Etiologies of Malnutrition in ESRD

Transcription

1 透析患者常見的營養問題與飲食治療 彰化基督教醫院 陳虹霖營養師 Etiologies of Malnutrition in ESRD Decreased intake -anorexia -loss of taste - gastroparesis - medications - dietary restrictions - depression Inter-current illnesses Metabolic derangements of uremia Abnormalities of endocrine function 1

2 蛋白質熱量的營養狀態評估 營養測量指標之使用 1. 透析病人之營養狀況應以綜合之方法而非以單一方法評估 2. 沒有單一項的測量可供作為蛋白營養狀況的指標 3. 綜合測量熱量及蛋白之攝取 體內臟器蛋白儲量 (visceral protein pool) 肌肉量 其它身體成分測量及功能狀態, 作為辨認不同方面蛋白營養狀況的指標之敏感度及特異性 單一營養檢測指標無法反應出透析病人的營養狀況 營養評估應從整體性考量 才能提供客觀的評估結果 2

3 項目 監測 CKD 病人之營養狀態 Stage 3-5 監測頻率 透析 一般體重 % - 每月 理想體重 % 每 1~3 個月每 4 個月 SGA (subjective global. assessment) 每 1~3 個月 每 6 個月 血漿白蛋白每 1~3 個月每月 飲食評估每 3~4 個月每 6 個月 npna (normalized protein equivalent of nitrogen appearance) 每 3~4 個月 HD: 每月 CAPD: 每 3~4 個月 American Journal Kidney Disease, 2000: 35(6),Suppl2, s17-s104 American Journal Kidney Disease, 2000: 35(6),Suppl 2, s17-s104 3

4 Effects of Chronic Calorie-Protein Malnutrition on Renal Function Decreased renal plasma flow and GFR Impaired concentrating ability (polyuria) with normal diluting capacity Impaired ability to excrete acid loads - normal ability to decrease urine ph -markedly decreased titratableacid excretion because of substantial reduction in phosphate excretion in urine Impaired ability to excrete salt load Protein-Energy Wasting (PEW) PEW occurs when mechanisms to compensate for decreased protein intake fail PEW occurs frequently in patients with stages 4 and 5 CKD and established HD or PD patients Dietary protein and energy intake and the parameters of nutritional status (albumin, transferrin, BW, midarm muscle circumference, and percentage of body fat) decrease as GFR decreases toward 10 ml/min/1.73 m 2 4

5 PEW: Morbidity and Mortality Nutritional status of patients undergoing HD or PD is a powerful predictor of M&M Albumin, BW, muscle mass, and changes in BW are associated with M&M Comorbidity account for both the PEW and increased mortality Individuals with lower muscle mass are less likely to survive acute intercurrent illnesses Reverse epidemiology describes lower mortality with higher body weight, cholesterol level, and other traditional cardiac risk factors, that is believed to be caused by PEW PEW: Treatment Treatment: reverse acute illness, provide adequate protein and calories, and muscle loading to rebuild muscle mass In CKD, dietary protein intake should be liberalized Reduction of inflammation portends a good prognosis Dietary supplements are helpful in restoring albumin in p ts with low spontaneous protein and/or calorie intake Intradialyticparenteral nutrition appears effective, but not superior to oral feeding 5

6 PEW: Treatment Dietary supplements are not effective in restoring muscle mass without muscle loading Feeding can increase muscle protein synthesis, but this is matched by increased breakdown in individuals at rest Anabolic agents (GH, IGF-1, anabolic steroids) and appetite stimulants (progesterones) are under evaluation Many anabolic agents have had successful small-scale trials The role of carnitine, used in the transport of fatty acids, and its supplementation has been debated Assessment of Nutritional Status in Kidney Disease: Biochemical Assessment Serum cholesterol level very low in PEW Biochemical tests of protein stores No valid or reliable somatic (muscle) protein marker Albumin, transferrin, prealbumin, and methylhistidine are used for visceral proteins Albumin level is nonspecific indicator: decreases with inflammation and has a long half-life Prealbumin and transferrin levels may more accurately reflect the current nutritional state, but also increase with inflammation Creatinine level reflects muscle mass, but variability in excretion/clearance and change with meat intake 6

7 Special Consideration: HD Nutrient losses: A.A. losses are approximately 8-10 g during dialysis, depending on the type of dialyzer About 25 g of glucose are removed during a HD session with a glucose-free dialysate About 30 g of glucose are absorbed when dialysate containing glucose of 180 mg/dl Vitamins B1, B2, and B6; ascorbic acid, and folic acid are prone to be lost with dialysis, whereas loss of vitamin B12, which is protein bound, is negligible Special Consideration: Hemodialysis Sodium and water must be tightly restricted Excessive Na intake may lead to large interdialytic weight gains, HTN, edema, CHF, and increased risk of death Restriction of Na intake and glucose control will reduce water intake to appropriate level K, Mg, and P are poorly cleared by hemodialysis Dietary intake not 70 meq or 2 g of K per day If 1.0 meq/l Mg is in dialysate Mg intake should be mg/d Patients on HD should be prescribed 8-17 mg/kg/d of P Very low-phosphorus diets (800mg/d) are unpalatable, phosphorus binders usually are required 7

