AMIN-RENALAMIN-RENAL INSTANT DRINKINSTANT DRINK

Renal Failure and MalnutritionRenal Failure and Malnutrition Reutilization of NitrogenReutilization of Nitrogen New concept of non-essential amino acidsNew concept of non-essential amino acids Modification of vitamins and minerals in renal Modification of vitamins and minerals in renal

failurefailure Usage in AMIN-RENALUsage in AMIN-RENAL Clinical Experience in EAA SupplementClinical Experience in EAA Supplement

龐振宜 藥師

Factors Contributing to Accelerated Protein Factors Contributing to Accelerated Protein Breakdown in ARFBreakdown in ARF

Circulating proteaseCirculating protease Elaboration of catabolic hormonesElaboration of catabolic hormones

CorticosteroidsCorticosteroids EpinephrineEpinephrine GlucagonGlucagon

Decreased responsiveness to the anabolic effects of Decreased responsiveness to the anabolic effects of InsulinInsulin

Secondary hyperparathyroidismSecondary hyperparathyroidism Inadequate nutrient intakeInadequate nutrient intake catabolic effects of dialytic therapycatabolic effects of dialytic therapy

6 - 9 g A. A. lost in hemodialysis6 - 9 g A. A. lost in hemodialysis 130 - 180 gm / exchage during peritoneal dialysis130 - 180 gm / exchage during peritoneal dialysis

Guildlines for protein administration in acute Guildlines for protein administration in acute and chronic renal failureand chronic renal failure

Patients not regularly dialyzedPatients not regularly dialyzed Dialysis undesirable or contraindicated 14-28 gm EAA /day

Dialysis not contraindicatedDialysis not contraindicatedGFR 70ml/min without progression ≧ no protein restrictionGFR 70ml/min with progression≧ 0.55-0.70gm/kg/dayGFR 5-70ml/min 0.55-0.60gm/kg/daySupplement for each hemodialysis or peritoneal dialysis 40-42gm

Patient regularly dialysisPatient regularly dialysisHemodialysis 1.2-1.4gm/kg/dayPeritoneal dialysis (CAPD) 1.2-1.5gm/kg/day

急性腎衰竭的營養治療急性腎衰竭的營養治療 EXTENT OF CATABOLISM MILD MODERATEEXTENT OF CATABOLISM MILD MODERATE SEVERE SEVERE

Excess urea appearanceExcess urea appearance(above N intake)(above N intake)

<5 g<5 g 6-12 g >12 g 6-12 g >12 g

Clinical settingClinical setting Drug toxicity Elective surgery Severe injury or Drug toxicity Elective surgery Severe injury or +/- infection sespsis+/- infection sespsis Mortality 20% 60%Mortality 20% 60% >80% >80%

Dialysis frequency rareDialysis frequency rare As needed As needed Frequent Frequent

Route of nutrient Oral Enteral and/or Enteral and/or Route of nutrient Oral Enteral and/or Enteral and/or administration parenteral parenteraladministration parenteral parenteral

Energy recommendations 25 glucose 25-35 glucose + fatEnergy recommendations 25 glucose 25-35 glucose + fat 35-45 glucose + fat 35-45 glucose + fat (Kcal/kg/day) (Kcal/kg/day)

Protein (g/kg/day) 0.6-0.8 EAA 0..8-1.2 EAA + NEAA 1.0-1.5 EAA +NEAAProtein (g/kg/day) 0.6-0.8 EAA 0..8-1.2 EAA + NEAA 1.0-1.5 EAA +NEAA

Nutritions used Food, enteral formulas, Enteral Formulas, Glucose, Enteral Formulas, Nutritions used Food, enteral formulas, Enteral Formulas, Glucose, Enteral Formulas, EAA solution 50-70%; fat emulsion 10-20%; Glucose, 50-70% EAA solution 50-70%; fat emulsion 10-20%; Glucose, 50-70% EAA + NEAA Solution fat emulsion, 10-20%;EAA + NEAA Solution fat emulsion, 10-20%; EAA + NEAA SolutionEAA + NEAA SolutionNutrition management of ARF 3rd 1993,Chapter15

高必須氨基酸高必須氨基酸高熱量高熱量

尿素氮再利用尿素氮再利用 合成非必須氨基合成非必須氨基酸酸

Giordano - Giovannetti TheoryGiordano - Giovannetti TheoryGlucose Analine Cycle

Giordano - Giovannetti DietGiordano - Giovannetti DietAmin-Renal Instant DrinkAmin-Renal Instant Drink

Decrease the rate of urea productionDecrease the rate of urea production Improve uremic symptomsImprove uremic symptoms Stable or decrease BUNStable or decrease BUN Increase lean body massIncrease lean body mass Stable or decrease eletrolytesStable or decrease eletrolytes

