NUTRITIONAL STATUS AND DIETARY GUIDELINES OF PREDIALYTIC AND HEMODIALYTIC PATIENTS

7/31/2019 NUTRITIONAL STATUS AND DIETARY GUIDELINES OF PREDIALYTIC AND HEMODIALYTIC PATIENTS

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NUTRITIONAL STATUS AND DIETARY GUIDELINESOF PREDIALYTIC AND HEMODIALYTIC PATIENTS

Thesis submitted to the University of Agricultural Sciences, Dharwad in partial fulfilment of the requirements for the

Degree of

MASTER OF HOME SCIENCE

In

FOOD SCIENCE AND NUTRITION

By

SWETA SUMAN

DEPARTMENT OF FOOD SCIENCE AND NUTIRTIONCOLLEGE OF RURAL HOME SCIENCE,

UNIVERSITY OF AGRICULTURAL SCIENCES,DHARWAD - 580 005

JULY, 2006


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ADVISORY COMMITTEE

DHARWAD (USHA MALAGI)

JULY, 2006 MAJOR ADVISOR

Approved by :Chairman : ___________________________

(USHA MALAGI)

Members : 1. _________________________ (RAMA K. NAIK)

2.__________________________ (P. W. BASARKAR)

3. _________________________ (KASTURIBA B.)

4.__________________________ (I. S. HASABI)


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CONTENTS

Chapter

No.

Title

I INTRODUCTION

II REVIEW OF LITERATURE

III MATERIAL AND METHODS

IV EXPERIMENTAL RESULTS

V. DISCUSSION

VI. SUMMARY

VII. REFERENCES

VIII. APPENDICES

IX. ABSTRACT


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LIST OF TABLES

Table

No.

Title

1 Demographic profile of selected chronic renal failure patients

2 Clinical and health status of subjects at the time of investigation

3 Etiology of chronic renal failure in the subjects

4 Symptoms of kidney disease at the time of onset

5 Prevailing clinical signs of the subjects at the time of investigation

6 Stage of kidney disease based on Glomerular Filtration Rate (GFR)(ml/min)

7 Prevailing complications of selected chronic renal failure subjects

8 Prevalent vices in the subjects

9 Exercise behaviour of the subjects

10 Mean anthropometric measurements of the subjects

11 Classification of the subjects based on Body Mass Index (BMI) andWaist to Hip Ratio (WHR)

12 Age-wise classification of the subjects based on Triceps SkinfoldThickness (TSF)

13 Age-wise classification of the subjects based on Mid Upper ArmCircumference (MUAC)

14 Age-wise classification of the subjects based on Mid Arm MuscleCircumference (MAMC)

15 Mean food intake of the subjects

16 Mean nutrient and electrolyte intake of the subjects

Contd..


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Table

No. Title

17 Mean vitamin intake of the subjects

18 Mean food intake of the subjects according to gender

19 Classification of the subjects based on adequacy of nutrients

20 Dietary modification followed by the subjects

21 Biochemical profile of selected subjects

22 Biochemical profile of dialytic patients before and after dialysis

23 Classification of selected subjects based on protein and hemoglobinstatus

24 Classification of selected subjects based on lipid profile

25 Classification of subjects based on associated conditions forplanning individual diets


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LIST OF FIGURES

FigureNo.

Title

1 Etiology of chronic renal failure in the selected subjects

2 Classification of selected subjects based on protein andhemoglobin status


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LIST OF PLATES

Plate

No.

Title

1 Dietary survey

2 Weight measurement

3 Edema

4 Hemodialytic patient

5 Model diet plan for a predialytic non-diabetic patient with GFR 25ml/min

6 Model diet plan for a predialytic non-diabetic patient with GFR 26-70 ml/min

7 Model diet plan for a hemodialytic patient

8 Model diet plan for a hemodialytic diabetic patient


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LIST OF APPENDICES

Appendix

No.

Title

I Questionnaire

II Diet plans

III Dietary tips for kidney disease


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I. INTRODUCTION

The prevalence of chronic renal disease is rising worldwide. The global patientpopulation with an end stage renal disease continues to grow at the rate of 7 per cent perannum due to demographic transition, increase in disease leading to chronic renal diseaseand increased availability of diagnostic and therapeutic facilities (Shyam and Sreenivas,2005).

Renal disease may be part of a systemic, inherited, drug induced disease or a resultof an infection, affecting glomeruli or blood vessels supplying blood to the kidney, renaltubules, interstitium, epithelial lining and urinary tract. The world wide prevalence of etiologyof chronic kidney disease was given by Anonymous et al . (2002). Diabetes mellitus 34 percent, hypertension 29 per cent, glomerulonephritis 14 per cent, obstructive nephropathy 9 per cent, pyelonephritis and interstitial kidney disease 3 per cent, polycystic kidneydisease 3 per cent, drug induced nephropathy 1 per cent, unknown (not detected) 7 percent. Chronic renal disease is defined by the level of kidney function and the evidence ofkidney damage. The National Kidney Foundation (Kidney Disease Outcomes QualityInitiatives) (NKF-K/DOQI), Clinical Practice Guidelines for Chronic Renal Disease (2002),identified five stages of renal disease defined by the glomerular filtration rate (Anon., 2005b).Community based prevalence figures are not available in India for chronic renal disease.However, it is estimated that approximately one lakh new patients develop end stage renal

disease in India annually. This number is likely to be an underestimate, as it is based on dataonly from a few tertiary care centres. The progression of the renal disease is though slowinitially, becomes exponential in the later phases and requires renal replacement therapy.

Estimates reveal that renal units in India are offering treatment to 80 to 100 newpatients, with end stage renal disease (serum creatinine =10mg/dl), per million populationeach year. To add to this burden, there is an unknown number whose creatinineconcentrations are approaching this arbitrary threshold.

End stage renal disease population has exceeded 7,00,000 by turn of the century.Therapeutic options for such patients are limited, the choice is between two forms ofreplacement therapy i.e. , maintenance dialysis and renal transplantation. The latter is themost desirable treatment, nevertheless the major limiting factor is the lack of available organs,hence, majority have to remain on long term/life long dialysis (Gulati, 2001).

The patients with renal disease are often present with nonspecific signs andsymptoms, including nausea, anorexia, lethargy, edema, dyspnea, diminished urine outputand hematuria.

Complications of chronic renal failure include fluid and electrolyte disorders causinghyponatremia or hypernatremia and hypokalemia or hyperkalemia. Secondaryhyperparathyroidism are associated with symptoms of bone disease, persistenthyperphosphatemia and / or soft tissue calcification. Vitamin D is usually required to replacedecreased renal production of calcitriol, but vitamin D compounds can causehypercalcemia and hyperphosphatemia.

Few other complications associated with chronic renal disease are anaemia andhyperlipidemia leading to a many fold increased risk for cardiovascular disease (Anon., 2005).Other than these complications patients with end stage renal disease undergoing renalreplacement therapy are prone to develop several types of malnutrition, including proteinenergy and deficiencies of certain minerals (eg, iron and possibly zinc and selenium) andvitamins (eg, vitamin B-6 and vitamin C, folic acid and 1,25 dihydroxy cholecalciferol) andpossibly impaired bioactivity of other essential nutrients (eg, carnitine).

Depression, low socioeconomic status and multiple medications are associated withmalnutrition which leads to morbidity and mortality.

Hence, there is a need for assessing nutritional status in chronic renal patients so thatappropriate therapy can be prescribed and the effect of such treatments monitored andprovide nutritional support followed by drug therapy.


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Assessment of nutritional status can provide valuable information concerning nutrientintake and requirement and can identify patients who are at risk for various nutritionaldisorders. Among the disorders which are common in uremic patients are protein and caloriedeficiency and excessive salt and water intake (Kopple, 1974).

Thus dietary therapy which is an integral component of medical care is required forthe patient with progressive or end stage renal disease and its goal is to minimize uremictoxicity and other metabolic disorders of renal failure, possibly slowing the rate of progressionof chronic renal failure while maintaining body protein store.

Ironically, there is a paucity of data on nutritional profile of renal patients in India andno research efforts are insight, except for a few limited studies. Hence, the present study hasbeen planned to throw light in this direction with the following objectives :

1. To assess the nutritional status of renal patients in terms of anthropometry, dietary andbiochemical methods

2. To document the related complications of renal patients, and

3. To plan suitable dietary guidelines for renal patients


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II. REVIEW OF LITERATURE

Wasting and malnutrition occur commonly in patients with renal failure. The causesare multifactorial and include inadequate intake of nutrients, loss of nutrients in dialysate,intercurrent illnesses, uremic toxins, and endocrine abnormalities such as insulin resistance,hyperglucagonemia and hyperparathyroidism. Malnutrition and wasting may contribute to

many aspects of the uremic syndrome, including increased susceptibility to infection, impairedwound healing, decreased strength and vigor and poor rehabilitation and quality of life.

These above facts stress the need for assessing nutritional status in uremic patients,for prescription of appropriate therapy and effective treatment monitoring.

Conversely anthropometric parameters, dietary history and biochemical value suchas serum protein measurements provide valuable data concerning the nutritional status ofthe patient. The interaction between nutrients and biochemical parameters in terms of serumurea nitrogen to serum creatinine ratio and urea nitrogen appearance are useful for selectingoptimal protein intake.

The dietary therapy which aims towards preserving the body cell mass and function,fluid electrolytes and acid-base homeostasis, mineral balance and with early use of dialysis,

the avoidance of uremic toxicity is of paramount importance. Disturbances in thesecomponents superimpose the patients to develop life threatening complicatons. Dietarytherapy can be interms of dietary modifications including dietary prescription andsupplementations as per the need of the patient.

The literature related to predisposing factors to chronic renal disease, nutritionalassessment, complications prevailing in nephrotic patients and the related dietary therapy arereviewed in this.

2.1 PREDISPOSING FACTORS TO CHRONIC RENAL FAILURE

Renal disease can occur due to various causes, which appear either limited to thekidney or may be part of a systemic process, called as predisposing factors. These factorscan lead to the complete failure of the organ termed as chronic renal failure.

