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Ariyanopparut S, Metta K, Avihingsanon Y, Eiam-Ong S, Kittiskulnam P. The role of a low protein diet supplemented with ketoanalogues on kidney progression in pre-dialysis chronic kidney disease patients. Sci Rep 2023; 13:15459. [PMID: 37726370 PMCID: PMC10509207 DOI: 10.1038/s41598-023-42706-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Abstract
In slowing kidney progression, numerous pre-dialysis chronic kidney disease (CKD) patients could not adhere to the well-established dietary pattern, including a very low protein diet, 0.3-0.4 g/kg/day, plus a full dose ketoanalogues (KAs) of amino acids. We evaluated the role of a low protein diet (LPD), 0.6-0.8 g/kg/day, combined with KAs (LPD-KAs) on CKD progression. We extracted data in the retrospective cohort using electronic medical records (n = 38,005). Participants with LPD-KAs for longer than six months were identified. An unmatched control group, LPD alone, was retrieved from the same database. Cox proportional hazard models were performed to examine the associations between LPD-KAs and outcomes. The primary outcome was either a rapid estimated glomerular filtration rate (eGFR) decline > 5 mL/min/1.73m2/year or commencing dialysis. Other secondary outcomes include changes in proteinuria, serum albumin, and other metabolic profiles were also assessed. A total of 1042 patients were finally recruited (LPD-KAs = 543). Although patients with LPD-KAs had significantly lower eGFR and a prevalence of diabetes, age, and dietary protein intake were comparable between LPD-KAs (0.7 ± 0.2 g/kg/day) and LPD alone groups (0.7 ± 0.3 g/kg/day, p = 0.49). During a median follow-up of 32.9 months, patients treated with LPD-KAs had a significantly lower risk of kidney function decline (HR 0.13; 95% CI 0.09-0.19, p < 0.001) and dialysis initiation (HR 0.24; 95% CI 0.12-0.49, p < 0.001) than LPD alone after adjusting for confounders. The annual rate of eGFR decline in patients receiving LPD-KAs was 4.5 [3.4-5.5] mL/min/1.73m2 compared with 7.7 [6.0-9.4] mL/min/1.73m2 in LPD alone (p = 0.001). According to KAs dose-response analysis, the daily dose of ≤ 5 tablets was conversely associated with a higher risk of the primary endpoint, whereas the association disappeared among patients receiving a dose of > 6 tablets. The spot urine protein creatinine ratio and serum phosphate levels were not significantly different between groups. LPD-KAs could retard kidney progression compared with LPD alone. This favorable effect was significant among CKD patients receiving a daily KAs dose of more than six tablets. Future randomized controlled trials should be performed to verify these findings.
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Affiliation(s)
| | - Kamonchanok Metta
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyawan Kittiskulnam
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Division of Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand.
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2
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Cecchi S, Di Stante S, Belcastro S, Bertuzzi V, Cardillo A, Diotallevi L, Grabocka X, Kulurianu H, Martello M, Nastasi V, Paci Della Costanza O, Pizzolante F, Di Luca M. Supplemented Very Low Protein Diet (sVLPD) in Patients with Advanced Chronic Renal Failure: Clinical and Economic Benefits. Nutrients 2023; 15:3568. [PMID: 37630758 PMCID: PMC10457928 DOI: 10.3390/nu15163568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
The supplemented very low-protein diet (sVLPD) has proven effective in slowing the progression of stage 5 chronic renal failure and postponing the start of the dialysis treatment. However, sVLPD could expose the patient to the risk of malnutrition. This diet is also difficult to implement due to the required intake of large number of keto-analogue/amino acid tablets. In our Center, the Department of Nephrology and Dialysis of Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, of Italy, respecting the guidelines of normal clinical practice, we prescribed sVLPD (0.3 g/prot/day) supplemented with only essential amino acids without the use of ketoanalogues in stage 5 patients and verified its efficacy, safety and clinical and economic effects. Over the 24 months period of observation the progression of chronic kidney disease (CKD) slowed down (mean eGFR 11.6 ± 3.3 vs. 9.3 ± 2.7 mL/min/1.73 m2, p < 0.001) and the start of the dialysis treatment (adjusted HR = 0.361, CI 0.200-0.650, p = 0.001) was delayed without evidence of malnutrition, in compliant vs. non-compliant patients. This led to a substantial cost reduction for the National Health System. This non-interventional longitudinal observational study is part of standard clinical practice and suggests that VLPD supplemented with essential amino acids could be extensively used to reduce the incidence of dialysis treatments, with a favorable economic impact on the NHS.
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Affiliation(s)
- Sofia Cecchi
- Department of Clinical and Molecular Science, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Silvio Di Stante
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Sara Belcastro
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Veronica Bertuzzi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Assunta Cardillo
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Laura Diotallevi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Xhensila Grabocka
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Hrissa Kulurianu
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Mauro Martello
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Valentina Nastasi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Osmy Paci Della Costanza
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Francesca Pizzolante
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Marina Di Luca
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
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3
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Dawson J, McLean C. Nutrition in Conservative Kidney Management: From Evidence to Practice. Semin Nephrol 2023; 43:151399. [PMID: 37506469 DOI: 10.1016/j.semnephrol.2023.151399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Conservative kidney management (CKM) is a treatment option for kidney failure, particularly for the elderly and those with co-morbidities. Dietitians can play an important role in the provision of CKM by enhancing patients' quality of life through the management of nutrition impact symptoms (symptoms that result in decreased eating, including anorexia, nausea, dry mouth, and taste changes), as well as symptoms that result from malnutrition, including fatigue, weakness, activity intolerance, slow wound healing, and low mood. There are many gaps in the literature regarding optimal nutritional recommendations for patients on CKM. More research is needed on symptom management and interventions to delay or slow the progression of malnutrition and frailty. This article provides an overview of important nutritional considerations, a synthesis of the current literature, and recommendations for application of evidence into the practice of CKM.
