1
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Crahim V, Verri V, De Lorenzo A, Tibirica E. Reduced systemic microvascular function in patients with resistant hypertension and microalbuminuria: an observational study. J Hum Hypertens 2024:10.1038/s41371-024-00958-7. [PMID: 39289473 DOI: 10.1038/s41371-024-00958-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 08/23/2024] [Accepted: 09/12/2024] [Indexed: 09/19/2024]
Abstract
Resistant hypertension (RH) may be associated with microalbuminuria (MAU), a marker of cardiovascular risk and target organ damage, and both may be related to microvascular damage. Laser speckle contrast imaging (LSCI) is an innovative approach for noninvasively evaluating systemic microvascular endothelial function useful in the context of RH with or without MAU. Microalbuminuria was defined as a urine albumin-to-creatinine ratio between 30 and 300 mg/g. Microvascular reactivity was evaluated using LSCI to perform noninvasive measurements of cutaneous microvascular perfusion changes. Pharmacological (acetylcholine [ACh], or sodium nitroprusside [SNP]) and physiological (postocclusive reactive hyperemia [PORH]) stimuli were used to evaluate vasodilatory responses. Thirty-two patients with RH and a normal urine albumin-to-creatinine ratio (RH group) and 32 patients with RH and microalbuminuria (RH + MAU) were evaluated. Compared with patients without MAU, patients with RH + MAU showed reduced endothelial-dependent systemic microvascular reactivity, as demonstrated by an attenuation of microvascular vasodilation induced by PORH. On the other hand, ACh-induced vasodilation did not differ between groups. The results also revealed reduced endothelial-independent (SNP-induced) microvascular reactivity in hypertensive patients with MAU compared with patients without MAU. In this study, there was evidence of endothelial dysfunction associated with impaired microvascular smooth muscle function in patients with RH + MAU. This may suggest that patients with RH need more intensive therapeutic strategies for the control of blood pressure to avoid further vascular damage and the resulting consequences.The study was registered at ClinicalTrials.gov ( https://register.clinicaltrials.gov ) under protocol # NCT05464849, initial release 12/07/2022.
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Affiliation(s)
| | - Valéria Verri
- National Institute of Cardiology, Rio de Janeiro, Brazil
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2
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Kunchur MG, Mauch TJ, Parkanzky M, Rahilly LJ. A review of renal tubular acidosis. J Vet Emerg Crit Care (San Antonio) 2024; 34:325-355. [PMID: 39023331 DOI: 10.1111/vec.13407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 10/14/2022] [Accepted: 11/11/2022] [Indexed: 07/20/2024]
Abstract
OBJECTIVE To review the current scientific literature on renal tubular acidosis (RTA) in people and small animals, focusing on diseases in veterinary medicine that result in secondary RTA. DATA SOURCES Scientific reviews and original research publications on people and small animals focusing on RTA. SUMMARY RTA is characterized by defective renal acid-base regulation that results in normal anion gap hyperchloremic metabolic acidosis. Renal acid-base regulation includes the reabsorption and regeneration of bicarbonate in the renal proximal tubule and collecting ducts and the process of ammoniagenesis. RTA occurs as a primary genetic disorder or secondary to disease conditions. Based on pathophysiology, RTA is classified as distal or type 1 RTA, proximal or type 2 RTA, type 3 RTA or carbonic anhydrase II mutation, and type 4 or hyperkalemic RTA. Fanconi syndrome comprises proximal RTA with additional defects in proximal tubular function. Extensive research elucidating the genetic basis of RTA in people exists. RTA is a genetic disorder in the Basenji breed of dogs, where the mutation is known. Secondary RTA in human and veterinary medicine is the sequela of diseases that include immune-mediated, toxic, and infectious causes. Diagnosis and characterization of RTA include the measurement of urine pH and the evaluation of renal handling of substances that should affect acid or bicarbonate excretion. CONCLUSIONS Commonality exists between human and veterinary medicine among the types of RTA. Many genetic defects causing primary RTA are identified in people, but those in companion animals other than in the Basenji are unknown. Critically ill veterinary patients are often admitted to the ICU for diseases associated with secondary RTA, or they may develop RTA while hospitalized. Recognition and treatment of RTA may reverse tubular dysfunction and promote recovery by correcting metabolic acidosis.
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Affiliation(s)
| | - Teri Jo Mauch
- University of Nebraska Medical Center and Children's Hospital, Omaha, Nebraska, USA
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | | - Louisa J Rahilly
- Cape Cod Veterinary Specialists, Buzzards Bay, Massachusetts, USA
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3
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Goraya N, Wesson DE. Pathophysiology of Diet-Induced Acid Stress. Int J Mol Sci 2024; 25:2336. [PMID: 38397012 PMCID: PMC10888592 DOI: 10.3390/ijms25042336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Diets can influence the body's acid-base status because specific food components yield acids, bases, or neither when metabolized. Animal-sourced foods yield acids and plant-sourced food, particularly fruits and vegetables, generally yield bases when metabolized. Modern diets proportionately contain more animal-sourced than plant-sourced foods, are, thereby, generally net acid-producing, and so constitute an ongoing acid challenge. Acid accumulation severe enough to reduce serum bicarbonate concentration, i.e., manifesting as chronic metabolic acidosis, the most extreme end of the continuum of "acid stress", harms bones and muscles and appears to enhance the progression of chronic kidney disease (CKD). Progressive acid accumulation that does not achieve the threshold amount necessary to cause chronic metabolic acidosis also appears to have deleterious effects. Specifically, identifiable acid retention without reduced serum bicarbonate concentration, which, in this review, we will call "covert acidosis", appears to cause kidney injury and exacerbate CKD progression. Furthermore, the chronic engagement of mechanisms to mitigate the ongoing acid challenge of modern diets also appears to threaten health, including kidney health. This review describes the full continuum of "acid stress" to which modern diets contribute and the mechanisms by which acid stress challenges health. Ongoing research will develop clinically useful tools to identify stages of acid stress earlier than metabolic acidosis and determine if dietary acid reduction lowers or eliminates the threats to health that these diets appear to cause.
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Affiliation(s)
- Nimrit Goraya
- Department of Internal Medicine, Baylor Scott & White Health, Temple, TX 76508, USA;
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
| | - Donald E. Wesson
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Dallas, TX 78712, USA
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4
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Singhania P, Dhar A, Deshpande A, Das D, Agrawal N, Chakraborty PP, Bhattacharjee R, Roy A. Rickets in proximal renal tubular acidosis: a case series of six distinct etiologies. J Pediatr Endocrinol Metab 2023; 36:879-885. [PMID: 37434360 DOI: 10.1515/jpem-2023-0155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVES Proximal renal tubular acidosis (pRTA) is characterized by a defect in the ability of the proximal convoluted tubule to reabsorb bicarbonate. The biochemical hallmark of pRTA is hyperchloremic metabolic acidosis with a normal anion gap, accompanied by appropriate acidification of the urine (simultaneous urine pH <5.3). Isolated defects in bicarbonate transport are rare, and pRTA is more often associated with Fanconi syndrome (FS), which is characterized by urinary loss of phosphate, uric acid, glucose, amino acids, low-molecular-weight proteins, and bicarbonate. Children with pRTA may present with rickets, but pRTA is often overlooked as an underlying cause of this condition. CASE PRESENTATION We report six children with rickets and short stature due to pRTA. One case was idiopathic, while the remaining five had a specific underlying condition: Fanconi-Bickel syndrome, Dent's disease, nephropathic cystinosis, type 1 tyrosinemia, and sodium-bicarbonate cotransporter 1-A (NBC1-A) defect. CONCLUSIONS Five of these six children had features of FS, while the one with NBC1-A defect had isolated pRTA.
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Affiliation(s)
- Pankaj Singhania
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Abhranil Dhar
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Aditya Deshpande
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Debaditya Das
- Department of Endocrinology and Metabolism, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Neeti Agrawal
- Department of Endocrinology, Medical College Kolkata, Kolkata, India
| | | | | | - Ajitesh Roy
- Department of Endocrinology, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
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5
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Wagner CA, Unwin R, Lopez-Garcia SC, Kleta R, Bockenhauer D, Walsh S. The pathophysiology of distal renal tubular acidosis. Nat Rev Nephrol 2023; 19:384-400. [PMID: 37016093 DOI: 10.1038/s41581-023-00699-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
The kidneys have a central role in the control of acid-base homeostasis owing to bicarbonate reabsorption and production of ammonia and ammonium in the proximal tubule and active acid secretion along the collecting duct. Impaired acid excretion by the collecting duct system causes distal renal tubular acidosis (dRTA), which is characterized by the failure to acidify urine below pH 5.5. This defect originates from reduced function of acid-secretory type A intercalated cells. Inherited forms of dRTA are caused by variants in SLC4A1, ATP6V1B1, ATP6V0A4, FOXI1, WDR72 and probably in other genes that are yet to be discovered. Inheritance of dRTA follows autosomal-dominant and -recessive patterns. Acquired forms of dRTA are caused by various types of autoimmune diseases or adverse effects of some drugs. Incomplete dRTA is frequently found in patients with and without kidney stone disease. These patients fail to appropriately acidify their urine when challenged, suggesting that incomplete dRTA may represent an intermediate state in the spectrum of the ability to excrete acids. Unrecognized or insufficiently treated dRTA can cause rickets and failure to thrive in children, osteomalacia in adults, nephrolithiasis and nephrocalcinosis. Electrolyte disorders are also often present and poorly controlled dRTA can increase the risk of developing chronic kidney disease.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland.
