الفهرس 
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Abstract
Hemodialysis is one of the most effective methods for continuing the life of end stage renal disease patients. Adequate dialysis maximizes well-being, minimizes morbidity, and helps a patient retain social independence.
The adequacy of HD is usually presented in the terms of Kt/V, an equation that takes into account the urea clearance in a single HD session. Many studies showed that Kt/V cannot represent accurately the removal of other toxins, indicating that this parameter alone should not be used as the sole indicator of HD adequacy.
Erythrocyte glutathione transeferase , an enzyme devoted to cell depuration against a lot of large and small toxins , is over expressed in uremic patients.
The aim of the present study was firstly to evaluate HD adequacy in patients with ESRD who were being maintained on regular HD in the pediatric hemodialysis unit of Menoufia university hospital and secondly to verify whether (e-GST) may represent a novel biomarker able to assess the HD adequacy complementary to
Kt /V urea parameter.
This study was conducted in the HD unit in the pediatric nephrology unit of Menoufia university hospital starting from 1/10/2015 to 1/10/2016 48 subjects were enrolled in this study .
The studied subjects were divided into two groups.
group I: included 30 children on MHD for more than 6 months and they were 15 males and 15 females.
group II: 18 healthy subjects were included in this group and they were 8 males and 10 females.
All the included patients were subjected to full history taking, complete physical examination and blood samples were collected from the arterial side of the vascular access and the following laboratory investigation were done:
CBC
Urea, BUN, serum creatinine (before and after dialysis), serum total calcium, phosphorous cholesterol and albumin.
Liver functions.
Serum iron & iron binding capacity.
Parathyroid hormone.
Serum ferritin.
URR and Sp Kt/V were calculated for all patients.
The activity of e-GST.
Laboratory parameter for control group
Serum, BUN, creatinine and liver functions were done
our result revealed that regarding Dialysis prescription of our patients All our patients were on three dialysis session per week the range of dialysis session length was 180-240 min, the mean of BFR was 4.9 ml / kg /min and the mean of their UF volume was 1.56 L. Effective surface area of The dialyzer membrane was 0.7 m2 in 46.7 %of cases and 1m² in 40% of cases and 1.3m² in 13.3% of cases. The type of Filter was high flux in 40% and low flux in 60%.As regard dialysis technique 73.3 % of our patients were on CHD while 26.6 were on HDF.
Temporary catheter was the most commonly used initial access and AVF was the most commonly used current access.
As regard the adequacy of dialysis the mean Sp Kt/V was 1.26 and the mean value for URR was 64.8% .Also in our study, we found that around 43% of the study population had Kt/V values less than 1.2 and there was highly significant positive correlation between SpKt/v and URR. There was no significant correlation between age, weight, height, or BMI and SpKt/V
Regarding dialysis data we found a significant positive correlation between SpKt/V and dialysis session length, while there was no significant correlation with other dialysis data or onset of hemodialysis therapy.
Regarding the correlation with laboratory parameter there was significant negative correlation between SpKt/V and serum K while no significant correlations were found with the other laboratory parameters as Hb, albumin, ca, phosphorus, parathormone hormone, or iron profile
Regarding e-GST activity ,the mean e-GST activity in the control group was 5.61 ±0.2 U/gmHb ,and for the patients on MHD
the mean e-GST activity was 9.61±0.94U/gm Hb, the differences in activity between patients and control group were statistically significant and we found signifcant negative correlation between dialysis dose and e-GST.
In our study we found significant negative correlation between e-GST and both dialysis session length and BFR.
Regarding the laboratory parameters and e-GST there was no significant correlation between e-GST and any of the following Hb, albumin, cholesterol, serum K, serum Ca Serum phosphorus or parathyroid hormone meanwhile there was significant positive correlation between e-GST and predialysis urea ,BUN and serum creatinine.
Regarding the hemodialysis technique , the patients on HDF had higher mean value of Sp Kt/v than patients on CHD but this difference was statistically insignificant ,meanwhile the mean level of e-GST was lower in patient on HDF than patients on CHD and this difference was statistically highly significant.
In another step the patients on MHD were further subdivided in 2 subgroups according to dialysis adequacy. Adequate dialysis subgroup with Sp Kt/V≥1.2 .56.6% of patients were included in this subgroup and inadequate dialysis subgroup with SP Kt/V<1.2and included 43.4% of patients.
We found no significant difference between both subgroups as regard age, gender, and blood flow rate .We found significant difference between both subgroups as regard dialysis session length.
E-GST was compared in both groups, we found that mean e-GST level in the inadequate dialysis subgroup was higher than the mean in the adequate dialysis subgroup (10.1±0.72 Vs 9.27± 0.95 U/gmHb) the difference in activity was statistically significant .There was no statistically significant difference in Hb level, calcium and albumin between 2 HD subgroups
We concluded that about 43 .3 % of our patients were receiving inadequate HD dose. Hemodialysis session length had a profound effect on dialysis adequacy. We also concluded that e-GST level was significantly higher in MHD patients than controls and its level was significantly correlated with both SPKt/V and URR, accordingly, we can consider it as a new tool for evaluation of the effect of HD in purifying blood.
We recommend that the delivered dose of HD needs to be measured monthly to recognize patients who are receiving suboptimal dialysis adequacy, also we need further studies on larger number of cases to detect cut off point of e-GST for adequate HD and to determine reference values along the different ages and situations.