الفهرس 
Chronic Kidney Disease (CKD)Only 14 pages are availabe for public view
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Abstract
Chronic kidney disease (CKD) is defined as an abnormality of kidney function, as determined by laboratory tests, urinalysis, or imaging tests, which have been present for at least 3 months. CKD has replaced “chronic renal failure” and “chronic renal insufficiency” as the globally accepted terminology for persistent renal dysfunction. chronic kidney disease in Egyptian children less than 5 years of age is attributed to parenchymatous disease in 73% of cases and obstructive etiology in 27% of cases, while after 5years of age, Parenchymatous disease is the cause in 67% and obstructive etiology constitutes 33% of cases . Hemodialysis should be initiated when one or more of the following are present: symptoms or signs attributable to kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus); inability to control volume status or blood pressure; a progressive deterioration in nutritional status refractory to dietary intervention; or cognitive impairment. This often but not invariably occurs in the GFR range between 5 and10 ml/min/1.73 m2. However, evaluation of the need for dialysis should begin at a higher GFR level, probably somewhere around 15-20 mL/ minute/1.73 m². Problems with criteria that are limited to clearance measures occur in patients with renal impairment who have problems with fluid overload, hyperkalemia, or “failure to thrive” that are out of proportion to their GFR. For example, patients with advanced cardiac disease and borderline GFR may have trouble with refractory fluid retention. Once these patients are initiated on dialysis, the emergency room visits and hospital admissions often decrease markedly or cease altogether. Delay in initiation of dialysis for such patients until their GFR fall into a specified range may have an adverse effect on their long term survival . chronic kidney disease (CKD) is associated with premature atherosclerosis and increased incidence of cardiovascular morbidity and mortality. Several factors contribute to atherogenesis and cardiovascular disease in patients with CRF. Notable among the CRF-induced risk factors are lipid disorders, oxidative stress, inflammation, physical inactivity, anemia, hypertension, vascular calcification, endothelial dysfunction, and depressed nitric oxide availability. In the past 30 years, numerous studies have been conducted to discern the features and the mechanisms of CRF-induced dyslipidemia. Most of the earlier studies were focused on the effect of CRF on the concentration, composition, and clearance of various plasma lipoproteins and their remnants. CRF results in profound dysregulation of several key enzymes and receptors involved in the metabolism of lipoproteins, particularly those of HDL and triglyceride-rich lipoproteins. Downregulation of LCAT, apoA-1, and hepatic lipase together with upregulation of CETP are largely responsible for the reduction in HDL cholesterol and elevation of HDL triglyceride in CRF. Downregulation of skeletal muscle and adipose tissue LPL, hepatic lipase, and the VLDL receptor and of hepatic LRP is collectively responsible for hypertriglyceridemia, impaired clearance, and elevated plasma levels of VLDL, IDL, and chylomicron remnants despite downregulation of hepatic triglyceride synthetic capacity (DGAT). Dysregulation of lipid metabolism can contribute to atherogenic diathesis and possibly to progression of renal disease and impaired energy metabolism in CRF. etween 30 and 50% of prevalent patients who are on hemodialysis (HD) have elevated serum levels of inflammatory markers. In some patients, this elevation is chronic, and in some, it is intermittent and generally is associated with breakthrough processes. Furthermore, on many occasions,HD sessions trigger inflammation in a way that is not always identifiable with the conventional markers. Inflammatory markers are powerful predictors of mortality after adjustment for other risk factors. Inflammation also is responsible for other mortality risk factors, such as anemia, malnutrition, vascular disease, and left ventricular hypertrophy, for lowering the high morbidity/mortality rate in patientswho are on HD, inflammation must be tackled. hemodialysis patients with inflammation have a poorer prognosis.Biochemical inflammatory markers help us to identify these patients. In most cases, the cause of inflammation can be determined through clinical investigation, and some of them may be eliminated or corrected. The prevention and the treatment of inflammatory syndrome is of high priority in patients who are on HD. ω-3 PUFAs are commonly found in marine and some plant oils, such as fish oils, algal oil, squid oil, echium oil, and flaxseed oil. They have several double bonds (C=C) beginning after the third carbon atom from the end of the carbon chain. They are considered as essential fatty acids, which cannot be synthesized by mammalian cells de novo but are vital for normal metabolism. ω-3 PUFAs include α-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA). ω-3 PUFAs have several benefits for minimizing CVD risks