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK.
| | - Robert Unwin
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Sergio C Lopez-Garcia
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Robert Kleta
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Stephen Walsh
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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6
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Santos F, Gil-Peña H. Long-term complications of primary distal renal tubular acidosis. Pediatr Nephrol 2023; 38:635-642. [PMID: 35543873 DOI: 10.1007/s00467-022-05546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023]
Abstract
The clinical manifestations of primary distal renal tubular acidosis usually begin in childhood, but the disease is caused by a genetic defect that persists throughout life. This review focuses on the complications of distal tubular acidosis that occur or remain long-term such as nephrocalcinosis and urolithiasis, growth impairment, bone mineralization, severe hypokalemia, kidney cysts, and progressive kidney failure, as well as other persistent manifestations that occur independent of acidosis but are associated with some inherited forms of the disease. The pathogenic factors responsible for kidney failure are discussed in particular because it is a complication to which different publications have recently drawn attention and which affects a high percentage of adults with primary distal renal tubular acidosis. The need to maintain optimal metabolic control of the disease and scheduled clinical follow-up throughout life and the importance of organizing protocols for the transition of patients to adult nephrology services are emphasized.
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Affiliation(s)
- Fernando Santos
- Department of Medicine, Pediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Asturias, Spain.
| | - Helena Gil-Peña
- Department of Medicine, Pediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Asturias, Spain
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7
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Adomako EA, Maalouf NM. Type 4 renal tubular acidosis and uric acid nephrolithiasis: two faces of the same coin? Curr Opin Nephrol Hypertens 2023; 32:145-152. [PMID: 36683539 PMCID: PMC9881823 DOI: 10.1097/mnh.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW The present review summarizes findings of recent studies examining the epidemiology, pathophysiology, and treatment of type 4 renal tubular acidosis (RTA) and uric acid nephrolithiasis, two conditions characterized by an abnormally acidic urine. RECENT FINDINGS Both type 4 RTA and uric acid nephrolithiasis disproportionately occur in patients with type 2 diabetes and/or chronic kidney disease. Biochemically, both conditions are associated with reduced renal ammonium excretion resulting in impaired urinary buffering and low urine pH. Reduced ammoniagenesis is postulated to result from hyperkalemia in type 4 RTA and from insulin resistance and fat accumulation in the renal proximal tubule in uric acid nephrolithiasis. The typical biochemical findings of hyperkalemia and systemic acidosis of type 4 RTA are rarely reported in uric acid stone formers. Additional clinical differences between the two conditions include findings of higher urinary uric acid excretion and consequent urinary uric acid supersaturation in uric acid stone formers but not in type 4 RTA. SUMMARY Type 4 RTA and uric acid nephrolithiasis share several epidemiological, clinical, and biochemical features. Although both conditions may be manifestations of diabetes mellitus and thus have a large at-risk population, the means to the shared biochemical finding of overly acidic urine are different. This difference in pathophysiology may explain the dissimilarity in the prevalence of kidney stone formation.
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Affiliation(s)
- Emmanuel A. Adomako
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Naim M. Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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8
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Hammi Y, Charfi H, Ferjani M, Sayari T, Mrad R, Gargah T. Particularités épidémiologiques, cliniques et évolutives de l’acidose tubulaire distale primitive chez l’enfant tunisien. Nephrol Ther 2022; 18:541-548. [DOI: 10.1016/j.nephro.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 11/07/2022]
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9
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Kazama I. Targeting ACE2 as a potential prophylactic strategy against COVID-19-induced exacerbation of chronic kidney disease. Inflamm Res 2022; 71:1123-1126. [PMID: 35871404 PMCID: PMC9308890 DOI: 10.1007/s00011-022-01619-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 03/31/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Patients with chronic kidney disease (CKD) are at higher risk for severe coronavirus disease 2019 (COVID-19). Such patients are more likely to develop “COVID-19-induced acute kidney injury (AKI)”, which exacerbates the pre-existing CKD and increases the mortality rate of the patients. COVID-19-induced AKI is pathologically characterized by acute tubular necrosis and the interstitial infiltration of proinflammatory leukocytes. In our rat model with advanced CKD, immunohistochemistry for angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) demonstrated their strong expression in the cytoplasm of damaged proximal tubular cells and the infiltrating leukocytes within the cortical interstitium, which overlapped with the lesions of COVID-19-induced AKI. Since ACE2 and TMPRSS2 are enzymes that facilitate the viral entry into the cells and trigger the onset of cytokine storm, the renal distribution of these proteins in advanced CKD was thought to be responsible for the development of COVID-19-induced AKI. Concerning such mechanisms, the pharmacological blockade of ACE2 or the use of soluble forms of the ACE2 protein may halt the entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into host cells. This would protect against the COVID-19-induced exacerbation of pre-existing CKD by preventing the development of AKI.
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Affiliation(s)
- Itsuro Kazama
- School of Nursing, Miyagi University, Gakuen, Taiwa-cho, Kurokawa-gun, Miyagi, 981-3298, Japan.
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10
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Abstract
Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.
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11
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Bushinsky DA, Krieger NS. Effects of Acid on Bone. Kidney Int 2022; 101:1160-1170. [DOI: 10.1016/j.kint.2022.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/11/2022]
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12
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Kalantar-Zadeh K, Lockwood MB, Rhee CM, Tantisattamo E, Andreoli S, Balducci A, Laffin P, Harris T, Knight R, Kumaraswami L, Liakopoulos V, Lui SF, Kumar S, Ng M, Saadi G, Ulasi I, Tong A, Li PKT. Patient-centred approaches for the management of unpleasant symptoms in kidney disease. Nat Rev Nephrol 2022; 18:185-198. [PMID: 34980890 DOI: 10.1038/s41581-021-00518-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/22/2022]
Abstract
Patients with chronic kidney disease (CKD) frequently experience unpleasant symptoms. These can be gastrointestinal (constipation, nausea, vomiting and diarrhoea), psychological (anxiety and sadness), neurological (lightheadedness, headache and numbness), cardiopulmonary (shortness of breath and oedema), dermatological (pruritus and dry skin), painful (muscle cramps, chest pain and abdominal pain) or involve sexual dysfunction, sleep disorders and fatigue. These symptoms often occur in clusters, with one of them as the lead symptom and others as secondary symptoms. Uraemic toxins (also called uremic toxins) are often considered to be the main cause of CKD-associated symptom burden, but treatment of uraemia by dialysis often fails to resolve them and can engender additional symptoms. Indeed, symptoms can be exacerbated by comorbid conditions, pharmacotherapies, lifestyle and dietary regimens, kidney replacement therapy and ageing. Patients with kidney disease, including those who depend on dialysis or transplantation, should feel actively supported in their symptom management through the identification and targeting of unpleasant symptoms via a tailored palliative care approach. Such an approach may help minimize the burden and consequences of kidney disease, and lead to improved patient outcomes including health-related quality of life and better life participation.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico. .,Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA.
| | - Mark B Lockwood
- Department of Behavioral Health Science, University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Ekamol Tantisattamo
- Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Sharon Andreoli
- James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Tess Harris
- Polycystic Kidney Disease Charity, London, UK
| | | | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Siu-Fai Lui
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico.,Hong Kong Kidney Foundation, Hong Kong, China
| | | | - Maggie Ng
- The International Federation of Kidney Foundation - World Kidney Alliance (IFKF-WKA), Mexico City, Mexico.,Hong Kong Kidney Foundation, Hong Kong, China
| | - Gamal Saadi
- Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ifeoma Ulasi
- Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Carol & Richard Yu PD Research Centre, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China.
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13
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Sromicki J, Kacl G, Föhl M, Hess B. Prospective long-term evaluation of incomplete distal renal tubular acidosis in idiopathic calcium nephrolithiasis diagnosed by low-dose NH 4CL loading - gender prevalences and impact of alkali treatment. J Nephrol 2022; 35:1619-1626. [PMID: 34973150 PMCID: PMC9300500 DOI: 10.1007/s40620-021-01207-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022]
Abstract
Purpose Prospective evaluation of the prevalence of incomplete distal renal tubular acidosis (idRTA) in idiopathic calcium stone formers (ICSF) diagnosed by half-dose ammonium chloride loading (NH4Cl, 0.05 g/kg body weight/day) and impact of alkali treatment of idRTA. Methods Evaluation of 386 consecutive idiopathic calcium stone formers (ICSF) (280 males, 106 females) for idRTA. If screening fasting urine pH was > 5.80, 1-day NH4Cl loading was performed without severe adverse effects. Normally, urine pH falls below 5.45. Results Sixty-four idiopathic calcium stone formers exhibited idRTA, one complete dRTA. Prevalence was higher in women (25.4%) than in men (13.6%). Thus, for more equilibrated comparisons, we formed pairs of 62 idiopathic calcium stone formers (ICSF) with and 62 without idRTA, matched for gender, age, BMI and serum creatinine. Idiopathic calcium stone formers with idRTA more often had hypercalciuria (p < 0.025) and urine citrate < 2 mmol/d (p < 0.05), formed calcium phosphate stones more frequently, exhibited higher numbers of stones/year (1.4 ± 1.5 vs. 0.9 ± 0.8, p = 0.034) and 2.5 times more intrarenal calcifications (4.6 ± 5.9 vs. 1.8 ± 3.6, p = 0.002). All idiopathic calcium stone formers with idRTA were recommended chronic alkali therapy. After 4–15 years of follow-up, stone events /years follow-up (stone passage or urologic intervention) were higher in patients non-adherent to alkali therapy (0.61 ± 0.92) than in patients adherent to treatment (0.11 ± 0.21, p = 0.006). Conclusion Incomplete distal renal tubular acidosis is 1.8-fold more prevalent among female idiopathic calcium stone formers, predicts more stone recurrences, predisposes to calcium phosphate stones and is associated with 2.5 times more intrarenal calcifications vs. non-idRTA patients. Chronic alkali treatment reduces clinical stone recurrences by 5.5 times. Graphical abstract ![]()
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Affiliation(s)
- Juri Sromicki
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.,Department of Cardiac Surgery, University Hospital, Zurich, Switzerland
| | - Georg Kacl
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.,Radiology, Klinik Im Park, Zurich, Switzerland
| | - Malin Föhl
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland
| | - Bernhard Hess
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.