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Affiliation(s)
- Jessica Dawson
- Department of Nutrition and Dietetics, St George Hospital, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
| | - Cameron McLean
- Department of Nutrition and Dietetics, St George Hospital, Sydney, New South Wales, Australia; School of Medical, Indigenous and Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
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4
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Mocanu CA, Cuiban E, Paul R, Radulescu D, Garneata L. A supplemented very low-protein diet could be effective, safe, and feasible in closely monitored patients with advanced CKD. Am J Clin Nutr 2022; 116:836-837. [PMID: 35849018 DOI: 10.1093/ajcn/nqac155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Carmen Antonia Mocanu
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Elena Cuiban
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology and Dialysis, "Sf Ioan Nou" Emergency Clinical Hospital, Bucharest, Romania
| | - Raluca Paul
- "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Daniela Radulescu
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology and Dialysis, "Sf Ioan Nou" Emergency Clinical Hospital, Bucharest, Romania
| | - Liliana Garneata
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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Ready to Change: Attitudes of an Elderly CKD Stage 3-5 Population towards Testing Protein-Free Food. Nutrients 2020; 12:nu12113519. [PMID: 33207579 PMCID: PMC7696537 DOI: 10.3390/nu12113519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 01/21/2023] Open
Abstract
The recent Kidney Disease Outcomes Quality Initiative (K-DOQI) guidelines suggest an early start of protein restriction, raising issues on willingness to change dietary habits. The aim of this exploratory real-life study was to report on a test of dietary products (protein-free, not previously available in France) in a large, mainly elderly, chronic kidney disease (CKD) population (220 patients, median age: 77.5 years, Charlson comorbidity index (CCI): seven, malnutrition inflammation score (MIS): five, estimated glomerular filtration rate (eGFR): 26 mL/min), also as a means to tailor further implementation strategies. Forty-nine patients (22.28%) were considered to be poor candidates for the trial (metabolically unstable or with psychological, psychiatric or logistic barriers); of the remaining 171, 80.70% agreed to participate. Patients to whom the diet was not proposed had lower eGFR and higher comorbidity (eGFR 21 vs. 27 p = 0.021; MIS six vs. four p: <0.001). Patients who refused were 10 years older than those who accepted (83 vs. 73 years p < 0.001), with a higher CCI (eight vs. seven p = 0.008) and MIS (five vs. four p = 0.01). In the logistic regression, only age was significantly associated with refusal to participate (Odds ratio (OR): 5.408; 95% CI: 1.894 to 15.447). No difference was found according to low/intermediate/high frequency of weekly use of protein-free food. Our study suggests that most of the patients are ready to test new diet approaches. Only old age correlated with refusal, but frequency of implementation depended on individual preferences, underlying the importance of tailored approaches to improve adherence.
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Piccoli GB, Di Iorio BR, Chatrenet A, D'Alessandro C, Nazha M, Capizzi I, Vigotti FN, Fois A, Maxia S, Saulnier P, Cabiddu G, Cupisti A. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (TOrino-Pisa study). Nephrol Dial Transplant 2020; 35:790-802. [PMID: 31435654 DOI: 10.1093/ndt/gfz147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/27/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Concerns about adherence and quality of life (QoL) limit the diffusion of low-protein diets (LPDs) as a way to slow chronic kidney disease (CKD) progression and postpone dialysis. The aim of this multicentre study is to assess dietary satisfaction in stable CKD patients. METHODS This was a multicentre cross-sectional study with long-term follow-up data. Prevalent patients on LPD for at least 6 months were selected in four Italian centres. QoL was assessed using the World Health Organization Quality of Life questionnaire, and diet satisfaction with the Modification of Diet in Renal Disease satisfaction questionnaire. Comorbidity was assessed by Charlson Comorbidity Index, estimated glomerular filtration rate (eGFR) was calculated by the CKD Epidemiology Collaboration equation and protein intake by Maroni-Mitch formula. Survival was analysed with Kaplan-Meier curves and Cox Proportional Hazard Model. RESULTS Four hundred and twenty-two CKD Stages 3-5 patients were enrolled. Over 95% were on moderately restricted diets (0.6 g/kg/day). Compliance was good (protein intake: 0.59 g/kg/day at baseline, 0.72 at the end of follow-up). Median dietary satisfaction was 4 on a 1-5 scale. QoL was not affected by the type of diet, but was influenced by age, comorbidity and setting of care. Two years later, at the end of follow-up, 66.6% of the patients were still on a diet; the main causes of discontinuation were dialysis and death. The dropout rate was low (5.5%); in Cox analysis, patient and renal survival were influenced by age and eGFR, but not by QoL, setting of care or type of diet. CONCLUSIONS LPDs are compatible with high dietary satisfaction and minimal dropout, at least in patients who are able to follow such a diet for at least 6 months.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antoine Chatrenet
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Marta Nazha
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Irene Capizzi
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antioco Fois
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Stefania Maxia
- Nephrology, Department of Medicine, Ospedale Brotzu, Cagliari, Italy
| | | | | | - Adamasco Cupisti
- Nephrology, Department of Medicine, University of Pisa, Pisa, Italy
