慢性肾脏病营养代谢中的脑-肾对话

大脑通过与代谢依赖通路和交感神经系统（SNS）的免疫通路沟通,在脑-肾脏轴中有相当程度的参与。在慢性 肾脏病的疾病进程中,神经系统疾病如脑血管疾病、认知障碍和神经病等的频繁出现,表明肾脏和大脑之间存在大量 的串扰。文章从慢性肾脏病患者的营养代谢特点为切入点,探讨了脑-肾对话在慢性病肾脏病中的病理生理机制, 如微血管和脑白质病变、同型半胱氨酸血症、激素与神经递质调节紊乱、免疫炎症反应和交感神经系统等影响肾脏和 大脑的体液和非体液双向通路调控机制,深入了解慢性肾脏病和终末期肾病患者营养代谢紊乱的病因和发病机制, 为优化蛋白质营养和改善预后提供更有效的策略。     

腹膜透析患者蛋白质能量消耗的危害与防治

正营养问题一直是透析患者重要而棘手的临床难题,而腹膜透析患者中蛋白质能量消耗(PEW)普遍且严重。2008年国际肾脏病营养与代谢专家委员会(ISRNM)提出了PEW的概念,并将其诊断标准定义为低血清白蛋白、低甲状腺素转运蛋白和低胆固醇,此后针对慢性肾脏病(CKD)患者PEW的防治进行了较为深入地探索。     

老年肾脏病的营养治疗

随着社会和医疗条件的不断改善,人口老龄化日益明显,老年肾脏病也成为一个突出问题。肾脏疾病与营养代谢关系密切,当有肾脏疾病时,会产生一系列营养代谢障碍,长期营养不良直接影响患者的生存率和生活质量。另一方面,营养物质摄入过多,也会加重肾脏负担,导致肾功能的进一步恶化。因此肾脏疾病时正确的营养供给是非常重要的。老年人由于其独特的生理特点,营养需求的变化,其肾脏病的营养治疗也具有特殊性。下面就老年人的生理代谢特点和营养需求以及老年肾脏病的营养治疗作一阐述。1　老年生理代谢特点和营养需求　　老年人生理机能的改变涉及…     

营养支持改善危重肾脏病患者营养状况的前瞻性研究

目的:调查危重肾脏病患者营养风险及营养不良发生率,前瞻性研究短期营养支持后危重肾脏病患者营养状况的变化. 方法:应用营养风险筛查2002量表(NRS2002)对2011年8月至2012年6月南京军区南京总医院全军肾脏病研究所ICU的患者进行筛查.对NRS2002评分≥3分患者行营养支持,同时测量和检测营养评价指标. 结果:466例患者完成NRS2002筛查,其中营养风险发生率87.3％,营养不良发生率25.1％.137(33.7％)例患者进入营养支持研究,其中男性76例(55.4％),女性61例(44.6％),平均年龄(40.0±17.3)岁.营养支持方式包括食物添加营养素23例(16.8％),肠内营养97例(70.8％),肠外营养2例(1.5％),肠内营养+肠外营养15例(10.9％).入院第1天、第3天、第7天,摄入热卡分别为15.4±7.3 kcal/kg、20.9±8.2 kcal/kg、22.3±8.5 kcal/kg(P =0.001);蛋白质摄入量分别为0.5±0.2g、0.6±0.3g、0.7±0.3g(P =0.001).入院第7天与第1天相比,血清白蛋白、前白蛋白、转铁蛋白、淋巴细胞计数升高明显(P=0.00l);男性及女性患者细胞内水/细胞外水比值(I/E)有不同程度提高. 结论:危重肾脏病患者营养风险发生率高达87.3％,营养不良发生率25.1％.短期营养支持后血清白蛋白、前白蛋白、转铁蛋白、淋巴细胞计数及体内水分分布异常较前改善.     

