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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 26  |  Issue : 2  |  Page : 250-254
Nutritional knowledge following interventional educational sessions in children on regular hemodialysis


1 Department of Pediatrics, Zagazig University, Zagazig, Egypt
2 Department of Community Medicine, Zagazig University, Zagazig, Egypt

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Date of Web Publication3-Mar-2015
 

   Abstract 

To evaluate the impact of nutritional knowledge following interventional educational sessions in chronic dialysis patients, we studied 40 children on chronic regular hemodialysis (HD) at the beginning and after six months of nutrition educational sessions using a predesigned questionnaire. We also measured the anthropometric parameters of nutrition to evaluate the impact of this education on the health of patients. We found a highly statistically significant increase in patients' scores and in adequate knowledge using the questionnaire after the educational sessions. Our results showed a statistically significant decrease in body mass index and weight after educational sessions for six months. Moreover, there were no significant decreases in serum phosphorus, ferritin, iron and creatinine, in contrast with no significant increase in hemoglobin, serum calcium, blood urea nitrogen and serum albumin. We conclude that nutritional education is significantly effective with regard to the level of knowledge, but not with regard to the attitude and practice in children on chronic HD.

How to cite this article:
Youssef DM, Abo Al Fotoh MN, Elibehidy RM, Ramadan SM, Mohammad EM. Nutritional knowledge following interventional educational sessions in children on regular hemodialysis. Saudi J Kidney Dis Transpl 2015;26:250-4

How to cite this URL:
Youssef DM, Abo Al Fotoh MN, Elibehidy RM, Ramadan SM, Mohammad EM. Nutritional knowledge following interventional educational sessions in children on regular hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Nov 18];26:250-4. Available from: http://www.sjkdt.org/text.asp?2015/26/2/250/152407

   Introduction Top


The World Health Organization defines malnutrition as "bad nourishment," characterized by "inadequate or excess intake of protein, energy, and micronutrients such as vitamins, and the frequent infections and disorders that result." [1]

Malnutrition is recognized to be a serious common complication of end-stage renal disease (ESRD) and is associated with increased morbidity and mortality in children. [2]

The risk of developing malnutrition in ESRD treated with hemodialysis (HD) is increased during dialysis, as it is often a catabolic procedure itself due to the loss of nutrients such as amino acids, glucose and water-soluble vitamins into the dialysate. [3] Concurrent illnesses and acute or chronic conditions, such as inflammation, infection, liver disease and cancer, may compromise the nutritional status of patients with ESRD. [4]

Inadequate dietary recommendations and low socioeconomic state are important factors that can cause malnutrition in dialysis patients, and these factors are not related to dialysis itself. [5]

The aim of this study was to evaluate the impact of nutritional knowledge on the health of chronic HD children following interventional nutrition educational sessions for six months.


   Materials and Methods Top


We conducted a prospective study on 40 patients with CKD stage 5 on regular HD in the Pediatric Dialysis Unit of the Zagazig University Hospital. The age of the cases ranged between two and 18 years, including 17 males and 23 females. The period of the study was six months.

Dialysis was performed with the Fresenius 2008 K, 4008 B and 4008 S machines. Hollow fiber polysulfone dialyzers (Fresenius, Bad homburg, Germany) were used, using a standard bicarbonate dialysate solution. The dialysis prescription was as follows: Three times a week, 3-5 h per session and blood flow between 180 and 300 mL/min, with target urea reduction ratio (URR) >65%.

The first visit was performed to introduce the investigator and become more familiar with the children. Then, we prepared the questionnaire, in which we asked them some questions to assess their knowledge about nutritional information. The investigator sat with every patient and the parents separately as most of the parents were illiterate.

