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Tài liệu Nghiên cứu tình trạng suy dinh dưỡng và nồng độ leptin huyết thanh ở bệnh nhân bệnh thận mạn đang lọc máu chu kỳ và lọc màng bụng liên tục tt tieng anh

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HUE UNIVERSITY UNIVERSITY OF MEDICINE AND PHARMACY VO THANH HUNG STUDY ON MALNUTRITION STATUS AND SERUM LEPTIN LEVELS IN END-STAGE RENAL DISEASE PATIENT IS ON MAINTENANCE HEMODIALYSIS AND OUTPATIENTS CONTINUOUS PERITONEAL DIALYSIS Specialized: INTERNAL MEDICAL Code: 9 72 01 07 SUMMARY THESIS OF MEDICAL DOCTOR HUE - 2020 The study was completed at: College of Medicine and Pharmacy, Hue University Science instructor: Assoc. Prof, PhD HOANG BUI BAO University of Medicine and Pharmacy, Hue University Reviewer 1: Assoc. Prof, PhD VU DINH HUNG Binh Duong Medic General Hospital Reviewer 2: Assoc. Prof, PhD HA HOANG KIEM Military Hospital, Viet Nam Military Medical University Reviewer 3: Assoc. Prof, PhD DINH THI KIM DUNG Hanoi Medical University The thesis will be defended in front of the doctoral evaluation council at Hue University Meeting at:…………………………………………………………… At: ......... time ........ date ......... month 2020. The dissertation could be found in: - National Library of Vietnam - Learning Resource Center – Hue University - Library of Hue University of Medicine and Pharmacy 1 BACKGROUND Malnutrition has been identified as one of the most important problems in patients with Chronic Kidney Disease (CKD) because it increases the progression of kidney disease on the one hand (reduces glomerular filtration rate and blood flow to the kidneys) in combination with inflammation and cardiovascular diseases increases mortality. In addition, malnutrition damages the function of the proximal renal tubules, as evidenced by an increase in the excretion of amino acids and phosphates. Malnutrition is a risk of death risk for end-stage renal disease due to decreased serum albumin, which promotes faster progression of renal failure. In France, the study of Aparicio Michel et al. Showed that in one patient undergoing hemodialysis treatment, one third of malnourished patients account for 20% - 36%. Therefore, any treatment strategy that improves energy consumption and nutritional quality affects the outcome and quality of life of patients on renal replacement therapy. Leptin is one of the first discovered adipokin of adipose tissue and confirms the important role of adipose tissue as an endocrine organ. Leptin helps to regulate the metabolism in the body by stimulating energy expenditure, inhibiting ingestion. Leptin normalizes immune function that is inhibited by malnutrition and leptin deficiency. Leptin in the blood is excreted mainly by the kidneys. For these reasons, we conduct a research project: "Study of malnutrition and serum leptin concentration in patients with chronic kidney disease on dialysis and continuous outpatient peritoneal dialysis", in order to the following goals: 1. To investigate of malnutrition by using indicators: SGA_3, Body Mass Index, serum prealbumin, serum albumin, normalized protein catabolic rate (nPCR) and serum leptin concentration in patients with chronic kidney disease are on Hemodialysis and continuous peritoneal dialysis at Can Tho General Hospital. 2. To find the factor related malnutrition, serum leptin levels and clinical, subclinical, and all-cause mortality in 12 months in these two patient groups. 2 Chapter 1: OVERVIEW 1.1. OVERVIEW OF CHRONIC KIDNEY DISEASE 1.1.1. Epidemiology In the United States, the statistics of the National Health and Nutrition Examination Survey (NHANES) on the proportion of patients with Chronic Kidney Disease (CKD) have been increasing in recent years. CKD for adults accounts for the following years: from 1999 to 2014 the percentage of CKD increased over time. The percentage of patients with CKD from phase 1 to stage 5 is as follows: from 1999-2002, there were 13.9% (12.9-14.8%), 20032006 up to 14.4% (13.1 -15.7%), 2007-2010 had 13.4% (12.6-14.2%) and 2011-2014 up to 14.8% (13.6-16.0%) had CKD. Increasing CKD rate, in the US for subjects greater than or equal to 66 years. The mortality rate for CKD patients aged 66 years or older has decreased by 31.5% since 2002, from 197 deaths per 1,000 patients per year to 135 deaths in 2014. 