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14
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Nephron overload as a therapeutic target to maximize kidney lifespan. Nat Rev Nephrol 2021; 18:171-183. [PMID: 34880459 DOI: 10.1038/s41581-021-00510-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 12/27/2022]
Abstract
Kidney lifespan is a patient-oriented outcome that provides much needed context for understanding chronic kidney disease (CKD). Nephron endowment, age-associated decline in nephron number, kidney injury history and the intrinsic capacity of nephrons to adapt to haemodynamic and metabolic overload vary widely within the population. Defining percentiles of kidney function might therefore help to predict individual kidney lifespan and distinguish healthy ageing from progressive forms of CKD. In response to nephron loss, the remaining nephrons undergo functional and structural adaptations to meet the ongoing haemodynamic and metabolic demands of the organism. When these changes are no longer sufficient to maintain kidney cell homeostasis, remnant nephron demise occurs and CKD progression ensues. An individual's trajectory of glomerular filtration rate and albuminuria reflects the extent of nephron loss and adaptation of the remaining nephrons. Nephron overload represents the final common pathway of CKD progression and is largely independent of upstream disease mechanisms. Thus, interventions that efficiently attenuate nephron overload in early disease stages can protect remnant kidney cells and nephrons, and delay CKD progression. This Review provides a conceptual framework for individualized diagnosis, monitoring and treatment of CKD with the goal of maximizing kidney lifespan.
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15
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Blijdorp CJ, Severs D, Musterd-Bhaggoe UM, Gansevoort RT, Zietse R, Hoorn EJ. Serum bicarbonate is associated with kidney outcomes in autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2021; 36:2248-2255. [PMID: 33377160 PMCID: PMC8643593 DOI: 10.1093/ndt/gfaa283] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Metabolic acidosis accelerates progression of chronic kidney disease, but whether this is also true for autosomal dominant polycystic kidney disease (ADPKD) is unknown. METHODS Patients with ADPKD from the DIPAK (Developing Interventions to halt Progression of ADPKD) trial were included [n = 296, estimated glomerular filtration rate (eGFR) 50 ± 11 mL/min/1.73 m2, 2.5 years follow-up]. Outcomes were worsening kidney function (30% decrease in eGFR or kidney failure), annual eGFR change and height-adjusted total kidney and liver volumes (htTKV and htTLV). Cox and linear regressions were adjusted for prognostic markers for ADPKD [Mayo image class and predicting renal outcomes in ADPKD (PROPKD) scores] and acid-base parameters (urinary ammonium excretion). RESULTS Patients in the lowest tertile of baseline serum bicarbonate (23.1 ± 1.6 mmol/L) had a significantly greater risk of worsening kidney function [hazard ratio = 2.95, 95% confidence interval (CI) 1.21-7.19] compared with patients in the highest tertile (serum bicarbonate 29.0 ± 1.3 mmol/L). Each mmol/L decrease in serum bicarbonate increased the risk of worsening kidney function by 21% in the fully adjusted model (hazard ratio = 1.21, 95% CI 1.06-1.37). Each mmol/L decrease of serum bicarbonate was also associated with further eGFR decline (-0.12 mL/min/1.73 m2/year, 95% CI -0.20 to -0.03). Serum bicarbonate was not associated with changes in htTKV or htTLV growth. CONCLUSIONS In patients with ADPKD, a lower serum bicarbonate within the normal range predicts worse kidney outcomes independent of established prognostic factors for ADPKD and independent of urine ammonium excretion. Serum bicarbonate may add to prognostic models and should be explored as a treatment target in ADPKD.
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Affiliation(s)
- Charles J Blijdorp
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David Severs
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Usha M Musterd-Bhaggoe
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald T Gansevoort
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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16
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Trepiccione F, Walsh SB, Ariceta G, Boyer O, Emma F, Camilla R, Ferraro PM, Haffner D, Konrad M, Levtchenko E, Lopez-Garcia SC, Santos F, Stabouli S, Szczepanska M, Tasic V, Topaloglu R, Vargas-Poussou R, Wlodkowski T, Bockenhauer D. Distal Renal Tubular Acidosis: ERKNet/ESPN Clinical Practice Points. Nephrol Dial Transplant 2021; 36:1585-1596. [PMID: 33914889 DOI: 10.1093/ndt/gfab171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 12/15/2022] Open
Abstract
Distal renal tubular acidosis (dRTA) is characterised by an impaired ability of the distal tubule to excrete acid, leading to metabolic acidosis. Associated complications include bone disease, growth failure, urolithiasis and hypokalaemia. Due to its rarity, there is a limited evidence to guide diagnosis and management, however, available data strongly suggest that metabolic control of the acidosis by alkali supplementation can halt or revert almost all complications. Despite this, cohort studies show that adequate metabolic control is present in only about half of patients, highlighting problems with treatment provision or adherence. With these clinical practice points the authors, part of the working groups tubulopathies in the European Rare Kidney Disease Reference network (ERKnet) and inherited kidney diseases of the European Society for Paediatric Nephrology (ESPN) aim to provide guidance for the management of patients with dRTA to facilitate adequate treatment and establish an initial best practice standard against which treatment of patients can be audited.
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Affiliation(s)
- Francesco Trepiccione
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Steven B Walsh
- Department of Renal Medicine, University College London, UK
| | - Gema Ariceta
- Division of Pediatric Nephrology. Hospital Universitario Vall d' Hebron. Universitat Autonoma de Barcelona. Barcelona, Spain
| | - Olivia Boyer
- Pediatric Nephrology, Necker Hospital, APHP, MARHEA, Imagine Institute, Paris University, Paris, France
| | - Francesco Emma
- Division of Nephrology, Bambino Gesu Children's Hospital - IRCCS, Rome, Italy
| | - Roberta Camilla
- Nephrology, Dialysis, Transplantation, Regina Margherita University Hospital, Turin, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany
| | - Elena Levtchenko
- Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
| | - Sergio Camilo Lopez-Garcia
- Department of Renal Medicine, University College London, UK.,Renal Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Fernando Santos
- Department of Pediatrics, Hospital Universitario Central de Asturias and Área de Pediatría, Dpto. de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | | | - Velibor Tasic
- University Children's Hospital, Medical School, Skopje, Macedonia
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rosa Vargas-Poussou
- Department of Genetics, Centre de Références MARHEA, Hôpital Européen Georges Pompidou Assistance Publique Hôpitaux de Paris, Paris France
| | - Tanja Wlodkowski
- Department of Paediatric Nephrology, University Children's Hospital, Heidelberg, Germany
| | - Detlef Bockenhauer
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany.,Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
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17
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Palmer BF, Kelepouris E, Clegg DJ. Renal Tubular Acidosis and Management Strategies: A Narrative Review. Adv Ther 2021; 38:949-968. [PMID: 33367987 PMCID: PMC7889554 DOI: 10.1007/s12325-020-01587-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/26/2020] [Indexed: 12/29/2022]
Abstract
Renal tubular acidosis (RTA) occurs when the kidneys are unable to maintain normal acid−base homeostasis because of tubular defects in acid excretion or bicarbonate ion reabsorption. Using illustrative clinical cases, this review describes the main types of RTA observed in clinical practice and provides an overview of their diagnosis and treatment. The three major forms of RTA are distal RTA (type 1; characterized by impaired acid excretion), proximal RTA (type 2; caused by defects in reabsorption of filtered bicarbonate), and hyperkalemic RTA (type 4; caused by abnormal excretion of acid and potassium in the collecting duct). Type 3 RTA is a rare form of the disease with features of both distal and proximal RTA. Accurate diagnosis of RTA plays an important role in optimal patient management. The diagnosis of distal versus proximal RTA involves assessment of urinary acid and bicarbonate secretion, while in hyperkalemic RTA, selective aldosterone deficiency or resistance to its effects is confirmed after exclusion of other causes of hyperkalemia. Treatment options include alkali therapy in patients with distal or proximal RTA and lowering of serum potassium concentrations through dietary modification and potential new pharmacotherapies in patients with hyperkalemic RTA including newer potassium binders.
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18
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Abstract
Evolutionary processes, including mutation, migration and natural selection, have influenced the prevalence and distribution of various disorders in humans. However, despite a few well-known examples, such as the APOL1 variants - which have undergone positive genetic selection for their ability to confer resistance to Trypanosoma brucei infection but confer a higher risk of chronic kidney disease - little is known about the effects of evolutionary processes that have shaped genetic variation on kidney disease. An understanding of basic concepts in evolutionary genetics provides an opportunity to consider how findings from ancient and archaic genomes could inform our knowledge of evolution and provide insights into how population migration and genetic admixture have shaped the current distribution and landscape of human kidney-associated diseases. Differences in exposures to infectious agents, environmental toxins, dietary components and climate also have the potential to influence the evolutionary genetics of kidneys. Of note, selective pressure on loci associated with kidney disease is often from non-kidney diseases, and thus it is important to understand how the link between genome-wide selected loci and kidney disease occurs in relation to secondary nephropathies.
