Jornal de Distúrbios Nutricionais e Terapia

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Nutrição Clínica 2020: Efeito do aconselhamento nutricional na forma de plano alimentar individualizado no nível de albumina sérica entre pacientes em hemodiálise - Suhair Abdalla Khalil Abdallah - Universidade Ahfad para Mulheres

Suhair Abdalla Khalil Abdallah

Introdução: O estado nutricional ideal é uma questão importante no tratamento de longo prazo de pacientes (HD) e é um pré-requisito para um melhor prognóstico de pacientes em HD. A Kidney Disease Outcomes Quality Initiative (KDOQI) recomenda o uso de práticas padronizadas em nutrição renal como parte central e integral do tratamento dietético de pacientes com doença renal em estágio terminal (ESRD) em HD. Um nutricionista com experiência renal deve ser responsável pela avaliação contínua do estado nutricional do paciente e pelo desenvolvimento de planos para cuidados dietéticos. Isso garante a avaliação adequada do estado nutricional e a identificação oportuna de pacientes em risco. A avaliação do estado nutricional é, portanto, parte integrante do tratamento nutricional. Vários parâmetros devem ser avaliados juntos, incluindo histórico de perda de peso, ingestão de proteína e energia na dieta, massa de gordura subcutânea e massa muscular e índice de massa corporal (IMC), avaliação global subjetiva (SGA) usada por autoridades de saúde para pontuar o estado nutricional de proteína-energia e vários marcadores bioquímicos (albumina sérica, pré-albumina e transferrina) foram usados ​​para avaliar os estoques de proteína visceral. Destes, a albumina sérica tem sido até agora a mais comumente usada. É a única medida de proteína corporal total, tanto muscular quanto visceral, que é o marcador mais frequentemente usado do estado proteico e é o padrão recomendado pelo KDOQI. Para ser usado na avaliação do estado nutricional entre DRC. É um marcador forte para a avaliação da desnutrição entre pacientes em HD. É improvável que uma albumina diminuída resulte em um aumento na morbidade e mortalidade. O que foi demonstrado para pacientes com ESRD cuja albumina está abaixo de 40 g/d e resulta em um risco excessivo de morte. O baixo nível de albumina é um analista sólido da humanidade e da doença entre pacientes em hemodiálise. É um marcador substituto de PEM que é comum entre pacientes com ESRD em HD com uma prevalência estimada de 10 a 70% e, sem dúvida, contribui para o aumento dos riscos de morbidade e mortalidade. Isso é agravado pelo fato de que esses pacientes perdem grandes quantidades de proteína no fluido de dialisato (o que leva à hipoalbuminemia nesse grupo) (a maioria dos estudos anteriores mostrou que a quantidade de aminoácidos perdidos no dialisato durante uma sessão de diálise pode variar de 4 a 13 g) e não tomam consistentemente as quantidades recomendadas de energia e proteína para pacientes com DRC em HD. Eles precisam de planos de refeições individualizados, mas raramente consultam um nutricionista. Em outras palavras, uma dieta especial é necessária para pacientes com DRC em HD. A ingestão diária recomendada de nutrientes para um adulto em HD é: proteína 1,2 g/kg de peso corporal (50% de alto valor biológico); energia para um adulto < 60 anos 35 kcal/kg e para um adulto > 60 anos ou obeso 30 kcal/kg; os minerais (mg/kg/dia) - sódio 2 - 4, potássio 40 e fósforo 17; os fluidos dependem da produção de fluidos + 500 ml.

Serum albumin is the most commonly used malnutrition marker in clinical practice as hypo albuminemia is considered to be a malnutrition risk among the patients on hemodialysis and a strong predictor of death. Low serum albumin levels are due to low intakes of energy and protein or insufficient energy intake resulting in poor protein utilization.

Purpose: This was a prospective, clinical trial hospital based (intervention) study to evaluate the effect of nutritional counseling in the form of individualized meal plan on serum albumin level among hemodialysis patients.