Rao and co workers (1988) found 2.6 per cent of the NIDDM subjects had persistentproteinuria. Lazzari and Brunelli (1991) found 7.7 per cent nephropathy in 514 type 2diabetics. It was more frequent when average daily glycemia was greater than 150 than when150mg/dl.

Yassine et al . (1991) conducted a retrospective cohort study to define the risk factorsfor nephropathy in NIDDM in 704 patients who were admitted between 1978 and 1987 toMichigan hospital. The results showed that incidence of complication increased with durationof diabetes (1% at 5 years, 5% at 10 years, 11% at 15 years, 33% at 20 years and 45% at 25years). Older age at diagnosis of diabetes and obesity were significantly associated with riskof nephropathy.

Risk factors related to subsequent renal mortality have been studied in seven yearsfollow up of 4740 middle aged diabetic subjects participating in multinational study at Arizona,Hong Kong and Tokyo (Fuller and Stevens, 1991). The presence of proteinuria at thebaseline examination was the strongest predictor of renal mortality in both type 1 and type 2diabetes mellitus. Age adjusted renal mortality increased significantly with diabetes duration inboth types of diabetes mellitus.

Mattack et al . (1992) conducted the retrospective studies of patients with NIDDM(n=141) from 1985-89 to know whether the predictive power of microalbuminuria isindependent of other cardio-vascular risk factors. The authors concluded that micro-


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albuminuria is a significant risk marker for mortality in diabetes, independent of other riskfactors. Its presence can be regarded as an index of increased cardiovascular vulnerability.

In India, majority of End Stage Renal Disease patients (ESRD) are Non-InsulinDependent Diabetes Mellitus (NIDDM). About 30-40 per cent of Insulin Dependent DiabetesMellitus (IDDM) and five per cent NIDDM patients die due to ESRD. Hyperglycemia can leadto diabetic nephropathy by non enzymatic glycation of proteins, abnormal and metabolism,

abnormal lipid metabolism (Maji, 1998).

Tanaka et al . (1998) investigated the rate of glycemic control and blood pressure indevelopment and progression of nephropathy in 123, age and diabetes duration matchedelderly Japanese NIDDM patients (60-75 years) for six years. Results showed that the groupthat developed micro-albuminuria from normoalbuminuria, showed a higher six year meanHbA1c than the group that remained narrow albuminuric (n=50, 9 Vs 8.1%). On the otherhand, the group that progressed from microalbuminuria to overt proteinuria showed a highersix year mean blood pressure than the group that remained micro-albuminuric (n=23, 106vs95). Thus the authors concluded that glycemic control is more potent factor than bloodpressure level on development of microalbuminuria. Nevertheless, in development of overtproteinuria from micro albuminuria, hypertension is the most crucial factor in elderly NIDDMpatients.

2.2 NUTRITIONAL ASSESSMENT OF CHRONIC RENALFAILURE PATIENTS

Malnutrition is relatively common problem among chronic renal failure patients. It canbe secondary to poor nutrient intake, increased losses in body composition and increasedprotein catabolic rate. For all these reasons nutritional assessment is of paramountimportance which can be done by various methods which are interlinked to each other.

2.2.1 Anthropometry

Blumenkrantz et al (1978) assessed the nutritional status of predialytic (n=79) anddialytic patients (n=26) through anthropometric measurements and compared the values withthe normal subjects (n=51). Relative body weight, triceps skin fold thickness, the percentage

body fat and mid upper arm muscle circumference were significantly lower in predialyticsubjects compared to normal and dialytic subjects. The mid upper arm muscle circumferenceand fat free mass each correlated with creatinine appearance (r=0.73, p


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they had significantly lower subscapular skin fold thickness, mid thoracic skin fold thicknessand estimated body fat when compared to females of control subjects (P


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normal subjects (n=51). Serum total protein, albumin, trnasferrin and C 3 were alsosignificantly decreased in predialytic patients compared to normal, with the greatest decreaseobserved for serum albumin and transferrin. In dialytic subjects these parameters were lessthan the normal, showing wasting and malnutrition in chronic renal failure and even inpopulations of dialytic patients who are considered to be particularly robust and healthy.

Guarnieri et al . (1980) studied the serum protein contents of patients undergoing

hermodialysis (n=18) and showed decreased serum total protein, albumin, transferrin, C 3 andpseudo cholinesterase whereas serum IgM content tended to be increased, compared tonormal values, showing the signs of malnutrition in these patients.

Harvey et al . (1980) monitored the dietary adherence in clinically stable, chronically,uremic men (n=6), with a protein intake of 60, 40, 20g/day for whom serum urea nitrogen tocreatinine ratio was supposed to be 8.6:1, 6.0:1 and 3.4:1 respectively. An increase in thisratio, in a patient who was ingesting known protein intake indicated catabolic stress.

Rubin et al . (1981) studied the effective method of assessing nutritional status of 14patients undergoing peritoneal dialysis, by serial simultaneous measurements (3 to 6 months)of total body potassium, which correlated negatively with episodes of peritonitis per monthand fell in 46 per cent of patients (2225185 mEq from the start to 2063126 mEq at the endof study), reflecting long term clinical consequences of peritonitis. Thus, it was concluded that

estimating total body potassium is an effective method of assessing nutritional status inpatients on peritoneal dialysis, as its an indicator of lean body mass and thus indirectly ofnitrogen balance.

Goldstein et al . (1989) studied the relationship between the blood levels of 25hydroxy vitamin D and the concentration of serum albumin in 26 patients with nephroticsyndrome and 26 patients with renal failure but without proteinuria. The blood levels of 25(OH) D 3 ranged 1.0 to 18.6 (8.61.0) ng/ml in patients with nephrotic syndrome and 11.6 to41.3 (24.83.2) ng/ml in patients with a comparable degree of renal failure but withoutproteinuria. The blood levels of 25 (OH) D 3 in patients with nephrotic syndrome showed adirect and significant (P


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(Handgrip strength and serum creatinine) were correlated with plasma IL-6, which indicatesan important role for this cytokine in the development of protein malnutrition and musclecatabolism in end stage renal disease.

2.3 DIETARY MODIFICATION IN CHRONIC RENAL FAILURE

Patients with renal disease are prone to develop several types of malnutrition. Itoccurs due to deficiency or over consumption of certain macro and micro nutrients. So dietarymodification is very important, which can either be done by counseling for prescribing therequired dietary intake or giving supplements to come on par with the recommended dietaryintakes.

2.3.1 Dietary prescription

Giordano et al . (1973) studied the effect of at least 1 g/kg of protein intake primarily ofhigh biological value on 40 dialysis patients. Patients were on liberal diet having at least 1g/kg of protein primarily of high biological value. The nutrient intake was measured over aperiod of seven days. On statistical analysis, high biological value protein intake wascorrelated to total amino acid levels, the essential amino acid levels and the non-essentialamino acid level in blood. Interestingly, there was a correlation between methionine intakeand the level of transferrin. Thus it was concluded that there was a higher need of protein,primarily of high biological value for dialytic patients to prevent protein malnutrition.

Heidland (1978) prescribed the nutrient requirements for 12 chronically uremic,predialytic patients whose Glomerular Filtration Rate (GFR) was less than 4 to 5 ml/min. Itwas suggested that diets providing 16 to 22 g of miscellaneous protein with either the nineessential amino acids (EAAs) or a combination of four EAAs and ketoacid or hydroxyacidanalogues of the other five EAAs may be used. Recommended vitamin intake refers to thequantities of supplemental vitamins to be administered. Vitamin A levels are elevated inuremia and supplements should not be administered. Phosphate binders are usually alsonecessary. Thus dietary intake may have to be supplemented to attain the desired levels.

Fiaschi et al . (1978) evaluated the effect of restricted protein and phosphorus diet on45 chronic renal failure patients (CRF) with plasma creatinine values of 2.9 to 3.5 mg/dl andGFR of 35 to 15 ml/min, consuming a dietary regimen containing about 40 Kcal/kg, 0.6 g/kg ofprotein with 75 per cent as high biological value, 600-750 mg of phosphorus and 1500 to2000 mg of calcium (with oral supplementation in all cases). An additional, usually intermittenttreatment with vitamin D (3 lakh to 6 lakh IU twice a week) or its analogs (dihydrotachisterol,0.250 to 0.375 mg/day) was prescribed in order to keep plasma calcium normal. It wasconcluded that a reliable follow-up of 5 years showed this regimen to be effective inmaintaining normal mean values of plasma calcium and phosphate and in preventing theprogression of secondary hyperparathyroidism.

Malluche et al . (1978) compared the effect of early intervention of protein andphosphorus restricted and calcium and vitamin D supplemented diet on two groups of chronicrenal failure subjects having plasma creatinine levels of 16.-2.8 mg/dl (n=20) and 2.8-3.5mg/dl n=28). After an 18-months follow up, plasma parathyroid hormone values (P


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limiting the cholesterol to less than 300 mg daily and altering the saturated to polyunsaturatedratio from 4:1 to 1:1 may be an effective treatment in reducing the high mortality fromcardiovascular and cerebrovascular disease in patients as hyperlipidemia contributes to thehigh mortality in dialysis patients from these diseases.

Giordano et al . (1980) studied the effect of a diet based on modulated nitrogen intaketo overcome malnutrition associated with long lasting low-protein intakes, and supplying

energy of at least 188 kJ/kg/day, in six chronic renal patients. Each patient underwent threedifferent regimens (A, B, C) of protein intake. In period A the protein intake was 0.33 g/kg aday. In period B, the patients were given 0.33 g/kg a day during day 1, 2, 3, 5, 6 and 1.0 g/kgduring days 4 and 7 of the week. In period C, the daily protein intake was the mean of theweekly value from day 1 to 7 of period B. Data obtained showed that in period A the ureanitrogen appearance rate (2.990 g/day) was equal to that in period B (2.700 g/day) and lowerthan that in period C (3.160 g/day). Thus it was concluded that modulating the low-proteinintake with a periodic increase or booster intake of dietary protein in uremic patients willremain effective to overcome malnutrition.

Maschio et al . (1980) evaluated the effect of protein and phosphorus restricted diet on24 patients in chronic renal failure (CRF) with plasma creatinine values of 1.6 to 2.8 mg/dl andGlomerular Filtration Rate (GFR) of 60 to 30 ml/min, consuming a dietary regimen containingabout 40 Kcal/kg, 0.8 g/kg of protein, 800 to 900 mg of phosphorus and 1500 to 2000 mg of

calcium (with oral supplementation). An additional, usually intermittent treatment with vitaminD (3 lakh to 6 lakh IU once or twice a week) or dihydrotachisterol (0.250 to 0.375 mg/day) wasalso prescribed in order to keep plasma calcium in the normal range. Thus, it was concludedthat after 2 years of follow-up, this regimen was shown to be very effective in maintainingnormal values of plasma calcium and phosphate and in preventing the progression ofsecondary hyperparathyroidism.

Kopple et al . (1986) examined the dietary requirements of six hemodialysis patientswho underwent nitrogen balance studies for 21 days. These individuals ingested a constantprotein intake but in which dietary energy intake varied every 3 week, in random order toabout 25, 35 and 45 Kcal/kg/d. Mean (SEM) nitrogen balance after equilibration andadjustment for changes in body urea nitrogen was 0.570.42 g/d. If one adjusts forunmeasured nitrogen losses, which was estimated to be about 0.5-1.0 g/d, balance wasneutral in these patients, but there was a rather large variance in nitrogen balances and some

patients were in negative nitrogen balance with this intake. So taking into account theprevalence of protein malnutrition in these patients, about 1.2 g protein/kg/d as a safe intakewas recommended that may fulfill the requirement of protein during frequent occurrence ofmild intercurrent illnesses.

Kopple et al . (1986) examined dietary protein requirement in eight patientsundergoing peritoneal dialysis who were fed low or high protein diets of 0.98 or 1.44 g/kg.Total energy intake were from both dietary intake and uptake of D-glucose from the peritonealdialysate averaged (41.31.9 and 42.11.2 Kcal)/kg/d with the low and high protein diets,respectively). The low and high-protein diets were fed for about 16-35 d and balance datawere collected for 14-33 d. There was a curvilinear relation between dietary protein intake andnitrogen balance. Nitrogen balance increased as protein intake rose until the protein intakewas 1.90 g/kg/d. At this intake, nitrogen balance was significantly positive. As dietary proteinincreased above this amount, there was no further increment in nitrogen balance. Thus, thesafe intake of protein, recommended for CAPD and requirement during illness for patientswas 1.2-1.3 g/kg/d.

Kopple et al . (1986) examined the effects of different energy intakes on nitrogenbalance and body composition in six predialytics with chronic renal failure (CRF); mean (SD)creatinine and urea clearances were 10.83.5 and 4.72.2 ml/min, respectively. Patients werestudied while they ingested a constant protein diet of about 0.55-0.60 g protein/kg/d and weregiven diets that provided 45, 35, 25 or 15 Kcal/kg/d. About 16 nitrogen-balance studies wereconducted while the patients ingested these different energy diets. The order in which thedifferent energy diets were fed to individual was determined randomly after equilibration andafter adjustment for change in body urea nitrogen and unmeasured losses correlated directly


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with dietary energy intake. When the estimated unmeasured nitrogen lossess of about 0.58g/d were adjusted for nitrogen balance was negative in one of four patients for, 45 Kcal, inone of five patients fed 35 Kcal, in 3 of 5 patients fed 25 Kcal and in both patients fed 15Kcal/kg/d. Urinary nitrogen appearance (UNA), UNA divided by nitrogen intake and severalplasma amino acid concentrations, measured after an overnight fast, each correlatedinversely with dietary energy intake. These observations suggested that, though in some CRFwho are ingesting about 0.55-0.60 g protein/kg/d may maintain neutral or positive nitrogen

balance with an energy intake of less than 30 Kcal/kg/day, a dietary intake providing about 35Kcal/kg/day is more likely to maintain neutral or positive nitrogen balance, maintain orincrease body mass and reduce net urea generation.

Slomowitz et al . (1989) examined dietary energy requirements in six maintenancehemodialysis (MH) patients who were given diets of 45, 35 and 25 Kcal/kg/d. Each dietaryenergy intake was ingested for 21-23 days with a constant protein intake of 1.13 0.02g/kg/day for each patient. Body weights rose with energy intakes of 45 and 35 Kcal (P


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low blood pressure was apparent at three years in reducing the rate of decline of glomerularfiltration rate.

2.3.2 Supplementation

Healy et al . (1977) studied the effect of 0.5 g/day of 1, 25 (OH) 2 D3 supplementationon 20 chronic renal failure with glomerular filtration rates (GFR) of 30 to 50 ml/min for sixmonths and found that this therapy raised serum calcium, reversed the defect in intestinalcalcium absorption, normalised the serum levels of parathyroid hormone and healed bonediseases. GFR remained stable during the six months of therapy. Thus, it was concluded thatinitiation of therapy with 1, 25 (OH) 2 D3 at the early course of renal failure could be beneficialfor the prevention of the progression of renal osteodystrophy.

Ell et al . (1978), investigated the metabolic effects of keto-acid supplements in fivechronic renal failure with particular reference to nitrogen balance, and urea metabolism atHarrow, England. Patients taking a diet containing approximately 5g N throughout werestudied during two periods of 1 month each. During weeks 3 and 4 of the 1 st month, thepatients were given a supplementary keto acid/essential amino acid mixture of 0.46g and inall other weeks of both months, they received an isonitrogenous glycine supplement.Ketoacids produced a reduction of plasma urea, urea synthesis and urea excretion and animprovement in nitrogen balance compared to glycine supplemented diet, thus ketodiet

supplement improved nitrogen balance.

Wathen et al . (1978) compared some of the metabolic effects of hemodialysis on 10non-diabetic fasting patients with (200 mg/dl) and without glucose in the dialysate bath whencarried out in succession on the first and second dialysis, respectively, of a thrice weeklyschedule. Unlike glucose dialysis, glucose free dialysis caused marked decrease in bloodlevels of glucose, insulin, lactate and pyruvate along with profound increase in acetoacetateand -hydroxybutyrate to meet energy demands causing glycogenolysis and gluconeogenesisto prevent critical hypoglycemia during glucose free dialysis. Thus glucose dialysis waseffective in preventing protein and lipid catabolism.

Alvestrand et al . (1980) studied a dietary treatment with an 18g protein dietsupplemented with essential amino-acid providing 1.8 to 2.7 g N/day or ketoanalogs (0.3 gN/day) as a long term alternative to dialysis in patients with severe renal insufficiency (n=68).

After institution of the dietary regimen, for an average of 215 days, serum urea and serumurea/creatinine ratio decreased from 104 to 94 mg/dl and 9.45 to 7.90 respectively whileserum creatinine increased slowly from 11.0 to 11.9 mg/dl due to progression of theunderlying renal disease. Serum albumin and transferrin were unchanged. The patients weretreated for 30 to 840 days before they were dialyzed. The three years cumulative survival inall 68 patients was 68 per cent, which is well at level with the survival rates of patients treatedwith dialysis. Thus treatment with an 18g protein diet plus essential amino acids or ketoacidscan considerably extend the period of conservative treatment and postpone the start ofregular dialysis without endangering life expectancy of the patients.

Maschio et al . (1980), studied the effect of early dietary phosphorus restriction andcalcium supplementation in the prevention of renal osteodystrophy in two groups of patientswith chronic renal failure. 45 patients with plasma creatinine values of 2.9 to 3.5 mg/dl werekept for 1 to 4 years on a diet containing 40 kcal/kg energy, about 0.6g/kg of protein, 600 to

750 mg of phosphorus and 1500 to 2000 mg of calcium (with oral supplementation). VitaminD or its analogs were prescribed for the patients. Since elevation of serum parathyroidhormone in early renal failure impaired homeostasis of plasma phosphate after a phosphateload, 24 patients with plasma creatinine values of 1.6 to 2.8 mg/dl were kept for six to 18months on a diet containing 40 kcal/kg energy, about 0.8g/kg of protein, 800 to 900 mg ofphosphorus and 1500 to 2000 mg of calcium (with oral supplementation). An additionaltreatment with vitamin D or its analogs was performed. After 18 months of follow up, thisregimen resulted in a fall of serum parathyroid hormone values with no progression oramelioration of bone lesions (defective mineralization and increased bone resorption) in theaffected patient. Thus early phosphorus restriction, calcium supplementation and vitamin D


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administration are effective means to prevent the development of both hyperparathyroidismand osteomalacia in patients with chronic renal failure.

Frohling et al . (1980) studied the conservative treatment in patients (n-26) withadvanced renal failure (glomerular filtration rate (


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2.4 COMPLICATIONS

Complications due to renal diseases are common, silent and potentially lethal whichmay result from dietary or normal imbalance, pharmacologic effects or abnormalities of renalor gastrointestinal function.

Stein et al . (1969) studied the causes for elevated levels of uremic toxin, GuanidinoSuccinic Acid (GSA) in six predialytic uremic patients. A linear relationship was observedbetween urinary excretion of urea and GSA in normal patients, but for any level of ureaexcretion, urinary GSA was greater in the uremic subjects. Since serum GSA was alsoelevated in uremia, these findings suggested that in renal failure either degradation of GSA isreduced, or more likely production of GSA is increased. Increased serum GSA levels havebeen implicated in abnormal coagulation and altered lymphocyte function in renal failure.

