慢性腎臟病患者營養狀態的評估 · pdf file2.npcr = 6.25(3.4 ÷52+0.031) =...

慢性腎臟病患者慢性腎臟病患者慢性腎臟病患者慢性腎臟病患者

營養狀態的評估營養狀態的評估營養狀態的評估營養狀態的評估

Assessment of nutrition status in CKD patients

童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院童綜合醫療社團法人童綜合醫院營養課營養課營養課營養課營養課營養課營養課營養課臨床組組長臨床組組長臨床組組長臨床組組長臨床組組長臨床組組長臨床組組長臨床組組長

李沛融李沛融李沛融李沛融李沛融李沛融李沛融李沛融營養師營養師營養師營養師營養師營養師營養師營養師

2

蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損(PEW)

Kidney international (2008) 73, 391–398

Malnutrition� induced by an inadequate diet.

Malnutrition� induced by an inadequate diet.

Wastin g� cannot be corrected only by increase the diet.

Wastin g� cannot be corrected only by increase the diet.

蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損(protein -energy wasting)

蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損(protein -energy wasting)

3reference: Teta D., World Kidney Day(2011)

CKD stages and protein -energy wasting(PEW)/malnutrition

4

Spontaneous decline in dietary protein intake parallels GFR reduction

reference: Teta D., World Kidney Day(2011)

Ikizer A, et al. JASN 1995; 6:1386-91

P<0.05

5

Relationship between nutritional status and the GFR : Results from the MDRD Study(1)

Kidney International, Vol. 57 (2000), pp. 1688–1703

N= 1785Men

-----Women

6

Relationship between nutritional status and the GFR : Results from the MDRD Study(2)

Kidney International, Vol. 57 (2000), pp. 1688–1703

N= 1785Men

-----Women

7

慢性腎衰竭病患慢性腎衰竭病患慢性腎衰竭病患慢性腎衰竭病患導致導致導致導致蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損(PEW)的因素的因素的因素的因素

Clinical Nutrition (2006) 25, 295–310

�攝取量↓攝取量↓攝取量↓攝取量↓��Malnutrition

�飲食受到限制(eg. protein-restricted diets)�尿毒毒性�厭食�腸胃道因素(胃輕癱、噁心、吸收能力下降…等)

� Wasting �� cannot be corrected only by increase the diet.

�輕微發炎反應�代謝性酸中毒�引起體蛋白分解

�內分泌因素(胰島素阻抗，高副甲狀腺素血症，血中leptin上升..等)

Kidney international (2008) 73, 391–398

臨床上常用的營養評估方法臨床上常用的營養評估方法臨床上常用的營養評估方法臨床上常用的營養評估方法

�蛋白質-熱量營養狀態評估，沒有單一指標可以代表，需綜合各類指標分析患者營養狀態。

�身體檢查與病史

(History and physical examination)

�食物攝取情形(Food intake)

�體位測量(Anthropometry)

�血液生化值(Laboratory data)

營養評估方法營養評估方法營養評估方法營養評估方法----1.身體檢查與病史

�症狀：噁心、嘔吐、厭食.

�病史：DM、腸胃道疾病.

�其他：心理問題、低社經地位.

營養評估方法營養評估方法營養評估方法營養評估方法----2.食物攝取情形

� 飲食訪談

� 飲食紀錄(24hr、三日、一週)

� 生化值推估蛋白質攝取量

�BUN/Cr ： <10 約0.6-0.8g/kg BW

>15 約1.2g/kg BW

�【24hr urine sample】

• Dietary protein intake(g/d) = 6.25×[UUN (g/d)

+0.03g/kg/day ×weight(kg)]

�計算nPCR (normalized Protein Catabolic Rate, 蛋白質代謝速率)

Reference from: 陳淑子教授講義

11

推估蛋白質攝取量推估蛋白質攝取量推估蛋白質攝取量推估蛋白質攝取量

�計算nPCR1.收集24小時尿液，檢測尿液尿素氮(UUN)換算單位UUN (g/day)=UUN(mg/dl) x總尿量(ml)÷105

2.公式nPCR=6.25 ( UUN ÷ 理想體重 +0.031)

【【【【範例範例範例範例】】】】154cm女性女性女性女性(IBW= 52kg)，，，，24小時尿液小時尿液小時尿液小時尿液1650ml，，，，UUN 205.8mg/dl 。。。。

1.單位換算 205.8*1650 ÷105= 3.4 g/d…UUN.2.nPCR

= 6.25(3.4 ÷ 52+0.031)= 0.6 g/Kg BW/d

營養評估方法營養評估方法營養評估方法營養評估方法----3.體位測量

�體重：

• IBW、actually body weight、edema free weight.

