腹透病人營養(yǎng)不良的管理課件

腹透病人營養(yǎng)不良的管理

董捷

北京大學(xué)第一醫(yī)院腎內(nèi)科---血液凈化并發(fā)癥論壇，2007，濟(jì)南---臨床--營養(yǎng)--管理通過合理的工作流程和完整的營養(yǎng)評(píng)估體系，結(jié)合臨床疾病需要，對(duì)營養(yǎng)和飲食狀況進(jìn)行不斷的評(píng)估、調(diào)整，其最終目的是達(dá)到體內(nèi)各種營養(yǎng)素的均衡。全面的營養(yǎng)評(píng)估項(xiàng)目飲食調(diào)查飲食蛋白質(zhì)攝入與代謝平衡熱量的攝入與消耗平衡主觀綜合性營養(yǎng)評(píng)估（SGA)人體測(cè)量握力試驗(yàn)生物電阻抗生化檢查營養(yǎng)不良的管理方法HighprevalenceofmalnutritioninPDpopulationPrevalenceofmalnutrition(%)WangDongetal,2002Jun,2001-Jan,2002,多中心橫斷面BJ,90ptsResidualrenalfunctionUremictoxinsEndocrineabnormalitiesAminoacidabnormalitiesAcidosisRenaldiseaseperseDialysateendotoxinsGraftandfistulainfectionsDialysisadequacyBioincompatibilityNutrientlosses(dialysate)DialysisprocedureInfection/InflammationCongestiveheartfailureVasculardiseaseDiabetesmellitusDepressionOthercomorbidity

Co-morbidityAgeGenderGeneticsDrugs(corticosteroids)SocialfactorsOtherfactorsProteinintakeEnergyintakeVitaminintakeIntake

LogisticAnalysisinACross-section

Studyin90CAPDPatientsin2002MalnutritionDPIDEITccrDMRRFLongtimeonPDCVDCRP董捷等。中華醫(yī)學(xué)雜志2003FentonSA,etal,AmJKidneyDis,1997;30:334-342CAPD/CCPD與HD患者的生存率比較(1990-94)隨訪月30405060708090061218243036424854100CAPDHD生存率%GroupI：TotalKt/V>1.7,residualGFR>0.5ml/minper1.73m2GroupII：TotalKt/V>1.7,residualGFR<0.5ml/minper1.73m2GroupIII：TotalKt/V<1.7,residualGFR<0.5ml/minper1.73m2JAmSocNephrol12:2450-2457,2001

RRF和透析充分性低的CAPD患者每日平均蛋白攝入和熱量攝入均低RRF與營養(yǎng)不良對(duì)腹透病人實(shí)施綜合營養(yǎng)管理措施，包括殘余腎功能正在丟失和已經(jīng)丟失的病人主要涉及水、小分子溶質(zhì)平衡和蛋白質(zhì)能量攝入可操作性強(qiáng)

Jun,2002-now預(yù)防營養(yǎng)不良的綜合策略策略一：穩(wěn)定的營養(yǎng)攝入2003DOQIGuidelineDPI

1.2-1.3g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d腹膜透析患者實(shí)際飲食蛋白攝入量普遍低于推薦值YearNo.ofPatientsDPI(g/kg/day)Wangetal.20032661.11Suttonetal.2001340.90Parketal.1999501.12Jacobetal.1995571.13Nolphetal.1993710.84Pollocketal.1990351.04(n=47)隨訪開始隨訪結(jié)束Group1Group2Group3Group1Group2Group3營養(yǎng)不良發(fā)生率50%50%58.8%25%33.3%41.2%隨訪期間總的營養(yǎng)不良發(fā)生率由53%下降至34%（P<0.05）2002.122003.12TotalXinkuiT,JieD,TaoWetal.JRenalNutri2003我們實(shí)施的營養(yǎng)攝入標(biāo)準(zhǔn)DPI

0.8-1.2g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d

策略二：小分子溶質(zhì)清除充分Adequacy:TheKDOQIRecommendations2001Guideline15:ForCAPD,thedeliveredPDdoseshouldbeatotalKt/Vofatleast2.0perweekandatotalcreatinineclearanceofatleast60L/wk/1.73m2forH&HAtransportersand50L/wkinLandLAtransporters

AJKD2001;37(Suppl1):S84新的閾值（目標(biāo)值）

溶質(zhì)CAPDKt/V≥1.7(EvidencelevelA)

水分無目標(biāo)值，容量平衡WkLoetal.ISPDGuidelines/Recommendations.PDI2006Timedependentmultivariateanalysisofsmallsolutetransportonpatientssurvivalinanuricpatients(NECOSAD)ParemerterCutoffpointsRelativeriskP-valueKt/V(l/w)>=1.7<1.7<1.511.473.280.310.02Ccr(l/w)>=45<45<4011.373.260.460.02JansenMAMetal.KidneyInt,2005

溶質(zhì)清除總清除

液體清除殘腎清除透析時(shí)間透析時(shí)間殘腎清除腹膜清除腹膜清除總清除

策略三：容量平衡

腹膜透析水與溶質(zhì)清除的變化時(shí)間(年)水容量(ml)總清除腹膜清除殘腎清除容量負(fù)荷蜜月期動(dòng)蕩期穩(wěn)定或惡化期策略三：容量平衡水份攝入約1-1.5L/d，攝鹽6g利尿劑平均增加尿量100-200ml，不保護(hù)殘腎適當(dāng)選用高濃度透析液（協(xié)議護(hù)理）新型透析液（葡聚糖透析液）

體表無水腫服兩種或以下降壓藥，BP<140/90mmHgBIA，DEXA細(xì)胞外液/總體水穩(wěn)定病例選擇和方法

June,2002June,200371CAPDpatientsn=4n=9n=43

n=15June,200543CAPDpatients

HDRT

PDDeath

RenalanddialyticKt/VandCcrin43CAPDpatientsduring2-yrfollow-upTime(mon)NpKt/VrKt/V

TKt/VpCcr(ml/min/1.73m2)rCcr(ml/min/1.73m2)TCcr(ml/min/1.73m2)6121824434343431.18±0.481.19±1.191.12±0.471.29±0.401.14±0.620.67±0.630.55±0.540.45±0.46*2.25±0.741.87±0.641.65±0.491.77±0.39*32.80±15.1836.17±15.6536.16±16.3841.05±13.5044.02±71.5844.15±75.5534.98±56.1625.51±28.12*76.82±64.2880.04±72.3170.13±38.9765.75±22.44

Repeated-ANOVAanalysisshowedsignificantdifferencesinrKt/V,TKt/VandrCcramong6,12，18and24monthsafterdialysis(*P=0.02)血白蛋白水平上升3333.53434.53535.53636.53737.53806121824時(shí)間P=0.0134.53±5.1035.08±4.7136.08±4.3437.30±4.5437.01±4.3938(g/l)37.53736.53635.53534.53433.533Fig1Serumalbuminlevelsin43CAPDpatientsduring2-yearfollow-up(month)營養(yǎng)不良發(fā)生率下降0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%06121824時(shí)間16(37.2%)28(65.1%)12(27.9%)10(23.3%)11(25.6%)P=0.0180%70%60%50%40%30%20%10%0%Fig2Theprevalenceofmalnutritionin43CAPDpatientsduring2-yearfollow-up(month)

Time(mon)NDPI(g/kg/d)DEI(kcal/kg/d)CRP(mg/L)CO2CP(mmol/l)ECW/TBWnECW6121824434343430.92±0.420.92±0.290.88±0.290.87±0.2229.32±11.428.49±8.127.52±6.7228.12±6.981.38±1.564.60±3.913.76±3.805.04±3.7225.17±3.5626.50±2.7024.58±1.5926.05±2.660.50±0.040.52±0.120.49±0.050.50±0.050.23±0.030.23±0.020.23±0.010.22±0.02

