A Prospective Observational Study Among Patients on Long Term Hemodialysis for Changes in Serum Electrolytes with Varying Urine Outputs and Impact of Patient Counselling on their Quality of Life-A Pilot Study

BACKGROUND Chronic kidney disease (CKD) is defined as a progressive loss of function occurring over several months to years and is characterized by the gradual replacement of normal kidney architecture with parenchymal fibrosis. End stage renal disease (ESRD) is defined as irreversible decline in a person's own kidney function, which is severe enough to be fatal in the absence of dialysis or transplantation. Since hemodialytic patients with greater urine output have a greater ability to excrete electrolytes, acids, and fluid compared to patients low urine output, they are likely to have less body accumulation of these elements. Health-related quality of life (HRQOL) is a critically important outcome for patients with ESRD.


INTRODUCTION
Chronic kidney disease (CKD), also called chronic renal insufficiency is defined as a progressive loss of function occurring over several months to years and is the gradual replacement of normal kidney structure with parenchymal fibrosis. According to kidney function, CKD is divided into stages 1 to 5, with each higher number signifying a more advanced stage of the condition [1] .
• Stage 1: normal eGFR ≥ 90 mL/min per 1.73 m 2 and persistent albuminuria • Stage 2: eGFR between 60 to 89 mL/min per 1.73 m 2 • Stage 3: eGFR between 30 to 59 mL/min per 1.73 m 2 • Stage 4: eGFR between 15 to 29 mL/min per 1.73 m 2 • Stage 5: eGFR of < 15 mL/min per 1.73 m 2 or end-stage renal disease ESRD refers to individuals with an estimated glomerular filtration rate below 15 mL per minute per 1.73 m 2 body surface area, or those requiring dialysis irrespective of glomerular filtration rate. Reduction in or absence of kidney function leads to a host of maladaptive changes including fluid retention (extracellular volume overload), anaemia, disturbances of bone and mineral metabolism, dyslipidaemia, and protein energy malnutrition. This review deals with ESRD in adults only [2] .

CLINICAL PRESENTATION OF ESRD Symptoms
• Uremic symptoms (fatigue, weakness, shortness of breath, mental confusion, nausea and vomiting, bleeding, and loss of appetite), as well as itching, cold intolerance, weight gain, and peripheral neuropathies are common in patients with stage 5 disease [2] .

Other Supportive Investigations
• Left ventricular hypertrophy may be observed, as well as increased homocysteine levels and increased C-reactive protein.

COMPLICATIONS OF CKD
The most frequent complications of CKD include fluid and electrolyte abnormalities, anemia, CKDrelated mineral and bone disorder (CKD-MBD) and renal osteodystrophy, hypertension, hyperlipidemia, and metabolic acidosis [2] .

Fluid and Electrolyte Abnormalities
• Sodium and Water Significant sodium retention is more common when the GFR is less than 10 ml/min./1.73 m 2 . Volume overload with pulmonary edema can result, but the most common manifestation of increased intravascular volume is hypertension, which may further contribute to progressive kidney damage [1] .

• Potassium Homeostasis
More significant and life-threatening elevations are likely to be observed in those with stage 4 and 5 CKD [1] .

• Metabolic Acidosis
In advanced CKD, all filtered bicarbonate is reclaimed. This decrease in urinary buffer results in decreased net acid excretion and consequently, metabolic acidosis develops [1] .

Anemia
The primary cause of anemia in CKD patients is a decrease in production of erythropoietin by the proximal tubular cells of the kidney, where approximately 90% of production occurs. In contrast, there is no correlation between the degree of anemia and erythropoietin concentrations in anemic ESRD patients. The result is a normochromic, normocytic anemia [1] .

Hypertension
The pathogenesis of hypertension in CKD is multifactorial, but for many, fluid retention is a major contributor. In addition to the other pathophysiologic mechanisms responsible for the development of hypertension, patients with ESRD may also have increased sympathetic activity, decreased activity of vasodilators such as nitric oxide, hyperparathyroidism, and structural changes in the arteries as contributing factors [1] .