Methods: The study was conducted on maintenance hemodialysis patients attending Dr Salma Hemodialysis & Transplant Center outpatient clinic, Khartoum. 134 adult patients (males & females) were divided into a test group (n=77) and a control group (n=57). The test group after nutritional counseling consumed individualized diets for a period of 6 months that provided adequate amounts of energy and protein according to the recommendations of the National Kidney Foundation whereas the control group sustained overwhelming their usual diets. Serum albumin was determined at baseline and every 2 months. Data were analyzed using SPSS.

Nutritional status assessment:

Intervention Eighty-three HD patients who were included in the study as test group received conventional nutritional counseling and individual meal plan to achieve adequate protein and calories intake. Monitoring was done during 6 months of follow up. The individual meal plan was designed and explained to patient and their families by the following ways:

Educational lecture: Educational lecture was given exclusively to the test group. It was presented by the researcher to the patients and their families during their dialysis session by using a data-show to educate the patients and their families on the nutritional needs to provide appropriate food with adequate calories and protein to the patients.

Presentation included all the important information needed to be known by ESRD patient on HD. It was concentrated on calorie and protein needed, fluids limitation, intake of sodium, potassium and phosphorus in foods. Information was provided in a simple way and was explained by pictures for more understanding.

Pamphlets: were prepared and distributed to all intervention group participants after the lecture and all the summary information that was presented was found in the sheet which the researcher called it as the over-all training sheet for renal patients on HD.

Individualized meal plans: Individual meal plan was designed individually to all intervention group participants after analysis of the full information that helped the researcher to conduct the meal plan. The meal plan was based on: patient’s economic status, medical history, diet history, like and dislike, chewing and swallowing status, food allergies, blood investigation result, age, weight, height and sex. (Food exchange list was used to help patients for food substitutes if participant unable to follow the meal prescribed according to like and dislike or socio economic reasons). After calculation of all nutrients needed by each participant, individual meal plan for the whole week was designed by researcher, typed, organized, color printed and given to participant with full explanation of uses. The meals planned were designed only for intervention patients, whereas control patients continued to receive their usual care.

Results: Demographic characteristic of the study sample: For the demographic characteristic of the study participants, test and control, Males represented a higher percentage than the females. The age group distribution of subject shows that most of the patients (46.3%) were in the active age group of 30 - 45 yrs. (49.4% test and 42.1% control). The majority (31.3%) had higher secondary school education (29.9% test and 33.3 % control), followed by 17.9% university graduates (23.4% test and 10.5% control), the rest were illiterate or with low educational level. Medical profile of the participants

The medical characteristics of the study: Participants are shown that 53.7% of the participant had hypertension (61.0% test and 43.9% control), while only 3.0% had diabetes mellitus and hypertension (1.3% test and 5.3% control) and the rest 43.3% did not have any comorbid disease (37.7% test and 50.9% control). The mean extents of dialysis eras were 57.08 ± 36.16 months for the together groups (61.77 ± 38.84 test and (50.75 ± 31.42 control group).

Serum albumin augmented progressively from 3.14 g/dl at zero to 4.32 g/dl at 6 months with test group. The study displays big alterations in accumulation of serum albumin level during the study with intervention group compared with control. The mean test group was (3.1, 3.3, 3.9 and 4.3) and the mean of control group was (3.2, 3.16, 3.19 and 3.84) in baseline, 2-4-6 months respectively.

Conclusion: The study demonstrated that effective nutritional counseling rendered to maintenance hemodialysis patients in the form of individualized meal plans that provided adequate energy and protein was active in the switch and enhancement of serum albumin equal among these patients. Therefore, nutritious counseling by skilled dietitians is mandatory in renal units as part of the medical therapy management to reduce the incidence of hypoalbminemia among hemodialysis patients.

Biography:

Suhair Abdalla Khalil Abdallah concluiu seu PhD em Nutrição Clínica pela Ahfad University for Women, Sudão. Ela é uma Dietista Clínica no King Faisal Specialist Hospital & Research Center, Reino da Arábia Saudita. Ela tem uma longa experiência de 18 anos no campo da nutrição clínica.

NOTA: Este trabalho foi parcialmente apresentado na 5ª Conferência Europeia de Nutrição e Dietética, realizada de 16 a 18 de junho de 2016 em Roma, Itália.