Clinical characteristics. Nutritional Management of Nephrotic syndrome 陳淑子. Causes. Medical Nutrition therapy

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1 Nutritional Management of Nephrotic syndrome 陳淑子 臺北醫學大學保健營養學系助理教授台灣營養學會臨床營養委員會腎臟專科小組召集人 1 Clinical characteristics Proteinuria Hypoalbuminemia Edema Hyperlipidemia Hypercoagulability Abnormal Bone metabolism 2 Causes 常見原發性腎絲球病變 Minimal change disease Membranous nephropathy Focal segmental glomerulosclerosis IgA nephropathy 常見次發性病因 Diabetic SLE Amyloidosis Toxins, Drugs, Infection. Medical Nutrition therapy Manage the symptoms Decrease proteinuria Minimize edema Control hyperlipidemia Maintain nutritional stores Supply adequate nutrition Decrease the risk of progression to renal failure 3 4 Nutritional metabolism (1) Protein loss Adult 3-20 g/day ( 平均 6~8 g/d) 單次 Urine protein/urine creatinine Children 50 mg/kg/day Primary derived from liver & immune system Nutritional metabolism (2) Intermediate size protein loss(40 Albumin 佔 70%~90% Transferrin Iron VitD binding protein Calcium Ceruloplasmin Znic, Cupper HDL & Clotting factor kd) 5 6 1

2 Nutritional metabolism (3) Protein loss protein synthesis 沒有流失的合成速率也會增加 Increase liver protein synthesis Majority of protein secreted by the liver Albumin & Fibrinogen Hypercoagulability Other proteins synthesis(not loss in urine) LDL, apob-100, Lipoprotein (a), Prothrombin Hyperlipidemia Amino acid mobilization from muscle Normally albumin synthesis of liver g/day 合成最高速率 : 2 倍 7 Mechanism of Proteinuria Glomerular basement membrane defect Glomerular barrier protein intake Glomerular capillary blood pressure glomerular filtration Protein loss Hypoalbuminemia 流失增加 非合成降低 8 The effect of High protein diet Liver albumin synthesis amino acid oxidation Kidney Glomerular capillary blood pressure Protein loss Total Effects Albumin pool Progression of CRF 動物實驗 9 Kaysen et. al. AJKD,Vol XII, No6,1988:pp Am. J. Physiol. 247:F192-F202, % protein 動物實驗 Albumin catabolism in the nephrotic rat 人體試驗 21% protein Urinary albumin excretion Serum albumin concentration 40% protein AJKD,vol XII, No6, 1988:pp KI, Vol.29(1986), pp Am. J. Physiol. 247:F192- F202, g/kg 0.8g/kg 1.6 g/kg 0.8g/kg 1.6 g/kg 0.8g/kg 2

3 人體試驗 Maroni et.al. J.Clin. Invest : Dietary protein intake 0.8 g/kg +1g protein per gram proteinuria 1.6 g/kg +1g protein per gram proteinuria Serum Albumin 無顯著差異 AJKD,vol XII, No6,1988:pp Manage the symptoms Proteinuria Maintain Nutritional status Protein Adult 0.8 g/kg/day (~ 1.0 g/kg/day ) 0.6 g/kg/day+urinary protein loss (HBV) 0.8 g/kg/day+urinary protein loss (HBV) Children RDA for age +urinary protein loss (HBV) urinary protein 12.4 % ± 2.1 dietary protein intake dietary protein intake ( hr urinary urea excretion/0.14)+ urinary protein excretion Kopple, Renal Disease 2nd serum albumin AJKD 2000,vol35.No6.p 臨床討論 藥物使用對營養狀態的影響 Steroid 6~8 weeks 食慾變好 Cyclophosphamide 8~12 weeks 噁心 嘔吐 食慾 年輕與老人不同 Herb Astragalus membranaceus(huang gi) Idiopathic membranous nephropathy AJKD 2007, vol50, No6.p Energy Adult 30~35 kcal/kg 維持理想體重為原則 Children kcal/kg/day RDA for age weight changes calorie intake 注意 CHO 來源及 steroid 使用 Blood sugar 18 3

4 Edema & Hypertension 成因 Hypoalbumemia 飲食調整 Sodium intake 注意事項 可能影響利尿劑效果 Albumin & drug Hypertension Membranous nephropathy Minimal change disease 19 Sodium and Fluid 原則上不需限水 Sodium intake 60~90 meq/d (1380~2070 mg) 3g~5g salt Dry weight Dietary sodium intake 20 Hyperlipidemia LDL Lipid synthesis VLDL Lipid removal rate HDL 偏低 loss albumin FFA lipoprotein lipase activity VLDL LCAT (lecithin cholesterol acyltransferase) Drug effect steroid diuretic 21 Lipids NCEP ATP II & III 30%-35%total calorie Saturated fat, trans fatty acid < 10% Polyunsaturated fat < 10% (P:S=1:1) Monounsaturated fat 10% Cholesterol < 300 mg increase fiber intake Drug Soy protein ω- 3 Fatty acid 以植物油烹調 少吃油炸食物 動物性蛋白質要適量 避免麵包 餅乾 糕餅等 每餐吃半碗青菜 22 Vitamins and Minerals Niacin, VitB1, VitB2 VitD, Calcium ( mg) 1500mg) Zinc, Cu K secondary hyperaldosteronism K ACEI K *iron : 不需額外補充 23 飲食衛教注意事項 腎病症候群飲食蛋白質攝取建議量及熱量與健康者的均衡飲食均衡飲食相同相同 強調不需要補充高蛋白 增加蛋白質攝取不會增加血清白蛋白濃度 鈉攝取量要降低 :3~5g salt 血脂異常調整 油脂種類 : MUFA & ω-3 避免飽和脂肪酸與反式脂肪酸 除非血鉀異常否則不必限制鉀的攝取 不需調整磷的攝取 可能增加 niacin, B1, B2,Ca,Zn 的需要量 24 4

5 Thank you for your attention 25 5