栄養障害と治療のジャーナル

概要

臨床栄養学 2020: 個別食事プランの形での栄養カウンセリングが血液透析患者の血清アルブミン値に与える影響 - スハイル・アブダラ・カリル・アブダラ - アフファド女子大学

スハイル・アブダラ・ハリル・アブダラ

はじめに: 最適な栄養状態は、(HD) 患者の長期管理における主要な問題であり、HD 患者の予後改善の前提条件です。腎臓病アウトカム品質イニシアチブ (KDOQI) は、末期腎不全 (ESRD) の HD 患者の食事管理の中心的かつ不可欠な部分として、腎臓栄養の標準化された実践の使用を推奨しています。腎臓の経験がある栄養士は、患者の栄養状態の継続的な評価と食事ケアの計画の作成を担当する必要があります。これにより、栄養状態の適切な評価とリスクのある患者のタイムリーな特定が保証されます。したがって、栄養状態の評価は栄養管理の不可欠な部分です。体重減少の履歴、食事性タンパク質およびエネルギー摂取量、皮下脂肪量および筋肉量、ボディマス指数 (BMI)、保健当局がタンパク質 - エネルギー栄養状態を評価するために使用する主観的全般評価 (SGA) など、いくつかのパラメータを併せて評価する必要があります。また、内臓タンパク質貯蔵量の評価には、いくつかの生化学マーカー (血清アルブミン、プレアルブミン、トランスフェリン) が使用されてきました。これらのうち、血清アルブミンがこれまでのところ最も一般的に使用されています。これは、筋肉と内臓の両方の全身タンパク質の唯一の測定値であり、タンパク質状態の最も頻繁に使用されるマーカーであり、KDOQI が推奨する標準です。CKD の栄養状態の評価に使用されます。HD 患者の栄養失調を評価するための強力なマーカーです。アルブミンの減少が罹患率および死亡率の上昇につながる可能性は低いです。これは、アルブミンが 40 g/日未満の ESRD 患者で示されており、死亡の過剰なリスクにつながります。アルブミン値が低いことは、血液透析患者の人間性と病気の確かな指標です。これは、HD を受けている ESRD 患者によく見られる PEM の代替マーカーであり、その有病率は 10 ～ 70% と推定されており、間違いなく罹患率と死亡率の上昇に寄与しています。これらの患者は透析液中に大量のタンパク質を失う（このグループでは低アルブミン血症につながる）という事実によって状況は悪化します（ほとんどの過去の研究では、1回の透析セッション中に透析液に失われるアミノ酸の量は4～13gの範囲であることが示されています）。HDを受けているESRD患者に推奨されるエネルギーとタンパク質の量を一貫して摂取していません。個別の食事プランが必要ですが、栄養士に相談することはほとんどありません。言い換えれば、HDを受けているESRD患者には特別な食事が必要です。HDを受けている成人の1日の推奨栄養素摂取量は、タンパク質1.2g/kg体重（高生物学的値の50%）、エネルギー（60歳未満の成人の場合は35kcal/kg、60歳以上または肥満の成人の場合は30kcal/kg）、ミネラル（mg/kg/日）- ナトリウム2～4、カリウム40、リン17、水分は水分排出量+ 500mlによって異なります。

Serum albumin is the most commonly used malnutrition marker in clinical practice as hypo albuminemia is considered to be a malnutrition risk among the patients on hemodialysis and a strong predictor of death. Low serum albumin levels are due to low intakes of energy and protein or insufficient energy intake resulting in poor protein utilization.

Purpose: This was a prospective, clinical trial hospital based (intervention) study to evaluate the effect of nutritional counseling in the form of individualized meal plan on serum albumin level among hemodialysis patients.

Methods: The study was conducted on maintenance hemodialysis patients attending Dr Salma Hemodialysis & Transplant Center outpatient clinic, Khartoum. 134 adult patients (males & females) were divided into a test group (n=77) and a control group (n=57). The test group after nutritional counseling consumed individualized diets for a period of 6 months that provided adequate amounts of energy and protein according to the recommendations of the National Kidney Foundation whereas the control group sustained overwhelming their usual diets. Serum albumin was determined at baseline and every 2 months. Data were analyzed using SPSS.

