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1、CRRT时的营养管理,提要,概述CRRT对代谢和营养物质的影响CRRT时如何实施营养支持？,关于ARF/AKI,传统ARF定义根据尿量和血肌酐水平的变化。鉴于急性肾衰竭诊断标准中存在的诸多问题，近年来,在ICU内的ARF领域已经出现许多重大进展.其中一个引人注目的事件是为帮助临床医生诊断ARF而设计的一种分期系统的发明，即RIFLE标准(Acute Dialysis Quality Initiative Group 2004)。,急性肾功能损伤的RIFLE分层诊断标准RIFLE标准,关于ARF/AKI,AKI is generally defined as an abrupt and sust
2、ained decrease in kidney function.一种新的ARF定义和诊断的方法,使ARF早期诊断 早期干预成为可能,从而影响临床结局.,关于ARF/AKI,有二种临床类型isolated kidney disease those where renal failure is a complication of severe illness,as is frequently the case in intensive care practice,关于CRRT,RRT有多种方法,包括PD、IHD、CRRT、和SLED等。在ICU主要为CRRT(CVVH、CVVHDF等)。,关于
3、CRRT,CRRT优点：（与IHD相比）。CRRT缺点：需持续抗凝（潜在出血的危险），持续地暴露于体外循环（可能导致营养物质流失、抗生素达不到治疗浓度、感染风险加大等）,关于CRRT,目前,对CRRT的研究方面,内容多集中在CRRT的角度来探讨如何改善ARF的预后。包括CRRT的应用时机、方法、剂量等。1.Current opinion in nephrology and hypertension 20072.JAMA,2008,关于CRRT,因研究的复杂性，目前对CRRT时代谢和一些营养物质特异性改变的内容较少。有关的一些建议多来自专家意见。,1.Nephrol Dial Transplan
4、t(2007)1 of 82.Clinical Nutrition(2006)25,295310,Nutritional programs for ARF patients must consider,与肾功能相关的特异性代谢改变。引起ARF的基础疾病程度和/或伴随疾病情况，及全身器官功能情况。CRRT 的方法和强度。,与肾功能相关的代谢改变,Macronutrients（protein and amino acid,carbohydrate、lipid）代谢异常，蛋白的需求增加。同时，各种氨基酸的代谢也发生异常。如某些非必需AA(e.g.tyrosine)不能正常合成而转变为必需AA；由于对
5、外源性AA的利用发生障碍，使细胞内外的AA池发生改变等。Micronutrients发生异常:一方面，肾的替代疗法可造成其流失，另外，过分的补充又容易发生中毒（肾调节功能减退）。其他：可加重前炎症反应，影响抗氧化系统功能等。,Clinical Nutrition(2006)25,295310,Nutritional requirements in patients with ARF,ESPEN Guidelines 2006,CRRT对代谢的影响有哪些?,增强分解代谢 水电解质失衡使水溶性、小分子物质大量流失，包括一些营养物质,protein needs of patients undergo
6、ing CRRT（Chima et at）,a mean protein catabolic rate of 1 18 43 g/day(1.7 0.7 g protein/kg per day)and a urea nitrogen appearance of 18.3 6.9 g/day。did not account for ultrafiltrate amino acid and protein losses.,Am Soc Nephrol 1993:3:15 16-1521,CRRT治疗时蛋白质的流失（Michele H等）,22份透析液/超滤液平均蛋白浓度为:4.24.0mg/dl
7、,CVVH(6.05.1mg/dl)高于CVVHDF(2.71.9mg/dl)。但总体不多,对超滤液50L的病人,在0.57.5g之间。不同的透析膜差别不大。与血蛋白浓度有弱的相关性(r=0.468,p0.03)。同期的血蛋白浓度为4.71.8mg/dl。,J.Am.Soc.Nephrol.1996;7:2259-2263,CRRT治疗时蛋白质的流失（Michele H等）,结论在高容量 CRRT 时，透析/超滤液中蛋白质的流失量为1.2 7.5 g/day（明显较原先报道的少）。AA的流失表示蛋白氮的进一步损失，综合文献结果估计为7 50 g/day。Ultrafiltrate protei
8、n and amino acid losses should be considered when determining nutritional requirements in CRRT procedures.,AA和N的平衡（Maxvold等）,方法：对6例需生命支持的小儿ICU病人，在CVVH/CVVHD期间，进行血浆氨基酸和尿素的清除率测定，并收集24小时的超滤液和尿液测定氮平衡。同时，患儿给予TPN（热卡摄入20-30%高于REE水平，蛋白量为1.5 g protein/kg per day),Critical Care Medicin 28(4),April 2000,1161-1
9、165,AA和N的平衡（Maxvold等）,Critical Care Medicin 28(4),April 2000,1161-1165,AA和N的平衡（Maxvold等）,Critical Care Medicin 28(4),April 2000,1161-1165,AA和N的平衡（Maxvold等）,总结在相同的血流量和透析/置换流量情况下，CVVH和CVVHD的尿素氮清除率相同。尽管予以标准的PN（containing 1.5 g/kg/day of protein and caloric intake of 20%to 30%above REE)，病人仍为负氮平衡。摄入的AA有1
10、112%因CRRT流失（与方法关系不大）。Glutamine的累积损失可加重氮失衡。a dose adjustment of amino acid delivery and formulation may be needed to overcome the negative amino acid and nitrogen balance in children with ARF on CRRT.,Critical Care Medicin 28(4),April 2000,1161-1165,CRRT时蛋白质和AA联合流失的相关因素,total output volumethe nature
