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1

..
.
.

(Vital organ)
( -
- )

-
(Hemodialysis-HD) (Continuous Ambulatory
Peritoneal Dialysis-CAPD) (dialyzer)
( 2 ) dialysate 4
(Kidney Transplantation-KT)

- 2
-
- 12x5 .
- 150
- 1-2

-
- cortex
- Medulla


(Nephron) 1

- (urea) (uric
acid)
-
- renin, erythropoietin vitamin D


(Acute glomerulonephritis) (Nephrotic syndrome)


(urea) -

(chronic kidney disease)


( DM HT)
( )

(BUN >20 ./.)
- () (
) ( erythropoietin )

() ()



* (Chronic Kidney Disease)
( Kidney biopsy
)
glomerular filtration rate (GFR) < 60 .//1.73 2
3 (K/DOQI 2002)

(Chronic Kidney Disease-CKD)


*
CKD
DM HT
CKD

( -HD)
(Nephro-nurse)
( ) (
2-3 4-5 )


( 12x5 cm)


( )
(.) 2543

216
1.
69,000
5,372.78
1,500
2.
13,320
5,605.00
45,960
7,947.00
3.
540
585,984
278,137.00
4.
12,000
5.
200
43,200
10,508.50
1,500
13,320
4,992.80
6.
200
7,644
4,992.80
7.
360
74,040
8.
19,678.00

-
- creatinine creatinine 1.5-2.0 mg/dl
-
- 10% ( )
(DM, HT)
- GFR 120 90 60 30 15
-

-
(
6 )

-
- (uncontrolled DM)

-
- atherosclerosis ,
-
- glomerulonephritis () ,
nephrotic syndrome ()
-
() ()
6



creatinine clearance (CCr) glomerulo filtration rate (GFR)


5

Ccr
/


> 20
1

64%

> 90

31%

60 89

4.3%

30 59

0.2%

30

15 29

0.2%

(0.1%)

< 15

< 10

Stage 3 5 CKD = 4.5% x 40 M. = 2

(CKD) (Pre-dialysis) 1-5


(1)
(5) (Pre-dialysis)

( 6 )
1-2 40%

3-5 (> 50%)


2


(
6 )
1-2 ()

5 (BUN) 100 ./.


(HemodialysisHD) (Continuous Ambulatory Peritoneal Dialysis-CAPD)
(Kidney Transplantation)
Pre-dialysis stage


(HD CAPD
KT) (
)

1.






( )

2. (, )

( Na, K)

3. (BP < 130/80
125/75 .) ( )

2000-3000 /
< 2000 /
(HT) CKD
()
B.P ( HT
)
4. ( )
(
)
FPG < 120 ./. HbA1C < 6.5%
*

5.
(dyslipidemia)
Total cholesterol (CHOL) < 200 /
Triglyceride (TG) < 150 /
LDL-cholesterol (LDL-C) < 100 /
HDL-cholesterol (HDL-C) > 50 /
dyslipidemia
Total cholesterol (TC) (> 200 /)
LDL-cholesterol (LDL-C) (> 100 130 /)
Triglyceride (TG) (> 150 / )
HDL-cholesterol (HDL-C) (< 45 /)

atherosclerosis cardiovascular
diseases
dyslipidemia

dyslipidemia atherosclerosis
cardio vascular accident 1 CKD

6. hyperphosphatemia
(> 4.8 /)
(Renal
osteodystrophy) secondary hyperparathyroidism
7. (27 /) (
)

8. ( -PCM )
CKD PCM
(0.6-0.8
/. IBW/)

10


30-35 1/ Ideal Body WT/
60 35 60 30

()
()

(55-60% )
complex carbohydrate () simple carbohydrate ()
30-35%
(< 10%)

(< 0.8 0.6 / IBW/

CCr < 60 ml/min; Cr > 1.5 mg/dl 0.8 / IBW/


CCr < 30 ml/min; Cr > 2.5 mg/dl 0.6 / IBW/
50% high Biological Value
( 50% )
0.6 / IBW/ (Amino acid
mixture)

11

( 5 )

(
high BV)

(1/25 ) ( high BV)
() ()
()

1 7
30 = 2 2 ()

1) ( )

2)

3)
PUFA 3 (EPA DHA)


1 9
30-35%
1

(Essential Fatty Acid) Polyunsaturated Fatty Acid
(PUFA) 6 3

12





Total Cholesterol (TC) < 200 ./.
LDL-C < 100 ./.
TG < 150 ./.
HDL-C > 45 ./.
(Saturated Fatty Acid-SFA) LDL-C (
)
Monounsaturated Fatty Acid (MUFA) LDL-C HDL-C
Polyunsaturated Fatty Acid (PUFA) 6 (
) LDL-C HDL-C PUFA
6 (LDL-C ) HDL-C
LDLC HDL-C TG ( dyslipidemia)


dyslipidemia CKD
( 30-35%
) 1800 60-70
( )

- ,
-
-
-
()

non-stick

13





SFA < 7% Cal; Trans FA < 1% Kcal
MUFA > 10% (10-15%) Kcal
PUFA : 6 3 < 10% Kcal
CHOL < 300 mg/
AHA 2001 Dietary Recommendation of in take


( SFA)

( ) (
)

PUFA 3 EPA DHA TG ( linolenic acid 3 )




() ( )
( )
(SFA) 2 lauric acid my-ristic acid
2 atherosclerosis
CVA CHD
(Butter)
SFA Myristic acid SFA

14



( 2 (better) SFA TransFA

1.
(SFA)
2. SFA ()
3.

