Leon Janeen B, Albert Jeffrey M, Gilchrist Gina, Kushner Irving, Lerner Edith, Mach Suzanne, Majerle Angela, Porter David, Ricanati Edmond, Sperry Laurine, Sullivan Catherine, Zimmerer Jennifer, Sehgal Ashwini R
Division of Nephrology, MetroHealth Medical Center, Cleveland, OH 44109, USA.
Am J Kidney Dis. 2006 Jul;48(1):28-36. doi: 10.1053/j.ajkd.2006.03.046.
Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients, yet few interventions are available to improve albumin levels. Moreover, the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear. We sought to determine whether targeting specific nutritional barriers will improve albumin levels.
We conducted a randomized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL (<37 g/L) at 44 long-term hemodialysis facilities. Study coordinators identified and intervened on specific barriers present among intervention patients, whereas control patients continued to receive the usual care. Barriers targeted included poor nutritional knowledge, poor appetite, help needed with shopping or cooking, low fluid intake, inadequate dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, and acidosis.
At baseline, intervention and control patients had similar albumin levels, dietary intakes, levels of inflammatory markers, and numbers of nutritional barriers. After 12 months, intervention patients had greater increases in albumin levels compared with control patients (+0.21 versus +0.06 g/dL [+2.1 versus +0.6 g/L]; P < 0.01), as well as greater increases in energy intake (+4.1 versus -0.6 Kcal/d/kg; P < 0.001) and protein intake (+0.13 versus -0.06 g/d/kg; P < 0.001). The intervention appeared most effective for barriers related to poor nutritional knowledge, help needed with shopping or cooking, and difficulty swallowing. About half the subjects had elevated levels of inflammatory markers, but there was no relationship between change in levels of albumin and inflammatory markers.
A nutrition intervention tailored to patient-specific barriers resulted in modest improvements in albumin levels regardless of levels of inflammatory markers.
低白蛋白水平是血液透析患者死亡率和发病率的有力预测指标，但改善白蛋白水平的干预措施却很少。此外，营养障碍与炎症在导致低白蛋白血症方面的相对重要性尚不清楚。我们试图确定针对特定营养障碍是否能提高白蛋白水平。
我们在44家长期血液透析机构对180例基线白蛋白水平低于3.7 g/dL（<37 g/L）的患者进行了一项随机对照试验。研究协调员识别并干预干预组患者中存在的特定障碍，而对照组患者继续接受常规护理。针对的障碍包括营养知识匮乏、食欲不佳、购物或烹饪需要帮助、液体摄入量低、透析剂量不足、抑郁、咀嚼困难、吞咽困难、胃肠道症状和酸中毒。
基线时，干预组和对照组患者的白蛋白水平、饮食摄入量、炎症标志物水平和营养障碍数量相似。12个月后，与对照组患者相比，干预组患者的白蛋白水平升高幅度更大（分别为+0.21与+0.06 g/dL[+2.1与+0.6 g/L]；P<0.01），能量摄入量（分别为+4.1与 -0.6 Kcal/d/kg；P<0.001）和蛋白质摄入量（分别为+0.13与 -0.06 g/d/kg；P<0.001）的增加幅度也更大。该干预措施对与营养知识匮乏、购物或烹饪需要帮助以及吞咽困难相关的障碍似乎最为有效。约一半受试者的炎症标志物水平升高，但白蛋白水平变化与炎症标志物之间无关联。
针对患者特定障碍的营养干预措施，无论炎症标志物水平如何，均可使白蛋白水平有适度改善。
