioning, it should be used as the route of feeding. In some cases, oral or enteral supplements may not be appropriate. In these circumstances, intradialytic parenteral nutrition (IDPN) may be an option.
The aim of this study is to compare between the effect of enteral nutrition and intradialytic parenteral nutrition on malnourished hemodialysis patients.After the Medical Ethical Committee in Ain Shams University approval and informed consent was taken from the patients, one hundred and thirty-five patients (fifty-eight males and seventy-seven females) were included in the study.
Patients were divided randomly into three equal groups, 45 patients for each group. Patients of Group A received intradialytic parenteral nutrition using same amount of proteins in the form of more aromatic amino acids in addition to enteral nutrition. While patients of Group B received intradialytic parenteral nutrition using same amount of proteins in the form of more branched chain amino acids in addition to enteral nutrition. And patients of Group C received enteral nutrition only.
Assessment of nutritional status was designed to measure serum albumin (g/dL), serum pre albumin (mg/dL), serum transferrin (mg/dL), BMI (kg/m2), Dialysis Malnutrition Score and nitrogen balance within 6 weeks.
Patients who received intradialytic parenteral nutrition, either using same amount of proteins in the form of more aromatic amino acids in addition to enteral nutrition (Group A) or using same amount of proteins in the form of more branched-chain amino acid in addition to enteral nutrition (Group B), showed an elevation in nutritional markers and anthropometric measurements within the period of the study which was greater when compared to patients who received only enteral nutrition (Group C).