1. AMIN-RENAL INSTANT DRINK l Renal Failure and Malnutrition l Reutilization of Nitrogen l New concept of non-essential amino acids l Modification of vitamins and minerals in renal failure l Usage in AMIN-RENAL l Clinical Experience in EAA Supplement 龐振宜 藥師

2. Factors Contributing to Accelerated Protein Breakdown in ARF  Circulating protease  Elaboration of catabolic hormones  Corticosteroids  Epinephrine  Glucagon  Decreased responsiveness to the anabolic effects of Insulin  Secondary hyperparathyroidism  Inadequate nutrient intake  catabolic effects of dialytic therapy 6 - 9 g A. A. lost in hemodialysis 6 - 9 g A. A. lost in hemodialysis 130 - 180 gm / exchage during peritoneal dialysis 130 - 180 gm / exchage during peritoneal dialysis

3. Guildlines for protein administration in acute and chronic renal failure Patients not regularly dialyzed Patients not regularly dialyzed   Dialysis undesirable or contraindicated 14-28 gm EAA /day  Dialysis not contraindicated   GFR ≧ 70ml/min without progression no protein restriction   GFR ≧ 70ml/min with progression 0.55-0.70gm/kg/day   GFR 5-70ml/min 0.55-0.60gm/kg/day   Supplement for each hemodialysis or peritoneal dialysis40-42gm  Patient regularly dialysis   Hemodialysis 1.2-1.4gm/kg/day   Peritoneal dialysis (CAPD)1.2-1.5gm/kg/day

4. 急性腎衰竭的營養治療 EXTENT OF CATABOLISM MILD MODERATE SEVERE EXTENT OF CATABOLISM MILD MODERATE SEVERE Excess urea appearance (above N intake) 12 g 12 g Clinical setting Drug toxicity Elective surgery Severe injury or Clinical setting Drug toxicity Elective surgery Severe injury or +/- infection sespsis +/- infection sespsis Mortality 20% 60% >80% Dialysis frequency rare As needed Frequent Dialysis frequency rare As needed Frequent Route of nutrient Oral Enteral and/or Enteral and/or Route of nutrient Oral Enteral and/or Enteral and/or administration parenteral parenteral administration parenteral parenteral Energy recommendations 25 glucose 25-35 glucose + fat 35-45 glucose + fat (Kcal/kg/day) Energy recommendations 25 glucose 25-35 glucose + fat 35-45 glucose + fat (Kcal/kg/day) Protein (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, 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 Solution EAA + NEAA Solution Nutrition management of ARF 3rd 1993,Chapter15

5.  高必須氨基酸  高熱量 尿素氮再利用  尿素氮再利用  合成非必須氨基酸 Giordano - Giovannetti Theory Glucose Analine Cycle

6. Giordano - Giovannetti Diet Amin-Renal Instant Drink D Decrease the rate of urea production D Improve uremic symptoms D Stable or decrease BUN D Increase lean body mass D Stable or decrease eletrolytes

7. New concept of NEAA in renal failure é Histidine Hemoglobin decrease progressively Hemoglobin decrease progressively é Glycine and analine As cytoprotective effect to proximal tubule cells As cytoprotective effect to proximal tubule cells é tyrosine precursor of catecholamines and thyroid hormones precursor of catecholamines and thyroid hormones Negative nitrogen balance Negative nitrogen balance 0 Theoretically, it may be beneficial to include NEAAs to maintain N balance and optimize protein synthesis Parenteral Nutrition 2nd, 1993, p567-673

8. New concept of NEAA in renal failure ë Arginine –Intermediate in the urea cycle –improved and more rapid achievement of positive nitrogen balance –improved immunoglobulins J.Y. Pang

9. Vitamin modification in renal failure C Increase pyridoxine and folic acid C Limited ascorbic acid C Increase soluble vitamins during dialytic procedures C Vitamin A should be withheld as hypervitaminosis A C Vitamin D is withdrown of hypercalcemia supervenes J.Y. Pang

10. AMIN-RENAL Instant Drink 營養分析表 J.Y. Pang

11. AMIN-RENAL Instant Drink 蛋白質分析 (5gm/serving) J.Y. Pang Contain 74% Essential Amino Acid in total protein

12. AMIN-RENAL Instant Drink Vitamins and Minerals J.Y. Pang

13. AMIN-RENAL INSTANT DRINK Approximate Osmolality 500mOsm/kg H 2 0 Reconstituted pH Approx. 5-7 Calories:Nitrogen Ratio Approx. 312:1 Caloric density at standard dilution 1.3 Kcal/cc Essential amino acids content 74% of protein J.Y. Pang

14. AMIN-RENAL INSTANT DRINK < 杯中倒進 150ml 冷水 < ( 流體量受限者 120ml) < 加入一包 Amin-Renal < 立即服用或冷藏 口服  加入 600ml 冷水於攪拌 器中  加入四包 Amin-renal  低速攪拌約 30 秒  置於適當容器準備管餵 管餵 J.Y. Pang

15. AMIN-RENAL INSTANT DRINK  完全以 Amin-Renal 為營養來源 每天 6-8 包 每天 6-8 包  最低有效劑量每天 4 包, 可供應 50% 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 Amin-Renal 時, 得額外攝取非蛋白質能量, 以維持氮平衡 得額外攝取非蛋白質能量, 以維持氮平衡  長期服用 Amin-Renal 不須額外補充 Vitamins and Minerals, 但須偵測調整 J.Y. Pang 用量

16. AMIN-RENAL INSTANT DRINK EAA supplements with a low protein diet J.Y. Pang U Nitrogen balance U Increase total serum protein, Serum albumin, serum complement and serum transferrin U Slow nerve conducting velocity and reduced muscle membrane potential U correct abmormalities in plasma and muscle amino acids levels

17. AMIN-RENAL INSTANT DRINK Correct of Uremic Cellular Injury J.Y. Pang Phase I : 1g protein/kg/day 1g protein/kg/day HD: 6hrs/3x/wk HD: 6hrs/3x/wk Phase II: 1g protein/kg/day 1g protein/kg/day HD: 6hrs/2x/wk HD: 6hrs/2x/wk Phase III: 0.5g protein/kg/day 0.5g protein/kg/day EAA supplement EAA supplement HD: 6hrs/2x/wk HD: 6hrs/2x/wk Am. J. kidney Disease Vol V,No5,May 1985

18. AMIN-RENAL AMIN-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 2.5 克 / 包 x 4 =10 克 EAA 額外攝取必須氨基酸量 2.5 克 / 包 x 4 =10 克 EAA 10 克 EAA / 40% = 25 克 可合成身體蛋白質量 10 克 EAA / 40% = 25 克 ( 蛋白質組成 EAA/NEAA 為 40:60) ( 蛋白質組成 EAA/NEAA 為 40:60) 25 克 / 6.25 = 4 克 Positive Nitrogen 量 25 克 / 6.25 = 4 克 4 克 - (2.5 克 x 4 包 Amin-Renal /6.25) = 2.4 克 體內合成蛋白質時被利用的總氮量 4 克 - (2.5 克 x 4 包 Amin-Renal /6.25) = 2.4 克 預估 50 公斤體重病患 BUN 減少量 2.4 克氮 / 35 公升體總水量 = 6.8 mg/dl 2.4 克氮 / 35 公升體總水量 = 6.8 mg/dl 新一代 Essential Amino Acids Formula

19. AMIN-RENAL AMIN-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