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7
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Cupisti A, Gallieni M, Avesani CM, D’Alessandro C, Carrero JJ, Piccoli GB. Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication. J Clin Med 2020; 9:E3644. [PMID: 33198365 PMCID: PMC7697617 DOI: 10.3390/jcm9113644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an "option" in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, University of Milan, 20157 Milan, Italy;
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy
| | - Carla Maria Avesani
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institutet, 14186 Stockholm, Sweden;
| | - Claudia D’Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden;
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy;
- Nephrologie, Centre Hospitalier Le Mans, 72100 Le Mans, France
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Esposito P, Garibotto G, Picciotto D, Costigliolo F, Viazzi F, Conti NE. Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes. Nutrients 2020; 12:nu12030873. [PMID: 32213942 PMCID: PMC7146629 DOI: 10.3390/nu12030873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
Pregnancy in women affected by chronic kidney disease (CKD) has become more common in recent years, probably as a consequence of increased CKD prevalence and improvements in the care provided to these patients. Management of this condition requires careful attention since many clinical aspects have to be taken into consideration, including the reciprocal influence of the renal disease and pregnancy, the need for adjustment of the medical treatments and the high risk of maternal and obstetric complications. Nutrition assessment and management is a crucial step in this process, since nutritional status may affect both maternal and fetal health, with potential effects also on the future development of adult diseases in the offspring. Nevertheless, few data are available on the nutritional management of pregnant women with CKD and the main clinical indications are based on small case series or are extrapolated from the general recommendations for non-pregnant CKD patients. In this review, we discuss the main issues regarding the nutritional management of pregnant women with renal diseases, including CKD patients on conservative treatment, patients on dialysis and kidney transplant patients, focusing on their relevance on fetal outcomes and considering the peculiarities of this population and the approaches that could be implemented into clinical practice.
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Wang M, Xu H, Chong Lee Shin OLS, Li L, Gao H, Zhao Z, Zhu F, Zhu H, Liang W, Qian K, Zhang C, Zeng R, Zhou H, Yao Y. Compound α-keto acid tablet supplementation alleviates chronic kidney disease progression via inhibition of the NF-kB and MAPK pathways. J Transl Med 2019; 17:122. [PMID: 30975176 PMCID: PMC6458753 DOI: 10.1186/s12967-019-1856-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Keto-analogues administration plays an important role in clinical chronic kidney disease (CKD) adjunctive therapy, however previous studies on their reno-protective effect mainly focused on kidney pathological changes induced by nephrectomy. This study was designed to explore the currently understudied alternative mechanisms by which compound α-ketoacid tablets (KA) influenced ischemia–reperfusion (IR) induced murine renal injury, and to probe the current status of KA administration on staving CKD progression in Chinese CKD patients at different stages. Methods In animal experiment, IR surgery was performed to mimic progressive chronic kidney injury, while KA was administrated orally. For clinical research, a retrospective cohort study was conducted to delineate the usage and effects of KA on attenuating CKD exacerbation. End-point CKD event was defined as 50% reduction of initial estimated glomerular filtration rate (eGFR). Kaplan–Meier analysis and COX proportional hazard regression model were adopted to calculate the cumulative probability to reach the end-point and hazard ratio of renal function deterioration. Results In animal study, KA presented a protective effect on IR induced renal injury and fibrosis by attenuating inflammatory infiltration and apoptosis via inhibition of nuclear factor-kappa B (NF-κB) and mitogen-activated protein kinase (MAPK) pathways. In clinical research, after adjusting basic demographic factors, patients at stages 4 and 5 in KA group presented a much delayed and slower incidence of eGFR decrease compared to those in No-KA group (hazard ratio (HR) = 0.115, 95% confidence interval (CI) 0.021–0.639, p = 0.0134), demonstrating a positive effect of KA on staving CKD progression. Conclusion KA improved IR induced chronic renal injury and fibrosis, and seemed to be a prospective protective factor in end stage renal disease.
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Affiliation(s)
- Meng Wang
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Huzi Xu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Octavia Li-Sien Chong Lee Shin
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Li Li
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Hui Gao
- Department of Nutrition, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Zhi Zhao
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Fan Zhu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Han Zhu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Wangqun Liang
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Kun Qian
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Chunxiu Zhang
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Rui Zeng
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Hanjing Zhou
- Department of Nephrology, Jinhua Hospital of Zhejiang University, 365 Renmin East Ave, Jinhua, 321000, Zhejiang, China.
| | - Ying Yao
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China. .,Department of Nutrition, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China.
