腹透病人營養(yǎng)不良的管理實(shí)用課件

1、腹透病人營養(yǎng)不良的管理腹透病人營養(yǎng)不良的管理（優(yōu)選）腹透病人營養(yǎng)不良的管理（優(yōu)選）腹透病人營養(yǎng)不良的管理全面的營養(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全面的營養(yǎng)評(píng)估項(xiàng)目飲食調(diào)查營養(yǎng)管理流程CQI 飲食記錄飲食和治療調(diào)整飲食和營養(yǎng)知識(shí)核對(duì)飲食反饋給病人教 育食譜分析營養(yǎng)評(píng)估營養(yǎng)管理流程CQI 飲食記錄飲食和治療調(diào)整飲食和營養(yǎng)營養(yǎng)不良的管理方法營養(yǎng)不良的管理方法High prevalence of malnutrition in PD populationPrevalence of malnutrition (%

2、)WangDong et al, 2002High prevalence of malnutritioJun,2001-Jan,2002 ,多中心橫斷面 BJ,90 ptsResidual renal functionUremic toxinsEndocrine abnormalitiesAmino acid abnormalitiesAcidosisRenal disease per seDialysate endotoxinsGraft and fistula infectionsDialysis adequacyBioincompatibilityNutrient losses (dia

3、lysate)Dialysis procedureInfection/Inflammation Congestive heart failureVascular diseaseDiabetes mellitusDepressionOther comorbidity Co-morbidityAge GenderGeneticsDrugs (corticosteroids)Social factorsOther factorsProtein intakeEnergy intakeVitamin intakeIntakeJun,2001-Jan,2002 ,多中心橫斷面 BJ,9 Logistic

4、Analysis in A Crosssection Study in 90 CAPD Patients in 2002Malnutrition DPI DEI Tccr DMRRFLong time on PDCVDCRP董捷等。中華醫(yī)學(xué)雜志 2003 Logistic Analysis in A CrossRRF inevitably lost after 23 yrsHIDAKA, et al. NEPHROLOGY 2003; 8:184191Initiation of PDGFR (mL/min/1.73m2) 0 6 12 18 24 30 36 42Time (months) J

5、an, 2002- Jun, 2002 思考和假想RRF inevitably lost after 23 yFenton SA, et al, Am J Kidney Dis, 1997; 30:334-342CAPD/CCPD與HD患者的生存率比較 (1990-94)隨訪月30405060708090061218243036424854100CAPDHD生存率 %Fenton SA, et al, Am J Kidney Time dependent multivariate analysis of small solute transport on patients survival i

6、n anuric patients (NECOSAD)5 ml/minper 1.（優(yōu)選）腹透病人營養(yǎng)不良的管理BIA，DEXA細(xì)胞外液/總體水穩(wěn)定DPI腹透病人水和溶質(zhì)的清除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Vitamin intakeJan, 2002- Jun, 2002 思考和假想0 per week and a total creatinine clearance of at least 60 L/wk/1.DEI 30-35kcal/kg/dNolph et al.腹透病人水和溶質(zhì)的清除Cheng et al. Clin Nephrol 2006Time depend

7、ent multivariate anGroupI： Total Kt/V 1.7, residualGFR 0.5 ml/minper 1.73 m2GroupII： Total Kt/V 1.7, residualGFR 0.5 ml/minper 1.73 m2GroupIII： Total Kt/V 1.7, residualGFR 1.7, rAY-M Wang，KI，2006AY-M Wang，KI，2006Patients with DPI 1.Patients with DPI0.nECW(kg/height)6月后兩組DPI水平趨于一致Nutrient losses (dia

8、lysate)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Patients with DPI0. Jun, 20策略一穩(wěn)定的營養(yǎng)攝入2003 DOQI GuidelineDPI 1.2-1.3g/kg/d (50% of high biologic value)DEI 30-35kcal/kg/d策略一穩(wěn)定的營養(yǎng)攝入2003 DOQI Guideline腹膜透析患者實(shí)際飲食蛋白攝入量普遍低于推薦值YearNo. of PatientsDPI(g/kg/day)Wa

9、ng et al.20032661.11Sutton et al.2001340.90Park et al.1999501.12Jacob et al.1995571.13Nolph et al.1993710.84Pollock et al.1990351.04腹膜透析患者實(shí)際飲食蛋白攝入量普遍低于推薦值YearNo. (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質(zhì) 喜好食物調(diào)查及食品交換份 及早添加各種口服營養(yǎng)制劑 保證透

