الفهرس 
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Abstract
The incidence of end-stage renal disease (ESRD) in the world has increased every year. The trend stands in marked contrast to the decline in coronary heart disease and stroke over the same time period. End-stage renal disease defines a situation of chronic irreversible renal failure in which prolonged survival is not possible without dialysis or renal transplantation with social and economical implications.
Identification of modifiable risk factors for the development of chronic renal disease is an important first steps in understanding and hopefully, reversing the increasing incidence of ESRD.
The recent trends in the pattern of occurrence of ESRD indicated the emergence of new and unidentified risk factors and those with the diagnosis of unknown chronic renal failure are over diagnosed with under-estimation of the toxic renal failure and this is best demonstrated in case of environmental exposure and the development of HD. In this study we tried to identify some of the possible risk factors which may be incriminated in the development of ESRD among a sample of Egyptian patients in order to provide some sort of foundation for subsequent useful preventive measures.
The study composed of objectives of which was to identify some of the epidemiological features of (HD) patients and to study the possible relation between vitamin A supplementation as antioxidant and health education programs on the prognosis of health status among HD patients.
This study was designed as a case-control intervention study aiming to identify some socio-demographic environmental risk factors of ESRD. All patient were (60) selected from hemodialysis center located in Imbaba General Hospital, were subjected to regular renal replacement therapy in the form of dialysis.
Patients were randomly selected from the same hospital, they were age and sex matched. Both groups were subjected to personal interview, revision of the health records.
• Control group (30 patients) who received placebo tablets for three months.
• Study group (30 patients) who received vitamin A orally (10.000 IU/day) for the same period.(Consent was obtained from all patients).
- Questionnaire was designed and it included personal information as age, gender, smoking, educational level, occupation, family living condition, hygienic behaviors and medical problems, possible etiology of renal failure. Socioeconmic score applied to all patients according to George (1981) and Wright and Hill (1986) scale.-Baseline laboratory investigations for all
- patients including blood picture, blood glucose, assessment of residual kidney function, hepatitis markers and HIV Ag & Ab, CRP, t.IgG, s.vitamin A and s.MDA as oxidant marker.
The intervention part of the study was designed to identify the possible relation of vitamin A supplementation and health education sessions and the prognosis of the disease.
- CRP, s.MDA, s.IgG and s.vitamin A were re-estimated at the end of intervention phase for all patients (study and control group).
- Pre and post health education evaluation test was applied to both groups.
The findings of the study can be summarized as follow:
• 25 (41.7%) out of the 60 participants were males and 35 (58.3%) were females with age ranging from 18 to 60 years with a mean of 47.98±1.33. However there were no significant statistical differences regarding their residence, marital status, income/month education level, occupation, and smoking between the two studied groups.
• As regard educational status, both groups show a high degree of illiteratacy (63.3%), (50.0%) respectively followed by primary level (20.0%),(23.3%),then secondary level (13.3%),(13.3%) respectively ,while it was(3.3%), (1.7%) in high institute grade.
• Concerning the occupational categories in both groups, there was no significant difference; the job status were classified according to the job classification which categories the jobs into professional grades. There is no statically significance among the studied groups because they were matching, house hold (House hold includes: house wife and non-employed subjects) were 36 from 60 patients (60.0%) followed by Worker (low educational level 16 from 60 patients (26.7%), followed by Commercial worker 5 from 60(8.3%), then worker of high institute 2 from 60(3.3%) followed by governmental worker 1 from 60 (1.7%)
• Socioeconomic status; there is no significant correlation in housing and socioeconomic scores data between the 2 groups of the study, Both groups show a high percentage of low socioeconomic scores: (76.7%),(66.7%) respectively, followed by mid scores (23.3%),(30.0%) then high socioeconomic score for both groups was 1(1.7%).
• Regarding to dietary information, there is no significant difference between two groups. (75.0%) of the studied groups had no dietary information, also there is no significant difference between two groups as regard meeting dietary physician, (96.7%) of all patients didn’t meet dietary physician pre or post dialysis session.
• The possible etiology of renal failure ,our results showed that unknown etiology associated with end-stage renal disease represented by (33.3%) , followed by hypertension (25.0%), followed by stones (13.3%) , then glomerulonephritis (acute, chronic, pyelo)(10%) , followed by prolonged use of analgesic (6.7%), followed by diabetes mellitus(5.0%). post partum hemorrhage (1.7%).