• 體重變化：體重減輕 vs.體重增加-水腫

� body fat and muscle mass ：：：：• 三頭肌皮層厚度(triceps skin fold, TSF; mm)

• 臂中圍(mid-upper-arm circumference, MAC; cm)

• 中臂肌肉環圍(mid-upper-arm muscles circumference, MAMC; cm)

營養評估方法營養評估方法營養評估方法營養評估方法----3.體位測量• 三頭肌皮層厚度三頭肌皮層厚度三頭肌皮層厚度三頭肌皮層厚度(TSF; mm)

• 測量身體儲存脂肪狀態

• edema

• 理想值：男性12.5mm，

女性16.5mm.• 測量值： >理想值120％為肥胖，

90-120％為營養正常，

90％-80％為輕度營養不良，

80％-60％為中度營養不良，

<60％為嚴重營養不良；

• 若<5mm：表示無脂肪可測，體脂肪

消耗殆盡.

From: http://steptofitness.com/xhtmlcss/fitness/ images/ skinfoldsite/FeTricep.JPG

營養評估方法營養評估方法營養評估方法營養評估方法----3.體位測量• 臂中圍臂中圍臂中圍臂中圍( MAC; cm)

• 中臂肌肉環圍中臂肌肉環圍中臂肌肉環圍中臂肌肉環圍( MAMC; cm)

• MAMC(cm)= MAC(cm)-[3.14 ×TSF(cm)]

• 測量身體肌肉消耗程度

• edema

• 理想值：男性24.8cm，

女性23.2cm.• 測量值： >標準值90％為營養正常，

90％-80％為輕度肌蛋白消耗，

80％-60％為中度肌蛋白消耗，

<60％為嚴重肌蛋白消耗.

From: http://www.bradfordrehabilitation.com/dietetics/imagegallery/ olecranon2-3.jpg

營養評估方法營養評估方法營養評估方法營養評估方法----4.血液生化值

�Albumin

�Transferrin

�Prealbumin

�Blood urea nitrogen

�Creatinine

營養評估方法營養評估方法營養評估方法營養評估方法---- 4.血液生化值

� Albumin�1. 標準值： 3.5 – 5.0 mg/dL�2. half life 20 days�3.功能： binds and transports small molecules;

maintains osmotic pressure.�4. a valuable test for predicting outcome�5. insensitivity to pure nutritional depletion

• a. elevated in dehydration• b. may be low in inflammation or shock

17

� Lowrie＆＆＆＆Lew研究顯示研究顯示研究顯示研究顯示(1990)，，，，血清白蛋白濃度與死血清白蛋白濃度與死血清白蛋白濃度與死血清白蛋白濃度與死亡率之關係：亡率之關係：亡率之關係：亡率之關係：

血清白蛋白血清白蛋白血清白蛋白血清白蛋白血清白蛋白血清白蛋白血清白蛋白血清白蛋白 (g(g/dL/dL )) 相對死亡率相對死亡率相對死亡率相對死亡率相對死亡率相對死亡率相對死亡率相對死亡率(4(4--4.5g4.5g/dL/dL ))之倍數之倍數之倍數之倍數之倍數之倍數之倍數之倍數

3.53.5--4.04.0 99倍倍

2.52.5--3.03.0 1515倍以上倍以上

＜＜2.52.5 1818倍以上倍以上

Malnutrition vs. Mortality

Am J Kidney Dis. 1990 May;15(5):458-82.

