Wong Petula, Smith Pamela, Rodger Diane
In-Centre Hemodialysis Unit, Capital Health, Queen Elizabeth II, Health Sciences Centre, Halifax NS.
CANNT J. 2003 Apr-Jun;13(2):31-46; quiz 37-9,46-8.
Protein energy malnutrition in dialysis patients has been well-described in the literature. Most malnourished patients with end stage renal disease (ESRD) suffer from a mixed marasmus-kwashiorkor type of malnutrition with loss of both somatic and visceral protein mass. Malnutrition is associated with increased risk of morbidity and mortality. Up to 50% of patients on dialysis have protein energy malnutrition (Mortelmans & Vanholder, 1999). Malnutrition may be under-recognized and under-reported in dialysis patients. Malnutrition may result from inadequate food intake secondary to the uremic condition, nausea, vomiting, loss of appetite, altered taste and other physiologic conditions that impede food intake or metabolism. The usual indices of nutritional assessment--body weight, body mass index (BMI), anthropometrics, etc., may be inaccurate in patients with ESRD, as the results are often skewed by fluid retention. Therefore, we often rely on weight loss, bloodwork, a pre-dialysis low serum potassium, phosphorus and urea, as early signs of a decreased food intake. When patients are malnourished, measures such as oral supplements and/or tube feedings may be used to augment protein and calorie intake. However, when these interventions are inadequate to reverse the malnutrition condition, intradialytic parenteral nutrition (IDPN) should be implemented. Although there is no definite supportive data to show that the use of IDPN improves morbidity and mortality of dialysis patients, there are data to support that IDPN has positive effects on numerous nutritional parameters (Acchiardo, 2000; Capelli et al., 1994; Foulks, 1999; Hiroshige et al., 1998; Ikizler et al., 1995; Korzets et al., 1999; Mortelmans & Vanholder, 1999; Saunders et al., 1999; Smolle et al., 1995). In this article, we will discuss the causes of malnutrition in dialysis patients, the use of IDPN on one of our patients, and the potential complications associated with IDPN.
透析患者的蛋白质能量营养不良在文献中已有充分描述。大多数终末期肾病（ESRD）的营养不良患者患有混合型消瘦 - 夸希奥科病型营养不良，体蛋白和内脏蛋白均有丢失。营养不良与发病风险和死亡风险增加相关。高达50%的透析患者存在蛋白质能量营养不良（Mortelmans和Vanholder，1999年）。营养不良在透析患者中可能未得到充分认识和报告。营养不良可能源于尿毒症状态、恶心、呕吐、食欲不振、味觉改变以及其他妨碍食物摄入或代谢的生理状况导致的食物摄入量不足。常用的营养评估指标——体重、体重指数（BMI）、人体测量学指标等，在ESRD患者中可能不准确，因为结果常因液体潴留而出现偏差。因此，我们常常依靠体重减轻、血液检查、透析前低血钾、低磷和低尿素水平，作为食物摄入量减少的早期迹象。当患者营养不良时，可采用口服补充剂和/或管饲等措施来增加蛋白质和热量摄入。然而，当这些干预措施不足以扭转营养不良状况时，应实施透析期间胃肠外营养（IDPN）。尽管没有确凿的支持数据表明使用IDPN可改善透析患者的发病率和死亡率，但有数据支持IDPN对众多营养参数有积极影响（Acchiardo，2000年；Capelli等人，1994年；Foulks，1999年；Hiroshige等人，1998年；Ikizler等人，1995年；Korzets等人，1999年；Mortelmans和Vanholder，1999年；Saunders等人，1999年；Smolle等人，1995年）。在本文中，我们将讨论透析患者营养不良的原因、我们一名患者使用IDPN的情况以及与IDPN相关的潜在并发症。