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19
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Alvirdizadeh S, Yuzbashian E, Mirmiran P, Eghtesadi S, Azizi F. A prospective study on total protein, plant protein and animal protein in relation to the risk of incident chronic kidney disease. BMC Nephrol 2020; 21:489. [PMID: 33203389 PMCID: PMC7672990 DOI: 10.1186/s12882-020-02079-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/23/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The link between dietary protein intake and the risk of kidney dysfunction is always a challenging issue. This study aimed to investigate the relationship between total protein, plant protein, and animal protein intake with the risk of incident chronic kidney disease (CKD). METHODS This study was performed on 1639 adults aged ≥27 years who participated in the Tehran Lipid and Glucose Study. Dietary data were evaluated using a valid and reliable semi-quantitative food frequency questionnaire (FFQ). Total protein content, plant protein, and animal protein of each participant were calculated. Glomerular filtration rate (GFR) less than 60 mL / min / 1.73 m2 has been considered as the definition of CKD. Odds Ratio (OR) was calculated using logistic regression to show the association between the risk of incident CKD and dietary exposures. RESULTS After adjusting for age, sex, body mass index, smoking, total energy intake, total fiber intake, dietary fat, physical activity, diabetes, and hypertension, there was no significant association of total protein and animal protein consumptions with the incidence of CKD. After adjustment for confounders, compared with the lowest tertile of plant protein consumption, OR of incident CKD in the highest tertile was 0.29 (95% confidence interval [95% CI] 0.15 to 0.55) with a significant trend (P for trend < 0.001). CONCLUSION The results of this study confirmed an inverse association between plant protein intake and the risk of incident CKD, which demonstrates the protective role of plant-based protein in a diet on kidney function.
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Affiliation(s)
- Sevda Alvirdizadeh
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Emad Yuzbashian
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P.O. Box: 19395-4763, Tehran, Iran.
| | - Parvin Mirmiran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P.O. Box: 19395-4763, Tehran, Iran.
| | - Shahryar Eghtesadi
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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20
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Queiroz DM, Valenzuela RGV, Marinho AWGB, Santos SSBD, Silva DOD, Dias MDS, Cruz LDO. Atypical clinical presentation of distal renal tubular acidosis: a case report registered in Amazonas, Brazil. J Bras Nefrol 2020; 42:380-383. [PMID: 32353105 PMCID: PMC7657058 DOI: 10.1590/2175-8239-jbn-2019-0224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/30/2020] [Indexed: 11/22/2022] Open
Abstract
We report an unusual case of a 24-year-old girl with a history of recurrent hypokalemic paralysis episodes and skin lesions on the lower limbs and buttocks, both of which had an acute evolution. In subsequent investigations, the patient also had nephrocalcinosis, nephrolithiasis, hyperchloremic metabolic acidosis and persistent alkaline urinary pH. The findings were consistent with distal renal tubular acidosis as the cause of hypokalemic paralysis. Clinical findings, immunological tests and the result of skin biopsy suggested primary Sjögren's syndrome as an underlying cause. The patient developed azotemia due to obstructive nephrolithiasis. All the features presented in this case are an unusual manifestation of distal renal tubular acidosis; so far, we are not aware of a similar report in the literature.
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21
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Kaur G, Krishan P. Serotonin 5HT 2A receptor antagonism mediated anti-inflammatory and anti-fibrotic effect in adriamycin-induced CKD in rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2020; 393:1269-1279. [PMID: 32342136 DOI: 10.1007/s00210-020-01826-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
A selective 5-HT2A receptor antagonist ketanserin has been used preclinically to improve renal blood flow because of its beneficial effect on autoregulation in various chronic kidney disease models. Ketanserin might be able to turn down adriamycin-induced chronic kidney disease, which is characterized by renal fibrosis, inflammation and structural and functional changes in glomeruli. In the present study, we investigated whether ketanserin suppresses these renal alterations or not. Wistar rats were administered with a single dose of adriamycin (6 mg/kg/i.v), which leads to development of severe tubulointerstitial fibrosis with altered renal function. Subsequent ketanserin treatment (5 mg/kg/p.o) for 4 weeks shown significant change in oxidative stress, serum and urine parameters in adriamycin-induced chronic kidney disease rats. Additionally, results showed that mRNA expression of TGF-β and collagen IV, which are known to promote fibrosis via various signaling pathways involved in the progression of renal disease, was suppressed by ketanserin treatment. Furthermore, expression levels of 5-HT2A and pro-inflammatory marker IL-6 have also been reduced significantly after ketanserin administration in adriamycin-treated animals. Moreover, histopathological studies also reveal the considerable structural changes after ketanserin treatment, and these results are further supported via data obtained from the percentage of glomeruli size changes. In conclusion, ketanserin reduces renal fibrosis and inflammation in adriamycin-induced chronic kidney disease by suppressing 5-HT2A, IL-6, TGF-β and collagen IV expression in renal tissue.
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Affiliation(s)
- Gagandeep Kaur
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India
| | - Pawan Krishan
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India.
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22
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Li X, Zheng S, Wu G. Amino Acid Metabolism in the Kidneys: Nutritional and Physiological Significance. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1265:71-95. [DOI: 10.1007/978-3-030-45328-2_5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Metabolic acidosis is defined as a pathologic process that, when unopposed, increases the concentration of hydrogen ions (H+) in the body and reduces the bicarbonate (HCO3-) concentration. Metabolic acidosis can be of a kidney origin or an extrarenal cause. Assessment of urinary ammonium excretion by calculating the urine anion gap or osmolal gap is a useful method to distinguish between these two causes. Extrarenal processes include increased endogenous acid production and accelerated loss of bicarbonate from the body. Metabolic acidosis of renal origin is due to a primary defect in renal acidification with no increase in extrarenal hydrogen ion production. This situation can occur because either the renal input of new bicarbonate is insufficient to regenerate the bicarbonate lost in buffering endogenous acid as with distal renal tubular acidosis (RTA) or the RTA of renal insufficiency, or the filtered bicarbonate is lost by kidney wasting as in proximal RTA. In either condition, because of loss of either NaHCO3 (proximal RTA) or NaA (distal RTA), effective extracellular volume is reduced and as a result the avidity for chloride reabsorption derived from the diet is increased and results in a hyperchloremic normal gap metabolic acidosis. The RTA of renal insufficiency is also characterized by a normal gap acidosis, however, with severe reductions in the glomerular filtration rate an anion gap metabolic acidosis eventually develops.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA -
| | - Deborah J Clegg
- Department of Health Studies, College of Arts and Sciences, American University, Washington, DC, USA.,Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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24
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Affiliation(s)
- Peter W. R. Lemon
- School of Physical Education, Recreation and Dance, Applied Physiology Research Laboratory, Kent State University, Kent, Ohio 44242, USA
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25
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Mirijello A, Viazzi F, Fioretto P, Giorda C, Ceriello A, Russo GT, Guida P, Pontremoli R, De Cosmo S. Association of kidney disease measures with risk of renal function worsening in patients with type 1 diabetes. BMC Nephrol 2018; 19:347. [PMID: 30514308 PMCID: PMC6280443 DOI: 10.1186/s12882-018-1136-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/13/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage ≥3 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage ≥3 CKD in a large cohort of patients affected by T1DM. METHODS A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage ≥3 CKD (eGFR < 60 mL/min/1.73 m2) or eGFR reduction > 30% from baseline was evaluated. RESULTS The mean estimated GFR was 98 ± 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR < 90 ml/min/m2 were independent risk factors for stage ≥3 CKD and renal function worsening. When compared to patients with eGFR > 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. CONCLUSIONS Albuminuria and eGFR reduction represent independent risk factors for incident stage ≥3 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening.
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Affiliation(s)
- Antonio Mirijello
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", IRCCS Casa Sollievo della Sofferenza, v.le Cappuccini, 71013, San Giovanni Rotondo, FG, Italy.
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Carlo Giorda
- Diabetes and Metabolism Unit ASL Turin 5, Chieri, Italy
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS) and Centro de Investigación Biomédicaen Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain.,U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS, Sesto San Giovanni, Milan, Italy
| | - Giuspina T Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", IRCCS Casa Sollievo della Sofferenza, v.le Cappuccini, 71013, San Giovanni Rotondo, FG, Italy.
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Sinha A, Oo P, Asghar MU, Cheema HA, Mehta SS, Leinwand JC, Janga K. Type II Renal Tubular Acidosis Secondary to Topiramate: A Review. Cureus 2018; 10:e3635. [PMID: 30755834 PMCID: PMC6351003 DOI: 10.7759/cureus.3635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022] Open
Abstract
Topiramate (TMP) is a broad-spectrum anticonvulsant drug used to treat a wide variety of seizure disorders, for migraine prophylaxis, and for many other indications. An important side effect of TMP is metabolic acidosis, which is mediated by renal tubular defects. TMP inhibits carbonic anhydrase, an enzyme that is necessary for acid handling in the proximal renal tubule. Patients can present with asymptomatic serum electrolyte derangements, acute change in mental status, hyperventilation, cardiac arrhythmias, or other sequelae of metabolic acidosis and associated respiratory compensation. If taken chronically, TMP can cause renal stone formation, bone mineralization defects, and several other effects secondary to changes in serum and urine pH and electrolytes. There is no well-studied way to prevent metabolic acidosis in patients taking TMP, but physicians should be vigilant when prescribing this drug to patients with the history of renal diseases and other comorbidities, and aware of this potential etiology of metabolic acidosis. We present a literature review of the underlying mechanisms involved in the development of renal tubular acidosis secondary to TMP and its clinical consequences.