慢性肾脏病住院患者的NRS2002营养筛查及其意义

目的应用营养风险筛查2002(Nutritional risk screening 2002,NRS2002)对慢性肾脏病(CKD)患者进行营养风险筛查,了解CKD住院患者的营养状况以及NRS2002评分与其他营养相关指标的关系,指导临床及早对患者进行营养干预、改善预后。方法对入院1周内的CKD住院患者应用NRS2002进行营养风险筛查,根据NRS2002评分将患者分为营养正常组和营养风险组;比较两组患者的一般情况;检测比较两组患者的血红蛋白(Hb)、淋巴细胞计数、肾功能(血肌酐、尿素氮、尿酸、24 h尿蛋白)、总蛋白、白蛋白(ALB)、血脂、电解质等水平;分析患者NRS2002评分与其他营养相关指标的关系。结果接受营养风险筛查的197例CKD住院患者中,具有营养风险的患者共有53例(26.9%);营养风险组患者的BMI、血红蛋白(Hb)、总胆固醇、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、血钠、血磷、尿素、肾小球滤过率(eGFR)水平均显著低于营养正常组患者,差异有统计学意义(P0.05)。Pearson相关分析结果显示,患者的NRS2002评分与其BMI、Hb、eGFR水平呈负相关,与其血钠水平呈正相关;患者的ALB水平与其eGFR水平呈负相关。结论 NRS2002评分能较全面地反映出慢性肾脏病住院患者的营养风险,为早期营养干预提供重要依据,对改善患者预后具有重要的临床意义。     

慢性肾脏病患者的营养治疗:明确目标,改进指导

<正>近年的研究表明,营养疗法在改善慢性肾脏病(CKD)患者营养状况、提高患者生活质量及预后方面,均有重要作用。因此,需要进一步加强CKD患者营养疗法的研究和应用,实现保护靶器官、改善营养状况的目标。营养治疗是CKD患者的客观需要营养素代谢失调,是CKD患者出现多种临床表现的主要原因之一,也是CKD患者肾衰竭进展的重要因素。     

老年慢性肾脏病合并肌少症的研究进展

肌少症是以骨骼肌质量、力量及功能降低为主要特征的退行性综合征。肌少症与衰老密切相关,但是,慢性肾脏病等疾病可以加速肌肉消耗,增加肌少症的发生率。慢性肾脏病患者易合并肌少症,其机制涉及炎症反应、蛋白质能量消耗、运动减少及维生素D缺乏等。早期识别肌少症的危险因素并对其进行干预,对于慢性肾脏病合并肌少症患者生活质量的改善至关重要。目前,干预措施主要有体育锻炼、营养补充及药物治疗等。本文就近年对老年慢性肾脏病合并肌少症的发病情况、机制及治疗的研究进展作一综述。     

慢性肾脏病饮食营养管理

有效的饮食营养管理对于延缓肾病进展,改善慢性肾脏病(CKD)患者的预后具有重要的意义。然而现有的CKD患者饮食营养管理中存在很多问题,如何进行有效的CKD饮食营养管理是亟待解决的重要课题。有效的CKD饮食营养干预应建立在慢性疾病管理基础上,提供有肾科营养师参与的团队治疗,建立规范的CKD饮食营养临床路径、随访目标并进行合理评估,同时实施多维度的饮食营养教育。     

老年慢性肾脏病合并糖尿病的营养治疗

营养治疗是慢性肾脏病（chronic kidney disease, CKD）治疗的重要组成部分，合并糖尿病的老年CKD的营养治 疗存在着特殊性。低蛋白饮食作为营养治疗的核心，可以改善合并糖尿病的老年CKD患者的预后，但同时引发营养 不良、血糖升高、心情低落的风险较年轻患者更高，因此适度的低蛋白饮食和及时的营养状态评估对于此类人群尤为 重要，同时应提高老年患者饮食治疗的依从性从而保障低蛋白饮食的实施。需要特别注意的是合并糖尿病的老年 CKD患者也常伴有心脑血管疾病等其他合并症，应该结合患者的营养状况，综合考虑制定个体化营养方案。     

EPO类药物的某些进展

贫血是慢性肾脏病（CKD）最常见的并发症之一，常导致患者生活质量下降。美国健康与营养调查研究会和肾脏病基金会调查发现，当肾小球滤过率（GFR）下降至60ml/min以下时，贫血的危险明显增大，当GFR在30～59ml/min时，约5％的患者出现贫血，而当GFR降至15～29ml／min时，44％的患者发生贫血。     

从肠内营养探讨补土法在克罗恩病中的应用

克罗恩病(Crohn’s disease,CD)是一种复发率极高、病因和发病机制仍然不明的胃肠道慢性肉芽肿性炎症性疾病,好发于回肠末端和结肠,病变严重者可累及各段消化道,青壮年为主要的患病人群,患者多表现出腹泻、腹痛、腹块、瘘管形成和肠梗阻等症状,部分患者还可能伴有发热、营养不良等肠外症状,尚不能治愈,且并发症多,极大程度影响了患者的生活[1]。     

Nutrition and growth in children with chronic kidney disease

Poor growth in chronic kidney disease (CKD) is a marker of disease severity and of quality of care. Causes are multifactorial, and include malnutrition, cachexia, hematological factors, endocrine problems and metabolic abnormalities. In this Review, we focus on the impact of inadequate nutrition on growth disturbances in children with CKD, and discuss all aspects of the epidemiology, causes and potential treatments. Regional variations in resources may be a factor that contributes to the observed differences. Successful nutritional management requires a multidisciplinary team that includes not only doctors but also skilled nurses and dieticians. Extremes of body mass index, representing undernutrition and overnutrition, are associated with poor outcomes and should be avoided when designing therapeutic strategies for optimizing nutrition and growth in children with CKD. Improved understanding of the pathophysiology of cachexia and wasting in patients with CKD could lead to the development of novel therapeutic strategies.     

