{"id":1944,"date":"2023-11-01T15:11:54","date_gmt":"2023-11-01T18:11:54","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=1944"},"modified":"2023-11-01T15:11:54","modified_gmt":"2023-11-01T18:11:54","slug":"nutricao-parenteral-intradialitica-2","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/nutricao-parenteral-intradialitica-2\/","title":{"rendered":"Quando e como introduzir a nutri\u00e7\u00e3o parenteral intradial\u00edtica em pacientes em hemodi\u00e1lise?"},"content":{"rendered":"

A necessidade de hemodi\u00e1lise devido ao comprometimento da fun\u00e7\u00e3o renal est\u00e1 associada a um incremento na taxa de mortalidade, bem como a piora na qualidade de vida1.<\/sup>. Muitos desses problemas podem ter rela\u00e7\u00e3o com o estado nutricional. Nesse contexto, acompanhar indicadores nutricionais \u00e9 importante para avaliar a evolu\u00e7\u00e3o do quadro. A partir disso \u00e9 poss\u00edvel propor interven\u00e7\u00f5es como nutri\u00e7\u00e3o parenteral intradial\u00edtica.<\/strong><\/p>\n

A import\u00e2ncia desse recurso \u00e9 ainda maior quando se leva em conta que entre 40% e 60% dos pacientes em hemodi\u00e1lise apresentam desnutri\u00e7\u00e3o2,4<\/sup>. Al\u00e9m dos piores progn\u00f3sticos, esse problema leva a aumento de custos com a perman\u00eancia hospitalar e a mais desfechos negativos, como a mortalidade2,5<\/sup>.<\/p>\n

Como \u00e9 feita e quais os objetivos da nutri\u00e7\u00e3o parenteral intradial\u00edtica?<\/h2>\n

A nutri\u00e7\u00e3o parenteral intradial\u00edtica, como o pr\u00f3prio nome indica, \u00e9 feita por meio da administra\u00e7\u00e3o da f\u00f3rmula nutricional pelo mesmo acesso em que \u00e9 feito o procedimento de hemodi\u00e1lise. Dessa forma, o paciente n\u00e3o precisa ser submetido a introdu\u00e7\u00e3o de um novo acesso com esse fim<\/strong> 1<\/sup>. Normalmente, a NP intradial\u00edtica \u00e9 administrada durante a sess\u00e3o de hemodi\u00e1lise. Ela costuma durar em torno de 4 horas e \u00e9 feita, em m\u00e9dia, 2 a 3 vezes por semana1<\/sup>.<\/p>\n

Embora seja uma interven\u00e7\u00e3o vital, a hemodi\u00e1lise est\u00e1 associada a diversas altera\u00e7\u00f5es nutricionais e metab\u00f3licas. \u00c9 comum, por exemplo, que pacientes com comprometimento renal submetidos ao procedimento apresentem perda de massa muscular6<\/sup>. Isso se d\u00e1 tanto pela natureza da doen\u00e7a renal cr\u00f4nica quanto por interfer\u00eancia da hemodi\u00e1lise sobre o processo de s\u00edntese prote\u00edca7,8,9<\/sup>. No mais, durante a di\u00e1lise e conforme a progress\u00e3o do preju\u00edzo renal pode haver perda de nutrientes8<\/sup> e acelera\u00e7\u00e3o do catabolismo proteico9<\/sup><\/strong>.<\/p>\n

Com isso, interven\u00e7\u00f5es nutricionais, inclusive durante a di\u00e1lise, s\u00e3o fundamentais para contornar essas defici\u00eancias e manter um adequado estado nutricional. Mas quando o aconselhamento nutricional e uso de suplementos nutricionais por via oral durante a di\u00e1lise n\u00e3o s\u00e3o efetivos, a nutri\u00e7\u00e3o parenteral torna-se um suporte nutricional necess\u00e1rio para fornecimento de maiores quantidades de calorias e prote\u00ednas<\/a> e manejo adequado do quadro cr\u00f4nico9-12.<\/sup>.<\/p>\n

Quais as principais indica\u00e7\u00f5es desta interven\u00e7\u00e3o em pacientes em hemodi\u00e1lise?<\/h2>\n