Nutritional status assessment:

Intervention Eighty-three HD patients who were included in the study as test group received conventional nutritional counseling and individual meal plan to achieve adequate protein and calories intake. Monitoring was done during 6 months of follow up. The individual meal plan was designed and explained to patient and their families by the following ways:

Educational lecture: Educational lecture was given exclusively to the test group. It was presented by the researcher to the patients and their families during their dialysis session by using a data-show to educate the patients and their families on the nutritional needs to provide appropriate food with adequate calories and protein to the patients.

Presentation included all the important information needed to be known by ESRD patient on HD. It was concentrated on calorie and protein needed, fluids limitation, intake of sodium, potassium and phosphorus in foods. Information was provided in a simple way and was explained by pictures for more understanding.

Pamphlets: were prepared and distributed to all intervention group participants after the lecture and all the summary information that was presented was found in the sheet which the researcher called it as the over-all training sheet for renal patients on HD.

Individualized meal plans: Individual meal plan was designed individually to all intervention group participants after analysis of the full information that helped the researcher to conduct the meal plan. The meal plan was based on: patient’s economic status, medical history, diet history, like and dislike, chewing and swallowing status, food allergies, blood investigation result, age, weight, height and sex. (Food exchange list was used to help patients for food substitutes if participant unable to follow the meal prescribed according to like and dislike or socio economic reasons). After calculation of all nutrients needed by each participant, individual meal plan for the whole week was designed by researcher, typed, organized, color printed and given to participant with full explanation of uses. The meals planned were designed only for intervention patients, whereas control patients continued to receive their usual care.

Results: Demographic characteristic of the study sample: For the demographic characteristic of the study participants, test and control, Males represented a higher percentage than the females. The age group distribution of subject shows that most of the patients (46.3%) were in the active age group of 30 - 45 yrs. (49.4% test and 42.1% control). The majority (31.3%) had higher secondary school education (29.9% test and 33.3 % control), followed by 17.9% university graduates (23.4% test and 10.5% control), the rest were illiterate or with low educational level. Medical profile of the participants

The medical characteristics of the study: Participants are shown that 53.7% of the participant had hypertension (61.0% test and 43.9% control), while only 3.0% had diabetes mellitus and hypertension (1.3% test and 5.3% control) and the rest 43.3% did not have any comorbid disease (37.7% test and 50.9% control). The mean extents of dialysis eras were 57.08 ± 36.16 months for the together groups (61.77 ± 38.84 test and (50.75 ± 31.42 control group).

Serum albumin augmented progressively from 3.14 g/dl at zero to 4.32 g/dl at 6 months with test group. The study displays big alterations in accumulation of serum albumin level during the study with intervention group compared with control. The mean test group was (3.1, 3.3, 3.9 and 4.3) and the mean of control group was (3.2, 3.16, 3.19 and 3.84) in baseline, 2-4-6 months respectively.

Conclusion: The study demonstrated that effective nutritional counseling rendered to maintenance hemodialysis patients in the form of individualized meal plans that provided adequate energy and protein was active in the switch and enhancement of serum albumin equal among these patients. Therefore, nutritious counseling by skilled dietitians is mandatory in renal units as part of the medical therapy management to reduce the incidence of hypoalbminemia among hemodialysis patients.

Biography:

スハイル・アブダラ・カリル・アブダラは、スーダンのアフファド女子大学で臨床栄養学の博士号を取得しました。彼女はサウジアラビア王国のキング・ファイサル専門病院・研究センターの臨床栄養士です。彼女は臨床栄養学の分野で 18 年の長い経験を持っています。

注:この研究の一部は、2016年6月16日から18日にイタリアのローマで開催された第5回ヨーロッパ栄養学会議で発表されました。