Transculturalization of a Diabetes-Specific Nutrition Algorithm: Asian Application

The prevalence of type 2 diabetes (T2D) in Asia is growing at an alarming rate, posing significant clinical and economic risk to health care stakeholders. Commonly, Asian patients with T2D manifest a distinctive combination of characteristics that include earlier disease onset, distinct pathophysiology, syndrome of complications, and shorter life expectancy. Optimizing treatment outcomes for such patients requires a coordinated inclusive care plan and knowledgeable practitioners. Comprehensive management starts with medical nutrition therapy (MNT) in a broader lifestyle modification program. Implementing diabetes-specific MNT in Asia requires high-quality and transparent clinical practice guidelines (CPGs) that are regionally adapted for cultural, ethnic, and socioeconomic factors. Respected CPGs for nutrition and diabetes therapy are available from prestigious medical societies. For cost efficiency and effectiveness, health care authorities can select these CPGs for Asian implementation following abridgement and cultural adaptation that includes: defining nutrition therapy in meaningful ways, selecting lower cutoff values for healthy body mass indices and waist circumferences (WCs), identifying the dietary composition of MNT based on regional availability and preference, and expanding nutrition therapy for concomitant hypertension, dyslipidemia, overweight/obesity, and chronic kidney disease. An international task force of respected health care professionals has contributed to this process. To date, task force members have selected appropriate evidence-based CPGs and simplified them into an algorithm for diabetes-specific nutrition therapy. Following cultural adaptation, Asian and Asian-Indian versions of this algorithmic tool have emerged. The Asian version is presented in this report.     

老年慢性阻塞性肺疾病早期肾损伤相关因素

目的：探讨影响老年慢性阻塞性肺疾病（COPD）患者早期肾损伤的临床指标。方法收集入住于宁夏人民医院呼吸内科的60例COPD患者作为研究对象（COPD组）;选择该院体检中心的30例健康体检者（对照亚组）。亚组：60例COPD组依据患病时间分为病程≤10年亚组和病程＞10年亚组;依据营养状况分为营养欠佳亚组和营养正常亚组。营养状况主要测定COPD患者白蛋白（ALB）、血红蛋白（Hb）、总胆固醇（TC）水平。评估COPD组及对照组的血清肌酐（SCr）、尿素氮（BUN）、β2微球蛋白（β2-MG）、白细胞（WBC）、中性粒细胞百分比（NE%）、血清胱抑素C（CysC）及估算肾小球滤过率（eGFR）等指标。结果与对照组比较,COPD组SCr、BUN、WBC、NE%差异无统计学意义（P＞0.05）,eGFR, ALB,Hb,TC均明显降低,CysC 及β2-MG明显升高,差异均有统计学意义（P＜0.05）;亚组分析,与病程≤10年亚组和营养状况正常亚组比较,血清CysC及β2-MG浓度在病程＞10年亚组及营养状况欠佳亚组均明显升高（P＜0.05）;eGFR在病程＞10年亚组明显低于病程≤10年亚组（P＜0.05）;SCr在各亚组间比较差异均无统计学意义（P＞0.05）;Pearson线性相关性分析：eGFR与ALB和Hb呈正相关,与患病时间呈负相关;CysC和β2-MG与eGFR呈负相关。结论老年COPD患者存在早期肾损伤,随COPD病程延长及ALB,Hb,TC降低,早期肾损伤加重;患病时间、血清ALB和Hb水平影响老年COPD患者慢性缺氧早期肾损伤,与早期肾损伤呈线性相关。     

The new KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and CKD

BACKGROUND/AIMS: The National Kidney Foundation (NKF) recently published new guidelines and clinical practice recommendations for the diagnosis and management of patients with diabetes and chronic kidney disease (CKD). METHODS: Guidelines were developed using an evidence-based approach. When sufficient evidence was lacking, recommendations were developed that reflect expert opinion. RESULTS: Guidelines describe the process for screening and diagnosis of kidney disease in the setting of diabetes and the management of hyperglycemia, hypertension, dyslipidemia, and nutrition. Recommendations describe the management of albuminuria in the normotensive diabetic patient and the potential value of albuminuria as a marker of treatment efficacy; the impact of diabetes and CKD in special populations; the importance of behavioral self-management; and the value of intensive multifaceted intervention in these high risk patients. CONCLUSIONS: The new guidelines and recommendations update and extend the scope of the NKF's Kidney Disease Outcomes Quality Initiative (KDOQI(TM)).     