Dessa forma, a nutri\u00e7\u00e3o parenteral intradial\u00edtica \u00e9 indicada para pacientes com doen\u00e7a ou les\u00e3o renal em hemodi\u00e1lise desnutridos ou em risco de desnutri\u00e7\u00e3o capazes de se alimentar por via oral, mas que n\u00e3o conseguem atingir as recomenda\u00e7\u00f5es nutricionais m\u00ednimas6,13,14<\/sup>.<\/strong> Com isso, esse recurso tende a ser ainda mais relevante em pacientes desnutridos que j\u00e1 foram submetidos a outras interven\u00e7\u00f5es com o intuito de manter o estado nutricional1<\/sup>.<\/p>\n

Entretanto, no caso de pacientes hemodial\u00edticos em risco de desnutri\u00e7\u00e3o, \u00e9 importante levar em conta que os m\u00e9todos de diagn\u00f3stico para determinar comprometimento nutricional, inflamat\u00f3rio e muscular s\u00e3o complexo e precisam de mais estudos para serem considerados padr\u00e3o de avalia\u00e7\u00e3o nesse grupo de pacientess15<\/sup>. <\/strong><\/p>\n

Logo, pode ser dif\u00edcil determinar tais condi\u00e7\u00f5es. Muitos fatores podem influenciar1<\/sup>, como por exemplo, \u00a0o fato da defini\u00e7\u00e3o ser subjetiva. <\/strong>Seja como for, interrogar o apetite do paciente16<\/sup>, avaliar a ingest\u00e3o alimentar16<\/sup> e utilizar ferramentas como a Avalia\u00e7\u00e3o Global Subjetiva (AGS) podem ser estrat\u00e9gias relevantes para avaliar o comprometimento nutricional17<\/sup>.<\/p>\n

Independente da indica\u00e7\u00e3o, a nutri\u00e7\u00e3o parenteral intradial\u00edtica deve ser vista como um complemento \u00e0 suplementa\u00e7\u00e3o nutricional oral1<\/sup>. Em artigo sobre o tema publicado no come\u00e7o de 2023<\/a>, os autores apontam que pacientes recebendo essa forma de terapia nutricional n\u00e3o devem ser capazes de manter uma ingest\u00e3o di\u00e1ria por via oral e\/ou enteral de, no m\u00ednimo, 20 kcal\/kg e 0,8 g de prote\u00edna\/kg\/dia1<\/sup>. Ademais, a nutri\u00e7\u00e3o parenteral pode ser importante para que o paciente alcance seus objetivos nutricionais de forma mais equilibrada1<\/sup>.<\/p>\n

Leia tamb\u00e9m: <\/em>Qual a import\u00e2ncia das dosagens adequadas na nutri\u00e7\u00e3o parenteral?<\/em><\/a><\/p>\n

 <\/p>\n

\"\"
Adaptado de Carrero, J. J., Severs, D., Aguilera, D., Fiaccadori, E., Gonzalez, M. G., Haufe, C. C., … & Visser, W. (2023). Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom? Clinical Kidney Journal, 16(1), 5-18.<\/figcaption><\/figure>\n

 <\/p>\n

Quais as recomenda\u00e7\u00f5es para a composi\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral intradial\u00edtica?<\/h2>\n

Determinada a necessidade de nutri\u00e7\u00e3o parenteral intradial\u00edtica, a composi\u00e7\u00e3o da f\u00f3rmula administrada dever\u00e1 levar em conta as necessidades particulares de cada paciente. Em geral, a <\/strong>presen\u00e7a de amino\u00e1cidos<\/strong><\/a> (componentes b\u00e1sicos das prote\u00ednas) \u00e9 o aspecto preponderante1<\/sup>. <\/strong><\/p>\n

Assim, a quantidade oferecida deve ser capaz de suprir as perdas geradas pelo processo de di\u00e1lise, bem como pelo comprometimento metab\u00f3lico. Dessa forma, as diretrizes da ESPEN indicam que a nutri\u00e7\u00e3o parenteral intradial\u00edtica deve fornecer, por sess\u00e3o, entre 30 e 60 gramas de prote\u00ednas13 <\/sup>.<\/p>\n

Em rela\u00e7\u00e3o \u00e0 demanda energ\u00e9tica, ela tende a ser compat\u00edvel com aquela de indiv\u00edduos saud\u00e1veis, considerado idade e sexo18<\/sup>. Com isso, o a oferta pode variar entre 800 e 1200 kcal, tamb\u00e9m por sess\u00e3o13<\/sup>.<\/sup> Normalmente, n\u00e3o s\u00e3o inclu\u00eddos eletr\u00f3litos nessa forma de suporte nutricional. Por fim, vitaminas e minerais (oligoelementos) s\u00e3o inclu\u00eddos conforme avalia\u00e7\u00e3o da necessidade1<\/sup>.<\/p>\n