Data were collected from each patient and recorded in a pre-designed questionnaire for assessment of nutritional knowledge, including sociodemographic characteristics of the patients, history of renal failure and dialysis and nutritional history with regard to certain food items, such as protein- and potassium-rich food. In addition, the patients underwent clinical assessment in the form of anthropometric measures of weight, height and body mass index (BMI), which is a good indicator of nutritional status. [6]

The questionnaire consisted of 25 questions; answers were either Yes or No. Getting a score of 1 for a correct answer and zero for a wrong answer, the total score was 25, and adequate knowledge meant the achievement of correct answers for 60% of the total score. The questionnaire was designed with extensive concerns of the population level of education and economic status.

Assessment of the attitude of the patients toward practicing the nutritional knowledge was carried out by the evaluation of BMI and laboratory markers.

Dry weight was assessed regularly before and after each HD session using an electro-digital scale. Height was measured in order to calculate the BMI [weight in kilograms divided by the height in meters squared (kg/m 2 )].

The education sessions were conducted every other week during the study period. At the end of the 6 th month, we evaluated the patients with the same questionnaire and re-measured the anthropometric and the laboratory parameters.

Six patients dropped out of the study at the end of the six months for the following reasons: Two patients died, three patients transferred from the unit and one patient received a kidney transplant.


   Statistical Analysis Top


The data were tabulated and statistically analyzed using SPSS for windows (version 10). The Student t-test, paired t-test and Chi Square (x 2 ) tests were used. Qualitative data were displayed in cross-tabulation and quantitative data were described in terms of the arithmetic mean ± standard deviation (SD). Bivariate techniques were used for the initial evaluation of contrasts. Thus, the chi-square and Fisher's exact tests were used for comparisons of frequencies of qualitative variables and the unpaired t test was used for comparisons of the means of quantitative variables. A P-value of <0.05 was considered significant and P <0.001 was considered highly significant.


   Results Top


[Table 1] shows the demographic data of the study patients and their parents.
Table 1: Demographic data of patients and parents.

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[Table 2] shows the comparisons between the numbers of correct answers on most questions concerning the nutritional elements. Post-education evaluation showed a highly significant increase in correct answers about most elements, whereas there was an insignificant increase in the correct answers about both zinc and copper.
Table 2: Comparison between correct answers of the questionnaire questions in the cases pre and post the education session.

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[Table 3] shows a highly statistically significant increase in patients' scores of adequate knowledge at the final questionnaire.
Table 3: Comparison of patients' Scores of the studied group in the questionnaire Pre and Post the education session (final score = 25). And comparing adequate knowledge of each group in the questionnaire Pre and Post the education session (No. of patients answered more than 60% of the questionnaire correctly).

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[Table 4] shows a statistically significant decrease of BMI in the children after the educational sessions for six months.
Table 4: Comparison of anthropometric measures between pre and post the education session.

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[Table 5] shows a statistically insignificant decrease in the serum levels of phosphorus, ferritin, iron and creatinine, while it shows an insignificant increase in the levels of hemoglobin, serum calcium, blood urea nitrogen and serum albumin.
Table 5: Comparison between investigation results in the case group pre and post the education session.

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   Discussion Top


Children on maintenance HD are at a risk of developing malnutrition that may result in increased mortality of approximately 30-times higher than expected for age when compared with those of healthy children. [7] The pediatric renal dietician is crucial to the successful management of nutrition in children with renal disease. Monthly reviews have been recommended for the dialysis patients under two years of age, and 3- to 4-monthly for older patients. [8]

In our study, we found a highly significant improvement in the scores of the answers of the patients to the questions related to nutrition after six months of education about the same.

However, there was a trend toward improvement in the biochemical markers at the end of the study period, but it did not reach statistical significance, and this matches the results of Harin et al. [9]

In our study, creatinine decreased at the end of the study period, indicating better dialysis adequacy, which can be explained by better tolerance to the dialysis with less hypotension episodes due to better control of dry weight with less interdialytic weight gain due to a lower sodium intake and better hemoglobin levels, such that the patients could spend more time on dialysis. In addition, there was a trend toward an increased blood urea nitrogen due to higher protein intake, which was comparable to the results from Harin et al. [9]

Our results showed that BMI and weight decreased significantly, due mostly to a decrease in the dry weight.

