EFFECT their nutritional status. Patients undergoing haemodialysis frequently

The present investigation was conducted on 60 patents (48 males and 12 females) in two stapes first is proper taken medication and dialysis therapy and second additional diet counselling (suggested to soy and paneer like high biological protein) in during the year, 2016 in MLB, Medical College, Jhansi (U.P.) India with the aim to assess and analyze effect of dietary counselling the nutritional status of patients (>19yrs) undergoing haemodialysis at least 2 month and in CKD -5 stage for last three months. Different biochemical parameters such as blood urea, creatinine, albumin etc along with amount of calorie and protein intake (20gm) given during haemodialysis superior the nutritional status of undernourished chronic kidney disease patients.
About proper diet counselling of the patients showed positive response (<0.005) while the only medication and dialysis therapy showed a undergoing undernourished in their nutritional status. Patients undergoing haemodialysis frequently develop protein-energy malnutrition which is related with morbidity and mortality rate increases. Special nutritional care is required for the dialysis patient to improve the net protein anabolism.

Keywords: Chronic Kidney Disease, Nutritional Status, Malnutrition, Hemodialysis, High Biological Protein
Kidney is the vital human organ essentially responsible for the filtration of nitrogenous and other metabolic waste products from the body through the urinary system and maintains the metabolism of biochemical especially haemostatics fluid, electrolyte and acid-base balance kidney is to help maintain blood pressure, activate vitamin D and produce erythropoietin. But, the efficiency of the kidney is a decline when there is a loss of nephron function (2). A chronic renal failure which is also known uraemia is a drastically high level of urea in the blood which may be the end result of acute glomerulonephritis and nephrotic syndrome.(3 ,4) CRF is a slowly progressive loss of renal function over a period of month or year resulting in abnormally low glomerular filtration rate which is usually determined indirectly by the creatinine level in the blood serum.(5)
The persons with stage 4 chronic kidney disease (CKD) have advanced kidney damage with a severe decrease in the glomerular filtration rate (GFR) to 15-30 ml/min (6,7). In the management of ESRD, dialysis is used on either temporary basis or permanent basis. There may be a possibility of a kidney transplant in the near future. Dialysis is an artificial process by which nitrogenous waste products are removed from the blood in the event of kidney failure (8,9). There is two main type of dialysis – Hemodialysis and peritoneal dialysis. The common characteristic adoption of both types of dialysis is the removal of the wastes and excess fluids from the body. It is most often found in a patient of chronic renal failure (CRF) during the period when the glomerular filtration rate (GFR) falls below 10 ml/min, but dialysis is yet to be started. Dialysis patient need a much higher intake of protein than the average person. Too little protein and calorie intake often leads to protein energy malnutrition. 11,12.

Table-1: Recommended dietary nutrient intake for hemodialysis patients
(Alpers, David H.et al 2008, Soucy M.et al.2008, Cano, N. J. M., et al 2008)
Nutrients Recommended intake
Dietary protein intake (DPI) • 1.2 g/kg/d for clinically stable patients
(at least 50% should be of high biological value)
Daily energy intake (DEI) • 35 kcal/kg/d if <60 years
• 30–35 kcal/kg/d if 60 years or older
Total fat 25–35% of total energy intake
Saturated fat <7% of total energy intake
Polyunsaturated fatty acids Up to 10% of total calories
Carbohydrate Rest of calories (complex carbohydrates preferred)
Total fiber “/>20–25 g/d
Sodium 750–2000 mg/d
Potassium 2000-2750 mg/d
Phosphorus 800-1000 mg/d
Calcium <1000 mg/d
Iron 10-18 mg/d
Water Usually 750-1500 ml/day
DPI: Dietary protein intake, DEI: Daily energy intake, HD: Hemodialysis
2. Materials and methods
All selected CKD patients included in this study is conducted on 60 consecutive CKD stage -5 patients in MLB, Medical College, Jhansi, India form February 25th, 2016 to December 30th, 2016 have aged between 19 to 65 years and undergone haemodialysis at least 2 months before. All the included patients have regular haemodialysis for minimum 2 times in a week. The patients are CKD-5 stage from last3 months. This prospective observational study was started after prior approval from Institutional Review Board (Human Ethics Committee), MLB, Medical College, Jhansi. Informed written consent was obtained from the patients before enrolment whose fulfilling the inclusion and exclusion criteria taken this study. The patients were divided into two groups, both were suffering from chronic renal failure with CKD-5 stage in last 3-month. Thirty patients were taken in each group. The group first with 30 patients undergoes with haemodialysis at regular interval, at least two times in a week. In Group second, all patients were having same condition as like group first but additional counselling proper diet suggested soy and paneer like high biological protein. 5 ml of intravenous blood samples were collected in plain tubes after an overnight fast. After collection, the samples were allowed to clot for half an hour following which the samples were centrifuged and serum was analysed. Serum total cholesterol (TC), triglycerides (TGs), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), were measured calorimetrically using commercially available kits on fully auto analyzer of Clinical Biochemistry Laboratory. VLDL cholesterol concentration was calculated using Friedewald’s Formula and nutritnal assessment done by 24 dietary recall methods all data collected 30 day interval 2 times in this study (17). Statistical data was recorded on Microsoft Excel programme. The comparison between two groups was done by paired t-test in Graph Pad Prism 7 software. (……………………)(Add statistical method ref.)
Tests Of CKD Patients Mean ± SD Of
Patients Undergone Hemodialysis Without Dietary Counselling P Value Statistically Significant (P ; 0.05) Mean ± SD Of
Patients Undergone Hemodialysis with Dietary Counselling P Value Statistically Significant (P ; 0.05)
Urea (mg/dl) 146.42±34.5 ;0.346 No 142.5±36.16 ;0.0001 Yes
Random Rbs 110.86±15.02 0.553 No 111.28±12.02 ;0.6484 No
Cholesterol (mg/dl) 173.37±33.01 ;0.0003 Yes 163.95±29.35 ;0.0145 Yes
HDL (mg/dl) 47.06±06 0.2984 No 50.7±7.0 ;0.0001 Yes
VLDL 32.27±7.25 ;0.0001 Yes 27.5±6.79 ;0.1762 Yes
Triglycerides 157.22±28.85 ;0.0001 Yes 137.9±37.72 ;0.37 N0
LDL 97.5±32.8 ;0.0001 Yes 99.71±26.33 ;0.0017 Yes
Serum. Creatine (mg/dl) 10.05±2.7 ;0.57 No 12.81±3.55 ;0.0001 Yes
Table -2 Biochemical Tests of CKD Patients
Table -3 Nutritional assessments of CKD Patients
S.albumin- serum albumin, MUAC- Mid-Upper Arm Circumference, Kcal- kilocalorie.

