الفهرس 
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Abstract
Survival in ESRD patients is made possible by removal of uremic solutes by dialysis, uremic toxins include small water-soluble compounds such as urea, protein-bound solutes or larger middle molecules such as beta 2-microglobulin (Vanholder et al.,2014).
An ideal dialysis therapy should remove all of these compounds However, only small toxins are easily removed by all dialysis techniques (Krieter et al.,2010).
Kt/V cannot represent the removal of other solutes and fluid, so this parameter should not be used alone as the sole indicator of dialysis adequacy (Basile et al.,2012).
Thus, other dialysis adequacy biomarkers have been identified such as Erythrocyte Glutathione transferase (E-GST) which is an enzyme able to detoxify the cell from endogenous and exogenous toxic compounds by using glutathione (GSH) or acting as a ligandin for toxins (Bocedi et al.,2019)
Aim of the study:
To verify whether E-GST is a novel biomarker of hemodialysis adequacy in different dialysis techniques {(standard bicarbonate hemodialysis (HD) and (HDF)} or complementary to the Kt/V urea parameter.
Patients and methods
A. Study design: cross sectional study
B. Patient selection:
This study was conducted on 40 ESRD patients on regular hemodialysis from Ain shams university hospitals hemodialysis units, according to the modality of hemodialysis:
The patients were divided into two groups matched as regard age and sex.
group A: 20 patients receiving conventional hemodialysis
group B: 20 patients receiving hemodiafiltration (HDF).
Control: 20 apparently healthy subjects.
Inclusion Criteria
1. Adults > 18 years.
2. ESRD on regular HD for at least 6 months, receiving 3 sessions /week, each session 4 hours.
Exclusion Criteria:
1. Hyperbilirubinemia.
2. Chronic liver disease.
C. Patients were subjected to the following:
1. An informed consent
2. History taking & examination including:
Etiology of ESRD, duration of hemodialysis in months, dry weight, dialysis prescription and Iron & erythropoietin therapy
3. Complete blood count (CBC).
4. Chemistry: (AST, ALT, total bilirubin,direct bilirubin Serum creatinine, calcium, phosphorus)
5. PTH
6. Iron study (serum iron, TIBC, Ferritin)
7. Pre-dialysis urea, post dialysis urea & Kt/V urea and urea reduction ratio (URR) will be calculated
8. Erythrocyte glutathione transferase with ELISA technique.
D. All control were subjected to:
1. An informed consent
2. Serum creatinine, Total & direct bilirubin.
3. HBA1C.
4. Erythrocyte glutathione transferase with ELISA technique.
E. samples collection &storage:
All samples were obtained by EDTA containing tube after collecting the samples, the serum was allowed to clot for 10-20 minutes at room temperature then Centrifugation was done (at 2000-3000 RPM) for 20 minutes. Then supernatants were collected and stored at -20℃..
Summary of the Results:
In this study there was no significant difference between conventional HD and post dilutional OL-HDF as regard age, sex, etiology and Access of HD and type of ESA.
The patients on post dilutional OL-HDF were more hypertensive(18 patients (90%)), they used larger dialyzer surface area & more pump flow and received more antihypertensive drugs, PPI in comparison to conventional HD patients.
The patients on post dilutional OL-HDF have higher hemoglobin level, lower ESA dose/week, lower ERI and lower PTH in comparison to conventional group p-value(0.006, 0.004, 0.011,0.002) respectively.
Erythrocyte glutathione transferase cut off value in HD patients 6 ng/dl and its sensitivity and specificity were100%
There was highly significant statistical difference between conventional HD, post dilutional OL-HDF and control group as regard E-GST (P value <0.0001)
The post hoc analysis of E-GST level showed significant difference between control and both (conventional HD and post dilutional OL-HDF) groups (p- value 0.0001&0.0001) respectively while there was no significant difference between (conventional HD & post dilutional OL-HDF) group (p-value 0.061)
E-GST has the same power to express dialysis adequacy like URR, Kt/V Urea as there is no significant statistical difference between conventional HD & post dilutional OL-HDF as regard markers of hemodialysis adequacy(URR& Kt/V) (P value >0.05) that was also reflected on EGST level
The patients were redistributed according to Kt/V into 2 groups: Adequate dialysis group (Kt/V > 1.3) & Inadequate dialysis group (Kt/V ≤ 1.3)
E-GST can differentiate either patients are receiving adequate hemodialysis or not like urea 2,URR and Kt/V as the patients with inadequate dialysis have significantly lower URR, higher Urea 2 and higher E-GST in comparison with patients with adequate dialysis)(p value 0.0001, 0.020, 0.0001) respectively
The prevalence of E-GST level in inadequate dialysis group (Kt/V ≤ 1.3) was 95% (19 patients) while in group receiving adequate dialysis (Kt/V > 1.3) prevalence was 40%(8 patients)
The hemodialysis patients who have elevated E-GST level have higher risk to have inadequate dialysis of 28.5 times than negative ones
The cut off point of E-GST to detect inadequate dialysis (Kt/V ≤ 1.3) is >14 ng/dl with 95% sensitivity, 60% specificity and area under curve (AUC) 0.871
There was significant correlation:
• E-GST level showed significant negative correlation with URR & Kt/V values in both conventional HD and HDF groups
• In HDF patients, E-GST level showed significant negative correlation with dialysate flow while positive with urea 1.
• In conventional HD, E-GST level showed significant negative correlation with duration of hemodialysis while positive with urea 2 and Direct bilirubin
• In control, E-GST level showed significant positive correlation with serum creatinine and direct bilirubin.
E-GST is a reliable and sensitive biomarker of uremic toxicity, its overexpression in ESRD can be used to assess toxins removal and adequacy of multiple dialysis sessions.