الفهرس 
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Abstract
T
he prevalence of chronic kidney disease (CKD) and end stage renal disease (ESRD) is increasing worldwide.
Maintenance hemodialysis (HD) is the mainstay of treatment for the patients with end stage renal disease not suitable for or awaiting renal transplantation. Cardiovascular morbidity is an important complication in these patients.
Dialysis adequacy is the recommended quantity of hemodialysis delivered which is required for adequate treatment of end stage renal disease (ESRD), such that the patient receives full benefit of hemodialysis. Adequacy of hemodialysis is an important determinant of patient morbidity and survival.
Patients on maintenance hemodialysis often show a significant decrease in quality of life. Hemodialysis patients experience numerous symptoms in terms of medical outcomes and also in terms of potential reduction in functioning and wellbeing.
The current study was conducted on 50 patients with chronic renal disease, who were followed-up at the Hemodialysis Units of the Department of Internal Medicine and Nephrology of Kobry El-Kobba Military Hospital in Cairo, participated in the study of dialysis adequacy. They were assessed during their regular dialysis sessions between February 2011 and August 2011.
The aim of this study was to evaluate the bone parameters and their relation to hemodialysis adequacy in a military hospital.
The results of the present study were summarized as the following:
The number of male patients was slightly higher than that of the female patients on maintenance hemodialysis (35.0% versus 15.0%). The mean age of the patients was 49.6±6.17 years. There was no significant statistically differences between three groups in age and gender (p > 0.05).
The results of our study showed systolic and diastolic blood pressures were recorded, and blood samples were drawn before the patient’s usual hemodialysis session. Hemoglobin concentrations, serum creatinine concentrations, blood urea concentrations, uric acid, serum sodium concentrations, and serum potassium concentrations were routinely analyzed.
Among our 50 chronic HD patients, mean age was 49.6±6.17 years, mean of dialysis duration was 23.3±24.1 months, BMI was 25±4 kg/m-2, Kt/V was 2.4±0.46, weekly creatinine clearance 76.5±75.4l, and daily urine output 550±610 ml day-1.
In the present study, we found the duration of hemodialysis of most of the patients was between less than one year to 10 years; at the time of study, 45.0% of patients were on dialysis longer than 1 year and 30.0% less than one year. There were 15.0% patients on hemodialysis over 5 years, and 10.0% on dialysis over 10 years.
This study found a significant number of patients on maintenance hemodialysis with chronic renal failure (CRF) of unknown etiology. The present study suggested that; the etiologies of the renal failure showed hypertensive nephropathy were the commonest cause of CRF among (27.0%) of the patients on chronic hemodialysis, while chronic glomerulonephritis were 18.0% in dialysis patients, and diabetes nephropathy were 16.0%. As regard, polycystic kidney disease, Reflux nephropathy, and SLE were the least common etiologies with non-significant differences between both patient groups. On the other hand, mean age at the start of hemodialysis was 37.3 years in chronic glomerulonephritis but 54.1 in chronic tubulointerstitial disease, and 54.8 in polycystic kidney disease.
The results of the present study shows the weight of studied groups was significantly higher among group IIB (X±SD: 74.2 ± 14.68Kg) than group IIA (X±SD: 67.8 ± 12.9Kg) with significant differences between both groups (t= 2.18, P=0.03)
Interdialytic weight gain (IWG) in our study patients was ranging from 0.8-7.4 kg (X±SD: 4.2±1.24 Kg). IWG was significantly higher among group IIA compared with group IIB (t = 4.43, P< 0.001).
The duration of dialysis in the study patients is ranging from 0.75-13 years (X±SD: 5.49±3.2 years); the mean duration of dialysis of the group IIB is 5.28±3.36 years, while that of group IIA is 5.86 ±2.9 years with non-significant difference between both groups. Our results showed highly statistically significant difference between both studied groups.
In our present study, drug adherence was highly significantly more attributed in compliant patients (96.87%) than non-complaints (19.44%) undergone hemodialysis.
Adherence to medications was assessed by the number of missed doses per day. The percentage of drug adherence was ranging from 40%-100% (91.7 ± 16.08SD), in group IIB it was (97.58±9.2SD), and while in group IIA it was (81.25 ±20.08 SD).