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10
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Wang AYM, Kalantar-Zadeh K, Fouque D, Wee PT, Kovesdy CP, Price SR, Kopple JD. Precision Medicine for Nutritional Management in End-Stage Kidney Disease and Transition to Dialysis. Semin Nephrol 2019; 38:383-396. [PMID: 30082058 DOI: 10.1016/j.semnephrol.2018.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease (CKD) is a global public health burden. Dialysis is not only costly but may not be readily available in developing countries. Even in highly developed nations, many patients may prefer to defer or avoid dialysis. Thus, alternative options to dialysis therapy or to complement dialysis are needed urgently and are important objectives in CKD management that could have huge clinical and economic implications globally. The role of nutritional therapy as a strategy to slow CKD progression and uremia was discussed as early as the late 19th and early 20th century, but was only seriously explored in the 1970s. There is a revival of interest recently owing to encouraging data as well as the increase of precision medicine with an emphasis on a personalized approach to CKD management. Although part of the explanation for the inconclusive data may relate to variations in study design and dietary prescription, diversity in genetic make-up, variations in the non-nutritional management of CKD, intra-individual variations in responses to dietary and nondietary treatment, psychosocial factors, and dietary compliance issues, these all may contribute to the heterogeneous data and responses. This brings in the evolving concept of precision medicine, in which disease management should be tailored and individualized according not only to clinical manifestations but also to the genetic make-up and biologic responses to therapy, which may vary depending on genetic composition. Precision nutrition management also should take into account patient demographics, social, psychological, education, and compliance factors, which all may influence the therapeutic needs and responses to the nutritional therapy prescribed. In this review, we provide a novel concept of precision medicine in nutritional management in end-stage kidney disease with a transition to dialysis and propose how this may be the way forward for nutritional therapy in the CKD population.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| | | | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Université de Lyon, Pierre Bénite, Lyon, France
| | - Pieter T Wee
- Department of Nephrology, VU University Medical Center and Institute for Cardiovascular Research of the Vrije Universiteit, Amsterdam, The Netherlands
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - S Russ Price
- Department of Internal Medicine, Department of Biochemistry and Molecular Biology, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Joel D Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA and the UCLA Fielding School of Public Health, Los Angeles, CA
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11
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Chauveau P, Lasseur C, Nodimar C, Moreau K, Trolonge S, Aparicio M, Combe C. [Low protein diet supplemented with ketoanalogues of amino acids in patients with chronic renal insufficiency]. Nephrol Ther 2018; 14 Suppl 1:S99-S102. [PMID: 29606271 DOI: 10.1016/j.nephro.2018.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 02/09/2018] [Indexed: 11/16/2022]
Abstract
Restricted protein diets in patients with chronic kidney disease have been debated for several decades. In chronic kidney disease as in other chronic diseases, the modulation of the nutritional intake is the object of a certain renewal. It is supported by recent studies that highlight the importance of modulating nutrient intake by diets that are healthier, less rich in animal proteins and richer in plants. The recent reintroduction in France of amino acid supplements and ketoanalogs of amino acids allows the prescription of a very restricted diet. Historical studies have only focused on the relationship between protein intake and renal function degradation. Recent studies on acid loading, bone metabolism or potassium intake allow revisiting the interest of restricted diets. As with any change in eating habits, the selection of patients, information, education and monitoring during the diet are very important and help prevent undernutrition: this is the purpose of this short review.
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Affiliation(s)
- P Chauveau
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France.
| | - C Lasseur
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | - C Nodimar
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | - K Moreau
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - S Trolonge
- Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | - M Aparicio
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - C Combe
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; Inserm U1026, place Amélie-Raba-Léon, 33000 Bordeaux, France; Université de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
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12
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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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13
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Geng Z, Wei L, Zhang C, Yan X. Astragalus polysaccharide, a component of traditional Chinese medicine, inhibits muscle cell atrophy (cachexia) in an in vivo and in vitro rat model of chronic renal failure by activating the ubiquitin-proteasome pathway. Exp Ther Med 2017; 14:91-96. [PMID: 28672898 PMCID: PMC5488485 DOI: 10.3892/etm.2017.4492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/17/2017] [Indexed: 12/29/2022] Open
Abstract
The present study aimed to determine the effect of Astragalus polysaccharide (APS) in an in vivo and in vitro rat model of muscle atrophy (cachexia) caused by chronic renal failure (CRF), along with the potential corresponding roles of atroglin-1 and the ubiquitin-proteasome pathway. A rat model of CRF was established using subtotal bilateral nephrectomy. It was observed by reverse transcription-quantitative polymerase chain reaction and western blot analysis that APS and the specific inhibitor of nuclear factor (NF)-κB, pyrrolidine dithiocarbamate (PDTC), significantly reduced the expression of atrogin-1, ubiquitin and the NF-κB subunit p65 mRNA in rat skeletal muscle in vivo and in vitro, respectively (P<0.05). NF-κB and PDTC also markedly reduced the expression of atrogin-1, ubiquitin and p65 protein. In addition, cultured rat myoblasts pretreated with tumor necrosis factor (TNF)-α exhibited significantly reduced expression of atrogin-1, ubiquitin and p65 mRNA in vitro (P<0.05). Fluorescence microscopy was subsequently used to evaluate TNF-α-treated myoblasts administered with APS or PDTC, whereby no evidence of muscle cell atrophy was observed in cells treated with APS. These data suggest that APS may delay muscle cell atrophy associated with cachexia in CRF by targeting atrogin-1 and the ubiquitin-proteasome pathway.