4.
(margarine) ( )



5. 2

()
55-60%

1. .
.


( 7% 14%)

15

1) . .
. .
()

20-25 /
. .
2) . .

(
)
( )

1 15 ( .) 18 ( .)
1.3 (1.) 2 (1.)
6-7 ()
6-7 / 2-3 /



2.

3. (
)


1
1 1 0.5

4.

16






( 300-500 / 1800
) complex carbohydrate

(complex carbohydrate)
simple carbohydrate

(
)
whole grain


CKD
calcium intake
CKD () (> 4.8
./.)

(Renal Osteodystrophy)
secondary hyperparathyroidism

17


( high bioavailability)
Ca:P
1:1

(calcium
supplement) calcium carbonate, calcium citrate,
1
(> 4.8 ./.)
700-800 ./
( )

(Phosphate binder)
Calcium carbonate
calcium carbonate calcium carbonate
2
phosphate binder
calcium supplement

(active vitamin D) 1,25(OH)2D3-calcitriol


1,(OH)D3 ( 25,(OH)D3) D3
1,(OH)D3
1,(OH)D3 1,25(OH)2D3-Calcitriol ( 0.5 g/d)


secondary hyperparathyroidism

18

Ca, P Vit D

CKD Ca
secondary
hyperparathyroidism

calcium salt ( carbonate)
phosphate binder hyperphosphatemia
calcium supplement calcitriol1,25(OH)2D3 supplement (Renal Osteodystrophy)
secondary hyperparathyroidism

65
58 Ideal Body Weight 60 30 Kcal/Kg
I.B.W./ 0.6 /Kg I.B.W./ 2000 mg/


1800 Kcal/

36
/

60-70 /

70
/
256 /
5
(Exchange) : ( )
= 3.5

19

1 2
() 2
( 1 1 )
1 = 3.5 7
( )
6 ( 6
( )
6 ( 90 )
2 3 ( 3 )
2 (
1 40 ) 1 2 (1 = 1 )

12 = 12 4
5 1500 Kcal
300 Kcal

( )
300 Kcal
()
75
5 (1 8 )
40
35 ( 3 )

20

: ( )
()
( )

( 300 /)
1 3
1800

36

70

3.5

6
1 ( 2 )
2

12
5 3
3
1 3
:

3.5
1
1
1.5

6
3
3
2 (1 )
2

2
1
1

3
1
1
1

12
4
4
4
5 3

21

**

1 (2 )

3 ( 3 )

- (
)

1 (
)

4 ( 1 1 )
1
1 (2 )
1 ( 2 )

1
4 ( 1 1 )

1.5 ( 3 )

3 ( 3 )

1
4 ( 1 1 )

22


DM


3

1

= 3
= 2

-
( )
= 4
4
= 1 + 1
1
100
1


1
( 2 )
3
( 3 )

-
( )

4
(
1 1 )

(8 )

23



2 = 1 ( 40 )

1/2 = 3 (1 ..)

1/2 = 1
1 = , ,

= 4 (1 + 1
= 4
1

,
1
3 1
2 ~ 40
(1 )

1/2
, ,

1 + 1

(6 )

24

* **
3
= 3

1/2
= 1 ()
1
= 2 ()
1 3
,
()
= 4 ()
4

* ()
** 1

()
1.5
1/2 1
( 1 ) ( 2 )
3
( 3 )

1 + 1
*

( 6 )

25

1)
2)
2000

20
150 mg./
40
350
60
450
36 g. 40 350

2000 350
= 1650
NaCl 40
1650 NaCl 1650 x 100
40
16500
=
4
=
4125

4

5
4 3
5
3

26

30-35% 3
( ) 4 3
5

1.

2.


3.

4.

( )
CKD
1. (Edema) HT

CKD 2000-3000 ./ /
2000 ./


1.
()

()
-

27



( )
( ) , , ,
,



2. ()
() :

, , ,

: , (),
, , ,

( , )
( )
, ,
()
(Worcestersauce)
()
( )

28

3.
1


4.







5.
5.1
( )
1
3

5.2

29

1.
2.
- 3-4
-
( )

1. (
)
2. (
)
3. / ,
4.
5. /
2.
(Hyperkalemia)
3.5-5.0 mEq/L 5.0 mEq/L

arrhythmia (cardiac arrest)
( predialysis
dialysis)

30


( CKD Hemodialysis
)
predialysis


(
)

1.

