..

erythropoiesis



, , , , , ,

glomerulonephritis 1
1
GFR (//1.73 2 )
1 GFR > 90
2 GFR 60-89
3 GFR 30-59
4 GFR 15-29
5 < 15 ()
 nephrons 50 serum creatinine (cr.)
creatinine 50
3 4 20-50 creatinine 2-5
/, Na, K, Mg, P



2 (1)

30-35 30-35 20-35 30-35 30-35
Cal/kg IBW K Cal/kg IBW K Cal/kg IBW K Cal/kg IBW K Cal/kg IBW

0.6-1 1.1-1.4 1.2-1.5 1.5-2 1.3-2

g/kg IBW g/kg IBW g/kg IBW g/kg IBW g/kg IBW
Na 1-3 2-3 2-4 2-4
g/day g/day g/day g/day

K 90-70
mEg/kg
P 8-12 < 17 < 17 < 17
mg/kg IBW mg/kg IBW mg/kg IBW mg/kg IBW
500-750
+


1000 /

10 creatinine 7 /

,
, , 5
 (nonoliguric) (oliguric) (anuric)

uremic
,


() CRRT (continuous renal replacement therapy)
CVVHD (continuous venovenous hemodiafiltration) CRRT 24

, Triceps BMI ()

GFR 20 /
(2)
1
2 (edema-free actual BW) SGA
3 nPNA (normalized protein nitrogen appearance)
urea kinetic
3.5 /
4 /
(3)

25-40 K Cal/ IBW 1.1-1.4 BEE

500-1000
K Cal/

30
protein urea urea
uremia
0.6 //
uremia
CRRT (4)
GFR < 25 / 0.28 //
keto acid uremia BUN



(5)
balance amino acid
enteral parenteral
physiologic stress steroid (
) 24 . UUN BUN 24 hr
UUN UNA (urea nitrogen appearance) BUN
1-3
UUN UNA urea genesis BUN
urea genesis negative nitrogen balance

nephrotic syndrome
glomerular permeability
albumin

lipoprotein nephrotic syndrome

uremia

glomeruli
tubules collecting GFR


1-3 / + 500 . insensible loss
nephrotic syndrome
tubule dehydration,
GFR Na
(K)
glomeruli
collecting tubular K
60 mEg/ hyperkalemia acidosis
catabolism
(P Ca)
P
parathyroid Ca P
hyperparathyroidism renal osteodystrophy
P
P Ca Co3 aluminums hydroxide
P aluminums
dementia osteomalacia acidosis sevelamer
P Ca Aluminum
(Mg)

Mg ,

PH
acidosis
Ca Co3
Na HCO3 TPN Na K
acetate


B6 RDA folic acid 0.8-1 .
B6 (5 . 10 . )
retinol bind protein hypervitaminosis A
D 25-hydroxy cholecalciferol
(calcifediol) 1-25 di hydroxy cholecalciferol (calcitriol) Ca
hypocalcemia calcitriol 0.25-0.5 / P

Trace element


erythropoietin (epoetin alpha)
(Zn) ZnSo4 220 /
,

Intradialytic Parenteral Nutrition (IDPN)

enteral

20





(glycogenolysis)

(hypoglycemia)

Krebs cycle ketone bodies

lipoprotein

transamination, animation deamination


encephalopathy
(BCAA)
leucine, Isoleucine Valine
aromatic (AAA) phenylalanine, tyrosine tryptophan
methionine
BCAA /AAA tryptophan / tryptophan

hepatic encephalopathy neuromuscular irritability, stupor coma
(decompensated liver disease)
, ,
false neuro transmitter

BCAA BCAA






(6)


malabsorption maldigestion
hypermetabolism , ascites, encephalopathy
24 hour urinary urea nitrogen

ascites 2 /
120 mmol/L

0.5-0.7 /
. 10-15

branched-chain 1.2-1.5 //
fat malabsorption


(DEXA) osteo
penia osteoporosis




Hypercholesterolemia
.
<10%
LDL <7%
<300 /
LDL <200 /
monounsaturated (MUFA)
Polyunsaturated (PUFA)
2 /
, , , ,
, , ,
5 /
Complex carbohydrate, ,


-
(ARF) - 0.8 //
Na, K, P, ARF
CRRT
CVVHD 1.5 //

- - 20-25 /
- Protein, /
Na, K - Na 1-3 /
<0.8-1.0 //
K hyperkalemia
< 1 /
- K, P, Mg
P 8-12 / /
P

- Ca
- calcitriol
-
- -
Na, K, P 30-35 . //
20-25 . //
-
1.1-1.4 /. /
1.2-1.5 /. /

< 17 /. /
Na 2-3 /, 2-4 /
K 40-70 /,
> 75 mEg/
500-750 +
1000 / ,

Ca
-
-
1.3-2 //
hyper metabolism steroid
- steroid
insulin resistance
- PUFA MUFA

- Na 2 /

- Ca P metabolic bone
disease vitamin D
hyperparathyroidism steroid

Na -
Na
- Fat Malabsorption
-

-
Na -
BCAA 0.5-0.7 /.

- ascitis Na
- BCAA
1.2-1.5 //

REFERENCES

1. National Kidney Foundation Kidney Disease Outcomes Quality Initiative: Clinical practice
guidelines for nutrition in chronic renal failure. Am J Kidney Dis 35:S1-S140, 2000;
available at http://www.kidney.org/professionals/kdogi/guidelines updates/doqi nut.html.
2. Owen WF, Jr., Lew NL, Liu Y, et al: The urea reduction ratio and serum albumin
concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med
329:1001-1006, 1993.
3. Klahr S, Levey AS, Beck GJ, et al: The effects of dietary protein restriction and blood-
pressure control on the progression of chronic renal disease. N Engl J Med 330: 877-884,
1994.
4. Moore E, Celano J: Challenges of providing nutrition support in the outpatient dialysis
setting. Nutr Clin Pract 20:202-212, 2005.
5. Kopple JD: Nutrition, diet and the kidney. In Shils ME, Shike M, Ross AC, (eds): Modern
Nutrition in Health and Disease, 10th ed. Baltimore. Lippincott Williams & Wilkins, 2005.
6. American Association for the Study of Liver Diseases, http://www.aasld.org/