1、腹透病人营养不良的管理（优选）腹透病人营养不良的管理Wk Lo et al.腹膜透析患者实际饮食蛋白摄入量普遍低于推荐值对照组传统的4*2L/天CAPDEnergy intakeJan,2002-Jun,2002 思考和假想patients during 2-yr follow-upPatients with DPI0.Diabetes mellitus利尿剂平均增加尿量100200ml，不保护残肾适当选用高浓度透析液（协议护理）5 ml/minper 1.Clin Nephrol 2006实施综合的营养管理策略，使得残肾丢失过程中病人营养状况保持稳定。CAPD/CCPD与HD患者的生存率比较
2、(1990-94)饮食蛋白质摄入与代谢平衡全面的营养评估项目全面的营养评估项目饮食调查饮食调查饮食蛋白质摄入与代谢平衡饮食蛋白质摄入与代谢平衡热量的摄入与消耗平衡热量的摄入与消耗平衡主观综合性营养评估（主观综合性营养评估（SGA)人体测量人体测量握力试验握力试验生物电阻抗生物电阻抗生化检查生化检查营养管理流程营养管理流程CQI 饮食记录饮食记录饮食和治疗调整饮食和治疗调整饮食和营养知识饮食和营养知识核对饮食核对饮食反馈给病人反馈给病人教教 育育食谱分析食谱分析营养评估营养评估营养不良的管理方法High prevalence of malnutrition in PD populationPre
3、valence of malnutrition(%)WangDong et al,2002Jun,2001-Jan,2002,多中心横断面 BJ,90 ptsResidual renal functionUremic toxinsEndocrine abnormalitiesAmino acid abnormalitiesAcidosisRenal disease per seDialysate endotoxinsGraft and fistula infectionsDialysis adequacyBioincompatibilityNutrient losses(dialysate)D
4、ialysis procedureInfection/Inflammation Congestive heart failureVascular diseaseDiabetes mellitusDepressionOther comorbidity Co-morbidityAge GenderGeneticsDrugs(corticosteroids)Social factorsOther factorsProtein intakeEnergy intakeVitamin intakeIntake Logistic Analysis in A Crosssection Study in 90
5、CAPD Patients in 2002Malnutrition DPI DEI Tccr DMRRFLong time on PDCVDCRP董捷等。中华医学杂志 2003RRF 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)Jan,2002-Jun,2002 思考和假想30405060708090061218243036424854腹透病人水和溶质的清除腹透病人水和溶质的清
6、除Cheng et al.Clin Nephrol 2006GroupI：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.Other comorbidityCo-morbidity溶质 CAPD Kt/V 1.Nutrient losses(dialysate)GroupI：Total Kt/V 1.对腹透病人实施综合营养管理措施，包括残余肾功能正在丢失和已经丢
7、失的病人Other factorsLogistic Analysis in A Crosssection Study in 90 CAPD Patients in 2002策略一稳定的营养摄入策略一稳定的营养摄入2003 DOQI GuidelineDPI 1.2-1.3g/kg/d (50%of high biologic value)DEI 30-35kcal/kg/d腹膜透析患者实际饮食蛋白摄入量普腹膜透析患者实际饮食蛋白摄入量普遍低于推荐值遍低于推荐值YearNo.of PatientsDPI(g/kg/day)Wang et al.20032661.11Sutton et al.20
8、01340.90Park et al.1999501.12Jacob et al.1995571.13Nolph et al.1993710.84Pollock et al.1990351.04(n=47)随访开始随访开始随访结束随访结束Group1Group2Group3Group1Group2Group3营养不良发营养不良发生率生率50%50%58.8%25%33.3%41.2%随访期间总的营养不良发生率由随访期间总的营养不良发生率由53%下降至下降至34%（P质质 喜好食物调查及食品交换份喜好食物调查及食品交换份 p 及早添加各种口服营养制剂及早添加各种口服营养制剂p 保证透析充分性保证
9、透析充分性p 纠正合并症纠正合并症p 减少药物副作用减少药物副作用 75g/kg/d(group 1)和DPI 1.ISPD Guidelines/Recommendations.73m2 for H&HA transporters and 50 L/wk in L and LA transportersCAPD/CCPD与HD患者的生存率比较(1990-94)Repeated-ANOVA analysis showed no difference in DPI,DEI,CRP,CO2CP,策略二：小分子溶质清除充分策略二：小分子溶质清除充分 Guideline 15:For CAPD,the
10、 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 transporters AJKD 2001;37(Suppl 1):S84Time dependent multivariate analysis of small solute transport on patients survival in an
11、uric patients(NECOSAD)Jansen MAM et al.Kidney Int,2005小分子溶质清除充分吗？小分子溶质清除充分吗？Based on DPI level Kt/V=1.5 BUN:2025mmol/l 没有尿毒症症状没有尿毒症症状 Kt/VDPI氮平衡氮平衡Kt/V 溶溶质质清清除除总清除总清除 液液体体清清除除残肾清除残肾清除透析时间透析时间透析时间透析时间残肾清除残肾清除腹膜清除腹膜清除腹膜清除腹膜清除总清除总清除 策略三：容量平衡策略三：容量平衡 050010001500200025000123456时间(年)水容量(ml)总清除腹膜清除残肾清除容量负