2. (
) CKD
3. (KCl-potassium chloride)
(NaCl)

CKD


4.
-
Potassium carbonate (K2CO3) CKD

31

-
CKD

-

CKD




3.
2.5 4.8 /
> 4.8 / 800 /

(0.6 /I.B.W. 1 Kg/)


< 800 /
700-800 /
( ) (phosphate binder)
() phosphate binder
carbonate citrate, (
aluminium aluminium)
(calcium supplement)
calcium compound calcium carbonate
phosphate binder

32

calcium carbonate phosphate binder

calcium carbonate supplement

()
()



(

)
4.
(purine) 2-7
./. CKD (> 7 ./.) purine
purine

purine
( ) ( )
()
()

() (
)

( ) ( ) (
2-3 )

33

5.
200 / 100 ( HDL ) (
Atherosclerosis )

1. < 300 /
2. (60-70 /)
LDL HDL

( CHOL PO4-)
( )
:
SFA
SFA ( )
( ) ()

( )
6.
(TG) 150 /100
( 30)


PUFA
3 (EPA DHA)
()

ATHEROSCLEROSIS
CHOL TG ATHEROSCLEROSIS
cardiovascular disease

34

35

36

37

1
1
1
1
1
1
1
1

1
1/2
4
1
2
1
1
1
2
1
1
1
1
1
1
2
1
1

-
465-600
960-1,420
1,150
420-490
202-227
220
492
339

- -.
40
1,288
100
1,081
60
1,100
10
191
15
560
16
275
150
894
150
562
15
170
50
977
350
1,480
295
416
390
881
354
1,352
300
1,819
60
235
110
426
50
110

38

1
1

1

1

1
1

1
15

- -.
1,130
100
1,006
100
303
30
504
45
152
16
305
30
152
15
101
6
395
30
300
1,450
240
1,117
98
463
25
105
30
177

39

()
-
-
-
-
- ( () )
-
-
- ( )
- ( )
-

- (Worcestersauce)
- ( )
- ( )
-
-
()
-
- ()
- -
-
-
- ( )
- ( )


( Monosodium glutamate MSG)

40

-
-
-
-
-

(
)
1.
2. /
3.
4. /


3-4

41

1)

2)
40 300 (

)

42

43

- (447-544 ./100 )

- (200-400 ./100 )
( )


- (100-200 ./100 )
()


- ( 100 ./100 )
- (< 50 ./100 )
2 3
1

- (437-442 ./100 ) ()

- (200-300 ./100 )

- (100-200 ./100 )

- ( 100 ./100 )
*

2 2
1

44

45

()

()
- (
) ()
- ()
( 25 )




()
()

(
)
( )
(
)

( ) ( )

46

purine

47

purine ( purine hyperurecemia gout)


100
-

1
( 150 )
,

()
,
(Meat-extract)

2
(50-150 )
-
-

-
-
- ,
-
- ,
-
-

3
(0-15 )
()
, ,

()

(
)

: Robinson, H-Normal and Therapeutic Nutrition 1972


(
) 1



()

48

49

()
() 4
() 1
(13 )
(10 )

()
()
()
()

( )

( )

( )

( )

100
100
25
100
80
100

800
748
187
301
240
466

100

90

100

86

92

80

80

63

52

47

43

39

100
100
100
100

150
101
300
50

50

50
17
33

252
252
0

240

34

240

(butter)
1
(cheese)

100
5
100
100

250
12.5
100
40

100
100
100
100
100
100

2000
3300
300
95
0
0

: .. 2530

1. (
)
2.

51

1.
CKD CKD

2.


3. CKD (dyslipidemia) /
HDL-C 30-35%
1
(Saturated Fatty Acids SFA) < 10%
(Monounsaturated Fatty Acid MUFA) > 10%
(Polyunsaturated Fatty Acid PUFA) < 10%
4. (LDL-C)
4.1 SFA ( )
4.2 (Trans-fatty acid)
4.3 ( )
(LDL-C)
2 (
)
5. 3

( )
()
1 ( )
( 3) ( ) 1
LDL-C
6. PUFA 3 (EPA DHA)
( ) 2

52

PUFA 3 - ( linolenic acid)



7. PUFA 6 linoleic
acid () PUFA 3 linolenic acid (
)
PUFA 6 LDL-C HDL-C
PUFA 3 TG PUFA 3 (EPA
DHA)
2
HDL-C ()
PUFA 6 linoleic acid
(Safflower oil) Sunflower oil, Cottonseed oil Corn oil


53

( LDL-C )

1.




2. 5
1 250 1
= 0 = 0
3.

4. (
)
5.

6.
7. (SFA) Polyunsaturated Fatty acid (PUFA)
(-6 linoleic acid LDL-C
HDL-C ) Monounsaturated Fatty acid (MUFA) (
LDL-C HDL-C)
(Olive oil)
(Canola oil)


(
linolenic acid (PUFA) -3
PUFA 6 )