腹透病人營養(yǎng)不良的管理演示

（優(yōu)選）腹透病人營養(yǎng)不良的管理當前第1頁\共有49頁\編于星期五\12點臨床--營養(yǎng)--管理通過合理的工作流程和完整的營養(yǎng)評估體系，結(jié)合臨床疾病需要，對營養(yǎng)和飲食狀況進行不斷的評估、調(diào)整，其最終目的是達到體內(nèi)各種營養(yǎng)素的均衡。當前第2頁\共有49頁\編于星期五\12點全面的營養(yǎng)評估項目飲食調(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)評估（SGA)人體測量握力試驗生物電阻抗生化檢查當前第3頁\共有49頁\編于星期五\12點營養(yǎng)管理流程-CQI飲食記錄飲食和治療調(diào)整飲食和營養(yǎng)知識核對飲食反饋給病人教育食譜分析營養(yǎng)評估當前第4頁\共有49頁\編于星期五\12點營養(yǎng)不良的管理方法當前第5頁\共有49頁\編于星期五\12點HighprevalenceofmalnutritioninPDpopulationPrevalenceofmalnutrition(%)WangDongetal,2002當前第6頁\共有49頁\編于星期五\12點Jun,2001-Jan,2002,多中心橫斷面BJ,90ptsResidualrenalfunctionUremictoxinsEndocrineabnormalitiesAminoacidabnormalitiesAcidosisRenaldiseaseperseDialysateendotoxinsGraftandfistulainfectionsDialysisadequacyBioincompatibilityNutrientlosses(dialysate)DialysisprocedureInfection/InflammationCongestiveheartfailureVasculardiseaseDiabetesmellitusDepressionOthercomorbidity

Co-morbidityAgeGenderGeneticsDrugs(corticosteroids)SocialfactorsOtherfactorsProteinintakeEnergyintakeVitaminintakeIntake當前第7頁\共有49頁\編于星期五\12點

LogisticAnalysisinACross-section

Studyin90CAPDPatientsin2002MalnutritionDPIDEITccrDMRRFLongtimeonPDCVDCRP董捷等。中華醫(yī)學雜志2003當前第8頁\共有49頁\編于星期五\12點RRFinevitablylostafter2-3yrsHIDAKA,etal.NEPHROLOGY2003;8:184–191InitiationofPDGFR(mL/min/1.73m2)06121824303642Time(months)

Jan,2002-Jun,2002思考和假想當前第9頁\共有49頁\編于星期五\12點FentonSA,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%當前第10頁\共有49頁\編于星期五\12點腹透病人水和溶質(zhì)的清除Chengetal.ClinNephrol2006當前第11頁\共有49頁\編于星期五\12點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/minper1.73m2JAmSocNephrol12:2450-2457,2001RRF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)不良當前第12頁\共有49頁\編于星期五\12點AY-MWang，KI，2006當前第13頁\共有49頁\編于星期五\12點對腹透病人實施綜合營養(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

Jun,2002-now預防營養(yǎng)不良的綜合策略當前第14頁\共有49頁\編于星期五\12點策略一：穩(wěn)定的營養(yǎng)攝入2003DOQIGuidelineDPI

1.2-1.3g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d當前第15頁\共有49頁\編于星期五\12點腹膜透析患者實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當前第16頁\共有49頁\編于星期五\12點(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當前第17頁\共有49頁\編于星期五\12點我們實施的營養(yǎng)攝入標準DPI

0.8-1.2g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d當前第18頁\共有49頁\編于星期五\12點實施技巧飲食調(diào)整蛋白質(zhì)結(jié)構(gòu)調(diào)整，量>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)制劑保證透析充分性糾正合并癥減少藥物副作用當前第19頁\共有49頁\編于星期五\12點

策略二：小分子溶質(zhì)清除充分當前第20頁\共有49頁\編于星期五\12點Adequacy:TheKDOQIRecommendations2001Guideline15:ForCAPD,thedeliveredPDdoseshouldbeatotalKt/Vofatleast2.0perweekandatotalcreatinineclearanceofatleast60L/wk/1.73m2forH&HAtransportersand50L/wkinLandLAtransporters

AJKD2001;37(Suppl1):S84當前第21頁\共有49頁\編于星期五\12點ADEMEX研究2002:NO965個腹透病人隨機對照研究對照組：傳統(tǒng)的4*2L/天CAPD實驗組：增加劑量使Ccr在60L/周,Kt/V在2.0生存情況：1年及2年生存率無差別當前第22頁\共有49頁\編于星期五\12點新的閾值（目標值）

溶質(zhì)CAPDKt/V≥1.7(EvidencelevelA)

水分無目標值，容量平衡WkLoetal.ISPDGuidelines/Recommendations.PDI2006當前第23頁\共有49頁\編于星期五\12點Timedependentmultivariateanalysisofsmallsolutetransportonpatientssurvivalinanuricpatients(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當前第24頁\共有49頁\編于星期五\12點小分子溶質(zhì)清除充分嗎？

BasedonDPIlevelKt/V>=1.5BUN:20-25mmol/l沒有尿毒癥癥狀

Kt/VDPI氮平衡Kt/V當前第25頁\共有49頁\編于星期五\12點

溶質(zhì)清除總清除

液體清除殘腎清除透析時間透析時間殘腎清除腹膜清除腹膜清除總清除

策略三：容量平衡

當前第26頁\共有49頁\編于星期五\12點腹膜透析水與溶質(zhì)清除的變化時間(年)水容量(ml)總清除腹膜清除殘腎清除容量負荷蜜月期動蕩期穩(wěn)定或惡化期當前第27頁\共有49頁\編于星期五\12點策略三：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，不保護殘腎適當選用高濃度透析液（協(xié)議護理）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細胞外液/總體水穩(wěn)定當前第28頁\共有49頁\編于星期五\12點

實施綜合的營養(yǎng)管理策略，使得殘腎丟失過程中病人營養(yǎng)狀況保持穩(wěn)定。董捷,王海燕。中華內(nèi)科雜志，2007，第1期營養(yǎng)管理成效一當前第29頁\共有49頁\編于星期五\12點病例選擇和方法

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

n=15June,200543CAPDpatients

HDRT

PDDeath當前第30頁\共有49頁\編于星期五\12點

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)當前第31頁\共有49頁\編于星期五\12點血白蛋白水平上升3333.53434.53535.53636.53737.53806121824時間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)當前第32頁\共有49頁\編于星期五\12點營養(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)當前第33頁\共有49頁\編于星期五\12點

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)當前第34頁\共有49頁\編于星期五\12點

實施綜合的營養(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)管理成效二當前第35頁\共有49頁\編于星期五\12點病例選擇和方法

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

n=14June,200635CAPDpatients

HDRT

PDDeath當前第36頁\共有49頁\編于星期五\12點BaselinelevelsofnutritionalindexesinoliguricandanuricCAPDpatientswithDPI≥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%)0.0000.0000.0080.7130.8530.1180.908當前第37頁\共有49頁\編于星期五\12點P=0.017P=0.0176月后兩組DPI水平趨于一致當前第38頁\共有49頁\編于星期五\12點P=0.0296月后兩組DEI水平趨于一致當前第39頁\共有49頁\編于星期五\12點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*0.3780.6360.7160.6110.6770.5690.8090.321當前第40頁\共有49頁\編于星期五\12點P=0.387兩組病人血Alb水平均保持良好當前第41頁\共有49頁\編于星期五\12點P=0.473兩組病人LBM維持穩(wěn)