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Affiliation(s)
- Zhenbo Geng
- Nephropathy Center of Integrated Traditional Chinese Medicine and Western Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China.,Department of Traditional Chinese Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China.,School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Department of Traditional Chinese Medicine, Fujian Provincial Hospital, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Lianbo Wei
- Nephropathy Center of Integrated Traditional Chinese Medicine and Western Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510282, P.R. China.,School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Chunhua Zhang
- Department of Traditional Chinese Medicine, Weihai City Chinese Hospital, Weihai, Shandong 264200, P.R. China
| | - Xiaohua Yan
- Department of Traditional Chinese Medicine, Fujian Provincial Hospital, Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
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14
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Di Iorio BR, Di Micco L, Marzocco S, De Simone E, De Blasio A, Sirico ML, Nardone L. Very Low-Protein Diet (VLPD) Reduces Metabolic Acidosis in Subjects with Chronic Kidney Disease: The "Nutritional Light Signal" of the Renal Acid Load. Nutrients 2017; 9:nu9010069. [PMID: 28106712 PMCID: PMC5295113 DOI: 10.3390/nu9010069] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/04/2017] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background: Metabolic acidosis is a common complication of chronic kidney disease; current guidelines recommend treatment with alkali if bicarbonate levels are lower than 22 mMol/L. In fact, recent studies have shown that an early administration of alkali reduces progression of CKD. The aim of the study is to evaluate the effect of fruit and vegetables to reduce the acid load in CKD. Methods: We conducted a case-control study in 146 patients who received sodium bicarbonate. Of these, 54 patients assumed very low-protein diet (VLPD) and 92 were controls (ratio 1:2). We calculated every three months the potential renal acid load (PRAL) and the net endogenous acid production (NEAP), inversely correlated with serum bicarbonate levels and representing the non-volatile acid load derived from nutrition. Un-paired T-test and Chi-square test were used to assess differences between study groups at baseline and study completion. Two-tailed probability values ≤0.05 were considered statistically significant. Results: At baseline, there were no statistical differences between the two groups regarding systolic blood pressure (SBP), diastolic blood pressure (DBP), protein and phosphate intake, urinary sodium, potassium, phosphate and urea nitrogen, NEAP, and PRAL. VLPD patients showed at 6 and 12 months a significant reduction of SBP (p < 0.0001), DBP (p < 0.001), plasma urea (p < 0.0001) protein intake (p < 0.0001), calcemia (p < 0.0001), phosphatemia (p < 0.0001), phosphate intake (p < 0.0001), urinary sodium (p < 0.0001), urinary potassium (p < 0.002), and urinary phosphate (p < 0.0001). NEAP and PRAL were significantly reduced in VLPD during follow-up. Conclusion: VLPD reduces intake of acids; nutritional therapy of CKD, that has always taken into consideration a lower protein, salt, and phosphate intake, should be adopted to correct metabolic acidosis, an important target in the treatment of CKD patients. We provide useful indications regarding acid load of food and drinks—the “acid load dietary traffic light”.
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Affiliation(s)
| | - Lucia Di Micco
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Stefania Marzocco
- Department of Pharmacy, School of Pharmacy, University of Salerno, Via Giovanni Paolo II 132, I-84084 Fisciano, Salerno, Italy.
| | | | - Antonietta De Blasio
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Maria Luisa Sirico
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Luca Nardone
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
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15
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Piccoli GB, Nazha M, Capizzi I, Vigotti FN, Scognamiglio S, Consiglio V, Mongilardi E, Bilocati M, Avagnina P, Versino E. Diet as a system: an observational study investigating a multi-choice system of moderately restricted low-protein diets. BMC Nephrol 2016; 17:197. [PMID: 27927186 PMCID: PMC5142321 DOI: 10.1186/s12882-016-0413-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no single, gold-standard, low-protein diet (LPD) for CKD patients; the best compliance is probably obtained by personalization. This study tests the hypothesis that a multiple choice diet network allows patients to attain a good compliance level, and that, in an open-choice system, overall results are not dependent upon the specific diet, but upon the clinical characteristics of the patients. METHODS Observational study: Three LPD options were offered to all patients with severe or rapidly progressive CKD: vegan diets supplemented with alpha-ketoacids and essential aminoacids; protein-free food in substitution of normal bread and pasta; other (traditional, vegan non supplemented and tailored). Dialysis-free follow-up and survival were analyzed by Kaplan Meier curves according to diet, comorbidity and age. Compliance and metabolic control were estimated in 147 subjects on diet at March 2015, with recent complete data, prescribed protein intake 0.6 g/Kg/day. Protein intake was assessed by Maroni Mitch formula. RESULTS Four hundreds and forty nine patients followed a LPD in December, 2007- March, 2015 (90% moderately restricted LPDs, 0.6 g/Kg/day of protein, 10% at lower targets); age (median 70 (19-97)) and comorbidity (Charlson index: 7) characterized our population as being in line with the usual CKD European population. Median e-GFR at start of the diet was 20 mL/min, 33.2% of the patients were diabetics. Baseline data differ significantly across diets: protein-free schemas are preferred by older, high-comorbidity patients (median age 76 years, Charlson index 8, GFR 20.5 mL/min, Proteinuria: 0.3 g/day), supplemented vegan diets by younger patients with lower GFR and higher proteinuria (median age 65 years, Charlson index 6, GFR 18.9 mL/min; Proteinuria: 1.2 g/day); other diets are chosen by an intermediate population (median age 71 years, Charlson index 6; GFR 22.5 mL/min; Proteinuria: 0.9 g/day); (p <0.001 for age, Charlson index, proteinuria, GFR). Adherence was good, only 1.1% of the patients were lost to follow-up and protein intake was at target in most of the cases with no differences among LPDs (protein intake: 0.47 (0.26-0.86) g/Kg/day). After adjustment for confounders, and/or selection of similar populations, no difference in mortality or dialysis start was observed on the different LPDs. Below the threshold of e-GFR 15 mL/min, 50% of the patients remain dialysis free for at least two years. CONCLUSION A multiple choice LPD system may allow reaching good adherence, without competition among diets, and with promising results in terms of dialysis-free follow-up. The advantages with respect to a non-customized approach deserve confirmation in further comparative studies or RCTs.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrologie, Centre Hospitalier Le Mans, 72000, Le Mans, France.