DIALYSIS
The main role of dialysis is the filtration of blood with the help of artificial equipment. Dialysis is the process where the waste products and excess fluid from the blood was removed when the kidney stop working. It involves the removal of solute across a semipermeable membrane down the concentration gradient by diffusive clearance and convective clearance mechanisms [2] .

ELECTROLYTES AND FLUID STATUS IN HEMODIALYSIS PATIENTS
As hemodialysis (HD) is not actual kidneys, they do not possess the same physiologic regulation of both fluid and electrolytes. In renal failure, acute or chronic, patients who have a tendency to develop hypervolemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and bicarbonate deficiency (metabolic acidosis). Sodium is generally retained but may appear normal, or hyponatremic, because of dilution from fluid retention [5] . CALCIUM: The majority of calcium resides extracellularly, and it is crucial for the function of neurons, muscle cells, function of enzymes, and coagulation. CHLORIDE: Chloride is part of gastric acid which plays a role in absorption of electrolytes, activating enzymes, and killing bacteria. MAGNESIUM: Magnesium is important in control of metabolism and is involved in numerous enzyme reactions. POTASSIUM: Potassium is mainly inside the cells of the body, so its concentration in the blood can range anywhere from 3.5 mEq/L to 5 mEq/L. SODIUM: Sodium is the most abundant electrolyte in the blood. Sodium and its homeostasis in the human body is highly dependent on fluids.

QUALITY OF LIFE IN HEMODIALYSIS PATIENTS
Quality of life is an increasingly important factor in the assessment of the management of chronic kidney disease patients undergoing hemodialysis. Several studies have shown a decreased quality of life and increased depression in the hemodialysis patient population [13] . Poor quality of life itself is also reported to increase complications such as depression and malnutrition and even increase mortality. For checking the quality of life Kidney Disease Quality of Life questionnaire form is used it includes 13 questions and the patients who score more shows a better quality of life and patients who score low score show a poor quality of life. Quality of life is assessed before and after patient counselling. The 13 questions include the; Patient's health-related questions, limitations in daily activities, emotional status, pain during the therapy, effect of kidney disease in day-to-day life, sleep patterns, diet restrictions and educaton [12] .

DIET AND DIALYSIS
Calorie intake: Amounts of fat and carbohydrate can be adjusted so the diet provides enough calories and still follows dietary guidelines for people with diabetes. Protein intake: Before dialysis a low-protein diet is required followed by high protein diet after dialysis. Potassium intake: Potassium is very important because it affects the ability of muscles to contract. Too much or too little potassium can harm the heart by disturbing the heart rhythm.
Sodium intake: Too much sodium increases thirst, but drinking too many liquids can cause swelling and increase blood pressure. High blood pressure can harm the heart or even cause a stroke. Phosphorus intake: In kidney disease, the body can't keep a balance between calcium and phosphorus. Calcium intake: Need to be sure that getting enough calcium to prevent bone disease, without drinking too much milk or eating too many dairy products [9] .

OBSERVATION AND RESULTS
The proposed study entitled, "Evaluating Changes in Serum Elecrolytes among Patients on long term Hemodialyisis and Impact of Patient Counselling on their Quality of Life " was a prospective observational study carried out in a multispeciality tertiary care hospital. In this study, the data was collected from 30 patients undergoing hemodialysis and were analysed. These 30 patients are classified into 3 groups based on varying amount of urine output per day, 10 patients in each group (Group1: <200ml/day; Group2: 200-500ml/day and Group3: >500ml/day).The study aimed to evaluate changes in serum electrolytes with varying urine outputs in chronic hemodialysis patients and assessing the impact of patient counselling on their quality of life.

AGE WISE DISTRIBUTION
The percentage distribution of patients based on age is shown in the following table

GENDER WISE DISTRIBUTION
The percentage distribution of patients based on gender is shown in the following table  From the table no.10, it is observed that the mean serum phosphate of patients with urine output >500ml/day have 4.18mg/dl, patients with urine output between 200-500ml have 4.56mg/dl while patients with urine output < 200ml/day have 4.88mg/dl. Thus from above table, it can be concluded that patient with greater urine output/day have better control on serum phosphate levels.