New concept of NEAA in renal failureNew concept of NEAA in renal failureHistidineHistidine

Hemoglobin decrease progressivelyHemoglobin decrease progressively

Glycine and analine Glycine and analine As cytoprotective effect to proximal tubule cellsAs cytoprotective effect to proximal tubule cells

tyrosine tyrosine precursor of catecholamines and thyroid hormones precursor of catecholamines and thyroid hormones

Negative nitrogen balanceNegative nitrogen balance

Theoretically, it may be beneficial to include NEAAs tTheoretically, it may be beneficial to include NEAAs to maintain N balance and optimize protein synthesiso maintain N balance and optimize protein synthesis

Parenteral Nutrition 2nd, 1993, p567-673

New concept of NEAA in renal failureNew concept of NEAA in renal failure

ArginineArginine

– Intermediate in the urea cycleIntermediate in the urea cycle

– improved and more rapid achievement of improved and more rapid achievement of positive nitrogen balancepositive nitrogen balance

– improved immunoglobulinsimproved immunoglobulins

J.Y. Pang

Vitamin modification in renal failureVitamin modification in renal failure

Increase pyridoxine and folic acidIncrease pyridoxine and folic acid Limited ascorbic acidLimited ascorbic acid Increase soluble vitamins during dialytic proIncrease soluble vitamins during dialytic pro

cedurescedures Vitamin A should be withheld as hypervitamVitamin A should be withheld as hypervitam

inosis Ainosis A Vitamin D is withdrown of hypercalcemia suVitamin D is withdrown of hypercalcemia su

pervenespervenesJ.Y. Pang

AMIN-RENAL AMIN-RENAL Instant DrinkInstant Drink

營養分析表營養分析表

Per serving % CaloriesServing Size 50 gmCalories 250 KcalCarbohydrate Maltodextrin Sucrose

31 gm 25 gm 5.5 gm

51

Fat Vegetable Oil

11 gm 41

Protein 5 gm 8

Per serving % CaloriesServing Size 50 gmCalories 250 KcalCarbohydrate Maltodextrin Sucrose

31 gm 25 gm 5.5 gm

51

Fat Vegetable Oil

11 gm 41

Protein 5 gm 8

J.Y. Pang

AMIN-RENAL AMIN-RENAL Instant DrinkInstant Drink

蛋白質分析 蛋白質分析 (5gm/serving)(5gm/serving)Lactalbumin Hydrolysate 2.50 gm

L-Leucine 0.35 gm

L-Isoleucine 0.22 gm

L-Valine 0.25 gm

L-Methionine 0.35 gm

L-Lysine 0.26 gm

L-Phenylalanine 0.35 gm

L-Tryptophan 0.08 gm

L-threonine 0.16 gm

L-Histidine 0.08 gm

L-Arginine 0.39 gm

J.Y. PangContain 74% Essential Amino Acid in total proteinContain 74% Essential Amino Acid in total protein

Vitamins Per Serving %USRDA

Minerals Per Serving %USRDA

Vit. A 625 I.U. 12.5 Sodium 98mg **Vit. D 50 I.U. 12.5 Potassium 70mg **Vit. E 8 I.U. 25.0 Chloride 115mg **Vit. K 10 ug ** Calcium 150mg 15.0Vit. C 15 mg 25.0 Phosphorus 90mg 9.0Vit. B1 0.37mg 25.0 Magnesium 50mg 12.5Vit. B2 0.43mg 25.0 Iodine 18.8ug 12.5Vit. B6 1.0mg 50.0 Manganese 0.62mg **Vit. B12 1.5ug 25.0 Copper 0.25mg 12.5Folic Acid 100 ug 25.0 Zinc 1.88mg 12.5Niacin 5mg 25.0 Iron 2.25mg 12.5Biotin 75ug 25.0 Selenium 25ug **Pantothenic Acid 2.5mg 25.0 Chromium 18.8ug **Choline 75mg ** Molybdenum 18.8ug **

AMIN-RENAL AMIN-RENAL Instant DrinkInstant Drink

Vitamins and MineralsVitamins and Minerals

J.Y. Pang

AMIN-RENALAMIN-RENAL INSTANT DRINKINSTANT DRINK

Approximate Osmolality 500mOsm/kg HApproximate Osmolality 500mOsm/kg H2200

Reconstituted pH Approx. 5-7Reconstituted pH Approx. 5-7

Calories:Nitrogen Ratio Approx. 312:1Calories:Nitrogen Ratio Approx. 312:1

Caloric density at standard dilution 1.3 Kcal/ccCaloric density at standard dilution 1.3 Kcal/cc

Essential amino acids content 74% of proteinEssential amino acids content 74% of protein