Norbeck et al . (1978) undertook the study to give more detailed information on theconcentrations of triglycerides and cholesterol in the three lipoprotein classes, very low(VLDL), low (LDL) and high density lipoproteins (HDL) in 39 fasting patients suffering fromchronic uremia. The dietary calories were 33, 56 and 11 per cent from fat, carbohydrate andprotein respectively and the daily intake of protein was restricted to approximately 1g/kg/day.The findings consisted of raised concentrations of triglycerides in Very Low DensityLipoprotein (VLDL) and Low Density Lipoprotein (LDL) above the median of the controls. Butvery low concentrations of cholesterol in low density lipoproteins and still lower in high densitylipoproteins. With the conventional typing system for hyperlipidaemia, type IIA, III and IV werepresent in 6, 9 and 30 per cent of patients respectively. The ratio between cholesterol andtriglycerides (0.67) was higher than in the controls (0.51) in VLDL but lower in LDL. Thus, itwas concluded that above mentioned abnormalities could be particularly malignant and amajor contributing factor to the rapid development of atherosclerotic manifestations in chronicrenal failure.

Phillips et al . (1980) studied the relationship between aminoaciduria in chronic renalfailure (CRF) patients (n=24) with vitamin D and parathyroid status. Sequentialmeasurements of fractional clearance of aminoacids, plasma 25 hydroxy-vitamin D andserum parathyroid hormone were made. All patients initially hadhyperaminoaciduria, secondary hyperparathyroidism and osteomalacia. Treatment with 1, 25-dihydroxy cholecalciferol or 1 -hydroxycholecalciferol significantly improved amino acidreabsorption irrespective of the initial degree of aminoaciduria. Cholecalciferol or 25-hydroxycholecalciferol improved amino acid transport in patients with hyperaminoaciduria.Reduction in aminoaciduria during treatment with 25(OH) D 3 may have depended on avariable ability to synthesize 1, 25 (OH) 2 D3. Changes in amino acid transport did not correlatewith changes in serum parathyroid hormone. It was suggested that defective amino acidreabsorption in patients with CRF is due at least in part to deficiency of 1, 25 (OH) 2 D3.

Goldstein et al (1989) studied the effect of vitamin D deficient state in 7 patients withnephrotic syndrome (creatinine clearance 30 ml/min). The blood levels of the amino-terminalfragment of parathyroid hormone in these seven patients displayed an inverse relationshipwith the concentration of ionized calcium. The concentrations of ionized calcium (3.690.10mg/dl) in blood were significantly lower (P


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hypertensive CRF had the highest degree of dyslipidemia. CRF with diabetes mellitus had thehighest triglyceride value (207.340.29 mg/dl) and the lowest high density lipoproteincholesterol value (37.26.5 mg/dl). It was also observed that as the value of serum creatinineincreased, the hemoglobin value decreased accordingly. Thus it was concluded that the highdegree of cardiovascular complications were due to association of hypertension, diabetes,dyslipidemia and anaemia in this group of patients.

Influence of co-morbid disease with malnutrition on mortality in peritoneal dialysispatients from that of only malnutrition was dissociated by Chung et al . (2003). A total of 153consecutive peritoneal patients were included. Nutritional status was assessed by subjectiveglobal assessment. Comorbid survey was done and graded by Davies index (Davies et al .,2002). There was a high prevalence of malnutrition and co-morbid disease at the start ofpertioneal dialysis and that the combined presence of co-morbid disease and malnutrition wasassociated with high mortality. Malnutrition alone was associated with statistically insignificantincrease in mortality. Thus it was concluded that malnutrition without co-morbid diseases maynot be associated with significant mortality.


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III. MATERIAL AND METHODSChronic renal failure patients are often catabolic and malnourished. To treat

malnutrition effectively, the nutritional profile of the patient and assessment is of paramountimportance. Hence, study was conducted to assess the nutritional status and dietaryguidelines of predialytic and hemodialytic patients. The details of material used and themethodology employed has been described in this chapter.

3.1 LOCALE OF THE STUDYThe study was conducted at Dialysis unit, In and Out-patient wards of Karnataka

Institute of Medical Sciences (KIMS), Hubli, Karnataka.

3.1.1 Selection of sampleTwenty-five chronic kidney failure patients undergoing maintenance hemodialysis

were selected from dialysis unit and 20 pre dialytic patients were taken from In and Out-patient wards of KIMS, Hubli.

3.2 DEVELOPING TOOLSA detailed questionnaire was developed, to elicit information on various aspects

related to renal patients including demographic profile, clinical and health status, symptoms atthe onset of disease, existing signs, etiology of renal disease, medications andsupplementations being used, stage of renal diseases, complications seen, life style factorsand nutritional profile with respect to anthropometry, dietary intake and biochemicalparameters. The questionnaire was structured and modified based on the suggestions of theexperts.

Further, the developed questionnaire was pre-tested on renal patients at KIMS andrequired changes were made (Appendix I).

3.2.1 General informationData generation on general information of chronic renal failure patients included, age,

gender, education, occupation, monthly income of family, family size, number of earningmembers, activity pattern of respondent and marital status.

3.2.2 Clinical and health statusInformation on onset of kidney disease, date of commencement of maintenance

hemodialysis, other diseases/disorders present before the onset of kidney disease, symptomsat the onset of kidney disease, physical examination of patients for signs, type of kidneydisease, etiology, medication and supplementation were included in this section.

The Glomerular Filtration Rate (GFR) of patients was computed based on the hospitalrecords. The serum creatinine levels, age and actual body weight of the subjects wereconsidered for computation of GFR.

Cockcroft-Gault formula was used for calculating GFR (Anon., 2005e) and thesubjects were classified based on their GFR (Anon., 2005b).

GFR = [(140-age) x body weight (kg)] / (Serum creatinine x72) for men] x 0.85 in women

Complications observed in chronic renal failure (CRF) patients, were noted fromhospital records.

3.3 LIFE STYLE FACTORSPresent prevalent vices in subjects such as smoking, alcohol intake, and tobacco

chewing were recorded. An information on exercise habits with special reference to type,regularity, benefits observed and who advised alike were collected.


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Plate 1. Dietary survey

Plate 2. Weight measurement


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3.4 ANTHROPOMETRIC ASSESSMENTAnthropometric measurements viz. , height (cm), weight (kg), waist (cm), hip (cm) and

mid upper arm circumferences (cm) and triceps skinfold thickness (mm) were recorded as perthe guidelines suggested by Jelliffe (1966).

The height was measured using height chart to nearest 0.1 cm. The subjects wereweighed using portable platform weighing balance to nearest 0.5 kg with causal clothes andbarefoot. A narrow flexible, non-elastic tape was used to measure the mid upper armcircumference (MUAC), waist and hip circumferences. The measurements were made tonearest 0.1 cm. Triceps skinfold thickness was measured with Harpenden calipers to thenearest 0.1 mm.

Body Mass Index (BMI) was computed using the formula given by Garrow (1987) toclassify the individual as normal, obese or under weight.

Weight (kg)

Body mass index =

(Height) (m)

BMI Classifications

BMI Class WHO classification

< 18.5 Underweight

18.5-22.9 Normal

>23 Overweight

>25 Obese I

>30 Obese II

(Anon., 2006)

The abdominal obesity was assessed by waist/hip ratio (Lean et al ., 1995).

Male 0.95 obese

< 0.95 normal

Female 0.80 obese

< 0.80 normal

Mid arm muscle circumference (MAMC) was calculated by using formula given below(Jelliffe, 1966).

MAMC (cm) = Mid upper arm circumference (cm) 0.314 x triceps skinfold thickness (mm).

3.5 DIETARY SURVEYData regarding the frequency of food consumption, choices of foods after the onset of

disease and after dialysis were documented. The foods specially included, restricted andavoided for the present condition, reasons and who advised were recorded.

Food consumption pattern was assessed on consecutive 3 days by 24 hours dietaryrecall method. A set of standardized vessels were used to obtain estimates of the amount ofraw and cooked food consumed by the subjects. The ingredients used in preparing the foodand method of preparation was carefully recorded.


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3.5.1 Nutrient intake and adequacyThe nutrient intake of patients was computed based on the diet survey data. For this

purpose the amount of cooked food consumed by the patients were converted into rawingredients. Food items consumed by patients were prepared in the laboratory to getapproximate amount of raw ingredients.

The nutritive value of the raw ingredients such as energy, carbohydrates, protein, fat,

minerals such as calcium, sodium, copper, phosphorus, potassium, zinc, iron, magnesiumand vitamins like -carotene, thiamine, riboflavin, niacin and folate was computed. Ascorbicacid was computed for foods consumed raw. Nutrient computation was done by usingAnnapurna VAR 3, software developed by M.R. Chandrashekhar of Bangalore.

The requirement of energy, fuel nutrients and electrolytes were computed based onthe ideal body weight, range of energy prescribed for the patient, associated conditions andage of the patients. The fuel nutrients such as proteins, fats, carbohydrates and electrolyteslike sodium and potassium consumed by each group of patients viz. , dialytic and predialyticwere compared with the requirements for each patient. Further, the subjects were classifiedas high, adequate and low based on the nutrient adequacy.

3.6 BIOCHEMICAL PARAMETERSBiochemical parameters were documented from the case f iles of each patient

maintained in the hospital. For dialysis patients, biochemical profile recorded at the time offirst dialysis and the present status were documented. Biochemical profile included serumalbumin, total protein, creatinine, urea, sodium, potassium, calcium, phosphorus and lipidprofile including total cholesterol, triglycerides, High Density Lipoprotein Cholesterol (HDL-C)and Low Density Lipoprotein Cholesterol (LDL-C) was computed using the following formula(Anonymous, 2005c).

Triglyceride

VLDL-C =

5

LDL-C = Total cholesterol (HDL-C + VLDL-C)

3.7 FORMULATING SUITABLE DIETARY GUIDELINESSuitable dietary guidelines for chronic renal failure patients were formulated based on

the ideal body weight, associated conditions, age and basal energy expenditure. Ideal bodyweight was calculated using Brocas Index.

Ideal body weight = Height 100

Basal Energy Expenditure (BEE) for calculating energy requirement was done usingHarris-Benedict equation.

BEE for male = [66+(13.7 x body weight (kg)) + (5 x height (cm)) (6.8 x age)]

BEE for female = [655+(9.6 x body weight (kg)) + (1.8 x height (cm)) (4.7 x age)]

The figure got from BEE is multiplied by 1.2 for sedentary activity and 1.3 formoderate activity to get the value of BEE (Anon., 2005d).

