PREPORUKE ZA PRAĆENJE, PREVENCIJU I LIJEČENJE PROTEINSKO-ENERGIJSKE POTHRANJENOSTI U BOLESNIKA S KRONIČNOM BUBREŽNOM BOLESTI

Nikolina Bašić-Jukić, Josipa Radić, Dragan Klarić, Marko Jakić, Božidar Vujičić, Marijana Gulin, Željko Krznarić, Eva Pavić, Petar Kes, Bojan Jelaković, Sanjin Rački

Bolesnici s kroničnom bubrežnom bolesti imaju visoku stopu pobolijevanja i smrtnosti od srčano-žilnih bolesti kojoj u velikoj mjeri pridonosi i pothranjenost. Razvoju pothranjenosti pridonosi niz čimbenika rizika povezanih sa samom bubrežnom bolesti, ali i s nadomještanjem bubrežne funkcije dijalizom. Proteinsko-energijsku pothranjenost (PEP) potrebno je razlikovati od samog pojma pothranjenosti. Povezana je s upalom, trošenjem energijskih zaliha u mirovanju, niskim serumskim vrijednostima albumina i prealbumina, gubitkom mišićne mase s gubitkom tjelesne mase ili bez gubitka tjelesne mase te lošim kliničkim ishodom. Uključuje prehrambene i metaboličke poremećaje koji se javljaju u bolesnika s kroničnom bubrežnom bolešću, a dovode do razvoja stanja kroničnog katabolizma te gubitka mišićnog i masnog tkiva. Može biti prisutna i u adipoznih bolesnika, što se rijetko prepoznaje. Prevencija je najbolji pristup zbrinjavanju bolesnika. Potrebno je prepoznati bolesnike s povećanim rizikom od razvoja PEP-a i terapijski intervenirati. Prvi su koraci u liječenju nutritivno savjetovanje i promjene prehrambenih navika obavezno vodeći računa o unosu kuhinjske soli. Primjena enteralnih pripravaka sljedeći je korak u postizanju terapijskih nutritivnih ciljeva, nakon čega slijedi i intradijalitička parenteralna prehrana te u konačnici totalna parenteralna prehrana. Osim nutritivnih aspekata liječenja, nužno je istodobno liječiti i ostale probleme poput anemije, sekundarnog hiperparatiroidizma i acidoze uz osiguravanje odgovarajuće doze dijalize. Postizanje terapijskih ciljeva zahtijeva multidisciplinarni pristup, pri čemu se optimalni rezultati postižu suradnjom nefrologa, gastroenterologa i nutricionista.

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW.