Kronik hemodiyaliz hastalarında hemodiyaliz seansı sırasında yüksek proteinli oral diyet alımının nütrisyon parametreleri üzerine etkisi
Intradialytic protein enriched oral meal for hemodialysis patients and its effects on nutritional parameters
Yazar: AKİLE HAFIZ SARAÇOĞLU
Danışman: PROF. YUSUF ORHAN
İstanbul Üniversitesi / Sağlık Bilimleri Enstitüsü / Beslenme ve Diyetetik Ana Bilim Dalı
Derece: Doktora, 2007
Konu: Beslenme ve Diyetetik = Nutrition and Dietetics ; Nefroloji = Nephrology
Dizin: Renal diyaliz = Renal dialysis

Özet:
Son donem bobrek yetmezligi, iilkemizde de turn diinyada oldugu gibi onemli sagliksorunlanndan birisidir. Giderek artan sayidaki bu hasta grubunda uremiye bagh PEM ileseyreden kas kitle kaybi, yuksek oliim ve hastaneye yatis ile yakindan ilgilidir. Son9ahsmalar SDBY hastalarimn diyaliz islemi ile birlikte kronik enflamasyon ve 9esitli eszamanli faktorlerden dolayi kas kitle kaybina yatkrn olduklanru gostermektedir.Beslenme de direkt ya da dolayh yollardan hasta raorbidite ve mortalitesini etkilemekteolan faktorlerden birisidir. Proteindeki yetersizlik ise, 90k ku9iik azalmalannm bilehasta survisi uzerindeki olumsuz etkileri yiiziinden, diger turn beslenme problemlerinekiyasla 90k daha fazla ilgi toplar. Bu 9ahsmada intradiyalitik oral besin destegi ileniitrisyon parametrelerinin ve hasta memnuniyetinin nasil etkilenecegini arastirmayiplanladik.Qahsmaya en az 6 aydrr HD programmda olan non-diyabetik 40 hasta (20 kontrol; yas(yil)=48,73±l 1,55 ve 20 9ahsma; yas(yil)=50,15±10,97) alindi. Qalisma grubu 3 ay sureile yuksek proteinli (0,8g/kg/ogfin); kontrol grubu ise rutin (0,23g/kg/6giin) beslendi.Qahsmamn oncesi ve sonrasmda anamnez, FM, antropometrik ve biyosimik o^umlerve SGD ile MBD testleri yapildi. Diyaliz yeterliligi parametresi olarak KX/V kullamldi.^alisma grubunda; BKl, UKQ, TAD, P, albumin, prealbutnin, transferrin, ferritin, Htcve MBD#da artis; tire, kreatinin, Na, kolesterol, total proteinde azalis anlamh iken;kontrol grubunda; UF, P, albumin, prealbumiri, Fe, transferin de artis; iire, kreatinin, Na,total proteinde azalis anlamhydi.Kilo, BQ, TDBK, TAS, NDS, glikoz, iirik asit, K, Ca, PTH, Hb, MBD, SGD'dekidegisiklikler her iki grupta da anlamli degildi. KWde her iki grupta da kantitatifazalma oldu. Ancak bu, 9ahsma grubunda istatistik'i olarak anlam ifade etmezken,kontrol grubunda azalmanm istatistik'i olarak anlamlihgi dikkat 9ekiciydi.Yapilan 9ahsmalara bakildiginda, uremiye bagh kas kitle kaybma yol a9anetyolojilerden birinin de kayiplar yanmda, besin ahmmda azalmadir. Durum boyleolunca, PEM'unu onlemek i9in intradiyalitik yuksek proteinli beslenmenin hastalarmnutrisyonei parametrelerine kisa donemde oiumlu etkileri oldugu, fosfor artismdankorkularak proteinin kati kisitlanmasma gerek olmadigi goruldti. Bugiine kadarbeslenme durumunun degerlendirilmesinde sik kullamlan SGD'nin 90k da guvenilir biryontem olmadigi; oysa KBY hastalannda rutin kullanimda olmayan MBD'nin ucuz,guvenilir, non-invazif ve hastamn yasam kalitesim de degerlendiren degerli bir yontemoldugu ve testin (daha uzun stireli ve olgu sayisi fazla 9ahsmalar ile) SDBY hastalarmagore adapte edilerek daha guvenilir modifikasyonlarmm elde edilebilecegi sonucunavanldi.Anahtar Kelimeler: Hemodiyaliz, intradiyalitik beslenme, protein, beslenmeparametreleri, subjektif degerlendirme

Abstract:
End stage renal disease is one of the most important health problems in our country as itis in the world. Increasing attention has been paid recently to the problem of protein andenergy malnutrition and its effects on mortality and morbidity in HD patients. Proteindeficiency has received more attention then other nutritional problems, because itsconsequences are more easily measured and many studies have demonstrated theadverse effects of even small decreases in serum albumin on patient's survival.This review discusses the indicators of early malnutrition and the effects of oralintradialytic nutrition on patient's nutritional status (anthropometric and biochemical)and patients satisfaction with it. Non-diabetic of 40 patients on regular HD wereincluded in the study. The study group was fed with 0,8g/kg protein enriched meal; andthe control group was given 0,23g/kg/protein meal (regular meal) for 3 months.Nutritional status was checked by laboratory data, anthropometric measurements(height, dry weight, BMI, mid arm and waist circumference and triceps skin foldthickness), SGA and MNA. In the study group; BMI, MAC, TAD, P, serum albumin,prealbumin, transferrin, ferritin, hematocrit and MNA were statistically increased whileurea, creatinin, Na, total cholesterol, total protein decreased. Where as in the controlgroup; ultrafiltration, P, serum albumin, prealbumin, Fe, transferrin were increased,while urea, kreatinin, Na, total protein were decreased.None of weight, MAC, total iron binding capacity, pulse rate, glucose, uric acid, K, Ca,PTH, hemoglobin, MNA, and SGA had a significant change. Kt/V was decreased inboth groups, but this was a statistically valuable change in control group while it didn'thave a statistical value in the study group. Phosphorus was increased in both groups,where it wad still in between reference values in the study group, but the increase in thephosphorus for the control group was statistically valuable. Majority of patients hasprotein and energy malnutrition which is the most important cause for mortality andmorbidity in HD patients. Factors responsible for this are variable where inadequate andinappropriate dietary intake is one of the most important one. The review addresses thebeneficial of intradialytic oral nutrition on nutritional status and patient's satisfactionwith it.There is no reason to set a limit to protein intake because of its relation withphosphorus. SGA is not a reliable test for evolution of nutritional status of patients onHD. Rather then SGA, MNA can give more reliable results about patient's nutritionalstatus and it can be much more dependable if modified for ESRD patients.Key Words: Hemodialysis, intradialytic nutrition, protein, nutritional parameters,subjective assessments.