营养失调与治疗杂志

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临床营养 2020：个性化膳食计划形式的营养咨询对血液透析患者血清白蛋白水平的影响 - Suhair Abdalla Khalil Abdallah - 阿法德女子大学

苏海尔·阿卜杜拉·哈利勒·阿卜杜拉

简介： 最佳营养状况是（HD）患者长期管理的一个主要问题，也是改善 HD 患者预后的先决条件。肾脏疾病结果质量倡议 (KDOQI) 建议将肾脏营养的标准化实践作为 HD 终末期肾病 (ESRD) 患者饮食管理的核心和组成部分。具有肾脏经验的营养师应负责持续评估患者的营养状况并制定饮食护理计划。这可确保适当评估营养状况并及时识别有风险的患者。因此，营养状况评估是营养管理的一个组成部分。应同时评估几个参数，包括体重减轻史、膳食蛋白质和能量摄入量、皮下脂肪量和肌肉量以及体重指数 (BMI)、卫生官员用来评估蛋白质能量营养状况的主观整体评估 (SGA) 和几种生化标志物（血清白蛋白、前白蛋白和转铁蛋白）已用于评估内脏蛋白质储存。其中，血清白蛋白迄今为止是最常用的。它是衡量全身蛋白质（包括肌肉和内脏）的一种指标，是蛋白质状态最常用的标志物，也是 KDOQI 推荐的标准。用于评估 CKD 患者的营养状况。它是评估 HD 患者营养不良的有力标志物。白蛋白降低不大可能导致发病率和死亡率增加。这对于 ESRD 患者的白蛋白低于 40 g/d 而言，已证明会导致死亡风险过高。低白蛋白水平是血液透析患者人性和疾病的可靠分析指标。它是 PEM 的替代标志物，PEM 在接受 HD 的 ESRD 患者中很常见，估计患病率为 10 - 70%，无疑会增加发病率和死亡率。更为严重的是，这些患者在透析液中流失了大量的蛋白质（这导致该组患者出现低白蛋白血症）（先前的大多数研究表明，一次透析过程中流失到透析液中的氨基酸量可能为 4 至 13 克。并且，这些患者并没有持续摄入推荐量的 HD ESRD 患者的能量和蛋白质。他们需要个性化的膳食计划，但他们很少咨询营养师。换句话说，HD 的 ESRD 患者需要特殊饮食。HD 成人的每日建议营养摄入量为：蛋白质 1.2 克/公斤体重（高生物值的 50%）；能量：60 岁以下成人 35 千卡/公斤，60 岁以上成人或肥胖 30 千卡/公斤；矿物质（毫克/公斤/天）——钠 2-4、钾 40 和磷 17；液体取决于液体输出量 + 500 毫升。

Serum albumin is the most commonly used malnutrition marker in clinical practice as hypo albuminemia is considered to be a malnutrition risk among the patients on hemodialysis and a strong predictor of death. Low serum albumin levels are due to low intakes of energy and protein or insufficient energy intake resulting in poor protein utilization.

Purpose: This was a prospective, clinical trial hospital based (intervention) study to evaluate the effect of nutritional counseling in the form of individualized meal plan on serum albumin level among hemodialysis patients.

Methods: The study was conducted on maintenance hemodialysis patients attending Dr Salma Hemodialysis & Transplant Center outpatient clinic, Khartoum. 134 adult patients (males & females) were divided into a test group (n=77) and a control group (n=57). The test group after nutritional counseling consumed individualized diets for a period of 6 months that provided adequate amounts of energy and protein according to the recommendations of the National Kidney Foundation whereas the control group sustained overwhelming their usual diets. Serum albumin was determined at baseline and every 2 months. Data were analyzed using SPSS.

Nutritional status assessment:

Intervention Eighty-three HD patients who were included in the study as test group received conventional nutritional counseling and individual meal plan to achieve adequate protein and calories intake. Monitoring was done during 6 months of follow up. The individual meal plan was designed and explained to patient and their families by the following ways:

Educational lecture: Educational lecture was given exclusively to the test group. It was presented by the researcher to the patients and their families during their dialysis session by using a data-show to educate the patients and their families on the nutritional needs to provide appropriate food with adequate calories and protein to the patients.

Presentation included all the important information needed to be known by ESRD patient on HD. It was concentrated on calorie and protein needed, fluids limitation, intake of sodium, potassium and phosphorus in foods. Information was provided in a simple way and was explained by pictures for more understanding.

Pamphlets: were prepared and distributed to all intervention group participants after the lecture and all the summary information that was presented was found in the sheet which the researcher called it as the over-all training sheet for renal patients on HD.

Individualized meal plans: Individual meal plan was designed individually to all intervention group participants after analysis of the full information that helped the researcher to conduct the meal plan. The meal plan was based on: patient’s economic status, medical history, diet history, like and dislike, chewing and swallowing status, food allergies, blood investigation result, age, weight, height and sex. (Food exchange list was used to help patients for food substitutes if participant unable to follow the meal prescribed according to like and dislike or socio economic reasons). After calculation of all nutrients needed by each participant, individual meal plan for the whole week was designed by researcher, typed, organized, color printed and given to participant with full explanation of uses. The meals planned were designed only for intervention patients, whereas control patients continued to receive their usual care.

Results: Demographic characteristic of the study sample: For the demographic characteristic of the study participants, test and control, Males represented a higher percentage than the females. The age group distribution of subject shows that most of the patients (46.3%) were in the active age group of 30 - 45 yrs. (49.4% test and 42.1% control). The majority (31.3%) had higher secondary school education (29.9% test and 33.3 % control), followed by 17.9% university graduates (23.4% test and 10.5% control), the rest were illiterate or with low educational level. Medical profile of the participants

The medical characteristics of the study: Participants are shown that 53.7% of the participant had hypertension (61.0% test and 43.9% control), while only 3.0% had diabetes mellitus and hypertension (1.3% test and 5.3% control) and the rest 43.3% did not have any comorbid disease (37.7% test and 50.9% control). The mean extents of dialysis eras were 57.08 ± 36.16 months for the together groups (61.77 ± 38.84 test and (50.75 ± 31.42 control group).

Serum albumin augmented progressively from 3.14 g/dl at zero to 4.32 g/dl at 6 months with test group. The study displays big alterations in accumulation of serum albumin level during the study with intervention group compared with control. The mean test group was (3.1, 3.3, 3.9 and 4.3) and the mean of control group was (3.2, 3.16, 3.19 and 3.84) in baseline, 2-4-6 months respectively.

Conclusion: The study demonstrated that effective nutritional counseling rendered to maintenance hemodialysis patients in the form of individualized meal plans that provided adequate energy and protein was active in the switch and enhancement of serum albumin equal among these patients. Therefore, nutritious counseling by skilled dietitians is mandatory in renal units as part of the medical therapy management to reduce the incidence of hypoalbminemia among hemodialysis patients.

Biography:

Suhair Abdalla Khalil Abdallah 在苏丹阿法德女子大学获得临床营养学博士学位。她是沙特阿拉伯费萨尔国王专科医院和研究中心的临床营养师。她在临床营养领域拥有 18 年的丰富经验。

注：本研究部分成果于 2016 年 6 月 16 日至 18 日在意大利罗马举行的第五届欧洲营养与饮食学会议上发表