Transplantation of an eight-organ multivisceraI graft in a patient with frozen abdomen after complicated Crohn's disease

To report an extended multivisceral transplantation (MVTx) including right kidney and ascending colon in a patient with complicated Crohn's disease (CD). A 36-year old female suffering from short bowel syndrome and frozen abdomen due to fistulizing CD after multiple abdominal operations underwent MVTx of eight organs including stomach, pancreatoduodenal complex, liver, intestine, ascending colon, right kidney, right adrenal gland, and greater omentum in November 2003. Immunosuppression consisted of alemtuzumab, tacrolimus and steroids. The patient was off parenteral nutrition by postoperative wk 3. She experienced one episode of pneumonia. The patient recovered completely and discharged 2.5 mo and was doing well 30 mo after MVTx. This is one of the very rare cases in which a complete mulitivisceral graft of eight abdominal organs was transplanted orthotopically.     

Transplantation of an eight-organ multivisceral graft in a patient with frozen abdomen after complicated Crohn＇s disease

To report an extended multivisceral transplantation (MVTx) including right kidney and ascending colon in a patient with complicated Crohn's disease (CD). A 36-year old female suffering from short bowel syndrome and frozen abdomen due to fistulizing CD after multiple abdominal operations underwent MVTx of eight organs including stomach, pancreatoduodenal complex, liver, intestine, ascending colon, right kidney, right adrenal gland, and greater omentum in November 2003. Immunosuppression consisted of alemtuzumab, tacrolimus and steroids. The patient was off parenteral nutrition by postoperative wk 3. She experienced one episode of pneumonia. The patient recovered completely and discharged 2.5 mo and was doing well 30 mo after MVTx. This is one of the very rare cases in which a complete mulitivisceral graft of eight abdominal organs was transplanted orthotopically.     

Strategies to Reduce Rehospitalization in Patients with CKD and Kidney Failure

Readmissions in patients with nondialysis-dependent CKD and kidney failure are common and are associated with significant morbidity, mortality, and economic consequences. In 2013, the Centers for Medicare and Medicaid Services implemented the Hospital Readmissions Reduction Program in an attempt to reduce high hospitalization-associated costs. Up to 50% of all readmissions are deemed avoidable and present an opportunity for intervention. We describe factors that are specific to the patient, the index hospitalization, and underlying conditions that help identify the “high-risk” patient. Early follow-up care, developing volume management strategies, optimizing nutrition, obtaining palliative care consultations for seriously ill patients during hospitalization and conducting goals-of-care discussions with them, instituting systematic advance care planning during outpatient visits to avoid unwanted hospitalizations and intensive treatment at the end of life, and developing protocols for patients with incident or prevalent cardiovascular conditions may help prevent avoidable readmissions in patients with kidney disease.     

Gallbladder disease in patients on long-term parenteral nutrition

Recent anecdotal reports suggest that total parenteral nutrition may be associated with an increased incidence of both acalculous cholecystitis and cholelithiasis. The validity of this association, however, has not been tested in a large population of patients on long-term total parenteral nutrition. Therefore, we assessed the incidence of gallbladder disease among our patients 15 yr and older who had received a minimum of 3 mo of total parenteral nutrition. Of the patients meeting these criteria, 128 were on total parenteral nutrition a mean of 13.5 mo. Nineteen had gallbladder disease before receiving total parenteral nutrition, leaving 109 patients at risk. Of these patients, 25 (23%) developed gallbladder disease after the initiation of total parenteral nutrition. Because of their known propensity for cholelithiasis, 94 of our patients with ileal disorders (Crohn's disease or ileal resection, or both) were considered separately. The 40% incidence of gallbladder disease in these 94 patients was significantly higher than expected from a series of similarly defined patients with ileal disorders not receiving total parenteral nutrition (p less than 0.05). We propose that the enhanced risk of gallbladder disease among patients on long-term total parenteral nutrition results from multiple factors working in concert to promote gallbladder stasis.