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Affiliation(s)
- Ankur Sinha
- Pulmonary and Critical Care, Maimonides Medical Center, Brooklyn, USA
| | - Phone Oo
- Department of Nephrology, Vassar Brothers Medical Center, poughkeepsie, USA
| | | | - Hira A Cheema
- Internal Medicine, Markham Stouffville Hospital, Markham, CAN
| | - Sanwal S Mehta
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | | | - Kalyana Janga
- Department of Nephrology, Maimonides Medical Center, New York, USA
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27
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Abstract
The prevalence of obesity in combination with sarcopenia (the age-related loss of muscle mass and strength or physical function) is increasing in adults aged 65 years and older. A major subset of adults over the age of 65 is now classified as having sarcopenic obesity, a high-risk geriatric syndrome predominantly observed in an ageing population that is at risk of synergistic complications from both sarcopenia and obesity. This Review discusses pathways and mechanisms leading to muscle impairment in older adults with obesity. We explore sex-specific hormonal changes, inflammatory pathways and myocellular mechanisms leading to the development of sarcopenic obesity. We discuss the evolution, controversies and challenges in defining sarcopenic obesity and present current body composition modalities used to assess this condition. Epidemiological surveys form the basis of defining its prevalence and consequences beyond comorbidity and mortality. Current treatment strategies, and the evidence supporting them, are outlined, with a focus on calorie restriction, protein supplementation and aerobic and resistance exercises. We also describe weight loss-induced complications in patients with sarcopenic obesity that are relevant to clinical management. Finally, we review novel and potential future therapies including testosterone, selective androgen receptor modulators, myostatin inhibitors, ghrelin analogues, vitamin K and mesenchymal stem cell therapy.
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Affiliation(s)
- John A Batsis
- Sections of General Internal Medicine and Weight and Wellness, and the Dartmouth Centers for Health and Aging, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, The Health Promotion Research Center and the Norris Cotton Cancer Center, Dartmouth College, Hanover, NH, USA.
| | - Dennis T Villareal
- Division of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX, USA
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA
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28
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Finer G, Landau D. Clinical Approach to Proximal Renal Tubular Acidosis in Children. Adv Chronic Kidney Dis 2018; 25:351-357. [PMID: 30139461 DOI: 10.1053/j.ackd.2018.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Proximal renal tubular acidosis (pRTA) is an inherited or acquired clinical syndrome in which there is a decreased bicarbonate reclamation in the proximal tubule resulting in normal anion gap hyperchloremic metabolic acidosis. In children, pRTA may be isolated but is often associated with a general proximal tubular dysfunction known as Fanconi syndrome which frequently heralds an underlying systemic disorder from which it arises. When accompanied by Fanconi syndrome, pRTA is characterized by additional renal wasting of phosphate, glucose, uric acid, and amino acids. The most common cause of inherited Fanconi syndrome in the pediatric age group is cystinosis, a disease with therapeutic implications. In this article, we summarize the clinical presentation and differential diagnosis of pRTA and Fanconi syndrome and provide a practical approach to their evaluation in children.
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29
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Cobalt treatment does not prevent glomerular morphological alterations in type 1 diabetic rats. Naunyn Schmiedebergs Arch Pharmacol 2018; 391:933-944. [PMID: 29860656 DOI: 10.1007/s00210-018-1511-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/09/2018] [Indexed: 01/11/2023]
Abstract
Early renal morphological alterations including glomerular hypertrophy and mesangial expansion occur in diabetic kidney disease and correlate with various clinical manifestations of diabetes. The present study was designed to investigate the influence of pharmacological modulation of HIF-1α (hypoxia inducible factor-1 alpha) protein levels, on these glomerular changes in rodent model of type 1 diabetes. Male wistar rats were made diabetic (Streptozotocin 45 mg/kg; i.p.) and afterwards treated with HIF activator cobalt chloride for 4 weeks. Renal function was assessed by serum creatinine, albumin, proteinuria levels, oxidative stress: reduced glutathione levels and catalase activity, and renal tissue HIF-1α protein levels were determined by ELISA assay. Histological analysis of kidney sections was done by haematoxylin and eosin (glomeruli diameter), periodic acid Schiff (mesangial expansion and glomerulosclerosis) and sirius red (fibrosis, tubular dilation) staining. Diabetes rats displayed reduced serum albumin levels, marked proteinuria, lower kidney reduced glutathione content, glomerular hypertrophy, glomerulosclerosis, mesangial expansion, tubular dilation and renal fibrosis. Cobalt chloride treatment normalised renal HIF-1α protein levels, reduced development of proteinuria and tubulo-interstitial fibrosis, but the glomerular morphological alterations such as glomerulosclerosis, mesangial expansion, increased glomerular diameter and tubular vacoulations were not abrogated in diabetic kidneys. Glomerular morphological abnormalities might precede the development of proteinuria and renal fibrosis in experimental model of type 1 diabetes. Pharmacological modulation of renal HIF-1α protein levels does not influence glomerular and tubular dilatory changes in diabetic kidney disease.
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Progression of chronic kidney disease in children - role of glomerular hemodynamics and interstitial fibrosis. Curr Opin Pediatr 2018; 30:220-227. [PMID: 29389683 DOI: 10.1097/mop.0000000000000594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an overview of the current advances in the understanding of the mechanisms involved in the progression of chronic kidney disease (CKD) with emphasis on the role of glomerular hemodynamics and tubulointerstitial fibrosis. RECENT FINDINGS Despite the varied causes of CKD, the progressive destruction of renal tissue processes through a complex common pathway. Current studies have highlighted both the role of the abnormal intrarenal hemodynamics and of the activation of fibrogenic biochemical pathway in the replacement of normal renal structure by extracellular matrix and ultimately by fibrosis. Molecular markers with the potential to contribute to the detection of tubular cell damage and tubulointerstitial fibrosis in the kidney has been identified. SUMMARY There is a clear need to understand and elucidate the mechanisms of progression of CKD to develop efficient therapeutic strategies to halt decline of renal function in children.
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Novel treatment strategies for chronic kidney disease: insights from the animal kingdom. Nat Rev Nephrol 2018; 14:265-284. [PMID: 29332935 DOI: 10.1038/nrneph.2017.169] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Many of the >2 million animal species that inhabit Earth have developed survival mechanisms that aid in the prevention of obesity, kidney disease, starvation, dehydration and vascular ageing; however, some animals remain susceptible to these complications. Domestic and captive wild felids, for example, show susceptibility to chronic kidney disease (CKD), potentially linked to the high protein intake of these animals. By contrast, naked mole rats are a model of longevity and are protected from extreme environmental conditions through mechanisms that provide resistance to oxidative stress. Biomimetic studies suggest that the transcription factor nuclear factor erythroid 2-related factor 2 (NRF2) offers protection in extreme environmental conditions and promotes longevity in the animal kingdom. Similarly, during months of fasting, immobilization and anuria, hibernating bears are protected from muscle wasting, azotaemia, thrombotic complications, organ damage and osteoporosis - features that are often associated with CKD. Improved understanding of the susceptibility and protective mechanisms of these animals and others could provide insights into novel strategies to prevent and treat several human diseases, such as CKD and ageing-associated complications. An integrated collaboration between nephrologists and experts from other fields, such as veterinarians, zoologists, biologists, anthropologists and ecologists, could introduce a novel approach for improving human health and help nephrologists to find novel treatment strategies for CKD.
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Abstract
Life with a solitary functioning kidney (SFK) may be different from that when born with two kidneys. Based on the hyperfiltration hypothesis, a SFK may lead to glomerular damage with hypertension, albuminuria and progression towards end-stage renal disease. As the prognosis of kidney donors was considered to be very good, having a SFK has been considered to be a benign condition. In contrast, our research group has demonstrated that being born with or acquiring a SFK in childhood results in renal injury before adulthood in over 50% of those affected. Most congenital cases will be detected during antenatal ultrasound screening, but up to 38% of cases of unilateral renal agenesis are missed. In about 25-50% of cases of antenatally detected SFK there will be signs of hypertrophy, which could indicate additional nephron formation and is associated with a somewhat reduced risk of renal injury. Additional renal and extrarenal anomalies are frequently detected and may denote a genetic cause for the SFK, even though for the majority of cases no explanation can (yet) be found. The ongoing glomerular hyperfiltration results in renal injury, for which early markers are lacking. Individuals with SFK should avoid obesity and excessive salt intake to limit additional hyperfiltration. As conditions like hypertension, albuminuria and a mildly reduced glomerular filtration rate generally do not result in specific complaints but may pose a threat to long-term health, screening for renal injury in any individual with a SFK would appear to be imperative, starting from infancy. With early treatment, secondary consequences may be diminished, thereby providing the optimal life for anyone born with a SFK.
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Abstract
Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.