For diabetic patients energy requirement was based on 10 per cent less weight thanideal body weight (Raghuram et al ., 1998).


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Carbohydrate requirement was computed by taking 50-60 per cent of total energy.Protein requirement for dialytics was 1.2 g/kg/day having 50 per cent of protein of highbiological value and for predialytics it was 0.6 g/kg/ day or 0.3 g/kg/day with essential aminoacid supplementation.

For 0.6 g/kg of protein, 2/3 was from high biological value and 0.3 g/kg of protein wascontaining vegetable proteins only based on Glomerular Filtration Rate (GFR) ml/min (Anon.,1995). For hepatitis protein prescribed was 1.5 g/kg/day. Rest of the total energy for allsubjects was from fat. For diabetic patients, energy distribution was done as follows(Raghuram et al ., 1998).

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Breakfast - 25 per cent

Lunch - 33 per cent

Snacks - 9 per cent

Dinner - 33 per cent

Insulin Dependent Diabetes Mellitus (IDDM)

Breakfast - 20 per cent

Lunch - 33 per cent

Snacks - 10 per cent

Dinner - 33 per cent

Bed time - 4 per cent

Sodium and potassium requirement for dialysis were 1-1.5 g/d and 1.5-2.7 g/d,respectively and that for predialytics, 1-3 g/d and 2 g/day respectively.

Recommendation of water intake for dialytics was 750-1500 ml/day and that ofpredialytics was 2000 ml/day, depending on urine output (Anon., 1995).

3.8 STATISTICAL ANALYSISThe responses of subjects were expressed in frequency and percentage.

The student t test was used as per the statisticians suggestions to test thesignificance of mean difference between the dialytic and predialytic patients, with respect todietary intake and biochemical parameters, and biochemical parameters of dialytics beforeand after dialysis.


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IV. EXPERIMENTAL RESULTSThe occurrence of poor nutritional status in patients with chronic renal failure has

been well documented. The reasons for malnutrition are complex and related to loss ofnutrients during dialysis, decreased food intakes and altered metabolic requirements. Sochronic kidney disease deserves attention and examination as it is a major cause of morbidityand mortality.

The results of the present study on nutritional status and dietary guidelines ofpredialytic and hemodialytic patients conducted during the year 2005-06 are presented in thissection.

4.1 GENERAL INFORMATION OF RENAL PATIENTS4.1.1 Demographic profile of chronic renal failure patients

The demographic profile of chronic renal failure patients is presented in Table 1.

Among 45 patients interviewed, 20 were predialytic and 25 were dialytic patients.Among predialytic patients 65 per cent were males and 35 per cent were females. Likewiseamong dialytic patients 84 per cent were males and rest were females.

Among the two categories of patients, majority were falling in the age group of 41-60

years (45% and 56% in predialytic and dialytic group, respectively) followed by 20-40 years(40 and 32%) and very few were more than 60 years in both the groups (15 and 12%).

Most of the predialytic patients had primary school level education (45%) followed byalmost equal number in college level (25%) and illiterate category (20%). But in dialytic group,majority had college level education (32%) followed by high school level education (28%) andprimary school level education (20%). Very few subjects were illiterates (4%).

In both the groups, majority of patients belonged to the Hindu religion (80% and 72%in predialytic and dialytic groups, respectively) followed by muslim religion (20 and 24%) andonly one belonged to Christian in dialytic group. Among predialytic patients 85 per cent werenon-vegetarians and almost similar number were seen in dialytic patients (88%). Majority ofthe patients in both groups were married (85 and 88% in pre-dialytic and dialytic groups,respectively).

Among chronic renal failure patients higher percentage had a medium sized family(75 and 68% in predialytic and dialytic groups, respectively) followed by small (15 and 20%)and large sized family (10 and 12%).

4.2 CLINICAL AND HEALTH STATUS4.2.1 Clinical and health status of chronic renal patients

The majority of predialytics and dialytics had the onset of kidney disease for the last24 months (80 Vs 60%). About 15 per cent of predialytics were suffering from kidney diseasefor the last 48-72 months and very few (15%) had it for more than 72 months. On the otherhand, 32 per cent of dialytics were diagnosed for the renal disease between 24 and had beensuffering from this disease from 48 to 72 months and for more than 72 months (Table 2).

Most of the renal patients in both the groups had presence of disorders prior to theonset of kidney disease (85% and 92% in predialytic and dialytic group, respectively). Majority

of the predialytic and dialytic subjects suffered from hypertension alone (47.00 Vs 60.80%),followed by both hypertension and diabetes (47.00 Vs 30.40%) and diabetes alone (5.80 Vs8.70%) prior to the onset of kidney disease.


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Table 1. Demographic profile of chronic renal failure patients

(N=45)

Predialytics (n=20) Dialytics (n=25)Characteristics

Frequency % Frequency %

Gender

Male 13 65.00 21 84.00

Female 7 35.00 4 16.00

Age (years)

20-40 8 40.00 8 32.00

41-60 9 45.00 14 56.00

>60 3 15.00 3 12.00

Education

Illiterate 4 20.00 1 4.00

Primary school 9 45.00 5 20.00

High school 2 10.00 7 28.00

Pre-university 4 16.00

College 5 25.00 8 32.00

Religion

Hindu 16 80.00 18 72.00

Muslim 4 20.00 6 24.00

Christian 1 4.00

Food habit

Vegetarian 3 15.00 3 12.00

Non-vegetarian 17 85.00 22 88.00

Marital status

Married 17 85.00 22 88.00

Unmarried 2 10.00 3 12.00

Widow(er) 1 5.00

Family size

Small (8) 2 10.00 3 12.00


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Table 2. Clinical and health status of subjects at the time of investigation

(N=45)

Predialytics (n=20) Dialytics (n=25)Variables


Onset of kidney disease*(months)

1-24 16 80.00 15 60.00

24-48 1 5.00 8 32.00

48-72 3 15.00 1 4.00

>72 1 4.00

Commencement of dialysis*(months)

1-24 21 84.00

24-48 NA NA 3 12.00

48-72

>72 1 4

Disorder before the onset ofkidney disease

None 3 15.00 2 8.00

Presence of disease/ disorder 17 85.00 23 92.00

Diabetes 1 5.80 2 8.70

Hypertension 8 47.00 14 60.80

Both 8 47.00 7 30.40

NA Not applicable* At the time of study

4.2.2 Etiology of chronic renal failure in the selected subjectsTable 3 is presented with the etiology of chronic renal failure in the selected subjects.

It was observed that the most common cause of chronic renal failure in predialytic group waschronic glomerulonephritis (40%) followed by diabetes mellitus (30%) and chronicpyelonephritis (25%) and only one patient was suffering from chronic tubulointerstitialnephritis. Similar trend was observed in dialytic group with chronic glomerulonephritis (40%)as the most common cause followed by diabetes mellitus (32%) and chronic pyelonephritis(12%). About eight per cent had hypertension as the cause of chronic renal failure followed byequal number of patients who had polycystic renal disease and chronic obstructivenephropathy (4% in each).

The common medications for both the groups of subjects were amlodipin, lasix,metaloz, minipres, acromin, dytor, ranitidine, methyldopa, aldactone, ramiprin and atenolol asprescribed by the physicians.

The common supplements found among the two groups were calcium, folic acid, B-complex, vitamin D 3, erythropoietin, iron and phostat.


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Table 3. Etiology of chronic renal failure in the subjects

Predialytics (n=20) Dialytics (n=25)Etiology

Frequency % Frequency %Medications

Diabetes mellitus 6 30.00 8 32.00 Amlodipin

Hypertension - - 2 8.00 Minipress

Chronic glomerulonephritis 8 40.00 10 40.00 Atenolol

Chronic tubulointerstitial nephritis 1 5.00 - - Lasix

Chronic pyelonephritis 5 25.00 3 12.00 Dytor

Familial and cystic renal disease - - 1 4.00 Metlaoz

Chronic obstructive nephropathy - - 1 4.00 Amlong


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4.2.3 Symptoms of kidney disease at the time of onsetTable 4 shows the symptoms of kidney disease at the time of onset. Among the 45

patients studied, edema and breathlessness were the most common symptoms (84.44% and82.22%, respectively) followed by oliguria and anorexia (73.33% and 66.66%, respectively).Headache, nausea, nocturia and vomiting were prevailing in almost 50 per cent of thesubjects. Very few subjects suffered from hematuria (11.11%) followed by loss ofconsciousness (22.22%) and convulsions (26.66%).

4.2.4 Prevailing clinical signs of the subjectsPrevailing clinical signs of the subjects at the time of investigation is presented in

Table 5. It was observed that clinical signs such as pallor of eyes and nails were common inall the subjects undergoing dialysis (100%) followed by edema (92%), swollen joints andexcoriation due to pruritus (52% and 48%, respectively). Similar signs were observed inpredialytics with maximum subjects having pallor of eyes (95%) followed by edema (75%).Pallor of nails was present in 55 per cent patients, followed by swollen joints and excoriationdue to pruritus. Very few subjects from both the groups had restless leg syndrome and poorwound healing.

Table 4. Symptoms of kidney disease at the time of onset

(N=45)

SubjectsSymptoms

Frequency %

Anorexia 30 66.66

Breathlessness 37 82.22

Convulsions 12 26.66

Frequent urination 19 42.22

Headache 25 55.55

Hematuria 5 11.11

Loss of consciousness 10 22.22

Nausea 27 60.00

Nocturia 22 48.88

Oliguria 33 73.33

Edema 38 84.44

Vomiting 26 57.78

Any other* 17 37.77

* Symptoms: Fever, acidity, abdominal pain, giddiness, sleep disturbances, dark colouredurine, pain in right side of chest, blood in cough, burning micturation, pain while breathing


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Table 5. Prevailing clinical signs of the subjects at the time of investigation

(N=45)

Predialytics (n=20) Dialysis (n=25)

Symptoms


Pallor of eyes 19 95.00 25 100.00

Excoriation due to pruritus 8 40.00 12 48.00

Pallor of nails 11 55.00 25 100.00

Restless leg syndrome 2 10.00 3 12.00

Swollen joints 10 50.00 13 52.00

Edema 15 75.00 23 92.00

Poor wound healing 1 5.00 4 16.00

4.2.5 Stage of kidney disease based on Glomerular Filtration Rate (ml/minGFR)Table 6 shows the stage of kidney disease based on glomerular filtration rate. It was

depicted that 80 per cent of the patients had GFR between 15-29 ml/min and were falling inthe fourth stage of kidney disease and the rest were falling in stage three (20%) of kidneydisease with GFR in between 30-59 ml/min.

