الفهرس 
INTRODUCTION
The physiology and function of the kidneyOnly 14 pages are availabe for public view
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Abstract
Chronic kidney disease (CKD) remains one of the most important public health problems in world, and its prevalence is gradually increasing. It becomes more important due to a high mortality and morbidity rate mainly based on cardiovascular events, and also due to the need for expensive treatment such as hemodialysis, continuous ambulatory peritoneal dialysis, and renal transplantation due to end stage renal disease (ESRD). Early diagnosis may prevent or delay the progression to ESRD. However CKD diagnosis is delayed in considerable cases, leading to a progression in the disease and an increase in prevalence due to the lack of epidemiologic studies and consensus on diagnostic criteria.
In the present study, our general aim was to assess the nutritional status of chronic kidney disease patients. The study was done in the outpatient clinic of kidney disease in Nephrology center Benghazi / Libya. The study design was cross-sectional approach.
The study sample included 105 (47 female +58 male) adult patients. Collection of data was carried by use of 4 tools: interviewing, physical examination, anthropometric assessment and record review. Data was collected from patients using a predesigned structured interview questionnaire. Personal characteristics, medical and diet history information and anthropometric measurements were taken. selected physical signs and laboratory parameters were recorded. Dietary information was obtained through 24 hour diet recall; calculation of nutrient intake, nutrient recommendation, and percent of adequacy was done. Screening of malnutrition was carried by use of some anthropometric parameters (Mid-upper-Arm Circumference, Triceps Skin fold thickness, Mid- Arm- Muscle Circumference, % of Ideal body weight and classification of BMI). Some body composition parameter’s (% total body fat, % lean body mass). Biochemical parameters (albumin level, hemoglobin concentration, and % Transferrin Saturation). Relations were done between GFR and study parameters. All the suitable statistical techniques were performed.
Results can be summarized as Follows:
The mean age of patients was 58.513.4 years, and the majority of studied sample was at age group (40-60) years, slightly more than half of the patients were males (55.2%) one third of the patients (33.3 %) were illiterate or read and write and the majority of patients were unemployed (78.1%) Family size ranged from 2-20 members with a median of 7 members.
The mean value of GFR of CKD was 29.815.7 ml/ min, The highest percent (41%) of the sample was at stage 3 CKD, followed by 30.5% who were at stage 4 CKD and 21.9% at stage 5 CKD and only 6.7% belonged to stage 2. The duration of disease ranged between 1-30 years with a median of 3 years. Multiple etiologies are responsible for CKD; the majority (95.2%) of the patients had hypertension, 43.8% had diabetes mellitus. According to their diet history 55.2% of the patients had dental problems and 44.8% of them had changes in appetite
Concerning gastrointestinal problems 30.5% of the patients did not suffer from any problems, almost 42% complained of constipation, followed by nausea in 38. 1%, vomiting and hiccough in 20% for each and taste disturbance was present in 3.8% of the patients. According to supplement intake, forty one percent do not take any type of supplement. About half of patients take Calcium supplement (47.6%), more than fourth of patients (26.7%) take vitamin D and iron supplement, while Erythropoietin was used by about 22.9% of the patients.
Only one third (36.2%) followed the dietary regimen which was given by dietary staff and it was mainly in the form of restricted dietary protein intake, and salt and salty food and fatty food.
Systolic blood pressure ranged from 90-200 mmHg with a mean of 133.4±19.7 mmHg. Treatment goal SBP was achieved in 31.4 % of cases. Diastolic blood pressure ranged from 60-110 mmHg with a mean of 80.71±9.54 mmHg, Treatment goal DBP was achieved in 43.8% of cases. It is to be noted that all patients were under antihypertensive drugs.
Anthropometric indicators used to assess nutritional status showed that all Anthropometric measurements were higher in females than that in males with exception of height and Percent of Ideal body weight.
Malnutrition parameters by use of anthropometric indicators, using MAMC, revealed that 67.6% of the sample had lower values than the reference.
Body composition parameters as indicator of malnutrition, concerning the percentage of total body fat, the majority (89.5%) of the sample had very high percentage of total fat, and the low percentage of lean body mass was detected in 62.9% of studied sample.
BMI as indicator of malnutrition, overweight formed thirty percent of the sample, being in males higher than that in females. Class I obesity formed about fifth of the total sample and at equal percent for both sexes. Class II obesity formed about less than fifth of total sample; it was higher in females than that in males. Class III obesity formed low percent in the total sample; it was higher in females than that in males.
Biochemical parameters as malnutrition indicators in studied sample showed that Serum Albumin was detected below 3.5 g/dl in 27.6% of total sample. In the majority of the studied sample the Hemoglobin concentration was below target level in 72.4% of total sample and Percentage of transferrin saturation was below the range, in about half (52.4%) of the total sample. All biochemical parameters were significantly lower in females than in males.
The results showed concerning dietary intake of critical mineral and electrolytes nearly all cases (97.1%) their calcium intake was below the recommendation and about one third (33.3%) their phosphorus intake was above the range of recommendation. Potassium intake was below the range of recommendation in the majority of the cases (86.7%)
The energy intake covered only three quarter of recommendation, and the mean of daily energy intake was 1453.8±441 kcal forming 78.9±25.89 from the recommendation; the percent of energy adequacy diminished by decrease in GFR. While protein intake was 63±238 g/day forming 171.9±67.4 from the recommendation i.e. it exceeded the recommendation.
The Correlation between GFR and some anthropometric measurements and biochemical parameters revealed that the GFR was higher in high BMI, MUAC, MAMC and in high hemoglobin concentration. Serum phosphate was significantly higher in stage 5 CKD than other early stages.
The GFR was higher in patients who did not have Weight loss than that in patients who suffered from weight loss this was not statistically significant, the GFR was higher in patients who did not have change in appetite than that in patients who had change in appetite with significant difference between them
The GFR was higher in patients who had no gastrointestinal disturbance followed by the patients who suffered from nausea and vomiting; Taste disturbance and food aversion showed the lowered GFR in the list of GI disturbances.
Percent of energy adequacy was related with GFR, where it decreased by advanced in degree of GFR.
from this study we conclude that malnutrition was widely spread among patients with chronic renal disease, and therefore this study recommends the following:
A. Reemphasize the role of the clinical dietitian as a professional member of the health care team in CKD clinic.A dietary counselling and nutritional education, done by nutritionist or a dietitian to ensure that patients are consuming an adequate diet, with relaxation of some of the usual dietary restriction. This should be individualized, and it is important to help every patient and his family to understand the requirements and remain sensitive to his personal food habits. Give written information that patients can review at home with key education Points. Be sure written material is on the patient reading level. Counsel patients on diet as often as possible; Offer counselling at least every 1-2 months.
B- Early intervention through referrals to nutrition clinic is needed to improve care of Patients with CKD and prevent or delay ESRD .To prevent the deterioration of nutritional status during the progression of CKD, high-energy intakes are recommended together with a close follow-up evaluation. Psychosocial and economical support should be provided whenever needed by the nutritionist and nephrologist.