Figure 11: Diagrammatic Representation of QOL before and after counselling
From the table no.11, it was observed that the mean score of quality of life in hemodialysis patients before counselling is 96.26 ± 8.94 while the mean score after patient counselling is 37.6 ± 3.51. Thus, from above table it can be concluded that the quality of life of patients have been improved after the patient counselling as the mean score decreases after the counselling.

DISCUSSION
In chronic kidney disease and end stage renal failure condition, the kidneys get damaged and thereby accumulation of nitrogenous waste products and fluid occurs. Hemodialyis is one of the treatment option for chronic kidney disease and end stage renal failure, which helps to remove the fluid and waste products from the body. Kidney disease quality of life 36 questionnaire form (KDQOL-36) is designed to measure the impact on overall health dialysis patients [12] . This study aims to evaluate changes in serum electrolytes with varying urine outputs in chronic hemodialysis patients and assessing the impact of patient counselling on their quality of life. The 3 groups considered in this study was Group 1: urine output <200 ml/day, Group 2: urine output 200-500 ml/day, Group 3: urine output >500 ml/day. The electrolytes checked in the study were Sodium, Potassium, Bicarbonate, Calcium, Urea, Creatinine, and Phosphate. Kidney disease quality of life 36 questionnaire form were used to check the impact of patient counselling on hemodialysis patients. In this study, the demographic data concludes that 49 male (81.6%) patients and 11 female (18.3%) total 60 patients were selected and dived equally into 3 groups according to urine output. Statistical analysis was performed using ANOVA test and a detailed analysis was performed. Thus study demonstrate that there is increase in sodium, potassium, urea, creatinine, and phosphate in group 1as compared to group2 and group 3, And reduced value in bicarbonate and calcium in group 1 as compared to group 2 and group 3. The observation of our study was similar to the study conducted by

Fernando Luiz et al. In their study 'Metabolic and Volume Status Evaluation If Hemodialysis Patients with or without Residual Renal Function in Long Interdialytic Interval'.
This cross sectional study describes patient without RRF had a higher increase in serum potassium, sodium, and phosphate and decreased calcium and bicarbonate level [6] .
The study demonstrates that most of the patients undergoing hemodialysis are from elderly group and the mean age of the study population is found to be 59. 4 [4] . The 13 questions include the; Patient's health-related questions, limitations in daily activities, emotional status, pain during the therapy, effect of kidney disease in day-to-day life, sleep patterns, and education. For the better outcome of the result the intake of fluids and certain foods must be limited. The QOL of hemodialysis patients was first noticed at the time of admission and after patient counselling the second follow up was taken at the 1 st month [12] . These outcomes were observed in a treatment duration of 6 months, through adequate follow-ups, Hence in our study we found the patients with greater urine output have better control on the serum electrolytes, and the patient counselling had greater impact on the patient QOL.

CONCLUSION
The present study demonstrates the variation in serum electrolytes according to varying urine output and the quality of life in hemodialysis patients. The primary objective of the study was to determine the changes in serum electrolytes on the basis of urine output per day. The study also involves the evaluation of quality of life of these patients before and after the patient counselling. The Kidney Disease Quality of Life-36 Questionnaire Form (Validated) was used to assess the quality of life. In our study, demographic and socioeconomic data conclude that more males are undergoing hemodialysis as compared to female. According to age wise distribution obtained for our study, shows that age group above 60 accounts for a greater number of patients. Significant variations are observed in serum electrolytes according to daily urine output of hemodialysis patients as the serum sodium, potassium, bicarbonate, calcium and phosphate are within the normal range in patients with greater urine output i.e. in group 2 and group 3. While the group 1 patients show highly imbalanced levels of these electrolytes. Comparing the serum creatinine and urea in different groups shows that the group 3 patients show better control on these parameters. The quality of life of the patient assessed by the Kidney Disease Quality of Life-36 Questionnaire Form (Validated) showed steep improvement in the quality of life, which was assessed before and after the patient counselling.