| | - Marta Nazha
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Irene Capizzi
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Federica Neve Vigotti
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Stefania Scognamiglio
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Valentina Consiglio
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Elena Mongilardi
- SCDU Urology, Department of Oncology, ASOU San Luigi, University of Torino, Torino, Italy
| | - Marilisa Bilocati
- Obstetrics, Department of Surgery, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Paolo Avagnina
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
| | - Elisabetta Versino
- SS Epidemiology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Torino, Torino, Italy
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16
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Piccoli GB, Nazha M, Capizzi I, Vigotti FN, Mongilardi E, Bilocati M, Avagnina P, Versino E. Patient Survival and Costs on Moderately Restricted Low-Protein Diets in Advanced CKD: Equivalent Survival at Lower Costs? Nutrients 2016; 8:E758. [PMID: 27898000 PMCID: PMC5188413 DOI: 10.3390/nu8120758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/23/2016] [Accepted: 11/16/2016] [Indexed: 12/20/2022] Open
Abstract
The indications for delaying the start of dialysis have revived interest in low-protein diets (LPDs). In this observational prospective study, we enrolled all patients with chronic kidney disease (CKD) who followed a moderately restricted LPD in 2007-2015 in a nephrology unit in Italy: 449 patients, 847 years of observation. At the start of the diet, the median glomerular filtration rate (GFR) was 20 mL/min, the median age was 70, the median Charlson Index was 7. Standardized mortality rates for the "on-diet" population were significantly lower than for patients on dialysis (United States Renal Data System (USRDS): 0.44 (0.36-0.54); Italian Dialysis Registry: 0.73 (0.59-0.88); French Dialysis Registry 0.70 (0.57-0.85)). Considering only the follow-up at low GFR (≤15 mL/min), survival remained significantly higher than in the USRDS, and was equivalent to the Italian and French registries, with an advantage in younger patients. Below the e-GFR of 15 mL/min, 50% of the patients reached a dialysis-free follow-up of ≥2 years; 25% have been dialysis-free for five years. Considering an average yearly cost of about 50,000 Euros for dialysis and 1200 Euros for the diet, and different hypotheses of "spared" dialysis years, treating 100 patients on a moderately restricted LPD would allow saving one to four million Euros. Therefore, our study suggests that in patients with advanced CKD, moderately restricted LPDs may allow prolonging dialysis-free follow-up with comparable survival to dialysis at a lower cost.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
- Nephrologie, Centre Hospitalier Le Mans, Le Mans 72000, France.
| | - Marta Nazha
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Irene Capizzi
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Federica Neve Vigotti
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elena Mongilardi
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Marilisa Bilocati
- Obstetrics, Department of Surgery, Città Della Salute e Della Scienza, University of Torino, Torino 10100, Italy.
| | - Paolo Avagnina
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, ASOU san Luigi, University of Torino, Torino 10100, Italy.
| | - Elisabetta Versino
- SS Epidemiology, Department of Clinical and Biological Sciences, ASOU san Luigi, University of Torino, Torino 10100, Italy.
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17
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Piccoli GB, Ventrella F, Capizzi I, Vigotti FN, Mongilardi E, Grassi G, Loi V, Cabiddu G, Avagnina P, Versino E. Low-Protein Diets in Diabetic Chronic Kidney Disease (CKD) Patients: Are They Feasible and Worth the Effort? Nutrients 2016; 8:E649. [PMID: 27775639 PMCID: PMC5084036 DOI: 10.3390/nu8100649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/11/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Low-protein diets (LPDs) are often considered as contraindicated in diabetic patients, and are seldom studied. The aim of this observational study was to provide new data on this issue. It involved 149 diabetic and 300 non-diabetic patients who followed a LPD, with a personalized approach aimed at moderate protein restriction (0.6 g/day). Survival analysis was performed according to Kaplan-Meier, and multivariate analysis with Cox model. Diabetic versus non-diabetic patients were of similar age (median 70 years) and creatinine levels at the start of the diet (2.78 mg/dL vs. 2.80 mg/dL). There was higher prevalence of nephrotic proteinuria in diabetic patients (27.52% vs. 13.67%, p = 0.002) as well as comorbidity (median Charlson index 8 vs. 6 p = 0.002). Patient survival was lower in diabetic patients, but differences levelled off considering only cases with Charlson index > 7, the only relevant covariate in Cox analysis. Dialysis-free survival was superimposable in the setting of good compliance (Mitch formula: 0.47 g/kg/day in both groups): about 50% of the cases remained dialysis-free 2 years after the first finding of e-GFR (estimated glomerular filtration rate) < 15 mL/min, and 1 year after reaching e-GFR < 10 mL/min. In patients with type 2 diabetes, higher proteinuria was associated with mortality and initiation of dialysis. In conclusion, moderately restricted LPDs allow similar results in diabetic and non non-diabetic patients with similar comorbidity.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
- Nephrologie, Centre Hospitalier Le Mans, Le Mans 72100, France.
