這個題目,我先選讀的是2009年“腎臟國際期刊(Kidney International)”的一篇回顧性文章,標題就是:口服磷結合劑。
控制血磷,有三大重點:
1. 透析一定要足夠
透析的時間與血流速度,都會影響清除磷的程度,至於透析的種類,文章中有提到,腹膜透析比血液透析略優一點點,每日短時間透析、或每日夜間長時間透析,也能清除更多的磷離子,不過後面這兩種方式,在台灣很難普及。因此,一般血液透析的患者,要確認自己洗得乾不乾淨,請看之前文章。
2. 飲食控制與衛教
我們知道,腎臟功能很差的患者,磷的排出會減少;而洗腎(血液透析)清除磷的能力,非常有限,一個星期平均身體淨收入6000-7000毫克的磷,而血液透析大約只能清除掉3000毫克,意思是:食物中超過五成的磷,都洗不掉。
既然磷洗不乾淨,就一定要控制進入身體的量,因此,想辦法把吃進去的磷減少,成了沒有辦法中的辦法,怎麼減少吃進去的磷?一、選擇低磷的食物,最基本入門的飲食選擇,請看之前文章,二、想辦法讓腸道減少吸收磷,如果能夠把食物中的磷抓住,身體就不會吸收這麼多磷囉,誰能夠抓住磷?就是下面要介紹的……。
3. 磷結合劑的使用
所有的磷結合劑,都應該餐中使用,效果最好。然而,說的衛教簡單,但實際的控制真的得靠腎友自己,洗腎患者中,高達九成的人都需要磷結合劑。這才是本系列文章想探討的重點,先表格整理一下
磷結合劑 | $$ | 降磷效果 | 味道口感 | 優點 | 缺點 |
---|
鋁片
| 便宜 | 強 | 可 | 如左列 | 含鋁,累積會有毒性 |
碳酸鈣 | 便宜 | 中等 | 可,嚼碎吞服 | 如左列 | 含鈣,累積會高血鈣、軟組織鈣化、或心血管鈣化 |
醋酸鈣 | 便宜 | 中等(比碳酸鈣略好) | 不好吞,味道差, 整顆吞服 | 鈣的負擔略比碳酸鈣低 | 含鈣,累積會高血鈣、軟組織鈣化、或心血管鈣化 |
Sevelamer (磷能解、磷減樂、腎安磷、釋磷美) | 貴 | 中等 | 可 | 不含鈣或鋁, 可以降血脂肪 | 需要比較多顆才有效,影響脂溶性維他命吸收 |
碳酸鑭 (福斯利諾) | 貴 | 強 | 需嚼碎 | 不含鈣或鋁 | 仍有微量鑭會被身體吸收 |
可以看的出來,表格中黃色底的三種磷結合劑,都是老藥、健保有給付、藥費便宜,但是他們本身所含的鈣或鋁,也是他們所背負的原罪,雖然鈣或鋁能夠和磷結合,但也可能被人體吸收,造成我們不喜歡的負擔;紫色底的兩種磷結合劑,算是較新的藥、健保沒有給付、藥費昂貴,目前,這兩種較新的藥,安全性都還算經的起考驗。
因為磷結合劑各有優缺點,需要詳加解釋,所以接下來幾篇文章,會分別深入探討,鋁片、兩種鈣片、兩種自費藥物的優缺點。
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