1.1.2. Define Chronic Kidney Disease (CKD) is a structural or functional kidney damage that persists for more than 3 months, manifested by albuminuria, or visual abnormalities or impaired renal function identified through Glomerular filtration rate <60 ml / minute / 1.73 m2. 1.1.3. Staging of Chronic Kidney Disease (CKD). Over the 12 years since the American Nephrology Association published guidelines for the diagnosis, classification and strategies for chronic kidney disease, CKD has been updated several times: 2002, 2009 and now 2012. Table 1.2. Classification of CKD stage according to American Nephrology Association 2012. Glomerular filtration rate Stage Description (mL/min/1.73 m2) 1 ≥ 90 Normal or high 2 60 – 89 Mitigation 3a 45 – 59 Mitigation – moderate 3b 30 – 44 Moderate-severe reduction 4 15 – 29 Heavy reduction 5 < 15 End- stage renal disease 3 1.2. NUTRITION IN CHRONIC KIDNEY DISEASE PATIENTS WHO ARE ON HEMODIALYSIS AND CONTINUOUS PERITONEAL DIALYSIS PATIENTS 1.2.1. Definition of malnutrition According to the World Health Organization (WHO), malnutrition is an imbalance in the supply of nutrients and energy compared to the body's need for cells to ensure the development of malnutrition and maintain the operation of their specialized functions. 1.2.3. The causes of malnutrition in patients with chronic kidney disease who are on hemodialysis and continuous outpatient peritoneal dialysis Causes of malnutrition in CKD patients include: Providing inadequate food intake: caused by anorexia when serum urea level increases, changes in taste, repetitive disease, psychological depression due to illness, prescribed diet unappetizing. Associated pathology: infection, diabetes, cardiovascular disease, oral problems. Dialysis process: promotes the elimination of nutrients such as: (amino acids, peptides, proteins, glucose, water-soluble vitamins ...) and promotes protein catabolism. Chronic kidney disease causes inflammation and can promote protein catabolism, anorexia. 1.2.4. Methods of assessing nutritional status 1.2.4.1. Subjective Global Assessment (SGA) (Appendix 1) In 1986, Destky et al., The study determined the nutritional status of patients undergoing gastrointestinal surgery and was then widely applied in the community. 1.2.4.2. Nutrition evaluation method according to Body Mass Index (BMI) BMI = Current body weight (kg) / Height (m)2. Currently, the World Health Organization (WHO) recommends using Body Mass Index (BMI,kg/m2) to evaluate nutrition status classification. BMI is often used to classify underweight or obesity in adults. BMI depends on muscle mass, fat mass and the total amount of water contained in the body. However, for the elderly and best used for those aged 20 to 65 years old is appropriate. 1.2.4.3. Serum prealbumin role in nutritional evaluation In 2002, Beck Frederick K. et al., Published the following criteria to diagnose nutritional risks according to prealbumin: serum 4 prealbumin < 0.5 g/L (<50 mg/L): severe malnutrition; 0.5 g/L ≤ serum prealbumin <1.5 g/L: mild malnutrition; 1,5 g/L ≤ serum prealbumin ≤ 3.5 g/L: no malnutrition (normal). 1.2.4.4. Serum albumin in the evaluation of nutrition in CKD patients. The World Health Organization (WHO) defines malnutrition as an "inadequate nutrient" situation characterized by "deficiency or excess of protein intake, lack of energy and disorders of micronutrients like vitamins". This definition implies that protein malnutrition (known as "malnutrition") will improve when the deficient nutrients are provided more adequately: albumin serum ≥ 35g/L is classified as not malnourished; 28g/L < albumin serum <35g/L called mild malnutrition; albumin serum ≤ 28g/L is called severe malnutrition. 