| | - Federica Ventrella
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Irene Capizzi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Federica N Vigotti
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elena Mongilardi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Giorgio Grassi
- SCDU Endocrinologia, Diabetologia e Metabolismo, Città della Salute e della Scienza Torino, Torino 10100, Italy.
| | - Valentina Loi
- SC Nefrologia, Brotzu Hospital, Cagliari 09134, Italy.
| | | | - Paolo Avagnina
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elisabetta Versino
- SSD Epidemiology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
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18
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Maxia S, Loi V, Capizzi I, Piccoli GB, Cabiddu G, Pani A. Compliance, illiteracy and low-protein diet: multiple challenges in CKD and a case of self-empowerment. BMC Nephrol 2016; 17:138. [PMID: 27683011 PMCID: PMC5041291 DOI: 10.1186/s12882-016-0353-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-protein diets (LPD) are an important means of delaying the need for dialysis and attaining a stable metabolic balance in chronic kidney disease (CKD). Many authors consider a low educational level and illiteracy to be adverse features for a good dietary compliance. CASE PRESENTATION We report the case of a 77-year old woman, illiterate, affected by advanced CKD (stage 4 according to KDIGO guidelines). She was initially ashamed of her problem and did not declare it, leading to an overzealous reduction in protein intake. However, with her daughter's help, who translated the dietary prescription into images, she overcame the barrier represented by illiteracy and was able to correctly follow the prescriptions, attaining good kidney function stability and preserving an adequate nutritional status. CONCLUSIONS The case underlines the importance of a personalized approach to dietary prescriptions and suggests that it is possible to achieve a good compliance to the dietary treatment of CKD also in patients with relevant cultural barriers.
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Affiliation(s)
- Stefania Maxia
- SC Nephrology and Dialysis, Brotzu Hospital, Piazzale Alessandro Ricchi 1, 09134, Cagliari, Italy
| | - Valentina Loi
- SC Nephrology and Dialysis, Brotzu Hospital, Piazzale Alessandro Ricchi 1, 09134, Cagliari, Italy
| | - Irene Capizzi
- SS Nephrology, SCDU Urologia, Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Regione Gonzole 10, 10043, Orbassano, Italy
| | - Giorgina Barbara Piccoli
- SS Nephrology, SCDU Urologia, Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Regione Gonzole 10, 10043, Orbassano, Italy.,Nephrologie, Centre Hospitalier Le Mans, 194 av. Rubillard, 72037, Le Mans, France
| | - Gianfranca Cabiddu
- SC Nephrology and Dialysis, Brotzu Hospital, Piazzale Alessandro Ricchi 1, 09134, Cagliari, Italy.
| | - Antonello Pani
- SC Nephrology and Dialysis, Brotzu Hospital, Piazzale Alessandro Ricchi 1, 09134, Cagliari, Italy
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19
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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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20
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Cupisti A, D'Alessandro C, Di Iorio B, Bottai A, Zullo C, Giannese D, Barsotti M, Egidi MF. Nutritional support in the tertiary care of patients affected by chronic renal insufficiency: report of a step-wise, personalized, pragmatic approach. BMC Nephrol 2016; 17:124. [PMID: 27600818 PMCID: PMC5012117 DOI: 10.1186/s12882-016-0342-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/29/2016] [Indexed: 01/16/2023] Open
Abstract
Background Dietary treatment is helpful in CKD patients, but nutritional interventions are scarcely implemented. The main concern of the renal diets is its feasibility with regards to daily clinical practice especially in the elderly and co-morbid patients. This study aimed to evaluate the effects of a pragmatic, step-wise, personalized nutritional support in the management of CKD patients on tertiary care. Methods This is a case-control study. It included 823 prevalent out-patients affected by CKD stage 3b to 5 not-in-dialysis, followed by tertiary care in nephrology clinics; 305 patients (190 males, aged 70 ± 12 years) received nutritional support (nutritional treatment Group, NTG); 518 patients (281 males, aged 73 ± 13 years) who did not receive any dietary therapy, formed the control group (CG). In the NTG patients the dietary interventions were assigned in order to prevent or correct abnormalities and to maintain a good nutritional status. They included manipulation of sodium, phosphate, energy and protein dietary intakes while paying special attention to each patient’s dietary habits. Results Phosphate and BUN levels were lower in the NTG than in the CG, especially in stage 4 and 5. The prevalence of hyperphosphatemia was lower in the NTG than in CG in stage 5 (13.3 % vs 53.3 %, p < 001, respectively), in stage 4 (4.1 % vs 18.3 % vs, p < 0.001) and stage 3b (2.8 % vs 9.5 % p < 0.05). Serum albumin was higher in NTG than in CG especially in stage 5 . The use of calcium-free intestinal phosphate binders was significantly lower in NTG than in CG (11 % vs 19 % p < 0.01), as well as that of Erythropoiesis stimulating agents (11 % vs 19 %, p < 0.01), and active Vitamin D preparations (13 % vs 21 %, p < 0.01). Conclusions This case-control study shows the usefulness of a nutritional support in addition to the pharmacological good practice in CKD patients on tertiary care. Lower phosphate and BUN levels are obtained together with maintenance of serum albumin levels. In addition, a lower need of erythropoiesis stimulating agents, phosphate binders and active Vitamin D preparations was detected in NTG. This study suggests that a nutritional support may be useful in the management of the world-wide growing CKD burden.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Biagio Di Iorio