4.2.6 Complications of the chronic renal failure subjectsComplications of the selected chronic renal failure subjects have been given in the

Table 7.

The complications of the selected subjects were based on biochemical parameters ofdialytics. All the subjects suffered from anaemia (100%) followed by hyperphosphatemia(66.66%) and hypocalcemia (54.54%). Majority revealed hyperkalemia (53.33%) compared tohypokalemia (13.33%) and only a few had hyponatremia (12.5%).


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Table 6. Stage of kidney disease based on Glomerular Filtration Rate (GFR) (ml/min)

Predialytics (n=20)

Glomerular Filtration Rate (ml/min) Stage

Frequency %

90 or higher 1 - -

60-89 2 - -

30-59 3 4 20.00

15-29 4 16 80.00


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4.3 LIFE STYLE PATTERN4.3.1 Prevalence of vices in renal patients

About 65 per cent of predialytics and 64 per cent of dialytics had no vices at the timeof investigation. Tobacco chewing was the most common vice found in predialytic and dialyticpatients (35 Vs 28%) followed by alcohol consumption (10 Vs 4%). These vices were alsopresent prior to the onset of disease, but were still prevailing after the onset of disease (Table8).

4.3.2 Exercise behaviour of selected patientsExercise behaviour of the predialytic and dialytic subjects has been presented here in

Table 9. Higher percentage of dialytics exercised compared to predialytic patients (52 Vs35%). Most common exercise followed was walking (20% in predialytic and 36% in dialyticpatients respectively) in both the groups followed by formal exercise (15% in predialytic and12% in dialytic patients, respectively). In addition, one dialytic subject also followed yoga(4%). All the dialytic subjects exercised regularly, whereas 25 per cent of predialytics wereregular exercisers and rest of them (10%) were not regular in the exercise. The reasonquoted for doing exercise were relief from pain in the leg and improvement in appetite. Thereasons for not exercising were-not effective and lack of interest.

Table 8. Prevalence of vices in the subjects

(N=45)

Predialytics (n=20) Dialytics (n=25)

Vices present


No vices 13 65.00 17 68.00

Alcohol consumption 2 10.00 1 4.00

Tobacco chewing 7 35.00 7 28.00

Multiple answers

Table 9. Exercise behaviour of the subjects

(N=45)

Predialytics (n=20) Dialytics (n=25)ParticularsFrequency % Frequency %

Reason

Exercising habit Doing exerciseYes 7 35.00 13 52.00 Feeling goodNo 13 65.00 12 48.00 Relief from leg pain

*Improvement in appetiteType of exercise Not doing exerciseWalking 4 20.00 9 36.00 Not effectiveFormal exercise 3 15.00 3 12.00 Not interestedYoga 1 4.00Regularity Who suggestedRegular 5 25.00 13 52.00 DoctorIrregular 2 10.00 - Own decision*Only in dialytic patients


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4.4 ANTHROPOMETRIC MEASUREMENT4.4.1 Mean anthropometric measurements of the subjects

Table 10 reveals the mean anthropometric measurements of the subjects.

The mean height, weight, waist and hip circumference of predialytic males werefound to be lower compared to dialytic males (1636.26 Vs 166.288.03 cm for height,

53.519.17 Vs 57.746.52 kg for weight, 76.3813.62 Vs 86.4210.8 cm for waistcircumference and 87.157.98 Vs 90.76 7.25 cm, for hip circumference in predialytics anddialytics, respectively). Mid upper arm circumference and triceps skin fold thickness werefound to be almost similar in both the male groups. However, a reverse trend was observed inthe anthropometric measurements of predialytics compared to dialytic females. Predialyticfemales showed higher mean values for height, weight, waist and hip circumference, midupper arm circumference and triceps skin fold thickness (156.577.44 Vs 1545.47 cm forheight, 50.5711.91 Vs 42.95 7.35 kg for weight, 78.424.64 Vs 69.5 7.93 cm for waistcircumference, 917.28 Vs 83.75 11.58 cm for hip circumference, 11.51 4.02 Vs 8.854.79mm for TSF and 24.713.14 Vs 232.94 cm for MUAC in predialytic and dialytic females,respectively).

4.4.2 Classification of chronic renal failure subjects based on Body MassIndex (BMI) and Waist to Hip Ratio (WHR)

Majority of the patients in both predialytics and dialytics were grouped under normalBMI followed by underweight category (Table 11).

Majority of predialytic males were normal (61.53%) followed by underweight(23.07%). Maximum percentage of predialytic females were normal (42.85%) and there wasan equal distribution of females, falling in underweight and overweight categories (28.57% ineach). In dialytic subjects, majority of males were normal (42.85%) and equal number weregrouped under underweight and overweight categories (28.57%). Equal number of dialyticfemales were falling in normal and underweight categories (50% each) and none wasobserved to be overweight.

Higher percentage of predialytic males were normal compared to dialytic males(61.53 Vs 42.85%) but there was a higher percentage of dialytic males compared topredialytic males with respect to those falling in underweight and overweight categories(28.57 Vs 23.07% in underweight and 28.57 Vs 15.40% in overweight categories for dialyticand predialytic males, respectively).

However, higher percentage of dialytic females were normal as well as underweightcompared to predialytic females (50 Vs 42.85% in normal and 50 Vs 28.57% in underweightcategories, respectively).

With respect to waist to hip ratio, majority of the patients were normal in both thegroups. Most of the predialytic males were normal (84.61%) with very few in the obesecategory (15.39%). But the trend was vice-versa in case of predialytic females. About 71.43per cent belonged to obese category and had abdominal obesity. The same trend wasfollowed in dialytic males and females. More number of predialytic males as well as femaleswere normal compared to dialytics and had normal WHR (84.61 Vs 61.91% for males and28.57 Vs 25% for females, respectively).

4.4.3 Age wise classification of the subjects based on mean value of Triceps

Skinfold ThicknessThe Table 12 shows the age wise classification of subjects based on Triceps Skinfold

Thickness (TSF). The mean TSF of all the males and females of dialytics and prediaytics ofdifferent age groups were lower than the NCHS standard values. The dialytic males of agegroup 35-44.9 years and 65-74.9 years had higher mean values for TSF compared topredialytic counterparts (9.523.05 Vs 6.81.41 cm in between 35-44.9 years and 10.623.36Vs 8.462.38 cm in between 65-74.9 years) except for the age group of 25-34.9 year(4.660.83 Vs 3.842.26 cm for predialytic and dialytic subjects, respectively).

Dialytic females falling in the age group of 25-34.9 years had higher mean value ofTSF compared to predialytic females (16 Vs 9.062.72 cm).


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Table 10. Mean anthropometric measurements of the subjects

Subjects Height(cm)

Weight(kg)

Waist circumference(cm)

Hip circumference(cm)

Mid uppcircumfere

Predialytics

Male (n=13) 163.536.26 53.519.17 76.3813.62 87.157.98 24.842.27

Female (n=7) 156.577.44 50.5711.91 78.424.64 917.28 24.713.14

Dialytics

Male (n=21) 166.288.03 57.746.52 86.4210.81 90.767.25 24.542.17

Female (n=4) 1545.47 42.957.35 69.57.93 83.7511.58 232.94


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Table 11. Classification of the subjects based on Body Mass Index (BMI) and Waist to Hip Ratio (WHR)

Body Mass Index Subjects Frequency

Underweight(23) No

Predialytics

Male 13 3 (23.07) 8 (61.53) 2 (15.40) 11 (84.6

Female 7 2 (28.57) 3 (42.85) 2 (28.57) 2 (28.5

Dialytics

Male 21 6 (28.57) 9 (42.85) 6 (28.57) 13 (61.

Female 4 2 (50.00) 2 (50.00) - 1 (25.

Note: Figures in parenthesis indicate percentage

*Waist to hip ratio Normal ObeseFor male


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4.4.4 Agewise classification of the subjects based on mean value of MidUpper Arm Circumference (MUAC)The Table 13 is presented with the age wise classification of subjects based on

MUAC.

The mean MUAC of all the subjects belonging to different age groups were lowerthan the standard values with respect to gender. The dialytic males, falling in the age-groupsof 35-44.9 years, 45-54.9 years and 65-74.9 years had higher mean value for MUACcompared to predialytic males (24.821.78 Vs 232.82 cm for 35-44.9 years, 25.431.51 Vs24.751.76 cm for 45-54.9 years and 262.64 Vs 25.662.08 cm for 65-74.9 years) except forthe age group of 55-64.9 years where predialytic males had higher mean value of MUACcompared to dialytic males (25.66 2.08 Vs 23.522.12 cm). The dialytic females of agegroup 25-34.9 years had higher mean value of MUAC compared to predialytic females (26.00Vs 23.33 3.51 cm).

4.4.5 Age-wise classification of the subjects based on mean value of Mid ArmMuscle Circumference (MAMC)The mean MAMC of all the males of dialytics and prediaytics of different age groups

were lower than the standard values (Table 14). However, in case of females all the MAMCvalues were lower in comparison with the standards except in the predialytic group of 35-44.9years who had higher MAMC in comparison with the standards (23.30 Vs 21.80 cm). Thedialytic males in the age-group of 25-34.9 years, 55.00-64.90 years and 65.00-74.90 yearshad higher mean values of MAMC compared to predialytic males (20.492.66 Vs 20.95 cmfor 25-34.90 years, 23.001.34 Vs 20.83 2.03 cm for 55-64.9 years and 23 1.34 Vs 22.61 1.72 cm for 65-74.9 years) except for the age-group of 35-44.9 years and 45-54.9 yearswhere predialytic males had higher mean value of MAMC (21.821.48 Vs 20.862.38 cm for35-44.9 years, and 22.170.74 Vs 21.52 0.56 cm for 45-54.9 years).