A partir disso, a nutri\u00e7\u00e3o parenteral intradial\u00edtica em pacientes com hemodi\u00e1lise deve ser mantida por per\u00edodos que variam entre tr\u00eas e seis meses1,19<\/sup><\/strong>. Assim, \u00e9 poss\u00edvel assegurar uma melhor evolu\u00e7\u00e3o do quadro mediante tal interven\u00e7\u00e3o nutricional19<\/sup>. Ap\u00f3s esse per\u00edodo, uma reavalia\u00e7\u00e3o deve ser feita para indicar a necessidade de continuidade do suporte1<\/sup><\/strong>.<\/p>\n

Aproveite agora e saiba mais sobre os cuidados essenciais para o manuseio e administra\u00e7\u00e3o da nutri\u00e7\u00e3o parenteral.<\/a><\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

Refer\u00eancias<\/p>\n

    \n
  1. Carrero, J. J., Severs, D., Aguilera, D., Fiaccadori, E., Gonzalez, M. G., Haufe, C. C., … & Visser, W. (2023). Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom?. Clinical Kidney Journal<\/em>, 16<\/em>(1), 5-18. Dispon\u00edvel em: https:\/\/academic.oup.com\/ckj\/article\/16\/1\/5\/6650677?login=false<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  2. Marcen R, Teruel JL, de la Cal MA, Gamez C. The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Spanish Cooperative Study of Nutrition in Hemodialysis. Nephrol Dial Transplant 1997;12:2324-31. Dispon\u00edvel em: https:\/\/academic.oup.com\/ndt\/article\/12\/11\/2324\/1812160?login=false<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  3. Burrowes JD, Cockram DB, Dwyer JT, Larive B, Paranandi L, Bergen C, et al. Cross-sectional relationship between dietary protein and energy intake, nutritional status, functional status, and comorbidity in older versus younger hemodialysis patients. J Ren Nutr 2002;12:87-95. Dispon\u00edvel em: https:\/\/www.jrnjournal.org\/article\/S1051-2276(02)29041-X\/fulltext<\/a>\u00a0 Acesso em 03 de outubro de 2023.<\/li>\n
  4. Cano NJ, Roth H, Apar\u00edcio M, Azar R, Canaud B, Chauveau P, et al. Malnutrition in hemodialysis diabetic patients: evaluation and prognostic influence. Kidney Int 2002;62:593-601. Dispon\u00edvel em: https:\/\/www.kidney-international.org\/article\/S0085-2538(15)48589-8\/fulltext<\/a> Acesso em 03 de outubro de 2023<\/li>\n
  5. Leavey SF, Strawderman RL, Jones CA, Port FK, Held PJ. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998;31:997-1006. Dispon\u00edvel em: https:\/\/www.ajkd.org\/article\/S0272-6386(98)00151-6\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  6. Ikizler TA, Burrowes JD, Byham-Gray LD et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis 2020;76(3 suppl 1): S1\u2013S107 Dispon\u00edvel em: https:\/\/www.ajkd.org\/article\/S0272-6386(20)30726-5\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  7. Ikizler TA, Pupim LB, Brouillette JR, Levenhagen DK, Farmer K, Hakim RM, et al. Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation. Am J Physiol Endocrinol Metab 2002;282:E107-16.\u00a0 Dispon\u00edvel em: https:\/\/journals.physiology.org\/doi\/full\/10.1152\/ajpendo.2002.282.1.E107?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org<\/a>\u00a0 Acesso em 03 de outubro de 2023.<\/li>\n
  8. Raj DS, Zager P, Shah VO, Dominic EA, Adeniyi O, Blandon P, et al. Protein turnover and amino acid transport kinetics in end-stage renal disease. Am J Physiol Endocrinol Metab 2004;286:E136-43.Dispon\u00edvel em: https:\/\/journals.physiology.org\/doi\/full\/10.1152\/ajpendo.00352.2003?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org<\/a>\u00a0 Acesso em 03 de outubro de 2023.<\/li>\n
  9. Pupim LB, Flakoll PJ, Brouillette JR, Levenhagen DK, Hakim RM, Ikizler TA. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 2002;110:483-92 Dispon\u00edvel em: https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC150418\/<\/a> Acesso em 03 de outubro de 2023<\/li>\n