1.2.4.5. Normalized Protein Catabolic Rate (nPCR, g/kg/day) * The basics of nPCR (Normalized Protein Catabolic Rate) In 2000, K/DOQI made the following recommendations on clinical practice issues regarding nutrition for CKD patients as follows: The protein supply to dialysis patients with CKD is limited to about 1.2 g/kg body/day. At least 50% of patients on protein diet should receive additional bio-protein in the diet in dialysis patients. See, an increase in mortality has been demonstrated when nPNA (similar to nPCR) is less than 0.8 or greater than 1.4 g/kg/day, while nPCR is considered to be the best recorded with the level between 1.0 - 1.4 g/kg/day. * Calculation of PCR PCR is usually calculated in g/kg/day, a parameter called standardized PCR (nPCR). Rarely, PCR is not normal for weight and is measured in g/day. * Hemdialysis patients: Calculation of nPCR (g/kg/day). nPCR = 0.22 + 0.036× ID rise in BUN × 24 ID interval  hrs  Note: ID rise in BUN: Concentration of urea before filtration of the first filter minus the amount of urea after filtration of the next filtration. ID interval (hrs): Time after finishing the first filter to the beginning of the next filter. 5 Other formula for calculating nPCR from Kt/V: nPCR = (0.0136 x F) + 0.25 Inside: F = Kt / V x ([urea before filtration + urea after filtration] ÷ 2) * For patients with continuous peritoneal dialysis Formula for calculating PCR: PCR = 6.25 x (Serum Urea concentration + 1.81 + [0.031x body weight (kg)]) The final time in this formula reflects the contribution of the protein metabolism. Serum Urea concentration = (Vu x Cu) + (Vd + Cd) In which: V and C are volume and concentration of urea concentration in urine (u) and (d) filtrate. 1.3. LEPTIN 1.3.1. Origin and structure of leptin serum Leptin is a cytokin-like hormone discovered in 1994. It is considered to be the most important invention related to obesity. Leptin is considered to be one of the main products excreted from fat cells. The word leptin comes from the Greek word: leptos means thin. This is a 16 kDa molecular weight polypeptide containing 167 amino acids. Subcutaneous adipose tissue secretes more leptin than visceral adipose tissue. Small amounts of leptin are also secreted from stomach tissue, placenta, muscle and brain. The secretion of leptin is regulated by many factors such as: Glucocorticoid, acute infection, pre-inflammatory cytokin concentration ... 1.3.2. Leptin regulates body weight Obesity is characterized by an increase in fatty acid storage in adipose tissue mass and is closely associated with the development of insulin resistance in peripheral tissues such as muscle, bone and liver. In addition to being the largest fuel source in the body, adipose tissue and macrophages are also the source of several secreted proteins. Leptin plays an important role in regulating the body's metabolism by stimulating energy expenditure, inhibiting ingestion. 1.3.3. Leptin effect on the kidneys The scientists found that leptin was associated with glomerular filtration rates in humans. When the leptin molecule is 14-16 kilodaltons, it has the ability to filter in the glomeruli. To assess the role of the kidney in eliminating leptin in the blood, the 6 scientists conducted leptin tests in the aorta and renal veins from patients with different levels of glomerular filtration. At the same time, measurement of the difference in renal leptin concentration and plasma flow rate in the kidney activates kidney function. 1.3.4. Serum leptin in patients with end-stage renal disease (ESRD) The serum leptin (ng/mL) is excreted primarily by the kidneys, indicating that serum leptin will be elevated in patients with end-stage chronic kidney disease. Several studies have found this correlation. In a study of 37 patients with chronic kidney disease on dialysis, it was found that pre-dialysis leptin was quadrupled compared to a group of 331 healthy subjects (37.6 ± 10.6 ng/mL vs 8.25 ± 7.25 ng/mL, with p = 0.01). Body Mass Index (BMI, kg/m2), positively correlated with serum leptin (1.30 ± 0.32 ng/mL vs 0.29 ± 0.01 ng/mL, with p = 0.005). Another study found similar results, independent of 141 patients with end-stage chronic kidney disease, who found average values in both sexes (male, 26.8 ± 5.7 ng/mL and female, 38.3 ± 5.6 ng/mL) were significantly higher (statistically significant (with p = 0.001) compared to the normal subjects (male, 11.9 ± 3.1 ng/mL) and female, 21,2 ± 3,0 ng/mL). 