Nutritional assessment
Tests Of CKD Patients Mean ± SD Of
Patients Undergone Hemodialysis Without Dietary Counselling P Value Statistically Significant (P ; 0.05) Mean ± SD Of
Patients Undergone Hemodialysis with Dietary Counselling P Value Statistically Significant (P ; 0.05)
Weight (Kg) 58.04±6.11 ;0.0001 Yes 56.8±6.7 ;0.0001 Yes
BMI 21.95±1.22 ;0.0001 Yes 21.41±1.7 ;0.0145 Yes
MUAC 22.18±1.47 ;0.0001 Yes 24.1±1.14 ;0.0067 Yes
Hb(mg/dl) 7.68±1.38 8.63±1.4 S.Albumin 3.49±0.4 ;0.03 Yes 3.5±0.4 ;0.187 No
Kcal 1580.5±164 ;0.0001 Yes 1644.0±96.93 ;0.357 No
Protein (gm/day) 58.1±6.0 ;0.0001 Yes 60.15±3.68 ;0.0001 Yes
4. Results and Discussion
It is revealed from table 2, 3 the dietary intake was recorded at the end of the month and then calculated to analyze the changes in the energy (calories) and protein intake. Patients with CRF are at high risk for CVD and cerebrovascular disease (CBVD), and they are more likely to die of CVD than to develop ESRD. CRF is associated with premature atherosclerosis and increased incidence of cardiovascular morbidity and mortality. Several factors contribute to atherogenesis and cardiovascular disease in patients with CRF, the notably among all is dyslipidemias (18). Chronic renal failure, per se, primarily affects the metabolism of high-density lipoprotein (HDL) and triglyceride (TG)-rich lipoproteins (19).
Protein-energy malnutrition is highly prevalent (25-50%) among dialysis patients and is associated with increased morbidity and mortality. The prevalence of CKD has been increasing day by day and it is well known that patients are more likely to die than to progress to end-stage renal disease. The presence of multiple classical and novel risk factors influences this group of patients and in fact patient with premature cardiovascular mortality is due to end-stage renal disease.
5.Conclusion :-
In this study result were showed elevated prevalence of malnutrition in HD subjects. Despite the better understanding of the pathophysiologic mechanisms of uremic malnutrition and the improvements made in nutritional support, the nutritional condition of CKD and ESRD patients remains a significant cause for concern. Multimodal therapeutic strategies should be considered. The nutritional status in patients on HD needs more attention. The role of nutrition in the management of CKD is important and needs to be further researched and newer guidelines are need of the hour. We hereby recommend that the assessment of nutritional status should be part of routine evaluation of all CKD patients.

The hemodialysis therapy should be deal with by a multidisciplinary team, as recommended for other high risk populations. A part of medical nutrition therapy is to provide nutrition education and periodic counselling by dieticians. For effective intervention, dieticians should present a guide for educating HD patients about individual nutritional needs. This guide should provide information about food sources, nutrients and usage exchange food lists
We acknowledge the support and cooperation from the patients enrolled in the study. We also thankful to the staff of Department of Medicine and Dialysis unit of MLB Medical College, Jhansi for their valuable help and support.

8.Conflict of interest- The author(s) declare(s) that there is no conflict of interest.



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