الفهرس 
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Abstract
Chronic kidney disease (CKD) is characterized by gradual irreversible deterioration of kidney function over time leading to manylifelong consequences. CKD in children has unique clinical features peculiar to this age such as effect on growth and development. Early identification and management of those at risk of growth failure promote a better quality of life and decrease the risk of overall morbidity and mortality.
Dietary management and optimizing nutrition intake in children with CKD arechallenging. Multidisciplinary team work is the key in the process of nutritional care in children with CKD. Timely individualized nutrition assessment, education, and counseling are important steps in the nutrition intervention plan for children with CKD.
The present study aimed tostudy the effect of dietary counseling on nutritional and metabolic parameters of children with CKD not on dialysis. Specific objectives were to assess the nutritional status of chronic kidney disease children (dietary intake, laboratory findings, and anthropometric measurements), to assess the routinely practiced nutritional management of chronic kidney disease children, and to test the effect of dietary counseling on the nutrients intake, growth status and laboratory parameters over a year of follow up for each patient.
The present study was carried out in the pediatric nephrology clinic in Alexandria University Children Hospital (Al-Shatby) and the new Almeiry hospital (Smouha). The study was conducted from December 2015 to June 2017.
The study was conducted on two phases:
1. Cross sectional phase with 63 already diagnosed CKD children were interviewed with their caregivers to answer a pre-designed questionnaire including sociodemographic data, disease history, and dietary habits.
Clinical examination was done for every child regarding blood pressure measurement, observation of edema and clinical signs of nutrientsdeficiencies.Laboratory data (serum hemoglobin, BUN, creatinine, serum albumin, total protein, serum sodium, potassium, calcium, phosphorus, and bicarbonate) were obtained from patients records. Anthropometric measurements were taken in the form of body weight, height, and BMI.Dietary intake of each child was obtained through 24 hour diet recall method then was analyzed using Egyptian Food Composition Tables of the National Nutrition Institute.
2. Interventional phase included 24 eligible cases after exclusion of those with other problems that could interfere with the intervention.They were subjected to nutritional intervention in the form of individualized nutritional counseling session 2 -3 months apart and re-evaluation of the nutritional parameters (24 hour diet recall, height for age, weight for age, BMI for age, and laboratory parameters) for about 4 times.Each caregiver was given a simple meal plan and a dietary advice sheet according to his/ her child assessment results based on the guidelines recommendations. The final assessment was done at the end of a year.
The collected data were statistically analyzed and results can be summarized as follows:
Boys were about 54.4% of the total sample. The mean age of the studied sample was 7 2.85 years. About three quarters (74.6%) of the sample were from rural areas and more than half of the fathers and mothers of the children were illiterate or read and write. More than half (54%) of the sample had positive parent consanguinity.
Congenital causes were the leading cause of CKD in 93.7% of children with no positive family history of renal diseases in 88.9% of the sample. Mean eGFR was 30.1 14.45 ml/min with minimum of 9.3 ml/min and a maximum of 58.3 ml/min. Abouthalf(47.6%) of the children were classified as CKD stage 3. Mean disease duration was 5.03 2.99 years with 57.1% of the children had disease onset at birth or during the first year of age. Growth retardation was evident whereas more than two thirds (69.9%) of the children were stunted and 39.7% were wasted. As well, anemia and bone deformities were common among the studied sample. About half of the children were following a modified diet either low salt, low protein, or low potassium and those were advised to do so by their pediatric nephrologist. Fluid intake was adequate among 55.6% of the children. As regards laboratory findings; mean serum creatinine was 2.45 1.44 mg/dl and mean BUN was 49.57 23.3 mg/dl. About half of the children were anemic, normal serum calcium was in 73% of children while hyperphosphatemia was found in 66.6% of them. The majority (84.1%) of the children had normal serum bicarbonate and serum sodium, potassium, and chloride were normal in near three quarters of them.
Median energy intake was 857.2 kcal/ day with median energy % adequacy of 74.5%. More than half of the children took more than adequate protein. Median calcium intake was less than adequate in 90.5% of the children while median phosphorus intake was more than adequate in 17.5%. The entire sample had adequate potassium intake.
The study also revealed in its longitudinal phase significant improvement in weight, height, serum albumin, and serum calcium by the end of the study. Significant decrease of both serum creatinine and BUN was also found by the end of the study.
The present study concluded that growth retardation (stunting and wasting) and anemiawere prevalent among CKD children. Poor caloric intake of CKD children was evident while protein intake was exceeding the DRI for age and stage. Low growth rates were also associated with the advanced disease stage and minimal change in height was associated with increased disease duration. The disease duration and onset of the disease were the significant factors to affect the growth of the children with CKD. Nutrition counseling played in part a role in improving some parameters in these children such as weight, height, serum BUN, creatinine, serum potassium, serum calcium, and serum phosphorus. Patient non compliance to medical prescriptions might havemasked the effect of nutrition intervention. Therefore the following recommendations are suggested:
• Early identification of the children at risk of growth retardation with frequent regular monitoring of growth and laboratory parameters and tailoring nutritional requirements
• Integration of nutritional assessment and education in the medical care plan with.
• Collaboration of the pediatric nephrologists, nurses, and nutrition specialists in the health care team.
• Promotion of adherence and compliance to the intake of calcium supplements and phosphate binders.
• Encouraging assessment of vitamin D and parathyroid hormone levels.
• Involving erythropoietin therapy and assuring its affordability in conjunction with other anemia treatment lines.