1.4. DOMESTIC AND FOREIGN RESEARCH In 2017, Trang Thi Khanh Ngo, studied the characteristics and prognostic value of malnutrition - inflammation - atheroma syndrome in patients with chronic kidney disease (including 174 patients, 57 chronic kidney disease patients without dialysis, 56 outpatient continuous dialysis patients and 61 hemodialysis patients). This author recorded a malnutrition rate of 36.8%, inflammation 21.3% and atherosclerosis 50.6%. In 2015, Ponnudhali D, et al., India, studied Protein energy and nutrition in CKD patients related to leptin and insulin roles. Group one (n = 45) is a chronic kidney disease without diabetes; group two (n = 45) healthy people without diabetes and with normal renal function. The results were as follows: serum leptin (ng/mL) in group one increased very high by 24.15 ± 17.44 ng/mL compared to group two 7.5 ± 1.28 ng/mL with significant differences statistics (with p = 0.0001). It was found that serum leptin and blood insulin were positively correlated with CKD patients. 7 Chapter 2: SUBJECTS AND METHODS OF RESEARCH 2.1. RESEARCH SUBJECTS Our study subjects included 259 patients with end-stage renal disease who were undergoing renal replacement therapy (including 207 hemodialysis patients and 52 continuous peritoneal dialysis patients). The study period is from June 2015 to June 2016. Research location: Internal Kidneys, Urology and Dialysis Department - Can Tho General Hospital. 2.1.1. Criteria for selecting a disease + End-stage renal disease + Hemodialysis with cycle time of 3 months or more. + Continuous peritoneal dialysis patients from 3 months or more. + Hemodialysis ensures 12 hours/week and continuous peritoneal dialysis with 4 filtration times/day (2 liters peritoneal dialysis/1 time). + Hemodialysis patients are allowed to use one type of gampro filter and bicarbonate filter fluid. Outpatient continuous dialysis patients using Dextrose 1.5% dialysis solution; 2.5% of Baxter. + Patients are managed outpatient treatment dialysis combined medical treatment of anemia, hypertension ... as recommended by the Vietnam Nephrology Association. + Patient agrees to participate in the study. 2.1.2. Standards excluded from study + Patients with sepsis must undergo continuous dialysis. + Patients with severe coma do not participate in full dialysis at the department. + Patients with stage IV severe heart failure, continuous breathing difficulties; Large ascites cirrhosis causes persistent breathing ... + Patients with late stage cancers. + Patients on peritoneal dialysis are peritonitis, unable to evaluate peritoneal function. + Patients do not agree to participate in the study. 2.2. RESEARCH METHODS 2.2.1. Research design + Design: cross-sectional description study + Sample size: choose a convenient sample size including all patients undergoing kidney replacement therapy, who have been on 8 dialysis at the Internal Kidneys - Urology and Dialysis Department – Can Tho General Hospital, eligible for sample selection were selected for the study (total number of patients eligible for sample selection was 259 patients). 2.2.2. Steps to proceed * Exploiting and patient history in the study subjects: * Clinical examination + Body: Circuits, temperature, blood pressure, edema, skin, mucous membranes .... + Measure height, weight, calculate BMI. + Nutrition evaluation according to SGA_3 evaluation board. * Subclinical tests: + Hematology. + Biochemistry: albumin, protein, prealbumin, urea, cretinin, blood ion. + CRPhs, serum leptin .... 