18

Kovesdy C, et al. Am J Clin Nutr 2009; 90:407-14

Risk of death versus serum albumin in non -dialysed CKD patients

reference: Teta D., World Kidney Day(2011)


� Transferrin 運鐵蛋白�1.標準值：200 – 336 mg/dL�2. half life 8 days�3.功能：iron-binding protein�4.more sensitive to change in nutritional state

• levels falls when diet is deficient in protein• low in chronic disease, cirrhosis, nephritic

syndrome.


� Pre-albumin (transthyretin) �1.標準值： 18 – 38 mg/dL�2. half life 2 days�3.功能： thyroxine -binding protein�4.sensitive index of visceral protein status�5.useful marker of response to nutritional support.


� BUN ，標準值： 7-25 mg/dlCreatinine，標準值： 0.6-1.3 mg/ dl

�BUN/Cr <10 蛋白質攝取約0.6-0.8g/kg

�BUN/Cr >15 蛋白質攝取約1.2g/kg

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CKD患者患者患者患者蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損蛋白質能量耗損的臨床診斷條件的臨床診斷條件的臨床診斷條件的臨床診斷條件Kidney international (2008) 73, 391–398

下列四項符合三項以上：下列四項符合三項以上：下列四項符合三項以上：下列四項符合三項以上：

� 血液生化值血液生化值血液生化值血液生化值

� Albumin <3.8g/dl� Prealbumin<30mg/dl� Cholesterol<100mg/dl

� 體重體重體重體重

� BMI<23(歐美標準；WHO18.5-25)� 非預期體重下降

• 三個月內>5% or 六個月內>10%� 體脂肪比例<10%

� 肌肉組織肌肉組織肌肉組織肌肉組織

� 肌肉耗損:三個月>5% or六個月>10%� 中臂肌肉環圍(MAMC)下降：>10%� Creatinine下降

� 食物攝取情形食物攝取情形食物攝取情形食物攝取情形

� 蛋白質攝取<0.6g/kg/day,持續2個月� 熱量攝取<25kcal/kg/day,持續2個月

23American Journal of Kidney Diseases, Vol 35, No 6, Suppl 2 (June), 2000.

非透析患者的營養評估非透析患者的營養評估非透析患者的營養評估非透析患者的營養評估 (K/DOQI guideline)

� CKD患者患者患者患者(GFR<20ml/min),應連續監測，應連續監測，應連續監測，應連續監測，至少一項：至少一項：至少一項：至少一項：

� Albumin• 1-3月/次

� BW or SGA.• 1-3月/次

� 食物(蛋白質)攝取量• 3-4月/次

� 腎臟功能惡化、生病、熱量攝取不足…等��增加追蹤頻增加追蹤頻增加追蹤頻增加追蹤頻率。率。率。率。

24

慢性腎臟病患者慢性腎臟病患者慢性腎臟病患者慢性腎臟病患者飲食建議量飲食建議量飲食建議量飲食建議量

Dietary Energy Intake(DEI) for nondialyzed patient(K/DOQI guideline)

� The recommended DEI for individuals with chro nic renal failure (CRF; GFR 25 mL/min) who are not und ergoing maintenance dialysis is 35 kcal/kg/d for those who are younger than 60 years old and 30 to 35 kcal/kg/d for individuals who are 60 years of age or older . (Evidence and Opinion)� Energy expenditure of nondialyzed individuals with CRF is similar to

that of healthy individuals.

� Metabolic balance studies of such individuals indicate that a diet providing about 35 kcal/kg/d engenders neutral nitrogen balance and maintains serum albumin and anthropometric indices.

� Because individuals more than 60 years of age tend to be more sedentary, a lower total energy intake of 30 to 35 kcal/kg/d is acceptable.

American Journal of Kidney Diseases(2000), 35: S60.

慢性腎臟病患者飲食建議量慢性腎臟病患者飲食建議量慢性腎臟病患者飲食建議量慢性腎臟病患者飲食建議量

26

Dietary Energy Intake for chronic renal failure(CRF )(ESPEN guideline, 2006)



� In Taiwan：：：：� 國民營養調查：25-35kcal/day � 建議男32kcal/kg, 女: 28kcal/kg

Reference from: 陳淑子教授講義

Protein requirement–CKD stage 1 to 3� The MDRD study was inconclusive regarding the benefits

of protein restriction on kidney disease progression, but there was no evidence of beneficial effect from dietary protein intake higher than the RDA .

