個別化營養諮詢對後期慢性腎臟疾病患者營養狀況之探討

The effect of individualized nutritional counselling on nutritional status in the patients with late-stage chronic kidney disease

林郁茹(Yu-Ju Lin)

指導教授 ： 趙振瑞

臺北醫學大學/公共衛生暨營養學院/保健營養學研究所/碩士(2014年)

https://doi.org/10.6831/TMU.2014.00056

摘要

根據衛生福利部公佈2012年公佈國人「十大主要死因」，腎炎、腎症候群、腎性病變位居第十位；慢性腎臟病(chronic kidney disease, CKD)在全世界人口中，30歲以上的成年人的罹病率達7.2%；65歲以上的患病率達23.4-35.8％。腎臟功能的衰退伴隨臨床上常見的特徵為：血液尿素氮、肌酸酐、尿酸上升；氮血症、貧血、代謝性酸中毒、高血磷、低血鈣等症狀。本研究預計回溯臺北醫學大學附設醫院經腎臟內科醫師診斷為慢性腎臟病第三至五期病人40例，且規律回診腎臟科，年齡介於20至90歲，一年內有兩次以上的營養諮詢紀錄，並有完整24小時飲食紀錄者，共計回溯15例。平均年齡75.1±9.8歲；平均BMI 24.1±3.1公斤/公尺2；平均收縮壓/舒張壓 139.7±13.6/79.7±13.2 毫米汞柱。營養諮詢後，飲食攝取熱量顯著高於營養諮詢前(1557.8±215.3 v.s 1378.1±215.3大卡；P＜0.00)；但仍低於飲食建議攝取量(1751.4±152.0大卡)。營養諮詢後醣類攝取有顯著增加(198.2±45.0 v.s 216.0±48.8 公克；P＝0.00)；飽和脂肪酸攝取顯著下降(18.3±10.3 v.s 23.9±10.4 公克；P＝0.03)；但未達建議量＜7%總熱量的建議目標。營養諮詢後膽固醇攝取顯著下降(117.6±88.7 v.s 184.0±116.2 mg/dL；P＝0.03)。若依性別分組，男、女性於營養諮詢後熱量攝取皆顯著高於營養諮詢前(男性：1441.9±247.0 v.s 1612.2±178.6大卡；P＜0.00；女性：1102.6±153.2 v.s 1316.7±205.4大卡；P＝0.00)。女性的蛋白質攝取在營養諮詢後顯著減少(41.6±7.5 v.s 37.5±6.6公克；P＝0.048)。
針對後期慢性腎臟病患者給予個別化的營養諮詢，病人的每日熱量攝取量與兩次諮詢間相比有顯著增加，但仍未達每日建議攝取量；三大營養素：醣類攝取量兩次營養諮詢間有顯著增加；飽和脂肪酸攝取量兩次營養諮詢間有顯著減少，蛋白質攝取則無顯著差異。而營養諮詢前後，病人體位、白蛋白、血壓、血容比、腎絲球過濾率皆無顯著差異。給予CKD病人適當且個別化的營養諮詢，可改善其整體熱量攝取量，但不影響病人的營養狀況。

關鍵字

慢性腎臟疾病 ； 營養諮詢 ； 營養狀況

並列摘要

According to the report by the Ministry of Health and Welfare in 2012, nephritis, nephrotic syndrome, and renal osteodystrophy ranked in tenth of the leading causes of death in Taiwan. The morbidity of chronic kidney disease (CKD) in the world's population in the adults above 30 years old is 7.2%, and the prevalence of CKD is 23.4-35.8% in the patients above 65 years old. The decline of renal function is associated with common clinical characteristics, such as increasing blood urea nitrogen, creatinine, and uric acid, azotemia, anemia, metabolic acidosis, hyperphosphatemia, and hypocalcemia. Our retrospective study recruited 40 patients who were diagnosed chronic kidney disease in stage 3 to 5 by nephrology physicians in Taipei Medical University Hospital, and followed up in outpatient department regularly. Inclusion criteria of CKD patients those age between 20-90 years, more than two times of nutritional counseling records within one year and completed 24-hour dietary records. Dietitians provided individualized dietary instruction according to patients’ different stages of chronic kidney disease and compared dietary intake before and after dietary counseling. Additionally, nutritional status and renal functions were monitored. The mean age was 75.1±9.8 years; mean BMI was 24.1±3.1 kg / m2; mean systolic / diastolic blood pressure were 139.7±13.6/79.7±13.2 mmHg. Total caloric intake was significantly increased after nutritional counseling (1557.8±215.3 v.s 1378.1±215.3 kcal; P<0.00), but still lower than dietary suggestion (1751.4±152.0 kcal). After nutritional counseling,carbohydrate was significantly increased(198.2±45.0 v.s 216.0±48.8 g；P＝0.00) and saturated fatty acids was significantly decreased (18.3±10.3 v.s 23.9±10.4 g; P = 0.03). After nutritional counseling, cholesterol intake was significantly decreased (117.6±88.7 v.s 184.0±116.2 mg/dL; P = 0.03). If we compared in gender, total caloric intake were both significantly higher in male and female after nutritional counseling (male: 1441.9±247.0 v.s 1612.2±178.6 kcal; P<0.00; female: 1102.6±153.2 v.s 1316.7±205.4 kcal; P= 0.00). Protein intake in female had a significant reduction (41.6±7.5 v.s 37.5±6.6g; P＝0.048) after nutritional counseling.
There was a significant increment in caloric intake in CKD patients with individualized nutritional counseling, but still not achieved dietary suggestion. There were no differences between 2 times of nutritional counseling in proteins intake, but higher in carbohydrate intake, and lower in saturated fatty acids intake. Also there were no significant differences in patients’ anthropometry, albumin, blood pressure, hematocrit and eGFR after nutritional counseling. Given CKD patients individualized nutritional counseling could improve their total calorie intake without changing their nutritional status.

並列關鍵字

chronic kidney disease ； nutritional counseling ； nutritional status

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