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Table 12. Age-wise classification of the subjects based on Triceps Skinfold Thickness (TSF)

Age (years) Predialytics(n=20)

Frequency Mean Dialytics (n=25) Frequency Mean

19-24.9 Male 0 - Male 1 5

Female 0 - Female 1 5

25-34.9 Male 3 4.660.83 Male 2 3.84

Female 3 9.062.72 Female 1 16.0

35-44.9 Male 2 6.801.41 Male 5 9.52

Female 1 14.80 Female 0

45-54.9 Male 2 10.133.81 Male 5 10.28

Female 0 - Female 2 6.82

55-64.9 Male 3 8.462.38 Male 5 8.52

Female 3 12.824.91 Female 0 -

65-74.9* Male 3 8.462.38 Male 3 10.62

* No female was there in age-group 65-74.9 years


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Table 13. Age-wise classification of the subjects based on Mid Upper Arm Circumference (MUAC)


Frequency Mean Dialytics (n=25) Frequency Mean

19-24.9 Male 0 - Male 1 2


25-34.9 Male 3 24.163.32 Male 2 23.00

Female 3 23.333.51 Female 1 26.0

35-44.9 Male 2 23.002.82 Male 5 24.82


45-54.9 Male 2 24.751.76 Male 5 25.43


55-64.9 Male 3 25.662.08 Male 5 23.52


65-74.9* Male 3 25.662.08 Male 3 26.00

* No female was there in age-group 65-74.9 years


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Table 14. Age-wise classification of the subjects based on Mid Arm Muscle Circumference (MAMC)


Frequency Mean Dialytics (n=25) Frequency Mea

19-24.9 Male 0 - Male 1 2


25-34.9 Male 3 21.83.53 Male 2 22.72

Female 3 20.492.66 Female 1 20.9

35-44.9 Male 2 20.862.38 Male 5 21.82


45-54.9 Male 2 21.520.56 Male 5 22.17


55-64.9 Male 3 20.832.03 Male 5 23.00


65-74.9* Male 3 22.611.72 Male 3 23.00

* No female was there in the age-group of 65-74.9 years


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4.5 DIETARY INTAKE4.5.1 Mean food intake of the subjects

The mean food intake of dialytics were higher compared to predialytic subjects forcereals (200.0796.34 Vs 122.6982.53 g), pulses (34.6428.22 Vs 20.7022.97 g), othervegetables (27.5649.74 Vs 15.3532.03 g), roots and tubers (43.4443.81 Vs 23.9022.61g), nuts and seeds (10.4916.40 Vs 4.076.30 g), fruits (17.0925.11 Vs 4.786.27 g), fatsand oils (13.0711.05 Vs 5.447.26 g) and sugar (18.0617.23 Vs 11.1014.06 g) except forgreen leafy vegetables and milk and milk products whose intakes were higher in predialytics(15.6530.00 Vs 8.4817.67 g for green leafy vegetables and 197.88171.31 Vs176.41131.19 g for milk and milk products) but the difference in mean intakes of two groupswas significant only for cereals (P


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Table 15. Mean food intake of the subjects

Foods (g) Predialytics (n=20) Dialytics (n=25)

Cereals 122.6982.53 200.0796.34

Pulses 20.7022.97 34.6428.22

Green leafy vegetables 15.6530.00 8.4817.67

Other vegetables 15.3532.03 27.5649.74

Roots and tubers 23.9022.61 43.4443.81

Nuts and oil seeds 4.076.30 10.4916.40

Milk and milk products 197.88171.31 176.41131.19

Meat/fish/poultry/egg - 65.72268.05

Fruits 4.786.27 17.0925.11

Fats and oil 5.447.26 13.0711.05

Sugar 11.1014.06 18.0617.23

3 day recall* - Significant at 5 per cent level

** - Significant at 1 per cent level


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Table 16. Mean nutrient and electrolyte intake of the subjects

(N=45)

Nutrients (g) Predialytics (n=20) Dialytics (n=25) t value

Energy (Kcal) 764493.11 1304533.22 3.52**

Protein 23.5015.57 38.2617.71 2.97**

Fat 19.2213.67 39.0226.04 3.28**

Carbohydrate 124.6280.29 204.9683.13 3.28**

Fibre 10.5469.05 16.536.11 2.70*

Electrolytes (mg)

Calcium 341.57260.59 519.60513.71 1.51 NS

Phosphorus 511.77360.33 876.24427.17 3.10**

Iron 6.295.98 12.327.44 3.02**

Zinc 2.001.70 3.381.49 2.83**

Magnesium 190.09157.98 314.33131.07 2.82**

Sodium 969.56753.46 1308.061203.11 1.15 NS

Potassium 702.13509.53 1079.92515.29 2.46*

* Significant at 5 per cent level** Significant at 1 per cent level

Table 17. Mean vitamin intake of the subjects(N=45)

Vitamin (mg) Predialytics (n=20) Dialytics (n=25) t value

Total carotene (g) 756.751395.74 584.28695.92 0.50 NS

Vitamin A (g) 192.07350.38 157.26175.46 0.41 NS

Thiamin 1.220.91 1.461.34 0.73 NS

Riboflavin 0.560.43 0.820.66 1.61 NS

Niacin 4.983.93 8.853.76 3.35**

Pyridoxine 1.606.45 0.240.12 0.94 NS

Folic acid 75.1870.37 100.3952.42 1.33 NS

Vitamin B 12 0.270.23 0.701.68 1.26NS

Ascorbic acid 21.6630.62 27.0820.56 0.68 NS

* Significant at 5 per cent level** Significant at 1 per cent levelNS-Non-significant


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Table 18. Mean food intake of the subjects according to gender

Male Food (g)

Predialytics (n=13) Dialytics (n=21) t value Predialytics (n=7) Dialytic

Cereals 134.7689.27 211.7597.10 2.36* 100.2768.78 138.747

Pulses 19.7521.71 34.5230.88 1.63 NS 22.4626.88 3

Green leafy vegetables 24.0734.72 6.1415.67 1.75 NS -

Other vegetables 11.3027.99 29.3847.06 1.40 NS 22.8539.75 18

Roots and tubers 24.0722.99 46.1053.73 1.66 NS 23.5724.42 29

Nuts and oil seeds 4.806.52 11.1117.50 1.49 NS 2.716.10

Milk and milk products 202.97160.84 174.19127.52 0.55 NS 188.42202.57 188

Meat/fish/poultry/egg - 78.25291.88 1.23 NS -

Fruits 5.177.20 13.7815.55 2.19* 4.074.45 34.50

Fats and oil 6.598.50 14.2611.34 2.24* 3.303.74 6.893

Sugar 9.608.89 19.5518.14 2.13* 13.9021.3 10.25

* Significant at 5% level

** Significant at 1% level


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Table 19. Classification of the subjects based on adequacy of nutrients

Predialytic

Male (n=13) Female (n=7) Combined(n=20) Male (n=21) Nutrients Adequacy

F % F % F % F % Energy (Kcal) Low 12 92.30 7 100.00 19 95.00 17 80.95 4

Adequate - - - - - - 2 9.52 High 1 7.69 - - 1 5.00 2 9.52 -

Carbohydrate (g) Low 10 76.92 6 85.71 16 80.00 10 47.61 4 Adequate 2 15.38 1 14.28 3 15.00 9 42.85 - High 1 7.69 - - 1 5.00 2 9.52 -

Protein (g) Low 7 53.84 4 57.14 11 55.00 19 90.47 4 Adequate 1 7.69 2 28.57 3 15.00 2 9.52 - High 5 38.46 1 14.28 6 30.00 - - -

Fat (g) Low 12 92.30 7 100.00 19 95.00 13 61.90 3 Adequate - - - - - - 5 23.80 High 1 7.69 - - 12 5.00 3 14.28 -

Sodium (mg) Low 8 61.53 4 57.14 12 60.00 9 42.85 3 Adequate 4 30.76 3 42.85 7 35.00 9 42.85 - High 1 7.69 - - 1 5.00 3 14.28 1

Potassium (mg) Low 13 100 7 100.00 - 100 16 76.19 4 Adequate - - - - - - 5 23.80 High - - - - - - - -

F=Frequency


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Whereas, predialytic females had higher mean intake of other vegetables and sugarcompared to dialytic females (22.8539.75 Vs 1821.18 g for other vegetables and13.9021.3 Vs 10.259.32 g for sugar). The mean intake of milk and milk products weresimilar for females of both the groups. Predialytic females did not eat green leafy vegetablesand none of the females in either groups had non-vegetarian food items. The differencesbetween the means were not significant for all the food consumed.

4.5.5 Classification of the subjects based on adequacy of nutrientsMajority of the predialytics had low adequacy for energy (95%), carbohydrate (80%),

protein (55%), fat (95%), sodium (60%) and all the subject had adequacy for potassium.Similar trend was seen for dialytics since majority were having low adequacy for energy(84%), carbohydrate (56%), protein 929%), fat (64%), sodium (48%) and potassium (80%)(Table 19).

When the both groups were compared, higher percentage of dialytics were havingadequate intake of nutrients compared to predialytics with respect to energy (8 Vs 0%),carbohydrate (36 Vs 15.38%), fat (24 Vs 0%) and potassium (20 Vs 0%) except for proteinand sodium. Higher percentage of predialytics had adequate intake of protein and sodiumcompared to dialytics (55 Vs 92% for protein and 60 Vs 48% for sodium predialytic anddialytics, respectively). However, higher percentage of dialytics had more than adequateintake compared to predialytics for energy (8 Vs 5%), carbohydrate (8 Vs 5%), fat (12 Vs 5%)and sodium (16 Vs 7.69%), except for protein whose intake was higher than adequacy incase of predialytics compared to dialytics (30 Vs 50%).

