慢肾脏病和低蛋白饮食PPT课件.ppt

慢性腎臟病與低蛋白飲食ChronicKidneyDiseaseandLowProteinDiet,腎臟科陳冠興,1,FactorsAssociatedwithLossofKidneyFunctioninCKD,SlowtheprogressionofkidneydiseaseHavebeenproventobeeffectiveStrictglucosecontrolindiabetesStrictbloodpressurecontrolACEIorARBHavebeenstudiedbutinconclusiveDietaryproteinrestrictionLipid-loweringtherapyPartialcorrectionofanemiaFrequentcausesofacutedeclineinGFRVolumedepletion;contrast;NSAID;antimicrobialagents;ACEI/ARB;cyclosporine;obstructionuropathy,2,什麼時候開始認為低蛋白飲食可能會延緩腎臟病的惡化?,3,TheEffectsofDietaryProteinRestrictionandBlood-PressureControlontheProgressionofChronicRenalDiseaseSauloKlahr,AndrewS.Levey,GeraldJ.Beck,ArleneW.Caggiula,LawrenceHunsicker,JohnW.Kusek,GaryStriker,forTheModificationofDietinRenalDiseaseStudyGroup*,4,MDRDstudy,研究設計StudyAGFR25-55mL/min(meanSCr1.90.5)Usualprotein1.3g/kg/d;lowproteindiet0.58g/kg/dN=585StudyBGFR13-24mL/min(meanScr3.40.9)Lowproteindiet;verylowproteindietN=255論文發表NEnglJMed330:877-884,1994JAmSocNephrol7:2616-2626,1996AJKD27(5):652-663,1996JAmSocNephrol10:2426-2439,1999,5,.75g/Kg/d,.62,.62-.68,.68-.75,6,Meta-AnalysisofLowProteinDietinProgressionofCKD,7,Cochranesystematicreviewandmeta-analysis,FouqueD,etal,CochraneDatabaseSystRev2006;19:CD001892.,8,如何確定病人是否有執行低蛋白飲食?,9,Duplicatemeal&ashanalysisDietaryrecall24hrurinecollectionforurea-N,10,Duplicatemeal&ashanalysis,GoodforresearchstudyBarrierNeedaccuratecollectionofduplicatemealsbypatientsorresearchassistantNeedlabmethodstoprocessspecimens:blender,freezing,burning,aciddigestionN2analyzerCostlyNoclinicalapplicationforindividualpatients,11,DietaryrecallAdvantage:BestpracticeampletimeforpersonelpatientinteractionPatientshavemorefreedomtoexpresstheirphysicalandemotionalconstraintBarrierNeedqualifieddietitianNeedpatientsunderstanding&cooperationInadequateinformativeaboutnutritionalvalueoflocalfoodsCalculationisuneasySubjecttobiologicalvariationMaynotbepracticalfornation-wideimplementation,12,MonitoringofdietaryproteinfromurineureaN,DPI=6.25totalu.urea-N+0.031KgBW+urineprotein,13,Benefitof24hurinecollectionforDPImonitoring,1.Cheap2.Slightlyinconvenientbutacceptablebymostpatients3.Accurateandreliablefeedback(topatient)4.Bodylanguageismoreconvincingpersuasive5.achievemorecompliancetotheguideline,14,Propermonitoring,1.U.protein:surrogatemarkerforglomerularpermselecturity2.Bodyweight:calorieintake(dry)3.24hUrineureaN+BW:nPNA(nDPI)4.24hU.Na:saltintake,15,低蛋白飲食會造成病人營養不良嗎?,16,低蛋白飲食對糖尿病腎病變有幫忙嗎?,17,DietaryproteinrestrictionsignificantlyreducestheriskofdeclineinGFRorcreatinineclearanceinpatientswithdiabeticnephropathy.,Lowproteindiet:effectonprogressionofCRFindiabeticCKDpatients:meta-analysis,PEDRINIetal.(1996):Effectofdietaryproteinrestrictionontheprogressionofdiabeticandnondiabeticrenaldiseases:ameta-analysis.AnnInternMed,124,627-632,18,LowProteinDietIncidenceofESRD/deathindiabeticnephropathy,HANSENetal.(2002):EffectofdietaryproteinrestrictiononprognosisinpatientswithdiabeticnephropathyKidneyInt,62,220-228,Aproteinrestrictionimprovesprognosisintype1diabeticpatientswithprogressivediabeticnephropathyinadditiontothebeneficialeffectofantihypertensivetreatment.,19,何謂SupplementedVeryLowProteinDiet(SVLPD)?,20,Caloricsupply,(kcal/kgbw/day),30-35,%fromcarbohydrates,67,%fromlipids,30,%fromproteins,3,Proteincontent,(g/kgbw/day),0.3-0.4(max.0.6),Phosphoruscontent,(mg/kgbw/day),5-7,Supplementedwith:,Calcium(g/day),0.5-1.0,VitaminD(IU/day),1,000,Iron(mg/day),100mg/kgbw/day,10-15,DietarymanagementinCKDCompositionofaKetoAcidTherapy,KA/AA(Ketosteril),21,MechanismsofProtectiveEffectsofLPD+KSinCKD,ReducesProimflammatoryCytokines,MetabolicDisorrdersCorrecti