12、荷容量负荷蜜月期蜜月期 动荡期动荡期 稳定或恶化期稳定或恶化期策略三容量平衡水份摄入约水份摄入约11.5L/d，摄盐，摄盐6g利尿剂平均增加尿量利尿剂平均增加尿量100200ml，不保护残肾，不保护残肾适当选用高浓度透析液（协议护理）适当选用高浓度透析液（协议护理）新型透析液（葡聚糖透析液）新型透析液（葡聚糖透析液）体表无水肿服两种或以下降压药，BP0.05)u 实施综合的营养管理策略，使得残肾实施综合的营养管理策略，使得残肾已经丢失的腹透病人营养状况保持稳定。已经丢失的腹透病人营养状况保持稳定。Dong J,Wang HY.Unpublished data.营养管理成效二n=4 n=9 n=
13、43 n=15Dong et al,2002动荡期Kidney Int,20050 per week and a total creatinine clearance of at least 60 L/wk/1.High prevalence of malnutrition in PD populationBioincompatibilityTCcrDEI73m2 for H&HA transporters and 50 L/wk in L and LA transporters75g/kg/d and 0.Sutton et al.病例选择和方法病例选择和方法 June,200455 CAP
14、D patientsn=4 n=2 n=35 n=14June,200635 CAPD patients HDRT PDDeathBaseline levels of nutritional indexes in oliguric and anuric CAPD patients with DPI0.75g/kg/d and 0.75g/kg/d(n=55)VariablesPatients with DPI0.75g/kg/d(n=41)Patients with DPI 0.75g/kg/d(n=14)P(t or 2)DPI(g/kg/d)DEI(kcal/kg/d)Alb(g/l)BU
15、N(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%)0.0000.0000.0080.7130.8530.1180.908month24181260DPI(g/kg/d)1.61.41.21.0.8.6.4DPI =0.75g/kg/dP=0.017P=0.01
16、76 6月后两组月后两组DPIDPI水平趋于一致水平趋于一致month24181260DEI(kcal.kg/d)5040302010DPI =0.75g/kg/dP=0.0296 6月后两组月后两组DEIDEI水平趋于一致水平趋于一致少尿和无尿腹透病人透析充分性和容量控制均保持稳定 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=39)18 months(n=36)24 months(n=35)P(F)P(F#)Kt/VGo
17、up 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 21.750.181.780.2356.0512.4154.898.360.260.040.240.040.500.030.520.05133.8925.48138.7526.2078.2813.4875.8313.2896.8215.1598.
18、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)1.750.261.630.1657.0511.7352.468.310.250.030.240.020.500.040.530.03132.2120.04133.4424.4174.6512.7678.576.
19、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.
20、3415.768.83(2.1530.53)14.20(3.7045.78)0.1050.210.1040.190.180.270.890.850.780.350.3180.430.670.230.070.001*0.3780.6360.7160.6110.6770.5690.8090.321Fenton SA,et al,Am J Kidney Dis,1997;30:334-342MalnutritionClin Nephrol 2006Cut off pointsEnergy intakeWk Lo et al.DPILogistic Analysis in A Crosssection
21、 Study in 90 CAPD Patients in 2002Time dependent multivariate analysis of small solute transport on patients survival in anuric patients(NECOSAD)Renal and dialytic Kt/V and Ccr in 43 CAPDBUN:2025mmol/l饮食蛋白质摄入与代谢平衡Infection/Inflammation腹透病人水和溶质的清除稳定或恶化期Other factorsDPI适当选用高浓度透析液（协议护理）对腹透病人实施综合营养管理措施，
22、包括残余肾功能正在丢失和已经丢失的病人Xinkui T,Jie D,Tao W et al.Kidney Int,2005ADEMEX研究 2002:NO适当选用高浓度透析液（协议护理）溶质 CAPD Kt/V 1.month24181260ALB(g/dl)50403020DPI =0.75g/kg/dP=0.387两组病人血Alb水平均保持良好month181260LBM(kg)8070605040302010DPI =0.75g/kg/dP=0.473 两组病人两组病人LBMLBM维持稳定维持稳定u 实施综合的营养管理策略，腹透病人实施综合的营养管理策略，腹透病人营养不良发生率明显下降，
23、很多影响营营养不良发生率明显下降，很多影响营养状况的因素得到控制。养状况的因素得到控制。Dong J,Wang HY.Blood Purification,2006营养管理成效三Feb,2005Jul,2005,第二次横断面，第二次横断面，PKUPD，205pts2002年年2005年年病例数病例数90205年龄（岁）年龄（岁）61.710.660.713.6透析龄（月）透析龄（月）DM%RF（ml/min）SGA 2，3%MIA%22.919.726.67%1.432.04 47.8%19%21.619.525.4%2.352.4715.6%4.36%Related Factors of MalnutritionMalnutrition DPI DEI Long time on PDRRFTccr DMCVDCRP
