慢性肾脏疾病患者的营养不良
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摘要
慢性肾脏疾病患者肾功能下降使代谢环境显著改变(如代谢性酸中毒、血脂异常、胰岛素抵抗),代谢性酸中毒与慢性肾脏疾病患者的蛋白质分解代谢增加有关。肾功能下降也可引起激素水平紊乱,激素水平改变与抑制慢性肾脏疾病患者食欲有关,导致营养素摄入不足。慢性肾脏疾病患者肠道菌群的显著改变是导致患者慢性炎症状态的一个重要因素,慢性炎症状态可增加静息能量消耗和代谢。蛋白质能量消耗本质上是身体蛋白质和能量储备地减少,在进展期慢性肾脏疾病患者和终末期透析的慢性肾脏患者中很常见。蛋白质能量消耗增加、营养素摄入不足、静息能量消耗增加这些因素最终可使慢性肾脏疾病患者发生营养不良。营养不良会增加儿童和成人慢性肾脏疾病发病率和死亡率的风险。食欲下降、饮食摄入减少,透析患者营养素丢失,激素失衡,炎症,分解代谢增强等多种因素相互作用易使慢性肾脏疾病患者发生营养不良。了解慢性肾脏疾病患者营养不良的病理生理机制有利于我们制定相关干预措施,以促进慢性肾脏疾病患儿的生长发育和减轻临床的不良结局。
The metabolic milieu in chronic kidney disease(CKD) is significantly altered due to renal functional decline(such as metabolic acidosis, dyslipidemia, insulin resistance), and metabolic acidosis is associated with increased protein catabolism in patients with CKD. Renal functional decline could also cause hormonal imbalance and it is implicated in the suppression of appetite in patients with CKD. In the end it leads to inadequate nutrient intake. The intestinal microbial flora is significantly altered in patients with CKD and plays a pathogenic role in the chronic inflammatory state seen in CKD. Chronic inflammatory state increases resting energy expenditure and catabolism. Protein-energy wasting, which essentially refers to decreased body protein mass and energy reserves, is common in advanced chronic kidney disease patients and end-stage kidney disease patients undergoing chronic dialysis. Increased protein catabolism, inadequate nutrient intake and increased resting energy expenditure and catabolism could lead to protein-energy wasting(PEW) in patients with CKD. Malnutrition can increase the risk of morbidity and mortality in children and adults with chronic kidney disease. Decreased appetite, reduced dietary intake, loss of nutrients in dialysis patients, hormone imbalance, inflammation, increased catabolism and other factors interact easily to cause malnutrition in patients with chronic kidney disease. A better understanding of pathophysiologic mechanisms of protein-energy wasting in patients with CKD might lead to the development of novel and effective therapies for malnutrition.
The metabolic milieu in chronic kidney disease(CKD) is significantly altered due to renal functional decline(such as metabolic acidosis, dyslipidemia, insulin resistance), and metabolic acidosis is associated with increased protein catabolism in patients with CKD. Renal functional decline could also cause hormonal imbalance and it is implicated in the suppression of appetite in patients with CKD. In the end it leads to inadequate nutrient intake. The intestinal microbial flora is significantly altered in patients with CKD and plays a pathogenic role in the chronic inflammatory state seen in CKD. Chronic inflammatory state increases resting energy expenditure and catabolism. Protein-energy wasting, which essentially refers to decreased body protein mass and energy reserves, is common in advanced chronic kidney disease patients and end-stage kidney disease patients undergoing chronic dialysis. Increased protein catabolism, inadequate nutrient intake and increased resting energy expenditure and catabolism could lead to protein-energy wasting(PEW) in patients with CKD. Malnutrition can increase the risk of morbidity and mortality in children and adults with chronic kidney disease. Decreased appetite, reduced dietary intake, loss of nutrients in dialysis patients, hormone imbalance, inflammation, increased catabolism and other factors interact easily to cause malnutrition in patients with chronic kidney disease. A better understanding of pathophysiologic mechanisms of protein-energy wasting in patients with CKD might lead to the development of novel and effective therapies for malnutrition.
引文
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2.Kang SS,Chang JW,Park Y.Nutritional status predicts 10-year mortality in patients with end-stage renal disease on hemodialysis.Nutrients.2017;9(4):E399.
3.Canpolat N,Caliskan S,Sever L,et al.Malnutrition and its association with inflammation and vascular disease in children on maintenance dialysis.Pediatr Nephrol.2013;28(11):2149-2156.
4.Mastrangelo A,Paglialonga F,Edefonti A.Assessment of nutritional status in children with chronic kidney disease and on dialysis.Pediatr Nephrol.2014;29(8):1349-1358.
5.Zha Y,Qian Q.Protein nutrition and malnutrition in CKD and ESRD.Nutrients.2017;9(3).
6.Mak RH.Cachexia in children with chronic kidney disease:challenges in diagnosis and treatment.Curr Opin Support Palliat Care.2016;10(4):293-297.
7.Stegmayr B.Uremic toxins and lipases in haemodialysis:a process of repeated metabolic starvation.Toxins(Basel).2014;6(5):1505-1511.
8.Stenvinkel P.Can treating persistent inflammation limit protein energy wasting?Semin Dial.2013;26(1):16-19.
9.Ishii H,Takahashi H,Ito Y,et al.The association of ankle brachial index,protein-energy wasting,and inflammation status with cardiovascular mortality in patients on chronic hemodialysis.Nutrients.2017;9(4).
10.Mitch WE.Cachexia in chronic kidney disease:a link to defective central nervous system control of appetite.J Clin Invest.2005;115(6):1476-1478.
11.Oner-Iyidogan Y,Gurdol F,Kocak H,et al.Appetite-regulating hormones in chronic kidney disease patients.J Ren Nutr.2011;21(4):316-321.
12.Stenvinkel P,Pecoits-Filho R,Lindholm B.Leptin,ghrelin,and proinflammatory cytokines:compounds with nutritional impact in chronic kidney disease?Adv Ren Replace Ther.2003;10(4):332-345.
13.Correa M,Laing DG,Hutchinson l,et al.Reduced taste function and taste papillae density in children with chronic kidney disease.Pediatr Nephrol.2015;30(11):2003-2010.
14.DeFronzo RA,Alvestrand A,Smith D,et al.Insulin action in uremia.Kidney.1983;16:S102-S114.
15.Jankowska M,Cobo G,Lindholm B,et al.Inflammation and protein-energy wasting in the uremic milieu.Contrib Nephrol.2017;191:58-71.
16.Kopple JC,Kalantar-Zadeh K,Mehrotra R.Risks of chronic metabolic acidosis in patients with chronic kidney disease.Kidney Int.Suppl.2005;(95):s21-s27.
17.Pickering WP,Price SR,Bircher G,et al.Nutrition in CAPD:serum bicarbonate and the ubiquitin-proteasome system in muscle.Kidney Int.2002;61(4):1286-1292.
18.Castillo-Rodríguez E,Pizarro-Sánchez S,Sanz AB,et al.Inflammatory cytokines as uremic toxins:“niSon todos los que estan,ni estan todos los que son”.Toxins(Basel).2017;9(4):E114.
19.Meuwese CL,Carrero JJ,Stenvinkel P.Recent insights in inflammation associated wasting in patients with chronic kidney disease.Contrib Nephrol.2011;171:120-126.
20.Jiang S,Xie S,Lv D,et al.Alteration of the gut microbiota in Chinese population with chronic kidney disease.Sci Rep.2017;7(1):2870.
21.Mafra D,Lobo JC,Barros AF,et al.Role of altered intestinal microbiota in systemic inflammation and cardiovascular disease in chronic kidney disease.Future Microbiol.2014;9(3):399-410.
22.Vaziri ND,Zhao YY,Pahl MV.Altered intestinal microbial flora and impaired epithelial barrier structure and function in CKD:the nature,mechanisms,consequences and potential treatment.Nephrol Dial Transplant.2016;31(5):737-746.
23.Slee AD.Exploring metabolic dysfunction in chronic kidney disease.Nutr Metab(Lond).2012;9(1):36.
24.Pickering WP,Price SR,Bircher G,et al.Nutrition in CAPD:serum bicarbonate and the ubiquitin-proteasome system in muscle.Kidney Int.2002;61(4):1286-1292.
25.Roshanravan B,Zelnick LR,Djucovic D et al.Chronic kidney disease attenuates the plasma metabolome response to insulin.JCIinsight.2018;3(16):122219.
26.Koppe L,Fouque D.The role for protein restriction in addition to renin-angiotensin-aldosterone system inhibitors in the management of CKD.Am J Kidney Dis.2018.
27.Hahn D,Hodson EM,Fouque D.Low protein diets for non-diabetic adults with chronic kidney disease.Cochrane Database Syst Rev.2018;10:CD001892.
28.Weiner DE,Tighiouart H,Ladik V,et al.Oral intradialytic nutritional supplement use and mortality in hemodialysis patients.Am J Kidney Dis.2014;63(2):276-285.
29.Ikizler TA,Cano NJ,Franch H,et al.Prevention and treatment of protein energy wasting in chronic kidney disease patients:a consensus statement by the International Society of Renal Nutrition and Metabolism.Kidney Int.2013;84(6):1096-1107.
30.Moraes C,Borges NA,Barboza J,et al.Effects of acute resistance exercise on acyl-ghrelin and obestatin levels in hemodialysis patients:a pilot study.Ren Fail.2015;37(5):851-857.
2.Kang SS,Chang JW,Park Y.Nutritional status predicts 10-year mortality in patients with end-stage renal disease on hemodialysis.Nutrients.2017;9(4):E399.
3.Canpolat N,Caliskan S,Sever L,et al.Malnutrition and its association with inflammation and vascular disease in children on maintenance dialysis.Pediatr Nephrol.2013;28(11):2149-2156.