2.2.3. Process of implementing research variables 2.2.3.1. Hemodialysis procedure * Hemodialysis + Using Polyflux 6L filter (Gampro): belongs to the type of fiber filter, ultrafiltration (hollow-fiber dialyzer, low-flux) with the polyamix vein membrane with a membrane area of 1.4 m2, Kuf: 8.6ml/mmHg/h. Reuse the filter according to the regulations of the Ministry of Health 6 times/fruit and the membrane filtration water system (RO) is also used according to the standard procedure of the Ministry of Health of Vietnam specified in Decision No. 2482 / QD-BYT. April 13, 2018. RO water standards are set by the Ministry of Health of Vietnam (Appendix 3). * Continuous outpatient peritoneal dialysis: The patient was placed on Baxter's gooseneck abdominal catheter for continuous peritoneal dialysis. Patients are trained to master self-manipulation following peritoneal dialysis procedures. 9 2.2.3.2. Quantification of serum leptin - Reaction principle: Figure 2.1. An illustration of the ELISA principle quantifying leptin concentration Normal: Male: 3.84 ± 1.79 ng/mL; Female: 7.36 ± 3.73 ng/mL. Boden G et al. Suggested the value of serum leptin in patients with chronic kidney disease with the following three levels: serum leptin ≤ 3.5 ng/mL: decreased leptin; 3.5 3 months). - Albuminuria (AER ≥ 30 mg/24 hours, ACR ≥ 30 mg/g or 3 mg/mmol). - Unusually urine sediment. - Electrolyte disorders or other abnormalities Mark of kidney due to tubular disease. damage (≥ 1 mark) - An abnormal detected by histology. - Structural abnormalities (morphological) detected by geometric images - History of kidney transplant. Reduced glomerular <60 mL/min/1.73m2 (classified as GFR filtration rate (GFR) G3a-G5) 11 * Method of implementation and evaluation of nutritional status by SGA_3. Patients were asked a questionnaire about their medical history and then they were clinically examined (Appendix 1). * Body Mass Index (BMI, kg/m2) BMI = Current body weight (kg)/Height (m)2 According to the World Health Organization (WHO), the threshold of adjusting BMI for Asian community is: Table 2.3. Nutrition evaluation according to BMI. Malnutrition Overweight Obesity Light Heavy moderately 18.50 - 24.99 16.0 - 18.49 < 16.0 25.0 - 29.99 ≥ 30 Normal WHO Southeast Asian Diabetes 18.50 - 22.99 16 - 18.49 Association < 16.0 ≥ 23.0 2.2.5. Data processing methods Processing data by the method of medical statistics, using the software program SPSS 18.0, Microsoft Excel 2010, with the help of computers. To investigate the correlation coefficient between the parameters, we calculate the correlation coefficient r with 95% confidence intervals. The correlation level is calculated as follows: .│r│ ≥ 0.7: correlated very closely. . 0.5 ≤ │r│ <0.7: close correlation. . 0.3 ≤ │r│ <0.5: moderate correlation. . r <0.3: very little correlation. . r (+): positive correlation. . r (-): inversely correlated. + Draw correlation diagram automatically on Execl. 2.3. ETHICS IN RESEARCH In the context of clinical research, medical research and other sociological studies, the human subject must follow scientific principles and must be based on laboratory and animal studies previously fully and simultaneously based on thorough knowledge from the scientific literature. We adhere to the basic ethical standards of biomedical research, ensure the privacy of our subjects and limit the impact of our research on physical and mental integrity, dignity of the research object. 12 2.4. RESEARCH CHART 13 Chapter 3 RESEARCH RESULTS 3.1. GENERAL CHARACTERISTICS OF STUDY SUBJECTS Diagram 3.1. Sex Research subjects Male (n=135, %) Famale (n=124, %) % n % n Hemodialysis (n=207) 51,2 106 48,8 101 Peritoneal dialysis (n=52) 55,8 29 44,2 23 Two group (n=259) 52,1 135 47,9 124 Comment: The two groups of patients with hemodialysis and peritoneal dialysis were higher than men but not significantly. Diagram 3.2. Age Age (year) Male (n=135) Famale (n=124) Research subjects Min Max ± SD X X ± SD Min Max Hemodialysis (n=207) 48,9 ± 13,7 17,0 84,0 49,6 ± 12,4 21,0 71,0 Peritoneal dialysis (n=52) 46,7 ± 17,4 17,0 81,0 47,8 ± 16,9 17,0 78,0 Two group (n=259) 48,2 ± 14,6 17,0 84,0 49,3 ± 13,3 17,0 78,0 Comment: The average age of the two groups: male (48.2 ± 14.6) and female (49.3 ± 13.3) are almost the same (the lowest is 17 years and the highest is 84 years). 