11、of the treatments solute removal(convection versus diffusion)the serum protein levelParenteral nutrition the nature and severity of the patients illness.,CRRT时Macronutrients平衡,遵守危重病人营养治疗的一般原则。CRRT时蛋白质需多增加1015 g/每天（AA流失量约为0.2 g/L，相当于5 10 g/day蛋白质；蛋白质流失量约1.27.5 g/day）。it should be emphasized that hype
12、rcatabolism cannot be simply overcome by increasing protein or amino acid intake.,CRRT时维生素的流失,vitamin C:100 mg/day losses during CRRTfolate:265 mg/d losses during CRRTthiamine:plays a key role in carbohydrate metabolism.It is likely that all water-soluble vitamins are lost in a similar way in the ef
13、fluent。,微量元素(Trace elements),Trace elements are essential nutrients with regulatory,immunologic and antioxidant functions resulting from their action as essential components or cofactors of enzymes(glutathione peroxidases and superoxide dismutase)throughout metabolism.The selenium status is particul
14、arly important to the antioxidant defense,because the activity of different glutathione peroxidases,which are selenoenzymes。,CVVHDF时铜、硒、锌和硫胺的平衡（Mette M 等）,Micronutrients were detectable in all effluents,and losses were stable over time in each patient(low within-patient variability).whereas the inte
15、rpatient variability was large.The 24-h balances were negative for selenium(0.97mol,or 2 times the daily RI),copper(6.54mol,or 0.3 times the daily RI),and thiamine(4.12 mg,or 1.5 times the RI)and modestly positive for zinc(20.7 mol,or 0.2 times the RI).,Am J Clin Nutr 2004;80:4106.,CVVHDF时铜、硒、锌和硫胺的平
16、衡（Mette M 等）,结论：CRRT可以使硒、铜和硫胺的大量流失，导致负平衡，并使血浓度降低。尽管予以常规的补充，长久的CRRT也有可能导致硒和硫胺的缺失。但对此是否需要2倍以上的常规量还有争议。不需额外补锌。增加的需要量必须通过PN补充。,Am J Clin Nutr 2004;80:4106.,CRRT期间微量元素的丢失（Mariann D等）,用ICP-MS技术（能测定90%周期表中的元素，敏感性高），测定10例接收CVVHDF的危重病人的铬、铜、锰、硒和锌的跨膜清除率，比较微量元素每日丢失的计算值（根据先期的体外实验数据推导的SC值和微量元素的正常血浓度来计算）和每日常规补充量。并
17、进一步比较CVVHD或CVVHDF和CVVH之间的不同。,Nephrol Dial Transplant(2007)1 of 8.,CRRT期间微量元素的丢失（Mariann D等）,Nephrol Dial Transplant(2007)1 of 8.,CRRT期间微量元素的丢失（Mariann D等）,结论5种微量元素均能被跨膜清除（不管通透性高低）。每天用标准的微量元素补充制剂足够补充流失量（当CVVHDF with a dialysate flow rate of 33.3 ml/min）,Nephrol Dial Transplant(2007)1 of 8.,CRRT时Micro
18、nutrients平衡,常规补充标准量适当追加剂量Micronutrient status should be monitored,CRRT时如何实施营养支持？,时机途径营养素个体化？,营养的时机和途径,In severe ARF,the recommendations for TF are the same as for other ICU patients.If possible,EN should be started within 24 h.supplementary parenteral nutrition may be needed.Parenteral amino acid su
19、pplementation may be required,especially in patients with ARF on RRT.,Are disease-specific formulae required inARF patients?,对大多数病人来说，标准配方是合适的。个体化是必要的，但实施困难。It is not known if formulae enriched in specific substrates such as glutamine,arginine,nucleotides or omega-3-fatty acids(immune-modulating formulae)might exert beneficial effects in ARF patients.,Nutrition therapy for acute renal failure:a new approach based on risk,injury,failure,loss,and end-stage kidney classification（RIFLE）,Current Opinion in Clinical Nutrition andMetabolic Care 2009,12:241244,