� K/DOQI Guideline

�A dietary protein intake of 0.75g/kg/day therefore appears reasonable for patients with CKD stages 1 to 3 (in the absence of evidence of malnutrition).

�but data are inconclusive, and individualized decision-making is advised.

� Patients with dietary protein intake less than approximately 0.75g/kg/day should have more close monitoring of nutritional status .

American Journal of Kidney Diseases (2002); 39:S1.


Protein requirement–CKD stage 4 to 5

� K/DOQI Guideline

� recommends consideration of low protein diet(0.6g/kg/day) for patient with GFR in the range of CKD Stage 4 and 5(GFR<25ml/min).

� the importance of maintaining a good nutritional status with advancing chronic kidney disease.

�generally would involve evaluation and monitoring by dietician.

American Journal of Kidney Diseases (2002); 39:S1.


29

Recommendations for protein intakes of metabolically stable patients with CRF.

(ESPEN guideline, 2006)



30

KetosterilKetosteril


Ketosteril per tablet contains:

67 mg α-ketoanalogue to isoleucine, Ca-salt101 mg α-ketoanalogue to leucine, Ca-salt68 mg α-ketoanalogue to phenylalanine, Ca-salt86 mg α-ketoanalogue to valine, Ca-salt59 mg α-hydroxy-analogue to methionine, Ca-salt

105 mg lysine-acetate53 mg threonine23 mg tryptophan38 mg histidine30 mg tyrosine

50 mg50 mg 總鈣量總鈣量總鈣量總鈣量總鈣量總鈣量總鈣量總鈣量36 mg36 mg 總氮量總氮量總氮量總氮量總氮量總氮量總氮量總氮量

KetosterilKetosteril


32

Supplemented with keto amino acid(KA)

� ESPEN guideline

�CKD stage4-5 (GFR<25ml/min )

� low protein diet：0.28g protein/kg BW/day + KA

�Ketosteril 建議攝取量建議攝取量建議攝取量建議攝取量

�1 tablet/ 5 kg BW

�健保給付

�限慢性腎衰竭病患行低蛋白飲食治療，連續三個月低蛋白飲食治療，連續三個月低蛋白飲食治療，連續三個月低蛋白飲食治療，連續三個月，每個月之血中肌酸酐均在血中肌酸酐均在血中肌酸酐均在血中肌酸酐均在 6 mg % 以上者，檢附相關檢驗報告，經核准後得使用六個月，每日至多使用六每日至多使用六每日至多使用六每日至多使用六顆顆顆顆。

�本品不得用於血液透析血液透析血液透析血液透析及換腎病患，並不得做為一般營養補充劑。


33

� Nutritional intervention strategy in CRF patients i sdetermined by speci fic metabolic alterations:

�insulin resistance,�abnormal plasma lipid clearance,�metabolic acidosis,�secondary hyperparathyroidism, uraemic bone disease,�impairments of vitamin D3 activation,�hyperkalaemia, hyperphosphataemia,�chronic inflammatory reaction,�activation of protein catabolism due to enhanced catabolism in intercurrent acute illness, acidosis and inflammation.

Nutritional intervention strategy in CRF patients .(ESPEN guideline, 2006)


34

� Intensive Nutritional Counseling for Chronic Renal Failure (CRF)� Interventions that maintain or improve nutritional status during progressive renal failure are likely to be associated with improved long-term survival after commencement of maintenance dialysis.�規律監測營養狀態

�Stage 3 without malnutrition�每6-12個月一次

�Stage 4-5�每1-3個月一次

�Nutritional status should be assessed more frequently if there is inadequate nutrient intake, frank protein-energy malnutrition, or the presence of an illness that may worsen nutritional status.

American Journal of Kidney Diseases(2000), 35: S60.

Nutritional intervention strategy in CRF patients .

Thanks for your attention

慢性腎臟病患者 營養狀態的評估 · pdf file2.npcr = 6.25(3.4 ÷52+0.031) =...

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慢性腎臟病患者營養狀態的評估 · pdf file2.npcr = 6.25(3.4 ÷52+0.031) =...