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Sabatino A, Regolisti G, Gandolfini I, Delsante M, Fani F, Gregorini MC, Fiaccadori E. Diet and enteral nutrition in patients with chronic kidney disease not on dialysis: a review focusing on fat, fiber and protein intake. J Nephrol 2017; 30:743-754. [PMID: 28884267 DOI: 10.1007/s40620-017-0435-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
The clinical data available on dietary requirements of patients with chronic kidney disease (CKD) not on dialysis are limited and largely inconclusive in terms of the renal, cardiovascular and nutritional outcomes achievable through dietary modifications. Restriction of protein intake during the early stages of CKD may in fact slow its progression, but at the same time this approach may also lead to protein-energy wasting, if energy intake is not adequate and properly monitored. Unfortunately, compliance to dietary recommendations is traditionally low in this patient population. A switch from saturated to mono- and polyunsaturated fats is generally recognized as advantageous for cardiac health; however, the benefits in term of renal function are largely unknown. Similarly, the association between dietary fiber intake and kidney disease is largely unknown. In fact, while there is evidence on the positive health effects of dietary fibers in the general population, nutritional guidelines for CKD lack formal recommendations concerning fiber intake. This paper reviews data and evidence from clinical trials and meta-analyses on renal and cardiovascular outcomes related to modifications in protein, fat and fiber intake. Suggestions for maintaining nutritional status through patient-oriented dietary patterns and enteral supplementation in CKD patients on conservative therapy are also presented.
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Affiliation(s)
- Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Giuseppe Regolisti
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Ilaria Gandolfini
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Marco Delsante
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Filippo Fani
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy. .,Postgraduate School of Nephrology, University of Parma, Parma, Italy.
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Forcellini Pedrollo E, Bellincanta Nicoletto B, Salomoni Carpes L, de Melo Cardoso de Freitas J, Buboltz JR, Carra Forte C, Bauer AC, Ceratti Manfro R, Corrêa Souza G, Bauermann Leitão C. Effect of an intensive nutrition intervention of a high protein and low glycemic-index diet on weight of kidney transplant recipients: study protocol for a randomized clinical trial. Trials 2017; 18:413. [PMID: 28874181 PMCID: PMC5585938 DOI: 10.1186/s13063-017-2158-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 08/21/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Excessive weight gain is commonly observed within the first year after kidney transplantation and is associated with negative outcomes, such as graft loss and cardiovascular events. The purpose of this study is to evaluate the effect of a high protein and low glycemic-index diet on preventing weight gain after kidney transplantation. METHODS We designed a prospective, single-center, open-label, randomized controlled study to compare the efficacy of a high protein (1.3-1.4 g/kg/day) and low-glycemic index diet versus a conventional diet (0.8-1.0 g/kg/day of protein) on preventing weight gain after kidney transplantation. A total of 120 eligible patients 2 months after transplantation will be recruited. Patients with an estimated glomerular filtration rate through the modification of diet of renal disease (MDRD) formula < 30 mL/min/1.73 m2 or urinary albumin excretion > 300 mg/24 h will be excluded. Patients' diets will be allocated through simple sequential randomization. Patients will be followed-up for 12 months with nine clinic appointments with a dietitian and the evaluations will include nutritional assessment (anthropometrics, body composition, and resting metabolic rate) and laboratory tests. The primary outcome is weight maintenance or body weight gain under 5% after 12 months. Secondary outcomes include body composition, resting metabolic rate, satiety sensation, kidney function, and other metabolic parameters. DISCUSSION Diets with higher protein content and lower glycemic index may lead to weight loss because of higher satiety sensation. However, there is a concern about the association of high protein intake and kidney damage. Nevertheless, there is little evidence on the impact of high protein intake on long-term kidney function outcome. Therefore, we designed a study to test if a high protein diet with low-glycemic index will be an effective and safe nutritional intervention to prevent weight gain in kidney transplant patients. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02883777 . Registered on 3 August 2016.
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Affiliation(s)
- Elis Forcellini Pedrollo
- Post Graduate Program in Health Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
| | - Bruna Bellincanta Nicoletto
- Post Graduate Program in Health Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
- Nutrition Course, Knowledge Area of Life Sciences, Universidade de Caxias do Sul, Caxias do Sul, RS Brazil
| | - Larissa Salomoni Carpes
- Nutrition Graduate Course, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS Brazil
| | | | - Julia Roberta Buboltz
- Nutrition Graduate Course, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS Brazil
| | - Cristina Carra Forte
- Post Graduate Program in Health Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
| | - Andrea Carla Bauer
- Post Graduate Program in Health Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
| | - Roberto Ceratti Manfro
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
- Post Graduate Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
| | - Gabriela Corrêa Souza
- Department of Nutrition, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil
- Food and Nutrition Research Center, Hospital de Clínicas de Porto Alegre (HCPA-UFRGS), Porto Alegre, RS Brazil
| | - Cristiane Bauermann Leitão
- Post Graduate Program in Health Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 90035-003 Porto Alegre, RS Brazil
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Goraya N, Wesson DE. Management of the Metabolic Acidosis of Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:298-304. [PMID: 29031356 DOI: 10.1053/j.ackd.2017.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/27/2017] [Indexed: 01/31/2023]
Abstract
Subjects with CKD and reduced glomerular filtration rate are at risk for chronic metabolic acidosis, and CKD is its most common cause. Untreated metabolic acidosis, even in its mildest forms, is associated with increased mortality and morbidity and should therefore be treated. If reduced glomerular filtration rate or the tubule abnormality causing chronic metabolic acidosis cannot be corrected, it is typically treated with dietary acid (H+) reduction using Na+-based alkali, usually NaHCO3. Dietary H+ reduction can also be accomplished with the addition of base-producing foods such as fruits and vegetables and limiting intake of H+-producing foods like animal-sourced protein. The optimal dose of Na+-based alkali that prevents the untoward effects of metabolic acidosis while minimizing adverse effects and the appropriate combination of this traditional therapy with dietary strategies remain to be determined by ongoing studies. Recent emerging evidence supports a phenomenon of H+ retention, which precedes the development of metabolic acidosis by plasma acid-base parameters, but further studies will be needed to determine how best to identify patients with this phenomenon and whether they too should be treated with dietary H+ reduction.
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Abstract
BACKGROUND The management of elderly patients with cancer is influenced by several factors that can vary widely among aging individuals. As the proportion of elderly individuals increases, the need for specific care guidelines for this population is critical. The National Comprehensive Cancer Network (NCCN) has developed guidelines to address these factors when formulating optimal treatment regimens for elderly patients and to avoid significant toxicity and maintain their quality of life. METHODS Factors that influence the appropriate treatment choices for the elderly, such as functional status, comorbidity, polypharmacy, and the presence of anemia, are reviewed, and the guidelines developed by the NCCN for treatment elderly patients are discussed. RESULTS The guidelines address these factors when defining the goal of therapy and formulating individualized treatment approaches for the elderly to provide optimal care for these patients, avoid significant toxicity, and maintain their quality of life. CONCLUSIONS The goal of therapy must be clearly defined, whether survival, remission, cure, or palliation of symptoms. Enrollment of elderly cancer patients onto clinical trials is encouraged so the guidelines can be validated.
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Affiliation(s)
- Stuart M Lichtman
- Don Monti Division of Medical Oncology, North Shore University Hospital, Manhasset, NY 11030, USA.
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Lubrano R, Gentile I, Falsaperla R, Vitaliti G, Marcellino A, Elli M. Evolution of blood pressure in children with congenital and acquired solitary functioning kidney. Ital J Pediatr 2017; 43:43. [PMID: 28449720 PMCID: PMC5408435 DOI: 10.1186/s13052-017-0359-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 04/13/2017] [Indexed: 01/13/2023] Open
Abstract
Background It is not yet clear if blood pressure and renal function changes evolve differently in children with a congenital or acquired solitary functioning kidney. This study aims to assess if there are any differences between these two types of solitary kidney patients. Methods Current research is a retrospective study assessing the evolution of glomerular filtration rate, proteinuria, and blood pressure in clinical records of 55 children with a solitary functioning kidney (37 congenital and 18 acquired). We used the medical records of children who had been assisted, in our unit of pediatric nephrology, for a period of 14 years (168 months), from the time of diagnosis, between January/1997 and December/2015. Results During the study period, glomerular filtration rate (T0 128.89 ± 32.24 vs T14 118.51 ± 34.45 ml/min/1.73 m2, p NS) and proteinuria (T0 85.14 ± 83.13 vs T14 159.03 ± 234.66 mg/m2/die, p NS) demonstrated no significant change. However, after 14 years of follow-up 76.4% of patients had increased levels of arterial hypertension with values over the 90th percentile for gender, age, and height. Specifically, children with an acquired solitary functioning kidney mainly developed hypertension [T0 2/17 (12%) vs T14 9/17 (52.9%) p < 0.025], whereas children with a congenital solitary functioning kidney mainly developed pre-hypertension [T0 3/38 (7.9%) vs T14 17/38 (44.7%) p < 0.0005]. Conclusions The renal function of children with solitary functioning kidneys remains stable during a follow-up of 14 years. However, these children should be carefully monitored for their tendency to develop arterial blood pressure greater than the 90th percentile for gender, age, and height.
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Affiliation(s)
- Riccardo Lubrano
- Pediatric Department, Pediatric Nephrology Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Isotta Gentile
- Pediatric Department, Pediatric Nephrology Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, Catania, Italy
| | - Giovanna Vitaliti
- Pediatric Department, Pediatric Nephrology Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Alessia Marcellino
- Pediatric Department, Pediatric Nephrology Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Marco Elli
- DiBiC-Biomedical and Clinic Science Department, "Luigi Sacco" - University of Milan, Milan, Italy
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The conundrums of chronic kidney disease and aging. J Nephrol 2016; 30:477-483. [PMID: 27885585 DOI: 10.1007/s40620-016-0362-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 01/13/2023]
Abstract
Chronic kidney disease (CKD), as presently defined, is a common disorder. Aging is a nearly universal phenomenon that can affect renal anatomy and function, but at variable rates in individuals. Loss of nephrons and a decline in glomerular filtration rate (GFR) is a characteristic of normal aging, called renal senescence. Using fixed and absolute thresholds for defining CKD on the basis of GFR for all ages may lead to diagnostic uncertainty (a conundrum) in both young and older subjects. This brief review will consider the physiological and anatomical changes of the kidney occurring in the process of normal renal senescence focusing on GFR and will examine the relevance of these observation for the diagnosis of CKD using GFR as the distinguishing parameter. Once a better understanding of the pathobiology underlying renal senescence is obtained, specific interventions may become available to slow the process.
