优化饮食蛋白质摄入对腹膜透析患者的作用研究

The effects of optimized dietary protein on peritoneal dialysis patients

目的分析优化饮食蛋白质摄入对腹膜透析(peritoneal dialysis,PD)患者营养及其相关指标的作用,探讨优质蛋白摄入率的独立相关因素。方法回顾性分析重庆医科大学附属成都第二临床学院成都市三人民医院肾脏科稳定PD治疗1个月以上患者,优质蛋白摄入率≥50%为优化组51例;优质蛋白摄入率<50%为非优化组41例。比较分析两组教育模式、3日饮食日记,饮食中蛋白质、热量、磷蛋白比值低的鸡蛋白质摄入量及摄入比,血清白蛋白、血红蛋白、血磷、成纤维细胞生长因子(fibroblast growth factor 23,FGF23)等,计算尿素清除指数、残余肾功能、周肌酐清除率、标准蛋白分解率,多元逐步回归法分析PD患者优质蛋白摄入率的独立相关因素。结果优化组与非优化组相比,每日蛋白摄入量[(1.09±0.41)比(0.86±0.25)g/(kg·d),t=3.097,P=0.003]、优质蛋白质量[(0.64±0.22)g/kg·d比(0.40±0.11)g/(kg·d),t=6.321,P<0.001]、鸡蛋白摄入比[(8.01±3.90)比(5.80±4.32)%,χ2=80.126,P=0.012]、血清白蛋白[(39.54±4.09)g/L比(36.08±4.71)g/L,t=3.769,P<0.001]、周尿素清除指数[(1.99±0.48)比(1.76±0.38),t=2.500,P=0.014]、周肌酐清除率[(62.21±15.73)L比(54.96±16.01)L,t=2.176,P=0.032]、残余肾功能[2.62(0.60,3.37)ml/min比1.52(0.44,3.00)ml/min,z=4.093,P=0.043]及接受强化微信管理[(76.47%)比(26.83%),χ2=22.574,P<0.001]更高,有统计学意义。优化组与非优化组相比血磷、血FGF23无统计学意义[磷:t=0.646,P=0.519,FGF23:z=1.701,P=0.192]。多元逐步回归分析显示优质蛋白摄入量(回归系数10.589,P=0.001)、鸡蛋白摄入比(回归系数0.358,P=0.033)、血清白蛋白(回归系数0.328,P=0.031)、标准蛋白分解率(回归系数6.123,P=0.009)、微信管理(回归系数6.380,P<0.001)、透析龄(回归系数4.54,P=0.002)是本研究中优质蛋白摄入率的独立相关因素。结论常规教育PD患者以磷/蛋白比值低的鸡蛋白为基础蛋白质摄入,并结合微信管理,进行摄入率至少50%优质蛋白质的优化饮食,可使PD患者获得更好的血清白蛋白,不增加高磷血风险,更好保护残余肾功能,且透析更充分,优质蛋白摄入率的独立相关因素可作为指导临床实施PD优化饮食蛋白质摄入的参考依据。

Objective To analyze the effects of optimized dietary protein on nutrition status and related parameters in peritoneal dialysis（PD） patients and to explore the independent factors for high quality protein intake. Methods A retrospective analysis was performed on patients with stable PD for more than one month.Patients were divided into optimized group（n=51） for those with high quality protein intake rate ≥50% and non-optimized group（n=41） for those with high quality protein intake rate 〈50%. Education mode, food diary in 3 days, dietary protein intake（DPI）, calorie intake, ratio of egg white protein in total protein intake, serum albumin, hemoglobin, phosphorus, parathyroid hormone and fibroblast growth factor 23（FGF23） were compared between the two groups. Urea clearance index（Kt/V）, total creatinine clearance（Ccr）, residual renal function（RRF） and normalized protein catabolic rate（n PCR） were calculated. Results Dietary protein intake（t=3.097, P=0.003）, high quality protein intake（t=6.321, P〈0.001）, percentage of egg white protein intake（χ^2=80.126, P=0.012）, serum albumin（39.54 ± 4.09 vs. 36.08 ± 4.71 g/L, t=3.769, P〈0.001）, Kt/V（t=2.500, P=0.014）, Ccr（t=2.176, P=0.032）, RRF（z=4.093, P=0.043） and ratio of education with intensified WeChat management（76.47% vs. 26.83%, χ^2=22.574, P〈0.001） were higher in optimized group than in non-optimized group. Serum phosphorus（t=0.646, P=0.519）, parathyroid hormone and FGF23（z=1.701, P=0.192）had no statistical differences between the two groups. Multiple regression revealed that high quality protein intake（P=0.001）, percentage of egg white protein intake（P=0.033）, n PCR（P=0.009）, dialysis age（P=0.002）,serum albumin（P=0.031） and We Chat management（P〈0.001） were the independent factors for high-quality protein intake rate. Conclusion The conventional education contents of higher ratio of egg protein intake for lower phosphorus intake, communication using We Chart and high quality protein intake ≥50% are useful for the increase of serum albumin and dialysis adequacy, protection of RRF and lower risk of hyperphosphatemia.The independent factors for higher quality protein intake can be used as references for the optimization of dietary protein intake in PD patients.