J.Y. Pang

AMIN-RENALAMIN-RENAL INSTANT DRINKINSTANT DRINK

杯中倒進杯中倒進 150ml150ml 冷水冷水 (( 流體量受限者流體量受限者 120m120m

l)l) 加入一包加入一包 Amin-RenalAmin-Renal 立即服用或冷藏立即服用或冷藏

口服口服 加入加入 600ml600ml 冷水於攪拌冷水於攪拌器中器中

加入四包加入四包 Amin-renalAmin-renal 低速攪拌約低速攪拌約 3030 秒秒 置於適當容器準備管餵置於適當容器準備管餵

管餵管餵

J.Y. Pang

AMIN-RENALAMIN-RENAL INSTANT INSTANT DRINKDRINK

完全以完全以 Amin-Renal Amin-Renal 為營養來源為營養來源 每天每天 6-8 6-8 包包 最低有效劑量每天最低有效劑量每天 44 包包 , , 可供應可供應 50%50% 所須所須 蛋白質及能量蛋白質及能量 嚴重代謝障礙須大量服用嚴重代謝障礙須大量服用 Amin-RenalAmin-Renal 時時 ,, 得額外攝取非蛋白質能量得額外攝取非蛋白質能量 ,, 以維持氮平衡以維持氮平衡 長期服用長期服用 Amin-Renal Amin-Renal 不須額外補充不須額外補充 Vitamins aVitamins and Minerals, nd Minerals, 但須偵測調整但須偵測調整

J.Y. Pang

用量用量

AMIN-RENALAMIN-RENAL INSTANT DRINKINSTANT DRINK

EAA supplements with a low protein dietEAA supplements with a low protein diet

J.Y. Pang

Nitrogen balanceNitrogen balance Increase total serum protein, Serum albumiIncrease total serum protein, Serum albumi

n, serum complement and serum transferrinn, serum complement and serum transferrin Slow nerve conducting velocity and reduced Slow nerve conducting velocity and reduced

muscle membrane potentialmuscle membrane potential correct abmormalities in plasma and muscle correct abmormalities in plasma and muscle

amino acids levelsamino acids levels

AMIN-RENALAMIN-RENAL INSTANT DRINKINSTANT DRINKCorrect of Uremic Cellular InjuryCorrect of Uremic Cellular Injury

J.Y. Pang

Patient Phase 1 Phase II Phase III

1 93.6 75.6 92.6

2 89.6 80.3 88.1

3 86.1 81.0 93.4

4 92.3 78.1 91.8

5 97.0 77.9 90.2

6 90.7 78.0 73.3

Mean 91.6 78.5 88.2

SD 3.7 1.9 7.6

Phase I :Phase I : 1g protein/kg/day1g protein/kg/day HD: 6hrs/3x/wkHD: 6hrs/3x/wkPhase II:Phase II: 1g protein/kg/day1g protein/kg/day HD: 6hrs/2x/wkHD: 6hrs/2x/wkPhase III:Phase III: 0.5g protein/kg/day0.5g protein/kg/day EAA supplementEAA supplement HD: 6hrs/2x/wkHD: 6hrs/2x/wk

Am. J. kidney Disease Vol V,No5,May 1985

AMIN-RENALAMIN-RENAL INSTANT DRINK( 口服 , 管餵 )

有效降低 BUN 值 維持體內電解質平衡每日攝取 4包 AMIN-RENAL 時

額外攝取必須氨基酸量 2.52.5 克克 // 包 包 x 4 =10 x 4 =10 克 克 EAAEAA

可合成身體蛋白質量 10 10 克 克 EAA / 40% = 25 EAA / 40% = 25 克克 (( 蛋白質組成 蛋白質組成 EAA/NEAAEAA/NEAA 為 為 40:60)40:60)

Positive Nitrogen 量 25 25 克克 / 6.25 = 4 / 6.25 = 4 克克體內合成蛋白質時被利用的總氮量 4 4 克 克 - (2.5 - (2.5 克 克 x 4 x 4 包包Amin-Renal /6.25) = 2.4 Amin-Renal /6.25) = 2.4 克克

預估 50公斤體重病患 BUN 減少量 2.42.4 克氮 克氮 / 35/ 35 公升體總水量 公升體總水量 == 6.8 mg/dl6.8 mg/dl

新一代Essential

Amino AcidsFormula

AMIN-RENALAMIN-RENAL INSTANT DRINK( 口服 , 管餵 )

腎衰竭氨基酸配方

降低急慢性腎衰竭 BUN 回復或減低高血鉀 回復或減低上升的血清磷及鎂 蛋白質合成改善細胞代謝平衡 促進 ARF 腎功能的恢復 降低 ARF 死亡率