3.2. NUTRITION SITUATION OF RESEARCH SUBJECTS 3.2.1. Nutritional status according to Body Mass Index (BMI, kg/m2), SGA_3, albumin and prealbumin Diagram 3.3. Nutrition assessment based on Body Mass Index(BMI) Overweight Normal Malnutrition BMI ≥ 23 18,5 ≤ BMI < 23 BMI < 18,5 Research subjects % n % n % n Dialysis (n=207) 27,0 56 51,7 107 21,3 44 Peritoneal dialysis (n=52) 30,8 16 46,1 24 23,1 12 Two group (n=259) 27,8 72 50,6 131 21,6 56 Comment: The two groups of patients with end-stage renal disease who were on hemodialysis and peritoneal dialysis assessed nutrition according to BMI, the rate of malnutrition was almost equal. 14 Diagram 3.4. Nutrition evaluation according to SGA_3 SGA_A SGA_B SGA_C Research subjects % n % n % n Hemodialysis (n=207) 33,3 69 29,5 61 37,2 77 Peritoneal dialysis (n=52) 36,5 19 30,8 16 32,7 17 Two group (n=259) 34,0 88 29,7 77 36,3 94 Comment: Nutrition assessment based on SGA_3 found that the rate of severe malnutrition of the two group accounted for 36.3%. Diagram 3.5. Nutrition evaluation according to the serum albumin (g/L). Albumin ≥ 35 28 < Albumin < 35 Albumin ≤ 28 % n % n % n Hemodialysis (n=207) 85,5 177 9,7 20 4,8 10 Peritoneal dialysis (n=52) 63,5 33 30,8 16 5,8 3 Two group (n=259) 81,1 210 13,9 36 5,0 13 Comment: The rate of malnutrition according to serum albumin concentration in two groups of slightly malnourished 13.9% and severe malnutrition 5.0%. Diagram 3.6. Nutrition evaluation according to the serum prealbumin Prealbumin 0,5 ≤ Prealbumin Prealbumin < 0,5 < 1,5 ≥1,5 Research subjects % n % n % n Hemodialysis (n=207) 95,7 198 1,9 4 2,4 5 Peritoneal dialysis (n=52) 80,8 42 19,2 10 0,0 0 Two group (n=259) 92,7 240 5,4 14 1,9 5 Comment: Serum prealbumin concentration in Hemodialysis patients group was high in serum prealbumin group <0.5 g/L, accounting for 95.7% of severe malnutrition. All groups of patients with continuous peritoneal dialysis had serum prealbumin concentration <1.5g/L and none of the patients had serum prealbumin concentration> 1.5 g/L (0.0%). 3.2.2. Serum leptin (ng/mL) of study subjects Diagram 3.8. Serum leptin of two study subjects Leptin ≤ 3,5 3,5 < Leptin < 7,5 Leptin ≥ 7,5 Research subjects % n % n % n Hemodialysis (n=207) 66,2 137 10,1 21 23,7 49 Peritoneal dialysis (n=52) 44,2 23 19,2 10 36,5 19 Two group (n=259) 61,8 160 12,0 31 26,2 68 Comment: The serum leptin (ng/mL) was as low as 3.5 0,05 Peritoneal dialysis (n=52) 96,2 50 3,8 2 Two group (n=259) 91,5 237 8,5 22 Comment: The mortality rate for Hemodialysis patients accounted for 9.7% much higher than continuous peritoneal dialysis after 12 months of follow-up. The mortality rate of the two study subjects accounted for 8.5% after 12 months of follow-up. 16 Diagram 3.12. Survival and risk of death by BMI after 12 months. Survival Mortality HR (n=237, %) (n=22, %) BMI (kg/m2) p (KTC 95%) % n % n No malnutrition 92,6 187 7,4 15 Mild and moderate 91,8 45 8,2 4 1,06 (0,35-3,20) 0,916 malnutrition Heavy malnutrition 62,5 5 37,5 3 5,31 (1,54-18,37) 0,008 Total 91,5 237 8,5 22 Comment: Hemodialysis and continuous peritoneal dialysis patients diagnosed with malnutrition according to BMI (kg/m2), severe malnutrition has a very high mortality rate of 37.5 % (HR: 5.31 Cl 95%; 1.54-18.37, with p = 0.008). Diagram 3.13. Survival and risk of death by nPCR after 12 months Survival Mortality HR (n=22, %) nPCR (g/kg/day) (n=237, %) p (KTC 95%) % n % n nPCR < 0,8 61,1 11 38,9 7 23,36(4,48-112,56) 0,001 0,8 ≤ nPCR ≤ 1,2 92,2 103 7,8 2 nPCR > 1,2 90,2 119 9,8 13 5,55(1,25-24,57) 0,024 Total 91,5 237 8,5 22 Comment: Normal cabotalic protein rate (nPCR) is low (nPCR <0.8) or high (nPCR> 1.2) respectively, 38.89% and 9.85% are much higher than 0.8 ≤ nPCR ≤ 1.2 (g/kg/day). Diagram 3.14. Multivariate regression analysis included nPCR, prealbumin, albumin and proteins associated with mortality for 12 months. Reliability 95% Nutrition Index B p RR Low High nPCR (g/kg/day) -.368 .569 .692 .195 2,453 Prealbumin HT (g/L) -.980 .412 .375 .036 3,912 Albumin HT (g/L) .133 .018 .876 .785 .977 Protein HT (g/L) .049 .196 1,050 .975 1,130 Constant -.035 .988 .965 Comment: In multivariate regression analysis including nPCR, serum prealbumin, serum albumin and serum protein, the serum albumin variable was associated with statistically significant mortality (with p = 0.018) multivariate rules: Mortality rate (Y) = 0.133 x albumin HT - 0.035. 17 Chapter 4 DICUSSION 4.1. GENERAL CHARACTERISTICS OF RESEARCH SUBJECTS 4.1.1. Sex Among 259 patients who shared the study subjects by gender: male 52.1%, female 47.9%. Patients with chronic kidney disease (CKD) were on Hemodialysis, male 51.2%, female 48.8% and continuous peritoneal dialysis, male 55.8%, female 44.2% between two equivalent study subjects between men and women. Cuong The Phan et al, found that men 52.4% and women 47.6%. From the above studies, the ratio between men and women does not have much difference between men and women. Our results also match those of other studies. This shows that the rates of end-stage renal disease (ESRD) that can occur for men as well as for women at home and abroad are almost the same. 4.1.2. Age The average age of two study subjects man (48.2 ± 14.6) years and women (49.3 ± 13.3) years. There is not much difference in age for the two kidney replacement treatments in ESRD patients. Thanh Van Nguyen et al. Found that the average age was (42.8 ± 13.2) years. ESRD patients were almost the same in each study, with no significant differences between the authors (the lowest age was 29 years old and the highest age was 85 years old, the average age was 51 years). 4.2. NUTRITION SITUATION OF RESEARCH SUBJECTS 4.2.1. Evaluate nutrition according to BMI, SGA_3, albumin and prealbumin 4.2.1.1. Nutrition assessment based on Body Mass Index (BMI,kg/m2) In our study, for Hemodialysis patients, nutritional evaluation according to BMI was 27.0% overweight, normal 51.7% and malnourished 21.3%. For patients with continuous peritoneal dialysis, it was 30.8%, 46.1% and 23.1%, respectively. It was found that in two study groups, Hemodialysis and continuous peritoneal dialysis evaluated nutrition according to BMI almost equal. In 2016, Mai Tuyet Vuong et al. Found that the average BMI was 19.7 ± 2.2 kg / m2 and malnutrition 31.8%, normal 61.8% and overweight and obesity 6, 4%. Compared to the above studies, our rate of malnutrition among Hemodialysis patients is higher than that of foreign authors but not much, compared to that of Mai Tuyet Vuong et al. The rate of malnutrition in our study is lower, we think the dialysis time in our study is relatively longer and the patients in our study are mostly poor patients. This is not good, which leads to a higher rate of malnutrition according to BMI in our study. 18 4.2.1.2. Nutrition evaluation according to SGA_3 Our research results, nutrition evaluation based on SGA_3 found in the hemodialysis patients group: 33.33%, 29.47% and 37.20%, and continuous peritoneal dialysis: 36.54%, 30.77% and 32.69%. Nutrition rate of SGA_3 determined by SGA_3 method is quite high in many studies showing the risk of nutrition in patients with ESRD undergoing kidney replacement is very large. this can be seen through the research results of the author, Thanh Van Nguyen in patients who have not received kidney replacement therapy, the rate of nutrition accounts for 71%. In addition, when treated with hemodialysis patients or continuous peritoneal dialysis, the rate of malnutrition will increase compared to patients before renal replacement therapy. Because this group of patients are at high risk of nutritis due to loss of nutrients during hemodialysis or continuous peritoneal dialysis. In addition, nutrition may be due to Hemodialysis patients and Continuous peritoneal dialysis, more quickly than normal protein cabotalic rate and poor economy. 4.2.1.3. Evaluation of nutrition according to serum albumin concentration (g/L) The percentage of non-nutritional concentrations according to serum albumin concentration for patients with ESRD who are outpatient dialysis and peritoneal dialysis is 85.5% and 63.5%. The number of patients with serum albumin concentration ≥ 35 g/L is 14.5% with nutritional rigs for patients Hemodialysis (in which 28 - Xem thêm -

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