4.Mastrangelo A,Paglialonga F,Edefonti A.Assessment of nutritional status in children with chronic kidney disease and on dialysis.Pediatr Nephrol.2014;29(8):1349-1358.
5.Zha Y,Qian Q.Protein nutrition and malnutrition in CKD and ESRD.Nutrients.2017;9(3).
6.Mak RH.Cachexia in children with chronic kidney disease:challenges in diagnosis and treatment.Curr Opin Support Palliat Care.2016;10(4):293-297.
7.Stegmayr B.Uremic toxins and lipases in haemodialysis:a process of repeated metabolic starvation.Toxins(Basel).2014;6(5):1505-1511.
8.Stenvinkel P.Can treating persistent inflammation limit protein energy wasting?Semin Dial.2013;26(1):16-19.
9.Ishii H,Takahashi H,Ito Y,et al.The association of ankle brachial index,protein-energy wasting,and inflammation status with cardiovascular mortality in patients on chronic hemodialysis.Nutrients.2017;9(4).
10.Mitch WE.Cachexia in chronic kidney disease:a link to defective central nervous system control of appetite.J Clin Invest.2005;115(6):1476-1478.
11.Oner-Iyidogan Y,Gurdol F,Kocak H,et al.Appetite-regulating hormones in chronic kidney disease patients.J Ren Nutr.2011;21(4):316-321.
12.Stenvinkel P,Pecoits-Filho R,Lindholm B.Leptin,ghrelin,and proinflammatory cytokines:compounds with nutritional impact in chronic kidney disease?Adv Ren Replace Ther.2003;10(4):332-345.
13.Correa M,Laing DG,Hutchinson l,et al.Reduced taste function and taste papillae density in children with chronic kidney disease.Pediatr Nephrol.2015;30(11):2003-2010.
14.DeFronzo RA,Alvestrand A,Smith D,et al.Insulin action in uremia.Kidney.1983;16:S102-S114.
15.Jankowska M,Cobo G,Lindholm B,et al.Inflammation and protein-energy wasting in the uremic milieu.Contrib Nephrol.2017;191:58-71.
16.Kopple JC,Kalantar-Zadeh K,Mehrotra R.Risks of chronic metabolic acidosis in patients with chronic kidney disease.Kidney Int.Suppl.2005;(95):s21-s27.
17.Pickering WP,Price SR,Bircher G,et al.Nutrition in CAPD:serum bicarbonate and the ubiquitin-proteasome system in muscle.Kidney Int.2002;61(4):1286-1292.
18.Castillo-Rodríguez E,Pizarro-Sánchez S,Sanz AB,et al.Inflammatory cytokines as uremic toxins:“niSon todos los que estan,ni estan todos los que son”.Toxins(Basel).2017;9(4):E114.
19.Meuwese CL,Carrero JJ,Stenvinkel P.Recent insights in inflammation associated wasting in patients with chronic kidney disease.Contrib Nephrol.2011;171:120-126.
20.Jiang S,Xie S,Lv D,et al.Alteration of the gut microbiota in Chinese population with chronic kidney disease.Sci Rep.2017;7(1):2870.
21.Mafra D,Lobo JC,Barros AF,et al.Role of altered intestinal microbiota in systemic inflammation and cardiovascular disease in chronic kidney disease.Future Microbiol.2014;9(3):399-410.
22.Vaziri ND,Zhao YY,Pahl MV.Altered intestinal microbial flora and impaired epithelial barrier structure and function in CKD:the nature,mechanisms,consequences and potential treatment.Nephrol Dial Transplant.2016;31(5):737-746.
23.Slee AD.Exploring metabolic dysfunction in chronic kidney disease.Nutr Metab(Lond).2012;9(1):36.
24.Pickering WP,Price SR,Bircher G,et al.Nutrition in CAPD:serum bicarbonate and the ubiquitin-proteasome system in muscle.Kidney Int.2002;61(4):1286-1292.
25.Roshanravan B,Zelnick LR,Djucovic D et al.Chronic kidney disease attenuates the plasma metabolome response to insulin.JCIinsight.2018;3(16):122219.
26.Koppe L,Fouque D.The role for protein restriction in addition to renin-angiotensin-aldosterone system inhibitors in the management of CKD.Am J Kidney Dis.2018.
27.Hahn D,Hodson EM,Fouque D.Low protein diets for non-diabetic adults with chronic kidney disease.Cochrane Database Syst Rev.2018;10:CD001892.
28.Weiner DE,Tighiouart H,Ladik V,et al.Oral intradialytic nutritional supplement use and mortality in hemodialysis patients.Am J Kidney Dis.2014;63(2):276-285.
29.Ikizler TA,Cano NJ,Franch H,et al.Prevention and treatment of protein energy wasting in chronic kidney disease patients:a consensus statement by the International Society of Renal Nutrition and Metabolism.Kidney Int.2013;84(6):1096-1107.
30.Moraes C,Borges NA,Barboza J,et al.Effects of acute resistance exercise on acyl-ghrelin and obestatin levels in hemodialysis patients:a pilot study.Ren Fail.2015;37(5):851-857.