by reducing inflammation, decreasing oxidative stress, inhibiting platelet activity, exerting antiarrhythmic effects, and improving triglyceride levels in the general population and patients with CKD . In addition, the modification of erythrocyte membrane fatty acid content by ω-3 PUFAs supplementation is an important process related to CVD risk reduction which may help in the interpretation of clinical trials in general populations and patients with CKD. Increasing erythrocyte membrane content of ω-3 PUFAs, and consequently the ω-3 index, and decreasing total saturated fatty acids, oleic acids, and AA may affect cellular function by changing transmembrane proteins and inflammatory mediators involved with cell signaling systems. The role of ω-3 PUFAs in vitamin D activation, vascular calcification prevention, cardiovascular events, and mortality should be further investigated in CKD patients. This cardioprotective effect of ω-3 PUFAs is explained by its ability to suppress inflammation, inhibit platelet activation/adhesion, and reduce thrombosis . The main effect of ω-3 PUFAs is reducing triglyceride levels in patients with hypertriglyceridemia, which is associated with CVD . In addition, ω-3 PUFAs reduced oxidative stress and had the possibility to inhibit vascular calcification in human studies and a rat model7 . Therefore, ω-3 PUFAs, which have several benefits in CVD, may be helpful to reduce CVD in CKD patients, who have a high prevalence rate of CVD . Patients and Methods This study was done in the pediatric hemodialysis unit in the pediatrics department at Menoufia university Hospital, during the period from January 2014 to April 2014. The Ethics Committee of faculty of medicine, Menoufia University of approved the study protocol, and informed written consent was obtained from each patient. The study included 28 patients with end stage renal failure (ESRD)on regular hemodialysis three times weekly for at least 3 months before the start of the study 5 of them were later excluded (3of them due to their age was more than 18 years and another 2 due to non compliance) . All patients were daily treated with 1000 mg (omega 3plus) containing 180 mg Eicosapentaenoic acid (EPA) and 120 mg Docosahexaenoic acid (DHA) for three months . All the patients were chosen in accordance with the following criteria: • Inclusion criteria: 5- End stage renal disease with childhood onset of hemodialysis & their age less than 18 years. 6- Regular hemodialysis, having at least three sessions a week. 7- Duration of hemodialysis more than3 months. • Exclusion criteria: 6. Predialysis stages of CKD 7. Patients on chronic peritoneal dialysis 8. Patients on regular hemodialysis < 3 months. 9. Primary (non-uremic) cardiovascular disease 10. Metabolic disease e.g (1ry hyperparathyroidism). 11. Histoy of acute inflammatory conditions All the study patients received 1 g of omega-3 fatty acid per day (1 gm omega-3 Plus once a day)for 3 months . Blood sample was taken from all patients for measurement of lipid profile, High sensitive CRP , complete blood count, serum levels of parathyroid hormone, iron, iron saturation, serum ferritin,& total calcium, phosphorous before the start of the study and after 3months at the end of the study. Statistical Analysis The results are expressed as means ± SD. The collected data were analyzed by SPSS-20statistical software using Paired t-test or Wilcoxon Signed-Rank test. P-values less than 0.05 were considered statistically significant. Results Overall, the 23 patients completed the study, their mean age was 14.52years range(8–18 years).,number of males was 12(52.2%)& number of females was11 (47.8%). The comparison of the studied variables before and after supplementation with Omega-3 fatty acids showed the following:. There were statistically high significant difference between the level of triglycerides before148.86± 44.41mg/dl, & after supplementation with omega-3 fatty acid 135.17± 45.99mg/dl, (P <0.001). There was no statistically significant difference in the levels of Hb, PTH, ferritin, total, LDL and HDL cholesterol before and after supplementation with omega-3 fatty acids (P >0.05). There was a significant association between hypertension and triglyceride level as there was positive correlation between serum levels of triglycerides & blood pressure (systolic,diastolic &mean). The mean hs-CRP level was 6.25±3.32mg/dl before supplementation, which decreased to 5.59±4.80mg/dl after supplementation, however it was not statistically significant. This study concluded that:- Conclusion 1-The use of 1 gm of omega-3 caused significant decrease in serum levels of triglycerides in children on hemodialysis. 2- There is positive correlation between triglyceride level & systemic blood pressure in children on hemodialysis. 3- Omega-3 may be needed to be taken in a larger doses to exert its anti inflammatory effect Recommendation This study recommends that:- 3. the use of omega-3 supplementation for the treatment of hypertriglyceridemia in children on hemodialysis. 4. Further studies with larger doses , longer duration & wider scale to assess the anti-inflammatory effect of omega 3 in children on hemodia.