In two studies, [10],[11] the educational program showed no statistically significant behavioral changes in the adult dialysis patients, nor in their laboratory investigations. In our study, the disproportion between the highly significant improvement in the knowledge about proper nutrition and the insignificant improvement in biochemical parameters can be explained by the presence of other factors like low socioeconomic status of most of the patients' families, low education level of their mothers and the nature of our patients as children who cannot go with strict diet regimens for long periods. Moreover, our study is considered a short-term one and may need longer follow-up and more repeated educational sessions to get better results.

We conclude that nutritional education is significantly effective with regard to the level of knowledge, but not with regard to the attitude and practice in children on chronic HD.

Conflict of interest: None declared.

 
   References Top

1.
Friedman AN, Fadem SZ. Reassessment of Albumin as a Nutritional Marker in Kidney Disease. J Am Soc Nephrol 2010;21:223-30.  Back to cited text no. 1
    
2.
Wong H, Mylrea K, Feber J, Drukker A, Filler G. Prevalence of complications in children with chronic kidney disease according to KDOQI. Kidney Int 2006;70:585-90.  Back to cited text no. 2
    
3.
Bellizzi V, Scalfi L, Terracciano V, et al. Early Changes in Bioelectrical Estimates of Body Composition in Chronic Kidney Disease. J Am Soc Nephrol 2006;17:1481-7.  Back to cited text no. 3
    
4.
van Manen JG, Korevaar JC, Dekker FW, Boeschoten EW, Bossuyt PM, Krediet RT; NECOSAD Study Group. Netherlands Cooperative Study on the Adequacy of Dialysis-2. How to adjust for comorbidity in survival studies in ESRD patients: A comparison of different indices. Am J Kidney Dis 2002;40: 82-9.  Back to cited text no. 4
    
5.
Hakim I. Nutritional requirements of hemodialysis patients. In: Handbook of nutrition and the kidney. Third edition. Vol. 12. USA: PA 19106-3780. Publisher: Lippincott-Raven; 1999. p. 253-68.  Back to cited text no. 5
    
6.
Foster BJ, Leonard MB. Nutrition in children with kidney disease: Pitfalls of popular assessment methods. Perit Dial Int 2005;25 Suppl 3:S143-S6.  Back to cited text no. 6
    
7.
Srivaths PR, Silverstein DM, Leung J, Krishnamurthy R, Goldstein SL. Malnutrition-inflammation-coronary calcification in pediatric patients receiving chronic hemodialysis. Hemodial Int 2010;14:263-9.  Back to cited text no. 7
    
8.
KDOQI Work Group. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: Update. Executive summary. Am J Kidney Dis 2009;53( Suppl 2):S11-104.  Back to cited text no. 8
    
9.
Rhee H, Jang KS, Song SH, Kim IY, Seong EY, Lee SB. Effects of 12 weeks nutrition education on nutritional status in hemodialysis patients. Kidney Res Clin Pract 2012;31(2): A69.  Back to cited text no. 9
    
10.
de Araujo LP, Figueiredo AE, d'Avila DO. Evaluation of an educational program on calcium and phosphorus metabolism for patients on hemodialysis. Rev Esc Enferm USP 2010; 44:928-32.  Back to cited text no. 10
    
11.
Aghakhani N, Samadzadeh S, Mafi TM, Rahbar N. The impact of education on nutrition on the quality of life in patients on hemodialysis: A comparative study from teaching hospitals. Saudi J Kidney Dis Transpl 2012;23:26-30.  Back to cited text no. 11
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Correspondence Address:
Dr. Doaa Mohammed Youssef
Department of Pediatrics, Zagazig University, Zagazig
Egypt
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DOI: 10.4103/1319-2442.152407

PMID: 25758871

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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