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Renal tissue oxygenation in children with chronic kidney disease due to vesicoureteral reflux. Pediatr Nephrol 2016; 31:2103-11. [PMID: 27230512 DOI: 10.1007/s00467-016-3419-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is a frequent cause of chronic kidney disease (CKD) in children. Using blood oxygenation level-dependent magnetic resonance imaging (BOLD-MRI), we measured cortical and medullary oxygenation in children with CKD due to VUR and compared the results to those obtained on healthy controls. METHOD The study population comprised 37 children (19 with CKD due to VUR and 18 healthy age-matched controls). BOLD-MRI was performed before and after furosemide treatment. MR images were analyzed with the region-of-interest (ROI) technique to assess the mean R2* values (=1/T2*) of the cortex and medulla of each kidney and with the concentric object (CO) technique that divides renal parenchyma in 12 equal layers. RESULTS R2* values were significantly lower (corresponding to higher oxygenation) in the cortex and medulla of kidneys of children with CKD due to VUR than in those of the healthy controls (cortex 16.4 ± 1.4 vs. 17.2 ± 1.6 s(-1) , respectively; medulla 28.4 ± 3.2 vs. 30.3 ± 1.9 s(-1) , respectively; P < 0.05), and furosemide-induced changes in medullary R2* were smaller in the former than in the latter (-5.7 ± 3.0 vs. -6.9 ± 3.4 s(-1), respectively; P < 0.05). Similar results were found with the CO technique. In children with a history of unilateral reflux (n = 9), the non-affected contralateral kidneys presented similar R2* values as the diseased kidneys, but their response to furosemide was significantly larger (-7.4 ± 3.2 vs. -5.7 ± 3.0, respectively; P = 0.05). CONCLUSIONS Chronic kidney disease due to VUR is not associated with kidney tissue hypoxia in children. The significantly larger furosemide-induced decrease in medullary R2* levels in the healthy group and unaffected contralateral kidneys of the VUR group points towards more intense renal sodium transport in these kidneys.
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Shah BV, Patel ZM. Role of low protein diet in management of different stages of chronic kidney disease - practical aspects. BMC Nephrol 2016; 17:156. [PMID: 27769183 PMCID: PMC5073729 DOI: 10.1186/s12882-016-0360-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a worldwide public health problem and more so in India. With limited availability and high cost of therapy, barely 10 % of patients with incident end stage renal disease (ESRD) cases get treatment in India. Therefore, all possible efforts should be made to retard progression of CKD. This article reviews the role of low protein diet (LPD) in management of CKD subjects and suggests how to apply it in clinical practice. DISCUSSION The role of LPD in retarding progression of CKD is well established in animal experimental studies. However, its role in human subjects with CKD is perceived to be controversial based on the modification of diet in renal disease (MDRD) study. We believe that beneficial effect of LPD could not be appreciated due to shorter duration of follow-up in the MDRD study. Had the study been continued longer, it may have been possible to appreciate beneficial effect of LPD. It is our contention that in all cases of CKD that are slowly progressive, LPD can significantly retard progression of CKD and delay the need for renal replacement therapy (RRT). To be able to apply LPD for a long period, it is important to prescribe LPD at earlier stages (1,2,3) of CKD and not at late stage as recommended by KDIGO guidelines. Many clinicians are concerned about worsening nutritional status and hence reluctant to prescribe LPD. This actually is true for patients with advanced CKD in whom there is spontaneous decrease in calorie and protein intake. In our experience, nutritional status of patients in early stages (1,2,3) of CKD is as good as that of healthy subjects. Prescribing LPD at an early stage is unlikely to worsen status. The role of LPD in retarding progression of CKD is well established in animal experimental studies. Even in human subjects, there is enough evidence to suggest that LPD retards progression of CKD in carefully selected subjects. It should be prescribed to those with good appetite, good nutritional status and a slowly progressive CKD at an early stage (stage 1,2,3). It may also be prescribed at stage 4 & 5 of CKD if the appetite and nutritional status are good.
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Affiliation(s)
- Bharat V. Shah
- Institute of Renal Sciences, Global Hospital, Parel, Mumbai, 400012 India
| | - Zamurrud M. Patel
- Institute of Renal Sciences, Global Hospital, Parel, Mumbai, 400012 India
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Attini R, Leone F, Parisi S, Fassio F, Capizzi I, Loi V, Colla L, Rossetti M, Gerbino M, Maxia S, Alemanno MG, Minelli F, Piccoli E, Versino E, Biolcati M, Avagnina P, Pani A, Cabiddu G, Todros T, Piccoli GB. Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: fifteen years of experience. BMC Nephrol 2016; 17:132. [PMID: 27649693 PMCID: PMC5029029 DOI: 10.1186/s12882-016-0339-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/29/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pregnancy in women with advanced CKD becoming increasingly common. However, experience with low-protein diets in CKD patients in pregnancy is still limited. Aim of this study is to review the results obtained over the last 15 years with moderately restricted low-protein diets in pregnant CKD women (combining: CKD stages 3-5, proteinuria: nephrotic at any time, or > =1 g/24 at start or referral; nephrotic in previous pregnancy). CKD patients on unrestricted diets were employed for comparison. METHODS STUDY PERIOD January, 2000 to September, 2015: 36 on-diet pregnancies (31 singleton deliveries, 3 twin deliveries, 1 pregnancy termination, 1 miscarriage); 47 controls (42 singleton deliveries, 5 miscarriages). The diet is basically vegan; since occasional milk and yoghurt are allowed, we defined it vegan-vegetarian; protein intake (0.6-0.8 g/Kg/day), keto-acid supplementation, protein-unrestricted meals (1-3/week) are prescribed according to CKD stage and nutritional status. Statistical analysis was performed as implemented on SPSS. RESULTS Patients and controls were similar (p: ns) at baseline with regard to age (33 vs 33.5), referral week (7 vs 9), kidney function (CKD 3-5: 48.4 % vs 64.3 %); prevalence of hypertension (51.6 % vs 40.5 %) and proteinuria >3 g/24 h (16.1 % vs 12.2 %). There were more diabetic nephropathies in on-diet patients (on diet: 31.0 % vs controls 5.3 %; p 0.007 (Fisher)) while lupus nephropathies were non-significantly higher in controls (on diet: 10.3 % vs controls 23.7 %; p 0.28 (Fisher)). The incidence of preterm delivery was similar (<37 weeks: on-diet singletons 77.4 %; controls: 71.4 %). The incidence of other adverse pregnancy related outcomes was non-significantly lower in on-diet patients (early preterm delivery: on diet: 32.3 % vs controls 35.7 %; birth-weight = <1.500 g: on diet: 9.7 % vs controls 23.8 %). None of the singletons in the on-diet series died, while two perinatal deaths occurred among the controls (p = 0.505). The incidence of small for gestational age (SGA <10th centile) and/or extremely preterm babies (<28th week) was significantly lower in singletons from on-diet mothers than in controls (on diet: 12.9 % vs controls: 33.3 %; p: 0.04 (Fisher)). CONCLUSION Moderate protein restriction in the context of a vegan-vegetarian supplemented diet is confirmed as a safe option in the management of pregnant CKD patients.
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Affiliation(s)
- Rossella Attini
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Filomena Leone
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Silvia Parisi
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Federica Fassio
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Irene Capizzi
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
| | | | - Loredana Colla
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Maura Rossetti
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Martina Gerbino
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | | | - Maria Grazia Alemanno
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Fosca Minelli
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Ettore Piccoli
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Elisabetta Versino
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Marilisa Biolcati
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Paolo Avagnina
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | | | | | - Tullia Todros
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Giorgina B. Piccoli
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
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44
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Bellizzi V, Cupisti A, Locatelli F, Bolasco P, Brunori G, Cancarini G, Caria S, De Nicola L, Di Iorio BR, Di Micco L, Fiaccadori E, Garibotto G, Mandreoli M, Minutolo R, Oldrizzi L, Piccoli GB, Quintaliani G, Santoro D, Torraca S, Viola BF. Low-protein diets for chronic kidney disease patients: the Italian experience. BMC Nephrol 2016; 17:77. [PMID: 27401096 PMCID: PMC4939662 DOI: 10.1186/s12882-016-0280-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients. DISCUSSION This paper describes the pathophysiological basis and rationale of nutritional treatment in CKD and also provides a report on extensive experience in the field of renal diets in Italy, with special attention given to approaches in clinical practice and management. Italian nephrologists have a longstanding tradition in implementing low protein diets in the treatment of CKD patients, with the principle objective of alleviating uremic symptoms, improving nutritional status and also a possibility of slowing down the progression of CKD or delaying the start of dialysis. A renewed interest in this field is based on the aim of implementing a wider nutritional therapy other than only reducing the protein intake, paying careful attention to factors such as energy intake, the quality of proteins and phosphate and sodium intakes, making today's low-protein diet program much more ambitious than previous. The motivation was the reduction in progression of renal insufficiency through reduction of proteinuria, a better control of blood pressure values and also through correction of metabolic acidosis. One major goal of the flexible and innovative Italian approach to the low-protein diet in CKD patients is the improvement of patient adherence, a crucial factor in the successful implementation of a low-protein diet program.
