الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Chronic renal failure (CRF) is a reduction in the glomerular filtration
rate (GFR). It has many causes including: glomerular diseases,
pylonephritis, hereditary nephropathies, urologic abnormalities,
multisystem disease as hemolytic- uremic syndrome and systemic lupus
erythematosus. It is a chronic low grade inflammatory condition affecting
multisystems with wide range complications as protein energy wasting
(PEW) and cardiovascular diseases
Chronic kidney disease (CKD) is a major public health problem.
Adverse outcomes of chronic kidney disease can be prevented through
early detection and treatment. Earlier stages of chronic kidney disease can
be detected through routine laboratory measurements.
CKD has been defined as kidney damage (manifested by renal
biopsy, blood, imaging or urine tests abnormalities) lasting for ≥3 months
with or without a decreased GFR or any patient who has a GFR < 60
ml/min /1.73 m² lasting for 3 months with or without kidney damage.
End-stage renal disease ESRD is a term defining patients with stage
5 CKD with GFR < 15 ml/min /1.73 m². Options for renal replacement
therapy (RRT) for ESRD include: Kidney transplantation, peritoneal
dialysis, haemodialysis and supportive therapy in the form of drugs for
hypertension, anemia and diet control.
Hemodialysis (HD) continues to be the most frequently utilized
modality for renal replacement therapy in ESRD pediatric patients.
Trace elements are vital for human body to maintain normal
complex physiological functions related to body’s growth and development
as they are involved in the composition of many enzymes and proteins and
play an important role in many metabolic pathways. So any disturbance in
their levels may have hazardous effects on children during growth and
developmental period. Cardiovascular diseases, anemia, immune
deficiency, bone disease and increased risk of cancers may occur with
excessive accumulation or depletion of trace elements.
They are called trace elements because of their low body
concentrations, which are few milligrams per kg or less. Daily dietary
requirement of trace elements is few milligrams, so, they are also known as
micronutrients.
Trace elements metabolism can be affected in renal insufficiency
with reduced renal function, uremic status, metabolic imbalance,
medications, special diets, dialysis process and the quality of the water
used for dialysis. So, various trace elements abnormalities have been
described in patients with CRF especially in those treated by hemodialysis.
In hemodialysis patients, trace elements accumulation is caused by
exposure to high volume of dialysate (300 litre/ week) in addition to lack
of renal clearance which increases the risk of toxicity of ingested trace
elements even when they are not present in dialysate. Trace elements
deficiency is attributed to their removal during the dialysis process, uremia
related anorexia and also dietary restrictions.
Although trace elements disturbances may contribute to morbidity
and mortality among hemodialysis patients, trace element imbalance in pediatric CRF patients has not been comprehensively studied. As most of
the studies have been done on adult patients, few studies done on pediatric
patients, further studies are needed to correlate trace elements imbalance
and clinical findings in pediatric patients. In this aspect; this study was
carried out to get more information about the status of trace elements in
Egyptian CRF pediatric patients.
The present study was done to detect the serum trace elements
{copper (Cu), zinc (Zn), manganese (Mn), selenium (Se) and cobalt (Co)}
levels in children with CRF on regular hemodialysis and those on
conservative treatment and compared them to healthy control children
matched for age and sex, to study the influence of dialysis duration on
these trace elements and the clinical impact of these trace element
imbalances on the children health.
Members of this study were divided into three groups: Group I: 25
children with end stage renal disease (ESRD) on regular haemodialysis
therapy, in Menoufia University Hospitals, for 6 ms - 7 years, three times
per week, with each dialysis session lasting for three to four hours. They
were (14) males and (11) females and their ages ranged from 5 to 18 years.
Group II: 20 children, 8 males and 12 females, with chronic renal
insufficiency on conservative treatment for 7 ms–3 years and not managed
by dialysis before. Their age ranged from 7 to 16 years and all of them had
GFR more than 15 ml/min./1.73m². Group III: 20 healthy children
matched for age and sex were served as control group.
All patients and controls were subjected to thorough history taking,
clinical examination including anthropometric measurement and estimation
of the blood pressure. Laboratory assessment was done measuring CBC, BUN, serum creatinine, CRP, serum iron, serum zinc, copper, selenium,
cobalt and manganese. Radiological investigation was done to measure
GFR by renal isotopic scan and bone density by DEXA scan.
The results of this study were tabulated and statistically analyzed
showing the following results:
• There was significant growth retardation in patients as compared to
controls as reflected by the decline in anthropometric measures.
• There was a significant elevated systolic, diastolic and mean blood
pressure in patients as compared to controls.
• There was a significant increase in incidence of recurrent infection,
bone and skin diseases in patients on dialysis compared to patients
on conservative treatment and controls.
• There was a significant decrease in hemoglobin level and a
significant increase in serum iron in patients compared to controls
and a significant decrease in platelet count in patients on dialysis
compared to controls while there was no significant change in
WBCs counts between patients and controls
• There was a significant increase in BUN and Serum creatinine in
patients compared to controls and a significant increase in CRP and
ESR in patients on dialysis compared to patients on conservative
treatment and controls.
• Patients on dialysis had decreased serum Zn, Cu, Se and Mn
compared to those on conservative treatment and controls.
Summary
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• Patients on conservative treatment had decreased serum Zn and Se
compared to controls.
• No significant change in serum cobalt in patients and controls.
• Zn, Cu, Se and Mn had direct correlations with weight, height and
mid arm circumference while their correlations to the duration of
dialysis were inversed.
• Zn, Cu and Se had inverse correlations with skin diseases,
recurrent infections and CRP, while their correlations to
hemoglobin levels were direct.
• Zn and Cu had direct correlation with serum iron.
• Inverse correlations were present between Se and mean blood
pressure and also between Zn and bone diseases.
In conclusion; children with CRF may show abnormalities in serum
levels of some trace elements that increase in severity with increasing
duration of hemodialysis. It was found that children with ESRD on regular
hemodialysis had a significant decreased serum level of Zn, Cu, Se and Mn
levels with no significant change in the serum Co level, while children with
CRF on conservative treatment had a significant decreased serum Zn and
Se levels with no significant change in serum Cu, Mn and Co levels.
Recommendations: Measurement of trace elements should be done
before starting dialysis and at regular intervals during dialysis with oral
trace element supplementation (as; oral zinc and selenium preparations) to
be given to the hemodialysis patients.