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QUESTION TIME. La supplementazione proteica nutrizionale è necessaria nel paziente in dialisi peritoneale?. Giuliano Brunori Ospedale Santa Chiara Trento Bari 19 marzo 2009. Supplementi per os (0.1- 0.3 g proteine kg BW/die). pre post p

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QUESTION TIME

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  1. QUESTION TIME La supplementazione proteica nutrizionale è necessaria nel paziente in dialisi peritoneale? Giuliano Brunori Ospedale Santa Chiara Trento Bari 19 marzo 2009

  2. Supplementi per os (0.1- 0.3 g proteine kg BW/die) pre post p Protidemia totale (g/dl) 6.20.7 6.70.7 <0.05 Albuminemia (g/dl) 3.460.51 3.820.46 <0.05 BUN (mg/dl) 63.66.3 87.67.5 <0.05 Creatininemia (mg/dl) 10.573.07 11.102.79 <0.05 Colesetrolemia (mg/dl) 18342 20237 NS Trigliceridemia 13668 201104 <0.05 PCR 0.910.20 1.150.22 NR Peso (kg) 52.38.9 54.68.6 NR Shimomura et al. Adv Perit Dial, 1993

  3. CONCLUSIONS: Oral EAAs induce a significant improvement in the serum albumin concentration in hemodialysis but not peritoneal dialysis subjects. Further study of their long-term effects on morbidity and mortality is warranted. Kidney Int. 2000 Jun;57(6):2527-38.

  4. * *Aminess N = 5 compresse/die, contenuto 720 mg per compressa

  5. RCT of oral admministration of egg-albumin based protein supplements* to CAPD Control group (15) Study group (13) p Variable 0 mths 6 mths 0 mths 6mths s. Albumin (g/dl) 2.66±0.6 2.80±0.5 2.64±0.3 3.06±0.7 < 0.05 BUN (mg/dl) 49.7±13 53.9±11 52.6±16 63.3±20 Hb (g/dl) 9.0 (6-11) 8.1 (7-12) 8.2 (7-11) 9.5 (8-10) Chol (mg/dl) 174 181 193 187 Phosphorus (mg/dl) 4.4 (2.8-5.4) 3.5 (2.0-4.8) 6.0 (4.9-7.3) 5.9 (4.2-6.9) < 0.05 *Supplemento: 15 g polvere (aggiunta ai cibi o alle bevande), due volte al giorno Gonzalez_Espinola L et al. Perit Dial Int 2005; 25:173-180

  6. RCT of oral admministration of egg-albumin based protein supplements to CAPD Control group (15) Study group (13) p Variable 0 mths 6 mths 0 mths 6mths Calorie intake (kcal) 1423±410 1567±381 1331±432 1872±698 <0.05 Protein intake (g/kg) 1.0±0.4 1.0±0.3 1.0±0.3 1.7±0.7 <0.05 nPNA (g/kg/day) 0.91±0.11 0.97±0.14 1.0±0.23 1.18±0.35 <0.05 BMI 24.2±3.9 24.5±3.2 22.3±2.7 22.5±3. Gonzalez_Espinola L et al. Perit Dial Int 2005; 25:173-180

  7. SGNA Δ albuminemia RCT of oral admministration of egg-albumin based protein supplements* to CAPD Gonzalez_Espinola L et al. Perit Dial Int 2005; 25:173-180

  8. 118-124 118-124 118-124 157 pts on HD 33 pts on PD 2 lattine al giorno, apporto: 25 g proteine, 500 calorie

  9. - Compensano le perdite di aminoacidi - Compensano l’inadeguato apporto proteico - Migliorano le alterazioni del profilo aminoacidico - Riducono il carico di glucosio - Possono migliorare l’assetto lipidico - Migliorano lo stato nutrizionale (?) - Accentuano l’acidosi Uso soluzioni con aminoacidi

  10. Turnover proteico:pre/post trattamento 16 pazienti; trattamento 21 giorni Metabolismo Proteico (g/kg/die) Peso (kg) Bilancio N Sintesi Catabolismo Bilancio Basale 68.7+11.8 0.022+0.028 2.25+0.59 2.01+0.65 0.24+0.18 Trattamento 69.0+12.0 0.022+0.035 2.49+0.97 2.14+1.00 0.35+0.23 p (B vs T) NS =0.002 NS NS 0.001 JD Kopple et al. Kidney Int 1995, 47:1148

  11. P=0.022 P=NS Protidemia totale e transferrina pre e post trattamento Protidemia Totale, g/dl totale, g/dl Transferrina, mg/dl totale, g/dl /dl , mg/dl , mg/dl P=0.033 P=0.033 P=0.033 P=0.033 P=0.022 P=0.022 P=0.022 P=NS 400 P=NS 400 P=NS 400 8.0 P=NS 8.0 8.0 400 8.0 P=NS P=NS P=NS 200 200 200 4.0 4.0 4.0 200 4.0 0 0 0 0.0 0 0.0 0.0 0.0 giorni 0 16 36 0 16 36 0 16 36 0 16 36 0 16 36 0 16 36 0 16 36 0 16 36 J, 1995 giorni J.D giorni , 1995 giorni from: JD Kopple et al, Kidney Int 1995; 47:1148

  12. Dialysate as food (APD patients) Prestudy End AAG End G Bicarbonate (mmol/L) 22.8±2.2b 24.5±1.7c 26.3±1.0 Urea (mmol/L) 22.7±7.1 21.1±4.1c 21.1±5.0 Phosphate (mmol/L) 2.0±0.4 1.9±0.6d 2.1±0.4 Albumin (g/L) 38±3.0 38±3.0 39±3.0 Net protein balance increase in all 8 pts in AAG period (-0.41±0.16) vs G (-0.62±0.16) (p<0.001) Nitrogen balance change from -0.60±2.38 in G period to 0.35±3.25 in AAG (p<0.061) Tjiong HL et al. JASN 2005; 16:1486-1493

  13. PD e sLPD • RCT a tre diversi livelli di introito proteico: • 1.2 g prot/kg/day (20 pts, 17 compl) • 0.6-0.8 g prot/kg/day (20 pts, 18 compl) • 0.6-0.8 g prot/kg/day + 0.12 g /kg/day di ketoacidi (20 pts, 18 compl) Ipotesi: LPD (sLPD) preserva la funzione renale, senza indurre NB negativo Jiang N et al, Nephrol Dial Transplant 2009; 24:2551-2558

  14. PD e sLPD • a 12 mesi eGFR • sLPD: 3.5 ml/min (t0: 3.9) • LPD: 2.2 ml/min (t0: 4.0) • HP: 2.6 ml/min (t0:4.3) Stabilità in tutti i gruppi dei parametri nutrizionali (albumina, BMI, SGA) nel gruppo sLPD riduzione statisticamente significativa dei livelli di PTH

  15. Conclusione • Dati discordanti • Utile nei pazienti con bassi introiti proteici • Palatabilità dei prodotti • Maggior utilizzo del counseling dietetico? • Utilizzo routinario, in pazienti con intake <0.8 g prot/kg/die di soluzioni contenenti AA? (certezza dell’assunzione) • Ruolo dei ketoacidi?

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