الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Expanding concern in hyperphosphatemia in dialysis patients was raised lately because it has been associated with cardiovascular and all-cause mortality. Considering the clinical implications of uncontrolled hyperphosphatemia, maintenance of phosphorus concentrations within an optimum range is standard of care in this patient population and it depends on phosphate lowering treatment, dialysis and phosphorus dietary restriction. A direct relation between phosphorus dietary restriction and serum phosphorus can be clearly documented in dialysis patients as it is apparently followed by a significant fall in serum phosphorus. Therefore, serum phosphorus could be used as a surrogate of dietary phosphorus intake in this population.
Dietary phosphorus restriction is complex because of the delicate balance between ensuring adequate protein intake and simultaneously restricting phosphorus intake as overzealous restriction of protein-associated phosphorus may contribute to protein energy malnutrition with an adverse impact on survival. Also the relationship between phosphorus sources and types (organic, inorganic) as well as differences in quality and quantity of phosphorus in each source are confusing. In conclusion, novel strategies as HD patients’ education and counseling are needed to combat these barriers.
The general objective of this study was to evaluate the impact of dietary counseling on control of hyperphosphatemia among Egyptian HD patients. The specific objectives of the study were to design and implement individualized renal diet plans for HD patients, determine the effectiveness of dietary phosphorus restriction on serum phosphorus levels in HD patients and assess the impact of the renal diet plans on anthropometric indices, laboratory indices and clinical parameters of protein energy malnutrition and hyperphosphatemia of HD patients.
The study was conducted on 100 anuric HD patients with serum level >5.5 mg/dl in the past six months prior to the study. The duration of the study was 3 months. The studied patients were subjected to full history taking (medical and dietary) using pre-designed questionnaire and laboratory investigations. Also anthropometric assessment, SGA tool for HD patients were used to evaluate their nutrition status. In addition, they received standard phosphorus education and individualized meal plans at baseline and at 6 weeks after intervention. Then the effect of the intervention on dietary phosphorus restriction and serum phosphorus was evaluated at 6 weeks after intervention and at the end of the study.
In the current study almost quarter of the studied patients were following low protein diet at baseline. The mean protein intake was 74.18 ± 22.92 g (0.9 g /kg IBW/day) at baseline and it was significantly increased at 6 weeks after intervention to 85.41 ± 23.49 g (1.1 g / kg IBW/day) then at the end of the study it was significantly increased in comparison to baseline to 84.38 ± 24.33 g (1 g / kg IBW/day), poor appetite was prevalent in 39 % of the studied patients. The mean energy intake of the studied patients was 1530.2 ± 527.4 kcal (19 kcal/ kg IBW/day) at baseline, then this value was decreased non-significantly during the study period to reach 1517.8± 542.7 kcal (18.9 kcal/kg IBW /day) at the end of the study. The SGA tool score revealed that the majority of the studied patients (87%) were well nourished at baseline and only 13% of the studied patients were suffering from mild to moderate malnutrition with no significant change during the study period.
The mean DW of the studied patients was 83.21± 13.53 kg at baseline, then it was significantly decreased during the study period till it reached 82.47± 13.78kg after 3 months of intervention. Furthermore, 98 % of the studied patient had a BMI of more than 20 kg/m2. The highest percentage (44%) of the studied patients were overweight and this percentage was non-significantly decreased (42 %) at the end of the study. In addition 37% percent of the studied patients were obese at baseline, then this percentage decreased significantly to 36% at 6 weeks after intervention then it decreased non-significantly to 34 % at the end of the study. There was a significant decrease in the mean TSF of the studied patients during the study duration. A significant increase in mean MAMA of the studied patients was found at 6 weeks after intervention then it showed non-significant increase in comparison to baseline at the end of the study, furthermore it showed a weak positive correlation with mean protein intake at both 6 weeks after intervention (r=0.347*, p < 0.001*) and at the end of the study (r= 0.235*, p = 0.019*).
Phosphorus intake of the studied patients at baseline was within the recommended level, then it was significantly decreased from 819.0 ± 526.5 mg to 791.0 ± 529.2 mg during the study period. On the other hand the mean inorganic phosphorus intake frequency score was high at baseline and it was significantly decreased at 6 weeks after intervention by 60.18 ± 21.89 % then it was non-significantly decreased by 47.86 ± 42.43 % in comparison to baseline. A modest positive correlation between dietary protein intake and dietary phosphorus intake was found at baseline (r= 0.627*, P< 0.001*).
The mean serum phosphorus in the studied patients was 6.62 ± 0.90 mg/dl at baseline and it showed weak positive correlation with dietary phosphorus intake (r= 0.287*, P= 0.004*), then it was significantly decreased to 5.83 ± 0.96 mg/dl at the end of the study. The mean calcium × phosphorus product was significantly decreased during the study period. The current study reported that there was a weak to modest positive correlation between different sources of inorganic phosphorus intake and serum phosphorus level which strength was decreased by time till it reached non-significance, except for fast food, after 3 months.
The results of the current study showed that the most potent factors which had affected serum phosphorus level as shown in the multilinear regression model were total protein intake and inorganic phosphorus intake at 6 weeks after intervention, then at the end of the study total protein intake remained effective while inorganic phosphorus intake lost its effectiveness. At the same time, the total phosphorus intake became significantly affecting serum phosphorus level replacing inorganic phosphorus intake at the end of the study.
from this study we concluded that the effectiveness of inorganic phosphorus intake became weaker at the end of the study owing to the convenience and availability of fast food denoting that dietary choices had an important role in phosphorus homeostasis in HD patients. A significant increase in mean protein intake of the studied patients occurred which was low at baseline denoting that individual dietetic counseling may be useful in reducing phosphate load and in limiting the phosphate burden related to an adequate protein intake.
The most important recommendations from this study:
1. It would be useful to sensitize patients to follow a diet with a low load of phosphorus, a mixed composition of food from plant and food from animal origin should be encouraged, while the intake of processed foods should be limited.
2. Strategies to improve compliance are necessary to decrease the incidence of hyperphosphatemia in HD patients.
3. More detailed information of the phosphate content of foods, described by manufacturers, can lead to better control of phosphorus intake with the HD patients’ diet.