  10. Veeneman JM, Kingma HA, Boer TS et al. Protein intake during hemodialysis maintains a positive whole body protein balance in chronic hemodialysis patients. Am J Physiol Endocrinol Metab 2003;284:E954\u201365. Dispon\u00edvel em: https:\/\/journals.physiology.org\/doi\/full\/10.1152\/ajpendo.00264.2002?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  11. Caglar K, Fedje L, Dimmitt R et al. Therapeutic effects of oral nutritional supplementation during hemodialysis.Kidney Int 2002;62:1054\u20139. Dispon\u00edvell em: https:\/\/www.kidney-international.org\/article\/S0085-2538(15)48643-0\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  12. Bossola M, Tazza L, Giungi S et al. Artificial nutritional support in chronic hemodialysis patients: a narrative review. J Ren Nutr 2010;20:213\u201323. Dispon\u00edvel em: https:\/\/www.jrnjournal.org\/article\/S1051-2276(10)00007-5\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  13. Cano NJ, Aparicio M, Brunori G et al. ESPEN guidelines on parenteral nutrition: adult renal failure. Clin Nutr 2009;28:401\u2013 14. Dispon\u00edvel em: https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(09)00108-3\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  14. Ikizler TA. Nutrition support for the chronically wasted or acutely catabolic chronic kidney disease patient. Semin Nephrol 2009;29:75\u20138 Dispon\u00edvel em: https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3788638\/<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  15. Fouque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauveau P, Cuppari L, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008;73:391-8. Dispon\u00edvel em: https:\/\/www.kidney-international.org\/article\/S0085-2538(15)52999-2\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  16. Carrero JJ, Qureshi AR, Axelsson J, et al. Comparison of nutritional and inflammatory markers in dialysis patients with reduced appetite. Am J Clin Nutr 2007;85:695-701. Dispon\u00edvel em: https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0002916523279757?via%3Dihub<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  17. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et al. Multicenter study of the validity and reliability of subjective global assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. Dispon\u00edvel em: https:\/\/www.jrnjournal.org\/article\/S1051-2276(07)00119-7\/fulltext<\/a> Acesso em 03 de outubro de 2023.<\/li>\n
  18. Kamimura MA, Draibe SA, Avesani CM, Canziani ME, Colugnati FA, Cuppari L. Resting energy expenditure and its determinants in hemodialysis patients. Eur J Clin Nutr 2007;61:362-7 Dispon\u00edvel em: https:\/\/www.nature.com\/articles\/1602516<\/a> Acesso em 10 maio de 2023.<\/li>\n
  19. Garc\u00eda de Lorenzo A, Arrieta J, Ay\u00facar A et al. Nutrici\u00f3n parenteral intradi\u00e1lisis en el enfermo renal cr\u00f3nico: consenso SEN-SENPE [Intra-dialysis parenteral nutrition in chronic renal patients: consensus SEN-SENPE]. Nutr Hosp 2010;25:375\u2013 77. Dispon\u00edvel em: https:\/\/scielo.isciii.es\/pdf\/nh\/v25n3\/original1.pdf<\/a> Acesso em 03 de outubro de 2023.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    A necessidade de hemodi\u00e1lise devido ao comprometimento da fun\u00e7\u00e3o renal est\u00e1 associada a um incremento na taxa de mortalidade, bem como a piora na qualidade de vida1.. Muitos desses problemas podem ter rela\u00e7\u00e3o com o estado nutricional. Nesse contexto, acompanhar indicadores nutricionais \u00e9 importante para avaliar a evolu\u00e7\u00e3o do quadro. A partir disso \u00e9 poss\u00edvel […]<\/p>\n","protected":false},"author":5902,"featured_media":1945,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[49],"tags":[70,235,234,67,203],"class_list":["post-1944","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigo-5","tag-desnutricao","tag-doenca-renal-cronica","tag-hemodialise","tag-nutricao-parenteral","tag-proteinas"],"acf":[],"yoast_head":"\nEntenda o papel da nutri\u00e7\u00e3o parenteral intradial\u00edtica<\/title>\n<meta name=\"description\" content=\"A nutri\u00e7\u00e3o parenteral intradial\u00edtica pode ser importante para contornar o impacto nutricional do tratamento da pessoa em hemodi\u00e1lise.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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