腹透病人营养不良的管理演示

（优选）腹透病人营养不良的管理当前第1页\共有49页\编于星期五\12点临床--营养--管理通过合理的工作流程和完整的营养评估体系，结合临床疾病需要，对营养和饮食状况进行不断的评估、调整，其最终目的是达到体内各种营养素的均衡。当前第2页\共有49页\编于星期五\12点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第3页\共有49页\编于星期五\12点营养管理流程-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第4页\共有49页\编于星期五\12点营养不良的管理方法当前第5页\共有49页\编于星期五\12点HighprevalenceofmalnutritioninPDpopulationPrevalenceofmalnutrition(%)WangDongetal,2002当前第6页\共有49页\编于星期五\12点Jun,2001-Jan,2002,多中心横断面BJ,90ptsResidualrenalfunctionUremictoxinsEndocrineabnormalitiesAminoacidabnormalitiesAcidosisRenaldiseaseperseDialysateendotoxinsGraftandfistulainfectionsDialysisadequacyBioincompatibilityNutrientlosses(dialysate)DialysisprocedureInfection/InflammationCongestiveheartfailureVasculardiseaseDiabetesmellitusDepressionOthercomorbidity

Co-morbidityAgeGenderGeneticsDrugs(corticosteroids)SocialfactorsOtherfactorsProteinintakeEnergyintakeVitaminintakeIntake当前第7页\共有49页\编于星期五\12点

LogisticAnalysisinACross-section

Studyin90CAPDPatientsin2002MalnutritionDPIDEITccrDMRRFLongtimeonPDCVDCRP董捷等。中华医学杂志2003当前第8页\共有49页\编于星期五\12点RRFinevitablylostafter2-3yrsHIDAKA,etal.NEPHROLOGY2003;8:184–191InitiationofPDGFR(mL/min/1.73m2)06121824303642Time(months)

Jan,2002-Jun,2002思考和假想当前第9页\共有49页\编于星期五\12点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%当前第10页\共有49页\编于星期五\12点腹透病人水和溶质的清除Chengetal.ClinNephrol2006当前第11页\共有49页\编于星期五\12点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与营养不良当前第12页\共有49页\编于星期五\12点AY-MWang，KI，2006当前第13页\共有49页\编于星期五\12点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第14页\共有49页\编于星期五\12点策略一：稳定的营养摄入2003DOQIGuidelineDPI

1.2-1.3g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d当前第15页\共有49页\编于星期五\12点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当前第16页\共有49页\编于星期五\12点(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当前第17页\共有49页\编于星期五\12点我们实施的营养摄入标准DPI

0.8-1.2g/kg/d

(50%ofhighbiologicvalue)DEI30-35kcal/kg/d当前第18页\共有49页\编于星期五\12点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第19页\共有49页\编于星期五\12点

策略二：小分子溶质清除充分当前第20页\共有49页\编于星期五\12点Adequacy:TheKDOQIRecommendations2001Guideline15:ForCAPD,thedeliveredPDdoseshouldbeatotalKt/Vofatleast2.0perweekandatotalcreatinineclearanceofatleast60L/wk/1.73m2forH&HAtransportersand50L/wkinLandLAtransporters

AJKD2001;37(Suppl1):S84当前第21页\共有49页\编于星期五\12点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第22页\共有49页\编于星期五\12点新的阈值（目标值）

溶质CAPDKt/V≥1.7(EvidencelevelA)

水分无目标值，容量平衡WkLoetal.ISPDGuidelines/Recommendations.PDI2006当前第23页\共有49页\编于星期五\12点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当前第24页\共有49页\编于星期五\12点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当前第25页\共有49页\编于星期五\12点

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

当前第26页\共有49页\编于星期五\12点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第27页\共有49页\编于星期五\12点策略三：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/总体水稳定当前第28页\共有49页\编于星期五\12点

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第29页\共有49页\编于星期五\12点病例选择和方法

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

n=15June,200543CAPDpatients

HDRT

PDDeath当前第30页\共有49页\编于星期五\12点

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)当前第31页\共有49页\编于星期五\12点血白蛋白水平上升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)当前第32页\共有49页\编于星期五\12点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)当前第33页\共有49页\编于星期五\12点

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)当前第34页\共有49页\编于星期五\12点

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第35页\共有49页\编于星期五\12点病例选择和方法

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

n=14June,200635CAPDpatients

HDRT

PDDeath当前第36页\共有49页\编于星期五\12点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当前第37页\共有49页\编于星期五\12点P=0.017P=0.0176月后两组DPI水平趋于一致当前第38页\共有49页\编于星期五\12点P=0.0296月后两组DEI水平趋于一致当前第39页\共有49页\编于星期五\12点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±27.2072.21±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当前第40页\共有49页\编于星期五\12点P=0.387两组病人血Alb水平均保持良好当前第41页\共有49页\编于星期五\12点P=0.473两组病人LBM维持稳