الفهرس 
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Abstract
Background: Hemodialysis (HD) patients are prone to protein energy wasting (PEW), which is a major risk and predictive factor of morbidity and mortality. The prevalence of malnutrition in predialysis chronic kidney disease (CKD) patients ranges from 20% to 80%, depending on the choices of population or nutritional markers. Patients undergoing maintenance HD also had high prevalence of malnutrition ranging from 23% to 73%. Therefore, malnutrition is considered to be a very common problem affecting HD patients. In HD patients, PEW can be caused by a reduced intake of nutrients, poor appetite, or an increased protein catabolism due to metabolic acidosis, hyperparathyroidism, insulin resistance, and inflammation. In any given condition, moderate to severe malnutrition induces body weight loss and alterations in body composition mainly reduction in fat and muscle mass and increase in total body fluids, with increase in extracellular water. End stage renal disease is a chronic disease that exerts a great negative impact on patients’ health-related quality of life (QOL) mainly due to the accompanied impairment or to the imposed limitations in almost all domains of their daily lives. HD represents a complex procedure for patients that requires frequent hospital or dialysis centers visits, mainly three times a week, thus implying substantial changes in the normal way of patients’ living. Nutritional status had been shown to impact on QOL in HD patients by various nutrition assessment parameters. Patients and Methods: Eighty-four MHD patients, treated at MNDU, were enrolled in the current study and subjected to thorough medical history taking and clinical examination. In addition, routine laboratory investigations were performed according to the local working protocol of the unit, with special consideration to serum albumin, cholesterol, TIBC, calcium, phosphorus, iPTH, ferritin and hsCRP. Kt/V was calculated as an expression of dialysis adequacy. Furthermore, anthropometrics, including BMI, TSF, MAC and MAMC, and body compositions were measured. Moreover, dietary history was taken by three-day dietary records, then MIS and mSGA forms were filled out. Subsequently, the ISRNM criteria for diagnosis of PEW were applied to the studied patients. Additionally, QOL of the patients was evaluated by using KDQOL-36™. In a second phase of the study, PEW patients were subjected to personalized nutritional intervention for 6 months including regulation of DEI, DPI and micronutrient requirements of each patient according to the National kidney foundation KDOQI Clinical Practice Guidelines (2000) on nutrition in chronic renal failure. After 6 months of intervention, the nutritional status and QOL of intervened PEW patients were reassessed once more. Results: Eighteen patients (21.4%) were found to have been suffering from PEW according to ISRNM criteria. Patients with PEW had higher MIS and mSGA in comparison to those without. They also had longer duration of HD and higher ferritin and hsCRP, but lower blood hemoglobin, serum iron and creatinine than the group of patients without PEW. Regarding QOL components, there was no statistically significant differences between both groups of patients regarding most components of QOL. In binary logistic regression for predicting PEW, hsCRP was found to be the most significant predictor, and ROC analysis revealed that an hsCRP of 15.95 mg/L with moderate sensitivity and specificity, was the cut-off value for ascertaining the presence of PEW. Fourteen patients completed six months of personalized nutritional intervention. Following such intervention, half of these patients became no longer suffering from PEW (responder group), while the others were non-responders. In the responder group, there was increase of total body fat percentage and decrease of TBW percentage with unchanged FFM after the six months of intervention. Moreover, after this period of intervention, there was improvement, although statistically insignificant, in all domains of QOL except for MHC in responder patients. Conclusion: from the results of the current study, it may be concluded that malnutrition is not uncommon problem in MHD patients, and it is associated with poor QOL. chronic inflammation plays an important role in the pathophysiology of PEW in MHD patients. In addition, in contrary to weak or absent effects on MHC, multiple nutritional and non-nutritional factors could have an appreciable implication on the PHC. Moreover, PTH level, physical health, and marital status of the studied patients may be major contributors to the positive response to nutritional intervention.