| Abstract: | 長期接受血液透析之病患，因蛋白質-熱量攝取不足及代謝上的改變，
易有營養不良的問題，增加其罹病率及死亡率。本研究目的在探討高蛋白質營養補充品對於改善營養不良血液透析患者營養狀況之效能及對血液透析治療之影響。本研究對象為沒有患肝硬化、惡病質(cachesia)且沒有使用類固醇藥物及糖化血色素（HbA1c）小於8.0之血液透析患者。研究對象皆符合營養不良之篩選條件：主觀整體評估（subjective global assessment；SGA）總評值為B或C級；研究期前三個月其血清白蛋白值皆小於3.8 gm/dL；及研究期前一個月其血清前白蛋白值小於30 gm/dL等三個研究條件中，符合兩個條件者。本研究每日所提供的口服高蛋白質營養補充品之營養含量設定為：熱量281Kcal，蛋白質22g (益富匯20g及益力康46g)。基準期（第0個月）及高蛋白質營養補充品給予期間（第1、2、3個月）評估受試者之飲食、血液生化、體位、適當透析指標及主觀整體評估。有18位受試者完成整個研究計畫納入資料分析。根據飲食紀錄結果得知，高蛋白質營養補充品提供受試者總熱量攝取量的1617%，總蛋白質攝取量的28~30%。受試者第0個月平均蛋白質攝取量為1.0 g/kg/day，給予高蛋白質營養補充品後，增加至1.3~1.4 g/kg/day。受試者第0個月平均熱量攝取量為27 kcal/kg，給予高蛋白質營養補充品後增加至3032 kcal/kg。尿素分佈體積之廓清分率（fractional clearance of urea as a function of its distribution volume；Kt/V）及尿素降低率（urea reduction ratio；URR）於研究期間並無顯著差異。標準化蛋白質異化代謝率（normalized protein catabolic rate；NPCR）在給予高蛋白質營養補充品後有明顯增加(p<0.01)。高蛋白質營養補充品介入前後，C-反應蛋白（C-reactive protein；CRP）濃度並無差異。受試者血清中白蛋白（albumin）濃度在給予高蛋白質營養補充品後亦明顯增加(p<0.01)，但前白蛋白（prealbumin）濃度並無顯著差異。除此之外，受試者血清中血液透析前血中尿素氮（pre-dialysis blood urea nitrogen；BUN）濃度於給予高蛋白質營養補充品後有明顯增加(p<0.05)，但高蛋白質營養補充品不影響血清磷（phosphorus）及鉀（potassium）濃度。給予高蛋白質營養補充品後受試者乾體重約增加1Kg，有顯著差異（p<0.05），而身體質量指數（body mass index；BMI）值亦於介入第二、三個月有明顯增加(p<0.05)。三頭肌皮下脂肪厚度（triceps skinfold thickness；TSF）、中臂環圍（midarm circumference；MAC）、中臂肌肉環圍midarm muscle circumference；MAMC），於研究期間並無顯著差異。高蛋白質營養補充品介入三個月期間，對體脂肪並無顯著影響，而無脂肌質於統計上雖無顯著差異，但有增加的傾向。除此之外，以主觀整體評估亦發現給予口服高蛋白質營養補充品顯著改善受試者之營養狀況。綜合以上結果可知，口服高蛋白質營養補充品為有效的營養介入方式，可以增加營養不良之血液透析患者的蛋白質及熱量攝取、增加體重、改善營養指標及有效的改善營養不良血液透析患者整體的營養狀況。
Both inadequate alimentation and metabolic alterations contribute to the malnutrition, which is frequently encountered in maintenance hemodialysis (MHD) patients. PEM is a powerful predictor of subsequent high morbidity and mortality in dialysis patients. Our purpose of this study was designed an antegrade longitudinal study to evaluate whether oral high protein supplement could improve the nutritional satus of malnourished dialysis patients and impact of oral high protein supplement on dialysis therapy. Candidates with liver cirrhosis, infections, HbA1c>8.0 or cachesia disease were excluded. The criteria for malnourished HD patients were based on a subjective global assessment（SGA）scores-overall SGA rating including B（mild to moderately malnourished）or C（severely malnourished）, biochemical indicators of malnutrition for the 3 months’ period before the oral high protein nutrition supplement interventions with serum albumin levels below 3.8 gm/dL and 1 months’ period before the oral high protein nutrition supplement interventions with serum prealbumin levels below 30gm/dL；presence of two out of three criteria were classified malnourished. The daily oral high protein supplements contained 281 kcal energy and 22 g protein（Whey-Aid 20 g and Nutri-Aid 46 g）. Month 0 was a baseline period for the usual diet；months 1,2 and 3 were nutritional intervention period. The nutritional status was monitored by dietary assessment, anthropometric parameters, blood biochemical assays, indicator of adequacy dialysis and subjective global assessment during the baseline period and the intervention period. Eighteen patients were finished and included in data analysis. The nutrition intervention stage, oral high protein nutrition supplement could provide 16%~17% in actual calorie intake and 28-30% of actual protein intake. Our results showed that the mean protein intake was 1.0 g/kg/day and mean calorie intake was 27 kcal/kg/day in the baseline. After oral high protein supplement provided as nutritional intervention for three consecutive months, the dietary assessment data showed that patients’ daily protein intake increased to 1.3~1.4 g/kg, calorie intake increase to 30~32 kcal/kg. During whole study period, fractional clearance of urea as a function of its distribution volume（Kt/V）and urea reduction ratio（URR）, they were all in the normal range, and there was no significant difference between the baseline period and the intervention period. The normalized protein catabolic rate（NPCR）was significantly increased after giving oral high protein supplement（p<0.01）. The C-reactive protein（CRP） was no statistical difference between the baseline period and the intervention period. Albumin was significantly increased（p<0.01），but prealbumin was no significant difference after giving oral high protein supplement. Additionally, after giving oral high protein supplement, serum pre-dialysis blood urea nitrogen was significantly increased（p<0.05）, but did not influence level of phosphorus and potassium in malnourished dialysis patients. After giving oral high protein supplement, patients’ dry weight increased 1 kg, being significantly increased（p<0.05）. Also the serial change of body mass index, being significantly increased in month 2 and month 3 (p<0.05). During whole study period, triceps skin-fold thickness（TSF）, mid-arm circumference（MAC）and mid-arm muscle circumference（MAMC）were no significant difference. Oral high protein supplement did not influence on body fat and lean body mass. The result of SGA score showed that oral high protein supplement improves the nutritional status of MHD with malnutrition. In conclusion, oral high protein nutritional supplement provided as nutritional intervention has effectively increased nutrients intake, gaining body weight, improving nutritional indexes, and improve the nutritional status of MHD with malnutrition. |