4.6 DIETARY MODIFICATION4.6.1 Dietary modification followed by the subjects

Table 20 depicts the dietary modification followed by the subjects. It was observedthat 10 per cent in the predialytic and 12 per cent in dialytic group did not include any specialfoods.

Higher percentage of dialytics included fruits like apple, guava and pineapplecompared to predialytics (32 Vs 10%) and the same trend was seen for inclusion of leachedvegetables (8 Vs 5% for dialytic and predialytic subjects, respectively). About 20 per cent ofdialytic subjects included chicken and fish as a special foods but none of the predialyticsincluded these foods in the diet. However, the reasons quoted for including the special foodswas due to the doctors advice. Inclusion of fruits was due to the low potassium content. Thevegetables were leached by boiling in water and discarding the water to reduce the potassiumcontent. Chicken and fish were eaten to increase the protein content of the diet.

Under foods restricted, 90 per cent among predialytics and 60 per cent among dialyticgroups did not practice any restriction for food items. The remaining patients, restricted waterintake (10 and 40 per cent in predialytics and dialytics, respectively) and salty food items (5and 24%, respectively). The reasons given for restricting water and salty food items were toprotect kidney and to decrease the sodium level.

Forty per cent of predialytics and 20 per cent of dialytics did not avoid any food items.The food avoided by the kidney patients were coconut water (60 and 80% by predialytics anddialytics, respectively), sweet items (30 and 32%, respectively) and banana (10 and 28%,respectively). Sweet items were avoided as they raised blood sugar in diabetic renal patientsand coconut water and banana were avoided as they raised the potassium levels in the blood.


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Table 20. Dietary modification followed by the subjects(N=45)

Predialytic(n=20)

Dialytic (n=25)Dietary modification

F % F %

Reasons for inclusion andrestriction

Foods speciallyincluded

No special food 2 10.00 3 12.00

Fruit like apple, guavaand pineapple

2 10.00 8 32.00 Doctors advice and they werelow potassium fruits

Leached vegetables* 1 5.00 2 8.00 To reduce potassium content

Chicken and fish - - 5 20.00 To raise protein level

Foods restricted

No restriction 18 90.00 15 60.00

Water 2 10.00 10 40.00 To protect kidney in body

Salty food items 1 5.00 6 24.00 Raises serum sodium level

Foods avoided

No avoidance 8 40.00 5 20.00

Coconut water 12 60.00 20 80.00

Fruits like banana 2 10.00 7 28.00Raises potassium level

Sweets 6 30.00 8 72.00 Raises blood sugar level

* Boiling vegetables and discarding the cooked waterF=Frequency

4.7 BIOCHEMICAL PARAMETERSBiochemical profile of the chronic renal failure have been recorded in Table 21. Mean

biochemical parameters of dialytic patients were significantly higher compared to predialyticsubjects for serum albumin (3.670.58 Vs 2.900.73 g/dl), serum total protein (6.781.60 Vs5.531.41 g/dl), serum creatinine (7.143.57 Vs 3.041.04 mg/dl) and serum urea(113.2064.12 Vs 111.1048.83 mg/dl). The mean lipids were in normal range for predialyticsand dialytics (total cholesterol 145.23 Vs 160.75 mg/dl, TG 121.14 Vs 60.08 mg/dl, HDL-C 34Vs 32 mg/dl and LDL-C 103 Vs 116.73 mg/dl for predialytics and dialytics, respectively).


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Table 21. Biochemical profile of selected subjects

Parameters Frequency Predialytics Frequency Dialytics t val

Serum protein status (g/dl)

Albumin 15 2.900.73 23 3.670.58 3

Total protein 10 5.531.14 6 6.781.60 1.5

Hemoglobin 20 8.612.49 16 8.601.76 0.0

Creatinine (mg/d) 20 3.041.04 19 7.143.57 4.8

Urea (mg/d) 20 111.1048.83 20 113.2064.12 0.11

Lipids (mg/dl)

Total cholesterol 12 145.2350.82 24 160.7560.67 0.83

Triglycerides 12 121.14118 24 60.0820.35 1.7

HDL-cholesterol 12 34.597.48 24 32.006.13 1.0

LDL-cholesterol 12 103.5822.31 24 116.7359.36 0.96

**Significant at 1 per cent level*Significant at 5 per cent level


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4.7.1 Biochemical profile of dialytic patients before and after dialysisTable 22 presents the biochemical profile of dialytic patients before and after initiation

of dialysis.

After dialysis there was a significant lowering in the mean serum creatinine(10.665.43 Vs 7.143.57 mg/dl) and urea (153.0766.19 Vs 113.2064.12 mg/dl) levels.Even after lowering these levels did not reach in the normal range. The mean total cholesterol,

LDL-cholesterol and serum calcium levels increased after dialysis (150.7131.75 Vs160.7560.67 mg/dl, 96.1935.58 Vs 116.7359.36 mg/dl and 7.851.21 Vs 8.190.78 mg/dl,respectively) but there was a decline in the serum level of triglycerides, HDL-cholesterol andphosphorus (80.6733.44 Vs 60.0820.35 mg/dl for triglycerides, 38.3926.4 Vs 326.13mg/dl for HDL-C and 6.173.42 Vs 5.341.33 mg/dl for phosphorus, respectively). However,the differences in the means were not significant. The mean values of serum albumin, totalprotein and hemoglobin were almost similar even after dialysis.

4.7.2 Classification of selected subjects based on protein and hemoglobinstatus

Classification of chronic renal failure subjects based on protein and hemoglobinstatus has been documented in Table 23. Majority of the subjects in predialytic groups weredeficient for serum albumin (46%), serum total protein (40%) and hemoglobin level (92.4% ofmales and 57.1% of females). Whereas, equal number of patients had low and acceptablelevels of serum albumin (26.6% each) and total protein (30% each). None of the males hadacceptable hemoglobin level whereas only one female recorded acceptable level.

On the other hand, majority of the dialytic subjects had acceptable levels of serumalbumin (73.9%) and total protein (50%) but none had acceptable hemoglobin level. Nonehad deficient serum albumin status and 33.3 per cent had deficient serum total protein. All themales were deficient for hemoglobin and there was an equal number of female falling indeficient and low categories for the same (50% each).

Higher percentage of dialytics had acceptable serum albumin and total proteincompared to predialytics (73.90 Vs 26.60% and 50 Vs 30% for serum albumin and totalprotein, respectively) but none of the dialytic patients had acceptable hemoglobin status whencompared with predialytics.

4.7.3 Classification of selected subjects based on lipid profileTable 24 reflects the classification of chronic renal failure subjects based on lipid

profile. Majority of the subjects in the both groups were having desired levels of cholesterol,LDL-cholesterol and triglycerides (91.66 and 87.5% for total cholesterol, 91.66 and 75% forLDL-cholesterol and 83.33 and 100% for triglycerides for predialytics and dialytics,respectively).

Among predialytics, half the subjects belonged to risk group for HDL-cholesterol(50%) followed by the borderline category (41.66%) and the rest belonged to the desirablegroup (8.33%). None of the predialytics were in the risk group for total cholesterol, LDL-cholesterol and triglycerides.

On the other hand, majority of the dialytics were classified in the risk group for HDL-cholesterol (70.83%) and rest were falling in borderline category. Equal number of dialyticsbelonged to the borderline and risk categories for LDL-cholesterol and only 12.5 per centwere classified in the risk category for total cholesterol. Higher percentage of predialytics haddesirable status for total cholesterol and LDL-cholesterol when compared to the dialytics(91.66 Vs 87.5% for total cholesterol and 91.66 Vs 75% for LDL-cholesterol respectively).However, triglycerides level was desirable in all the dialytics but only 83.33 per cent haddesirable level of triglycerides in predialytics.


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Table 22. Biochemical profile of dialytic patients before and after dialysis

Parameters Frequency Prior to dialysis Frequency After dialysis t val

Serum protein status (g/dl)

Albumin 9 3.560.25 23 3.630.58 0

Total protein 8 6.031.73 6 6.781.00 0

Hemoglobin 23 8.191.86 16 8.601.73 0.

Creatinine (mg/dl) 25 10.665.43 19 7.143.57 2.

Urea (mg/dl) 22 153.0766.19 20 113.2064.12 2.0

Lipids (mg/dl)

Total cholesterol 7 150.7131.75 24 160.7560.67 0.58

Triglycerides 7 80.6733.44 24 60.0820.35 1.5

HDL-cholesterol 7 96.1935.58 24 116.7359.36 0.6

LDL-cholesterol 7 38.3926.49 24 32.006.13 1.1

Serum electrolytes (mg/dl)

Calcium 11 7.851.21 7 8.190.78 0

Phosphorus 9 6.173.42 7 5.341.33 0.6

NS-Non-significant, **-Significant at 1 per cent level, *-Significant at 5 per cent level


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Table 23. Classification of selected subjects based on protein and hemoglobin status

Predialytics

Deficient Low Acceptable Deficient Parameters (g/dl) n

F % F % F %

n

F %

Serum albumin 15 7 46.00 4 26.60 4 26.60 23 - - 6

Serum total protein 10 4 40.00 3 30.00 3 30.00 6 2 33.33 1

Hemoglobin 20 16

Male 13 12 92.40 1 7.60 - - 14 14 100.00 -

Female 7 4 57.10 2 28.57 1 14.28 2 1 50.00 1

F=Frequency

(g/dl) Deficient Low AcceptableSerum protein


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Table 24. Classification of selected subjects based on lipid profile

Predialytics (n=12) Dialyt

Desirable Borderline Risk Desirable BordeParameters (mg/dl)

F % F % F % F % F

Total cholesterol 11 91.66 1 8.33 - - 21 87.50 -

LDL-C 11 91.66 1 8.33 - - 18 75.00 3

HDL-C 1 8.33 5 41.66 6 50 - - 7

TG 10 83.33 2 16.66 - - 24 100 -

F Freq

Documents

NUTRITIONAL STATUS AND DIETARY GUIDELINES OF PREDIALYTIC AND HEMODIALYTIC PATIENTS