8 Special Consideration: PD Nutrient losses P and K have increased clearance with PD => Potassium intake can be liberalized to 4 g Because of sodium sieving, water may be lost preferentially to sodium Tight Na restriction is essential and positive Na balance correlates with mortality Protein losses in PD vary from 5-15 g/24 h, with albumin as the major constituent Low HDL cholesterol levels correlate with apolipoprotein losses in dialysate Metabolic bone disease due to loss of vitamin D binding protein Protein losses mirror peritoneal transport characteristics in CAPD patients Special Consideration: PD Protein intake should be g/kg (with 50% of high biological value) Average losses of free a.a. into dialysate during CAPD vary from g/24 h Amino acid based dialysis fluids may supplement daily a.a. losses of amino acids during dialysis with glucose-based solutions Absorption of glucose ( g/24 h, averaging 8 kcal/kg/day) The high calorie load from dialysate makes it easier to obtain calorie goals, making protein goals more critical in planning the diet High sugar load contributes to the feeling of satiety Abdominal distention is not a significant contributor to satiety in most patients Increased insulin resistance from high sugar loads 8

9 NDT Plus (2010) 3:

10 蛋一個 = 7 公克蛋白質 飯一碗 = 8 公克蛋白質 肉 魚 豆腐一份 = 7 公克蛋白質 牛奶一杯 = 8 公克蛋白質 蔬菜一碗 = 2 公克蛋白質 Phosphorus metabolism Serum phosphorus levels are tightly regulated Although serum P level may be normal, the metabolism of P is complex. -best illustrated in the state of CKD - body constantly working to maintain P in normal range With overt hyperp, it is appropriate to utilize P reduction strategies Be wary of normal P levels, the body may be compensating by other means to avoid hyperp. 10

11 Phosphorus ~60% of dietary phosphorus is absorbed from mixed diet. nearly 100% of phosphorus-containing additives are absorbed. (Phosphorus additives are used liberally to enhance flavor) Diabetes Spectrum Volume 21, Number 1, 2008 Journal of Renal Nutrition, Vol 16, No 1 ( January), 2006: pp 主食類 高磷食物 薏仁 栗子 蓮子 綠豆 紅豆 菱角 花豆 毛豆 麥片 糙米 11

12 Reading labels to find out the hidden phosphorus 主要成份 : 麵粉 食用澱粉 精製棕櫚油 食鹽 麵質改良劑 ( 食品級碳酸鉀 重合磷酸鹽 ) 天然維生素 E( 抗氧化劑 ) β- 胡蘿蔔素 ( 著色劑 ) 12

13 that phosphorus binders be taken immediately before or after meals or snacks. How much phosphorus does dialysis remove? phosphorus removed in a dialysis treatment ranges from 250 to 1,000 mg per treatment. affected by»the pre-dialysis phosphorus level»type of dialyzer»the amount of dialysis received 13

14 Kidney International, Vol. 67, Supplement 95 (2005), pp. S28 S32 5~ < 10 mg/g lamb, beef, lobster, chicken breast 10 ~< 15 mg/g Soy protein and soy bean, salmon, peanut butter ~20 mg/g whole egg, dairy products, legumes, walnut, sausage, and fast food IJKD 2010;4:

15 Vegetarian or Meat protein which is good for P control? Source of dietary Phosphate Organic - animal protein 40~60% is absorbed (varies by degree of gastrointestinal vitamin-d-receptor activation) - vegetarian protein associate with Phytates, is less absorbed by human GI tract Inorganic - processed foods up to 100% may be absorbed IJKD 2010;4:

16 Dietary phosphorus should be restricted to 800 to 1,000 mg/day (adjusted for dietary protein needs) Intervention timing~ 1. Serum P level 2. ipth level Fig 9. Relationship between serum phosphorus and CCR. 16

17 透析患者鈣 磷異常處理總結 未治療併發症 治療管理 高血鈣 高血磷 次發性副甲狀腺功能亢進鈣過敏症 (Calciphylaxis) 搔癢鈣過敏症 HD: 使用低鈣透析液 PD: 使用低鈣透析液藥物 : 以不含鈣之降磷劑取代含鈣之降磷劑使用 ; 停止維生素 D 使用營養 : 限制鈣攝取 < 2000 毫克 ( 含鈣片 ) HD: 增加透析時間 PD: 增加留置時間或增加透析劑量藥物 : 給予降磷劑使用營養 : 減少高磷食物使用 ; 確認患者隨餐服用降磷劑 ; 限制每日磷攝取 毫克 Maintain optimal serum potassium levels Serum potassium : 3.5 to 5.5 meq/l Antihypertension medications - ACEi (Angiotensin-converting enzyme inhibitors) - ARB (Angiotensin Receptor Blockers) one of the side effects hyperkalemia Counseling RD for potassium-restricted diet (2 to 4 g potassium diet ) 17

18 Hyperkalemia? Serum potassium levels may remain within an acceptable range who on potassium-losing diuretics such as furosemide (Lasix) who continue to produce urine RD should use serum potassium levels to determine when, if, and to what degree dietary potassium should be restricted. Is the patient Hyperkalemia? If Yes, ACE inhibitor used? check urine output, constipation low-potassium diet intervention is required If No, keep present diet 18

19 簡易飲食評估及份量指導 飲食攝取評估 19

20 手掌量度法 (handy hand guides) 手掌大小 相當份量 1 個拳頭 1 碗 ( 飯 麵 蔬菜 ) 1 個握緊拳頭 1 個水果 1 個掌心 3 兩肉 1 個拇指尖 1 茶匙油脂 1 根大拇指 1 兩起司 1 把 1 兩花生或瓜子 Thank You 20