● 吉多利錠- Keto-analogues for CKD

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英文商品名： Ketosteril Tab
中文商品名：吉多利錠
學名：L-HISTIDINE /L-LYSINE/L-THREONINE /L-TRYPTOPHAN/L-TYROSINE etc
劑量：38mg/105mg/53mg/23mg/30mg
劑型：錠劑
藥商/藥廠名稱：臺灣費森尤斯卡比股份有限公司
健保碼： B018273100
藥品許可證字號：衛署藥輸字第018273號
衛生署適應症：慢性腎不全時氨基酸之補給
藥理作用：
攝取的必需胺基酸中以 Ketosteril (α酮酸-胺基酸)此種胺基酸組合最能有效降低體內含氮廢物的產生。Ketosteril 的結構為酮基類似物 (keto analogues)，可利用轉胺作用(transamination)將來自非必需胺基酸的氨(NH3)和本身結構中的酮基做取代，使氨(NH3)能在整個循環中被再次利用。當身體內部產生含氮的代謝產物，便會啟動尿素循環(Urea cycle)將氨轉為尿素(urea)，之後經腎臟隨尿液排出。人體內部主要的含氮代謝產物由氨(NH3)組成，攝取Ketosteril 時，經轉胺作用去結合體內多餘的氨基，來合成身體所需的各種胺基酸像是血球、抗體、荷爾蒙等等，剩餘的碳鏈因其已不具氨基，代謝路徑僅會進入檸檬酸循環(TCA cycle)而不會以尿素循環來進行代謝，因此能夠有效降低體內尿素的形成，減少尿毒素(Uremic toxins)的累積，減輕尿毒(Uremic)症狀。
另一方面，帶有氫氧酸(Hydroxy-acid)和酮酸(Keto-acid)結構的胺基酸較不易產生腎絲球高過濾期(glomerular hyperfiltration)，亦能對腎性高磷血症(renal hyperphosphatemia)及繼發性副甲狀腺機能亢進（secondary hyperparathyroidism）有正面的影響，除此之外，對於腎性骨病變(renal osteodystrophy)也有相當的改善空間。
懷孕分級：C
常用劑量：4-8 tab tid with meals
副作用/警語：高鈣血症、胃腸不適
注意事項：
1.本品需餐中服用。
2.應定期監測血清鈣含量。
3.本品使用於GFR 5-15ml/min, 且蛋白質攝取< 40g/day之病患。
4.內含鈣離子，若服用四環黴素應錯開時間。
保存方式：
藥品應置於攝氏 15 ~ 25 度乾燥處所；如發生變質或過期，不可再食用。
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Ketosteril (67mg per tablet)

Keto-analogues in pre-dialysis Chronic Kidney Disease patients: Review of Old and new data
Liliana Garneata, Gabriel Mircescu
Kidney Research and Clinical Practice, June 2012
“Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
Abstract
       Recently revealed high prevalence of Chronic Kidney Disease (CKD) raises concerns all over the world; evidence based strategies to delay progression were set up. Dietary approach is largely mentioned, but strong evidence is lacking.
      The reduced dietary protein intake has been reported for more than a century to improve uremic symptoms and even to postpone the initiation of renal replacement therapy (RRT); however, the nutritional intervention in uremia is still under debate.
       Different dietary protein regimens have been proposed for the CKD patients: (1) conventional low protein diet (LPD), with 0.6 g/kg per day; (2) very low protein diet (0.3 g/kg per day) supplemented with essential amino acids or (3) very low protein diet (0.3 g/kg per day) supplemented with an isomolar mixture of essential amino acids and nitrogen-free keto-analogues (SVLPD).
       Available data support SVLPD to be effective in ameliorating nitrogen waste products retention, acid-base and calcium-phosphorus metabolism disturbances and insulin-resistance and in delaying the RRT initiation, with no deleterious effect on the nutritional status in CKD patients.More recent studies report that SVLPD could also slow down the rate of decline in renal function, preserving the nutritional status and associating better outcome after the start of RRT.
       The possible delay of RRT initiation through nutrition could have major impact on patients’ quality of life. On the other hand, postponing RRT could have also a serious economic impact, particularly important in countries where the dialysis facilities still do not meet the needs. The nutritional intervention, particularly the SVLPD could be a new link in the RRT integrated care model.
       However, a careful selection of motivated patients who could benefit from such a diet, close nutritional monitoring and dietary counseling are highly required.