10、析充分性 糾正合并癥 減少藥物副作用 實(shí)施技巧 策略二：小分子溶質(zhì)清除充分策略二：小分子溶質(zhì)清除充分Adequacy: The KDOQI Recommendations 2001Guideline 15: For CAPD, the delivered PD dose should be a total Kt/V of at least 2.0 per week and a total creatinine clearance of at least 60 L/wk/1.73m2 for H & HA transporters and 50 L/wk in L and LA transpor

11、ters AJKD 2001; 37 (Suppl 1): S84Adequacy: The KDOQI RecommendaADEMEX研究 2002: NO965個(gè)腹透病人隨機(jī)對(duì)照研究對(duì)照組傳統(tǒng)的4*2L/天CAPD實(shí)驗(yàn)組增加劑量使Ccr在60L/周,Kt/V在2.0生存情況1年及2年生存率無差別ADEMEX研究 2002: NO965個(gè)腹透病人新的閾值（目標(biāo)值） 溶質(zhì) CAPD Kt/V 1.7 (Evidence level A) 水分 無目標(biāo)值，容量平衡 Wk Lo et al. ISPD Guidelines/Recommendations. PDI 2006 新的閾值（目標(biāo)值）T

12、ime dependent multivariate analysis of small solute transport on patients survival in anuric patients (NECOSAD)ParemerterCut off pointsRelative riskP-valueKt/V(l/w)=1.71.7=4545=1.5 BUN: 2025mmol/l 沒有尿毒癥癥狀 Kt/VDPI氮平衡Kt/V小分子溶質(zhì)清除充分嗎？Kt/VDPI氮平衡Kt/V 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 溶質(zhì)清除總清

13、除 液體清除殘腎清除透析時(shí)間透析時(shí)間殘腎清除腹腹膜透析水與溶質(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)總清除腹膜策略三容量平衡水份攝入約11.5L/d，攝鹽6g利尿劑平均增加尿量100200ml，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，BP0.05) TimeNDPIDEICRPCO2CPECWnECW643 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。Dong J, Wang HY. Unpublished

14、data.營養(yǎng)管理成效二 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)狀病例選擇和方法 June, 200455 CAPD patientsn=4 n= 2 n=35 n=14June, 200635 CAPD patients HDRT PDDeath病例選擇和方法 June, 200455 CAPD patiBaseline levels of nutritional indexes in oliguric and anuric CAPD patients with DPI0.75g/kg/d and 0.75g/kg/d (n=55)VariablesPatients with

15、 DPI0.75g/kg/d(n=41)Patients with DPI0.75g/kg/d(n=14)P(t or 2)DPI(g/kg/d)DEI(kcal/kg/d)Alb(g/l)BUN(mmol/l)Scr(umol/l)LBM(kg)Prevalence of malnutrition #(n,%)1.020.1832.355.63 37.452.8821.766.56859.02203.6741.6310.0512(29.26%)0.630.12*24.876.38 *34.723.81*21.367.63835.42190.6738.384.305(35.71%)0.0000

16、.0000.0080.7130.8530.1180.908Baseline levels of nutritionalP=0.017P=0.0176月后兩組DPI水平趨于一致P=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 DPI0.75g/kg/d (group 1)和DPI0.75g/kg/d (group 2) on 0, 6, 12, 18, 24月 Indexes0 months(n=55)6 months(n=47)12 months (n=3

17、9) 18 months(n=36)24 months (n=35)P(F)P(F#)Kt/VGoup 1Group 2Tccr (l/w/1.73m2)Goup 1Group 2nECW(kg/height)Goup 1Group 2ECW/TBWGoup 1Group 2SBP(mmHg)Goup 1Group 2DBP(mmHg)Goup 1Group 2MBP(mmHg)Goup 1Group 2CRP(mg/l) Group 1 Group 21.750.181.780.2356.0512.4154.898.360.260.040.240.040.500.030.520.05133.

18、8925.48138.7526.2078.2813.4875.8313.2896.8215.1598.6618.352.84(0.1732.65)3.74(1.1727.28)1.830.281.720.2458.0213.9552.397.180.250.030.220.030.510.030.520.02129.5122.66129.1628.5173.969.4875.337.1493.2313.7892.1217.544.14(0.1954.29)3.65(0.6559.30)1.750.261.630.1657.0511.7352.468.310.250.030.240.020.50

19、0.040.530.03132.2120.04133.4424.4174.6512.7678.576.7493.8112.9896.6717.064.91(0.9441.60)3.90(0.2611.97)1.700.211.650.2052.6312.6753.859.370.240.030.210.010.500.030.520.03135.2018.83122.4327.2072.2111.3275.827.8493.2611.4790.4616.567.34(0.1747.20)8.54(1.9227.08)1.710.291.680.2150.8611.5553.448.19-132.6522.12122.4327.2073.6512.2376.476.7994.4813.5489.3415.768.83(2.1530.53)14.20(3.7045.78)0.1050.210