腹透病人营养不良的管理演示文稿

腹透病人营养不良的管理演示文稿当前1页，总共45页。（优选）腹透病人营养不良的管理当前2页，总共45页。全面的营养评估项目饮食调查饮食蛋白质摄入与代谢平衡热量的摄入与消耗平衡主观综合性营养评估（SGA)人体测量握力试验生物电阻抗生化检查当前3页，总共45页。营养管理流程-CQI

饮食记录饮食和治疗调整饮食和营养知识核对饮食反馈给病人教育食谱分析营养评估当前4页，总共45页。营养不良的管理方法当前5页，总共45页。HighprevalenceofmalnutritioninPDpopulationPrevalenceofmalnutrition(%)WangDongetal,2002当前6页，总共45页。Jun,2001-Jan,2002,多中心横断面BJ,90ptsResidualrenalfunctionUremictoxinsEndocrineabnormalitiesAminoacidabnormalitiesAcidosisRenaldiseaseperseDialysateendotoxinsGraftandfistulainfectionsDialysisadequacyBioincompatibilityNutrientlosses(dialysate)DialysisprocedureInfection/InflammationCongestiveheartfailureVasculardiseaseDiabetesmellitusDepressionOthercomorbidity

Co-morbidityAgeGenderGeneticsDrugs(corticosteroids)SocialfactorsOtherfactorsProteinintakeEnergyintakeVitaminintakeIntake当前7页，总共45页。

LogisticAnalysisinACross-section

Studyin90CAPDPatientsin2002MalnutritionDPIDEITccrDMRRFLongtimeonPDCVDCRP董捷等。中华医学杂志2003当前8页，总共45页。RRFinevitablylostafter2-3yrsHIDAKA,etal.NEPHROLOGY2003;8:184–191InitiationofPDGFR(mL/min/1.73m2)06121824303642Time(months)

Jan,2002-Jun,2002思考和假想当前9页，总共45页。FentonSA,etal,AmJKidneyDis,1997;30:334-342CAPD/CCPD与HD患者的生存率比较(1990-94)随访月30405060708090061218243036424854100CAPDHD生存率%当前10页，总共45页。腹透病人水和溶质的清除Chengetal.ClinNephrol2006当前11页，总共45页。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患者每日平均蛋白摄入和热量摄入均低RRF与营养不良当前12页，总共45页。AY-MWang，KI，2006当前13页，总共45页。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失的病人主要涉及水、小分子溶质平衡和蛋白质能量摄入可操作性强

Jun,2002-now预防营养不良的综合策略当前14页，总共45页。策略一：稳定的营养摄入2003DOQIGuidelineDPI

1.2-1.3g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d当前15页，总共45页。腹膜透析患者实际饮食蛋白摄入量普遍低于推荐值YearNo.ofPatientsDPI(g/kg/day)Wangetal.20032661.11Suttonetal.2001340.90Parketal.1999501.12Jacobetal.1995571.13Nolphetal.1993710.84Pollocketal.1990351.04当前16页，总共45页。(n=47)随访开始随访结束Group1Group2Group3Group1Group2Group3营养不良发生率50%50%58.8%25%33.3%41.2%随访期间总的营养不良发生率由53%下降至34%（P<0.05）2002.122003.12TotalXinkuiT,JieD,TaoWetal.JRenalNutri2003当前17页，总共45页。我们实施的营养摄入标准DPI

0.8-1.2g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d当前18页，总共45页。实施技巧饮食调整蛋白质结构调整，量>质喜好食物调查及食品交换份

及早添加各种口服营养制剂保证透析充分性纠正合并症减少药物副作用当前19页，总共45页。

策略二：小分子溶质清除充分当前20页，总共45页。Adequacy:TheKDOQIRecommendations2001Guideline15:ForCAPD,thedeliveredPDdoseshouldbeatotalKt/Vofatleast2.0perweekandatotalcreatinineclearanceofatleast60L/wk/1.73m2forH&HAtransportersand50L/wkinLandLAtransporters

AJKD2001;37(Suppl1):S84当前21页，总共45页。ADEMEX研究2002:NO965个腹透病人随机对照研究对照组：传统的4*2L/天CAPD实验组：增加剂量使Ccr在60L/周,Kt/V在2.0生存情况：1年及2年生存率无差别当前22页，总共45页。新的阈值（目标值）

溶质

CAPDKt/V≥1.7(EvidencelevelA)

水分无目标值，容量平衡

WkLoetal.ISPDGuidelines/Recommendations.PDI2006当前23页，总共45页。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当前24页，总共45页。小分子溶质清除充分吗？

BasedonDPIlevelKt/V>=1.5BUN:20-25mmol/l

没有尿毒症症状

Kt/VDPI氮平衡Kt/V当前25页，总共45页。

溶质清除总清除

液体清除残肾清除透析时间透析时间残肾清除腹膜清除腹膜清除总清除

策略三：容量平衡

当前26页，总共45页。腹膜透析水与溶质清除的变化时间(年)水容量(ml)总清除腹膜清除残肾清除容量负荷蜜月期

动荡期

稳定或恶化期当前27页，总共45页。策略三：容量平衡水份摄入约1-1.5L/d，摄盐6g利尿剂平均增加尿量100-200ml，不保护残肾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）

体表无水肿服两种或以下降压药，BP<140/90mmHgBIA，DEXA细胞外液/总体水稳定当前28页，总共45页。

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。董捷,王海燕。中华内科杂志，2007，第1期营养管理成效一当前29页，总共45页。病例选择和方法

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

n=15June,200543CAPDpatients

HDRT

PDDeath当前30页，总共45页。

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)当前31页，总共45页。血白蛋白水平上升3333.53434.53535.53636.53737.53806121824时间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)当前32页，总共45页。营养不良发生率下降0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%06121824时间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)当前33页，总共45页。

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)当前34页，总共45页。

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。DongJ,WangHY.Unpublisheddata.营养管理成效二当前35页，总共45页。病例选择和方法

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

n=14June,200635CAPDpatients

HDRT

PDDeath当前36页，总共45页。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当前37页，总共45页。P=0.017P=0.0176月后两组DPI水平趋于一致当前38页，总共45页。P=0.0296月后两组DEI水平趋于一致当前39页，总共45页。少尿和无尿腹透病人透析充分性和容量控制均保持稳定

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