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Affiliation(s)
- Vincenzo Bellizzi
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy.
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | | | - Giovanni Cancarini
- O.U. Nephrology, A.O. Spedali Civili Brescia and University of Brescia, Brescia, Italy
| | - Stefania Caria
- Territorial Department of Nephrology and Dialysis, ASL Cagliari, Italy
| | - Luca De Nicola
- Nephrology Division, Second University of Naples, Naples, Italy
| | | | | | - Enrico Fiaccadori
- Pathophysiology of Renal Failure Unit, University of Parma, Parma, Italy
| | - Giacomo Garibotto
- Nephrology Unit, University of Genoa and IRCCS A.O.U. San Martino IST, Genoa, Italy
| | - Marcora Mandreoli
- Nephrology and Dialysis Unit, Ospedale S. Maria della Scaletta, Imola (BO), Italy
| | | | - Lamberto Oldrizzi
- O.U. Nephrology and Dialysis, Fracastoro Hospital, San Bonifacio (VR), Italy
| | - Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- Nephrologie, CH Le Mans, Le Mans France, Italy
| | - Giuseppe Quintaliani
- O.U. Nephrology, Dialysis and Transplantation, Santa Maria della Misericordia Hospital, Udine, Italy
| | - Domenico Santoro
- Perugia Department of Internal Medicine, University of Messina, Messina, Italy
| | - Serena Torraca
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy
| | - Battista F Viola
- O.U. Nephrology, A.O. Spedali Civili Brescia and University of Brescia, Brescia, Italy
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45
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Juraschek SP, Chang AR, Appel LJ, Anderson CAM, Crews DC, Thomas L, Charleston J, Miller ER. Effect of glycemic index and carbohydrate intake on kidney function in healthy adults. BMC Nephrol 2016; 17:70. [PMID: 27391484 PMCID: PMC4938908 DOI: 10.1186/s12882-016-0288-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 06/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Replacing carbohydrate with protein acutely increases glomerular filtration rate (GFR) but is associated with faster, long-term kidney disease progression. The effects of carbohydrate type (i.e. glycemic index, GI) on kidney function are unknown. METHODS We conducted an ancillary study of a randomized, crossover feeding trial in overweight/obese adults without diabetes or kidney disease (N = 163). Participants were fed each of four healthy, DASH-like diets for 5 weeks, separated by 2-week washout periods. Weight was kept constant. The four diets were: high GI (GI ≥65) with high %carb (58 % kcal) (reference diet), low GI (≤45) with low %carb (40 % kcal), low GI with high %carb; and high GI with low %carb. Plasma was collected at baseline and after each feeding period. Study outcomes were cystatin C, β2-microglobulin (β2M), and estimated GFR based on cystatin C (eGFRcys). RESULTS Mean (SD) age was 52 (11) years; 52 % were women; 50 % were black. At baseline, mean (SD) cystatin C, β2M, and eGFRcys were 0.8 (0.1) mg/L, 1.9 (0.4) mg/L, and 104 (16) mL/min/1.73 m(2). Compared to the high GI/high %carb diet, reducing GI, %carb, or both increased eGFRcys by 1.9 mL/min/1.73 m(2) (95 % CI: 1.1, 2.7; P < 0.001), 3.0 mL/min/1.73 m(2) (1.9, 4.0; P < 0.001), and 4.5 mL/min/1.73 m(2) (3.5, 5.4; P < 0.001), respectively. Increases in eGFRcys from reducing GI were significantly associated with increases in eGFRcys from reducing %carb (P < 0.001). Results for cystatin C and β2M reflected eGFRcys. CONCLUSIONS Reducing GI increased GFR. Reducing %carb by increasing calories from protein and fat, also increased GFR. Future studies on GI should examine the long-term effects of this increase in GFR on kidney injury markers and clinical outcomes. TRIAL REGISTRATION Clinical Trials.gov, number: NCT00608049 (first registered January 23, 2008).
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Affiliation(s)
- Stephen P Juraschek
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA
| | | | - Lawrence J Appel
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA
| | | | - Deidra C Crews
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA
| | - Letitia Thomas
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA
| | - Jeanne Charleston
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA
| | - Edgar R Miller
- The Johns Hopkins School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 1-500, Baltimore, MD, 21205, USA.
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46
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Tancredi G, Lambiase C, Favoriti A, Ricupito F, Paoli S, Duse M, De Castro G, Zicari AM, Vitaliti G, Falsaperla R, Lubrano R. Cardiorespiratory fitness and sports activities in children and adolescents with solitary functioning kidney. Ital J Pediatr 2016; 42:43. [PMID: 27117183 PMCID: PMC4847270 DOI: 10.1186/s13052-016-0255-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An increasing number of children with chronic disease require a complete medical examination to be able to practice physical activity. Particularly children with solitary functioning kidney (SFK) need an accurate functional evaluation to perform sports activities safely. The aim of our study was to evaluate the influence of regular physical activity on the cardiorespiratory function of children with solitary functioning kidney. METHOD Twenty-nine patients with congenital SFK, mean age 13.9 ± 5.0 years, and 36 controls (C), mean age 13.8 ± 3.7 years, underwent a cardiorespiratory assessment with spirometry and maximal cardiopulmonary exercise testing. All subjects were divided in two groups: sedentary (S) and trained (T) patients, by means of a standardized questionnaire about their weekly physical activity. RESULTS We found that mean values of maximal oxygen consumption (VO2max) and exercise time (ET) were higher in T subjects than in S subjects. Particularly SFK-T presented mean values of VO2max similar to C-T and significantly higher than C-S (SFK-T: 44.7 ± 6.3 vs C-S: 37.8 ± 3.7 ml/min/kg; p < 0.0008). We also found significantly higher mean values of ET (minutes) in minutes in SFK-T than C-S subjects (SFK-T: 12.9 ± 1.6 vs C-S: 10.8 ± 2.5 min; p <0.02). CONCLUSION Our study showed that regular moderate/high level of physical activity improve aerobic capacity (VO2max) and exercise tolerance in congenital SFK patients without increasing the risks for cardiovascular accidents and accordingly sports activities should be strongly encouraged in SFK patients to maximize health benefits.
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Affiliation(s)
- Giancarlo Tancredi
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy.
| | - Caterina Lambiase
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Alessandra Favoriti
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Francesca Ricupito
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Sara Paoli
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Marzia Duse
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Giovanna De Castro
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Anna Maria Zicari
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Giovanna Vitaliti
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
| | - Raffaele Falsaperla
- General Pediatrics Operative Unit, Vittorio-Emanuele University Hospital, University of Catania, via S. Sofia, Catania, 78-95123, Italy
| | - Riccardo Lubrano
- Pediatric Department, "Sapienza" University of Rome, Viale Regina Margherita 324, Rome, 00161, Italy
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High protein intake in neonatal period induces glomerular hypertrophy and sclerosis in adulthood in rats born with IUGR. Pediatr Res 2016; 79:22-6. [PMID: 26372514 DOI: 10.1038/pr.2015.176] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 06/22/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Intrauterine growth restriction (IUGR) and postnatal nutrition are risk factors for cardiovascular and renal diseases in both humans and animals. The long-term renal effects of protein intake early in life remain unknown. The objective was to evaluate the effects of a neonatal feeding with high protein (HP) milk on renal functions and structure in IUGR male rats. METHODS Maternal gestational low protein diet was used to produce IUGR. At day 5, IUGR pups were gastrostomized in the "pup-in-the cup" model and received either normal protein (NP) milk or HP (+50% protein content) milk until day 21. After weaning, the animals were fed the same standard diet. Renal functions and structure were assessed at postnatal day 18 (D18) and in adult offspring. RESULTS During the preweaning period, the postnatal weight gain between the two groups was unaffected. On D18, kidneys from HP offspring were heavier with significant glomerular hypertrophy (+40%, P < 0.05). HP diet was associated with significant proteinuria and glomerulosclerosis (+49%, P < 0.05). Glomerular number was unaltered. CONCLUSION Neonatal HP feeding following IUGR affects renal functions and structure at adulthood. These alterations may result from a single nephron glomerular hyperfiltration.
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48
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Abe M, Soma M. Multifunctional L/N- and L/T-type calcium channel blockers for kidney protection. Hypertens Res 2015; 38:804-6. [PMID: 26423789 DOI: 10.1038/hr.2015.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masayoshi Soma
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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49
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Abstract
Kidney disease is common in patients with type 1 and type 2 diabetes mellitus and is associated with adverse health outcomes, including progression to end-stage renal disease. In the general population, adherence to a healthy lifestyle is known to reduce the risk of cardiovascular events and death. Among individuals with diabetic kidney disease, modifications in lifestyle factors, including diet, physical activity, smoking habits, and body mass index, represent a promising cost-effective therapeutic adjunct to pharmacologic treatment of kidney disease incidence and progression.
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Affiliation(s)
- Chijoke Onyenwenyi
- Department of Medicine, Division of Nephrology, The University of Illinois at Chicago, 820 South Wood Street, 418W CSN, MC 793, Chicago, IL 60612, Phone (312) 996-6736, Fax (312) 996-7378,
| | - Ana C. Ricardo
- Department of Medicine, Division of Nephrology, The University of Illinois at Chicago, 820 South Wood Street, 418W CSN, MC 793, Chicago, IL 60612, Phone (312) 996-8392, Fax (312) 996-7378,
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50
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Kahleova H, Pelikanova T. Vegetarian Diets in the Prevention and Treatment of Type 2 Diabetes. J Am Coll Nutr 2015; 34:448-58. [DOI: 10.1080/07315724.2014.976890] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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