持续质量改进在慢性肾脏病患者饮食营养管理中的作用

目的 探讨持续质量改进(CQI)方法对慢性肾脏病(CKD)患者营养状态、肾功能进展及低蛋白饮食(LPD)依从性方面的影响.方法 选择北京友谊医院CKD门诊规律随诊的患者115例,采用PDCA四步法,即设计(plan)-实施(do)-检验(check)-应用(act),加强对其饮食管理12个月.分析比较CQI前后患者各项临床指标及饮食依从性方面的变化.结果 经过以低蛋白饮食为主导的CQI营养管理,CKD患者营养状况保持良好,握力、血红蛋白、血清白蛋白、总胆固醇、甘油三酯水平等指标与干预前比较无显著变化(P均＞0.05).患者主观感受改善,改良主观全面营养评价法评分由干预前的7.0(7.0,8.0)分降至7.0 (7.0,7.0)分(P=0.000).干预后反映肾功能进展的指标,改良MDRD公式计算出的肾小球滤过率有所下降,由(40.74±14.49)降至(37.94±16.86) ml/(min·1.73 m2) (P=0.000),年平均下降速率为(2.81±7.42) ml/(min·1.73 m2)；干预后的肌酐清除率无明显下降(P=0.910).患者对低蛋白饮食依从性得到改善,蛋白质摄入量(DPI)及氮表现率蛋白相当量(PNA)均较干预前显著下降,DPI/kg由(0.79 ±0.27)降至(0.64±0.15)g/(24 h· kg),PNA/kg由(1.02±0.32)降至(0.82±0.24)g/(24h·kg)(P均=0.000)；低蛋白饮食认知程度及依从性调查显示CQI营养管理12个月后,患者在知、信、行3个方面的评分以及整体评分均较干预前显著提高(P均=0.000).结论 CQI应用于CKD患者饮食营养管理可以使患者保持良好的营养状态,提高患者对低蛋白饮食的重视及依从性.

Effects of continuous quality improvement on dietary and nutrition management in patients with chronic kidney disease

Objective To evaluate the effects of continuous quality improvement （CQI） management on nutritional status, renal function progression, and compliance of low protein diet in patients with chronic kidney dis- ease （CKD）. Methods Totally 115 CKI） patients who were regularly followed up in CKD clinic services were re- cruited in this study. Plan, Do, Check, and Act （PDCA） method was adopted to manage the dietary of these pa- tients for 12 months. The clinical indicators and diet compliance before and after receiving CQI management were compared. Results After receiving the CQI management, the nutritional status of patients was well maintained; meanwhile, the average hand strength and the hemoglobin, serum albumin, total cholesterol, and triglyceride levels showed no significant changes （ all P 〉 0. 05 ）. Subjective feelings of patients were improved. The modified Subjec- tive Global Assessment of Nutrition （mSGA） score was decreased from 7. 0 （7.0, 8.0） to 7. 0 （7.0, 7.0） （P = 0. 000）. The estimated glomerular filtration rate （eGFR） calculated by formula of modified MDRD was decreased from （40. 74 ± 14. 49） to （37.94 ± 16. 86） ml/（ min . 1.73 m2 ） （P = 0. 000）, and the average descended speedwas （2. 81 ± 7. 42） ml/（min . 1.73 m2） per year. The creatinine clearance rate had no statistical difference be- tween pre- and post management （P =0. 910）, and the average descended speed was （0. 19 ± 17.01 ） ml/min per year. The daily protein intake （DPI） and protein equivalent of nitrogen appearance rate （PNA） were both signifi- cantly descended： DPI/kg decreased from （0.79 ±0.27） to （0.64 ±0. 15） g/ （24 h.kg） （P =0. 000）, and PNA/kg dropped from （ 1.02 ± 0. 32） to （0. 82 ± 0. 24 ） g/ （ 24 h . kg） （ P = 0. 000）. The scores of awareness and compliance of patients on low protein diet were significantly increased after CQI management （ P = 0. 000）. Coneulsion Applying CQI on dietary and nutrition management in CKD patients can maintain the good nutritional status and improve the compliance of low protein diet.