Only 4 patients (20.0%) of group IIA showed drug adherence while most of group IIB (20.20%) were adherent with highly significant differences between both patient groups (χ2: 4.6, p< 0.001).
According to K/DOQI guideline which recommended a serum PTH level between 150 – 300 pg/ml, 28.0% of patients had hyperparathryrodism (PTH level ≥ 300 pg/ml), Patient distribution with respect to PTH (0–150, 150–300, and > 300 pg/ml). There were 48.0% of patients respect to PTH levels < 150 pg/ml, and 28.0% > 300 pg/ml.
Our result showed that there was no significant increased in fast blood sugar in group IIA compared with control group and group IIB (p value > 0.05). As regard, in post prandial blood sugar had statistically significant differences between control group and subject groups (p value = 0.001).
The result in this study had no significant decreased in study groups compared with control group with ALT and AST (p value > 0.05). As regard, there were statistical significant differences in ALB between control group and subject groups (p value = 0.001).
The results of the present study found an increase in total cholesterol in patients with dialysis and chronic renal impairment. There was non-significant decreased in group IIA compared with group IIB. As regard, there were non-significant increased in study groups with triglyceride.
Also, the results found an increase in HDL between the three groups. As regard, there were statistical significant differences between control group and studied groups compared with LDL and TG, there were non-significant differences between control and studied groups (p value < 0.003; versus p value = 0.56 respectively).
These results which obtained in our study an increase in uric acid in control comparing to studied groups. As regard, there were statistical significant increased between control group and studied group (p value 0.005). Also, this table shows the results of serum creatinine and urea levels. Both uraemic markers were significantly increased (11 times higher) in the dialysis patients compared with the control group. There was significantly higher decreasing creatinine clearance in studies group comparing to control group.
Concerning parameters of dialysis adequacy, it was found that most of patients were reasonably well dialysed, although a significant number of patients on maintenance hemodialysis were underdialysed according to the parameters of dialysis adequacy.
Although ALP is a commonly collected laboratory measure, this is the first study to provide a description of ALP levels in a large international patient population and identify numerous HD patient characteristics associated with elevated ALP. This study establishes a strong relation between elevated ALP and higher risk of hospitalization and mortality, independent of the effects of serum phosphorus, calcium, and PTH.
The present study showed serum biochemistry at follow-up and diagnosis of renal osteodystrophy. Mean inorganic phosphorus level was 4.8±1.2 mg/ml, calcium (Ca2+) 9.4±1.04 mg/ml, intact parathyroid hormone (iPTH) 262±346 pg/ml, ionized Ca2+ 1.08±0.32 mg/ml, calcium phosphorus (Ca × P) product 39±19 mg2/dl2, total alkaline phosphatase 172±179 U/l, bone alkaline phosphatase 73±112 U/l and albumin 3.6±0.5 g/ml.
The present study showed the biochemical investigation among HD patients according to creatinine clearance. There was increasing in biochemical parameters between the three groups. There were highly significant increasing in levels of phosphate, total calcium, ALP, Ca x P levels and PTH levels between HD patients compared to control group (p < 0.001).
According to bone alkaline phosphatase (BAPL), there were statistically significance differences in gender, eGFR, serum ALP, and whole serum PTH levels (p < 0.05).
There were no significant differences in age, body mass index, systolic or diastolic blood pressure, prevalence of diabetes nephropathy, albumin level, hemoglobin level, calcium level, phosphorus level, and uremic acid level, between the two groups at baseline (p > 0.05).
The present study shows that ALP values were normal, and intact PTH was 3-4 times higher in group IIB than in group IIA. The group with higher intact PTH levels had lower calcium and higher phosphorus values. There was a statistically significance difference in phosphorus between the two groups (p < 0.05), while there was non-significant difference in ALP levels between the two groups (> 0.05). As regards, there were highly significant in serum calcium and PTH levels between the two groups (p < 0.001).
Mean serum phosphorus levels were also statistically different in the older age group ( 45 years) compared to the younger patients, with values of 4.5±1.1 and 5.1±1.4 mg/ml, respectively, (P=0.013).