• Regarding to baseline laboratory results concerning the study and control groups. Hb=hemoglobin decreased in both groups (mean 8.64gm /dl ±SD 1.77), TLC=total leucocytes count (mean 9.86 – ±SD 2.2), RBCs=red blood cells were slightly diminished in number (mean3.37-±SD 0.43).
• Hepatitis markers and HIV Ag and Ab among study and control groups , (60.0%) of all patients had positive HCV Ab test by ELISA technique while the HBsAg positive patients were (5.0%),all patients were negative for HIV Ag and Ab.
• At baseline, laboratory results for the two studied groups: 36 out of 60 patients were positive for CRP (60%) while negative were (40%). in case group 70.0% were positive and 30% were negative. 50% had positive s. CRP in control group.
- As regard total IgG mean and SD were 1558.52 mg/dl ±33.46. S. IgG among study group were 1436.4 mg/dl ,±SD 330.2 and 1671.9 mg/dl, ± SD 86.5 in control group.
- Vitamin A in the studied groups mean; 67.16 ug/dl ±1.31. It was 73.43, ± SD 5.1 and 61.55 ± SD 86.5,in study and control groups respectively.
- Regarding to S.Malondialdhyde, Mean (SD); 6.88 nmol/ml ±0.16, it was 6.37 nmol/ml ±SD 1.46 in study group vs 7.30 ±SD 0.88 nmol/ml for control.
- Pre health education evaluation test% mean (SD) was 37.71 ±1.55. In study group 41.07% ±SD 10.15 while in control 34.34% ±SD 12.20.
- Regarding to comparison of CRP sero-conversion changes among the two studied groups (pre and post intervention); pre –intervention the number of positive patients for CRP in the study group was 21 out of 30 (70%)while negative patients were 9 out of 30 (30.0%), post-intervention phase the number of positive patients were lower 11 from 28 (30.3%)while negative patients were 17 from 28(60.7%).In control group: the number of positive patients for CRP were 15 from 30 and negative patients were 15 out of 30 (50.0%),post-intervention phase: no significant changes observed, it was found that 50% of the control were positive .
• Total IgG changes after intervention; study group had significantly lower level of total IgG, 1237.13 (mg/dl) than control group 1689.02(mg/dl) with (p<0.01 (S).
• Concerning s. vitamin A; a higher level of s .Vitamin A was observed in study than control group (p<0.01 (S) .In the study group s. vitamin A was 76.60 ug/dl vs 60.53 ug/dl in control.
• Regarding to s.malondialdhyde; study group had significantly lower level than control group with ( p <0.01 (S). Study group showed mean 4.12 nmol/ml versus control which had higher serum level with mean 7.53 nmol/ml.
Data about health education programs showed that post health education evaluation test% was significantly higher in the study group than control group with (p<0.01).Study group had higher score with mean 58.87% vs control who had lower score 34.96%.Regarding to the changes among study group only; patients before health education session had mean score 41.0% while post test score was 58.87%with significant p <0.01.
from the previous results we can conclude:
1. Preventive interventions with exploration of the relevant risk factors are essential. Identification of the modifiable risk factors with the resultants useful hypotheses should be translated into effective preventive strategies which should be disseminated to those who can benefit from them. And the quality of their wide spread use should be monitored. Identification of both initiators (renal disease specific) and promoters (disease non specific) should be emphasized with the greatest potential to reduce the incidence of renal insufficiency.
2. The preventive strategies should have an important impact on HD incidence as they would target large numbers of patients at high risk for progression, examples include hypertension -related hypercreatinemia, diabetes mellitus, those occupationally at risk or residentially exposed to risk factors.
3. Administration of antioxidants as vitamin A in addition to conventional treatment of ESRD had significantly improved some infection markers as CRP, t.IgG and oxidant marker MDA as free radical.
4. Continues health education programs: This entails both the HD patients and medical staff with sufficient awareness, background knowledge and efficient skills regarding renal diseases and specifically the end-stage renal disease may contribute greatly in early diagnosis and prevent or delay progressive renal deterioration.