Associatedfactorsofmalnutritionin43CAPDpatientsduring2-yrfollow-upRepeated-ANOVAanalysisshowednodifferenceinDPI,DEI,CRP,CO2CP,ECW/TBW,nECWamong6,12，18and24monthsafterdialysis(P>0.05)

實(shí)施綜合的營養(yǎng)管理策略，使得殘腎已經(jīng)丟失的腹透病人營養(yǎng)狀況保持穩(wěn)定。DongJ,WangHY.Unpublisheddata.營養(yǎng)管理成效二病例選擇和方法

June,200455CAPDpatientsn=4n=2n=35

n=14June,200635CAPDpatients

HDRT

PDDeathBaselinelevelsofnutritionalindexesinoliguricandanuricCAPDpatientswithDPI≥0.75g/kg/dand<0.75g/kg/d(n=55)VariablesPatientswithDPI≥0.75g/kg/d(n=41)PatientswithDPI<0.75g/kg/d(n=14)P(torχ2)DPI(g/kg/d)DEI(kcal/kg/d)Alb(g/l)BUN(mmol/l)Scr(umol/l)LBM(kg)Prevalenceofmalnutrition#(n,%)1.02±0.1832.35±5.6337.45±2.8821.76±6.56859.02±203.6741.63±10.0512(29.26%)0.63±0.12*24.87±6.38*34.72±3.81*21.36±7.63835.42±190.6738.38±4.305(35.71%)0.0000.0000.0080.7130.8530.1180.908P=0.017P=0.0176月后兩組DPI水平趨于一致P=0.0296月后兩組DEI水平趨于一致少尿和無尿腹透病人透析充分性和容量控制均保持穩(wěn)定DPI≥0.75g/kg/d(group1)和DPI<0.75g/kg/d(group2)on0,6,12,18,24月Indexes0months(n=55)6months(n=47)12months(n=39)18months(n=36)24months(n=35)P(F)P(F#)Kt/VGoup1Group2Tccr(l/w/1.73m2)Goup1Group2nECW(kg/height)Goup1Group2ECW/TBWGoup1Group2SBP(mmHg)Goup1Group2DBP(mmHg)Goup1Group2MBP(mmHg)Goup1Group2CRP(mg/l)Group1Group21.75±0.181.78±0.2356.05±12.4154.89±8.360.26±0.040.24±0.040.50±0.030.52±0.05133.89±25.48138.75±26.2078.28±13.4875.83±13.2896.82±15.1598.66±18.352.84(0.17~32.65)3.74(1.17~27.28)1.83±0.281.72±0.2458.02±13.9552.39±7.180.25±0.030.22±0.030.51±0.030.52±0.02129.51±22.66129.16±28.5173.96±9.4875.33±7.1493.23±13.7892.12±17.544.14(0.19~54.29)3.65(0.65~59.30)1.75±0.261.63±0.1657.05±11.7352.46±8.310.25±0.030.24±0.020.50±0.040.53±0.03132.21±20.04133.44±24.4174.65±12.7678.57±6.7493.81±12.9896.67±17.064.91(0.94~41.60)3.90(0.26~11.97)1.70±0.211.65±0.2052.63±12.6753.85±9.370.24±0.030.21±0.010.50±0.030.52±0.03135.20±18.83122.43±27.2072.21±11.3275.82±7.8493.26±11.4790.46±16.567.34(0.17~47.20)8.54(1.92~27.08)1.71±0.291.68±0.2150.86±11.5553.44±8.19----------------132.65±22.12122.43±27.2073.65±12.2376.47±6.7994.48±13.5489.34±15.768.83(2.15~30.53)14.20(3.70~45.78)0.1050.210.1040.190.180.270.890.850.780.350.3180.430.670.230.070.001*0.3780.6360.7160.6110.6770.5690.8090.321P=0.387兩組病人血Alb水平均保持良好P=0.473兩組病人LBM維持穩(wěn)定

實(shí)施綜合的營養(yǎng)管理策略，腹透病人營養(yǎng)不良發(fā)生率明