- U.O.C. di Nefrologia, PO "A. Landolfi", PO di Solofra (AV), Solofra, Italy
| | - Anna Bottai
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Claudia Zullo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Massimiliano Barsotti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Maria Francesca Egidi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
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21
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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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22
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Piccoli GB, Capizzi I, Vigotti FN, Leone F, D’Alessandro C, Giuffrida D, Nazha M, Roggero S, Colombi N, Mauro G, Castelluccia N, Cupisti A, Avagnina P. Low protein diets in patients with chronic kidney disease: a bridge between mainstream and complementary-alternative medicines? BMC Nephrol 2016; 17:76. [PMID: 27391228 PMCID: PMC4939031 DOI: 10.1186/s12882-016-0275-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 06/14/2016] [Indexed: 01/11/2023] Open
Abstract
Dietary therapy represents an important tool in the management of chronic kidney disease (CKD), mainly through a balanced reduction of protein intake aimed at giving the remnant nephrons in damaged kidneys a "functional rest". While dialysis, transplantation, and pharmacological therapies are usually seen as "high tech" medicine, non pharmacological interventions, including diets, are frequently considered lifestyle-complementary treatments. Diet is one of the oldest CKD treatments, and it is usually considered a part of "mainstream" management. In this narrative review we discuss how the lessons of complementary alternative medicines (CAMs) can be useful for the implementation and study of low-protein diets in CKD. While high tech medicine is mainly prescriptive, prescribing a "good" life-style change is usually not enough and comprehensive counselling is required; the empathic educational approach, on which CAMs are mainly, though not exclusively based, may support a successful personalized nutritional intervention.There is no gold-standard, low-protein diet for all CKD patients: from among a relatively vast choice, the best compliance is probably obtained by personalization. This approach interferes with the traditional RCT-based analyses which are grounded upon an assumption of equal preference of treatments (ideally blinded). Whole system approaches and narrative medicine, that are widely used in the study of CAMs, may offer ways to integrate EBM and personalised medicine in the search for innovative solutions respecting individualization, but gaining sound data, such as with partially-randomised patient preference trials.
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Affiliation(s)
- Giorgina Barbara Piccoli
- />Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
- />Nephrologie, CH du Mans, Le Mans, France
| | - Irene Capizzi
- />Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
- />Nephrologie, CH du Mans, Le Mans, France
| | - Federica Neve Vigotti
- />Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
- />Nephrologie, CH du Mans, Le Mans, France
| | - Filomena Leone
- />Department of Surgery, SS Dietetics, città della salute e della scienza, University of Torino, Torino, Italy
| | - Claudia D’Alessandro
- />Department of Experimental and Clinical Medicine, SCDU Nephrology, University of Pisa, Pisa, Italy
| | - Domenica Giuffrida
- />Department of Surgery, SS Dietetics, città della salute e della scienza, University of Torino, Torino, Italy
| | - Marta Nazha
- />Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
- />Nephrologie, CH du Mans, Le Mans, France
| | - Simona Roggero
- />Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
- />Nephrologie, CH du Mans, Le Mans, France
| | - Nicoletta Colombi
- />Department of Clinical and Biological Sciences and of Oncology, Library, ASOU san Luigi, University of Torino, Torino, Italy
| | - Giuseppe Mauro
- />Department of Clinical and Biological Sciences and of Oncology, Library, ASOU san Luigi, University of Torino, Torino, Italy
| | - Natascia Castelluccia
- />Department of Clinical and Biological Sciences and of Oncology, Library, ASOU san Luigi, University of Torino, Torino, Italy
| | - Adamasco Cupisti
- />Department of Experimental and Clinical Medicine, SCDU Nephrology, University of Pisa, Pisa, Italy
| | - Paolo Avagnina
- />Department of Clinical and Biological Sciences, SSD Clinical Nutrition, ASOU san Luigi, University of Torino, Torino, Italy
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23
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Zemchenkov A, Konakova IN. Efficacy of the Essential Amino Acids and Keto-Analogues on the CKD progression rate in real practice in Russia - city nephrology registry data for outpatient clinic. BMC Nephrol 2016; 17:62. [PMID: 27389019 PMCID: PMC4936008 DOI: 10.1186/s12882-016-0281-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 06/14/2016] [Indexed: 12/15/2022] Open
Abstract
Background Renal replacement therapy (RRT) is growing by 10 % per year in Russia, but pre-dialysis care which can retard CKD progression and delay the start of RRT remains limited. We evaluate the effect of Essential Amino Acids and Keto-analogues (EAA/KA) on CKD progression. Methods The effect of low protein diet (LPD), supplemented by EAA/KA, on GFR slope changes between first and second treatment period (five sequential visits per period) in 96 patients withs CKD Stage 3B-5 was compared to GFR slope changes in the control group of 96 patients, randomly selected from matched (by gender, age, diagnosis and CKD Stage) cohort of 320 patients from the city Registry. The mean baseline eGFR was 23 ± 9 ml/min/1.73 m2; 29 % had CKD3B, 45 % - CKD4, 26 % - CKD5. Results The rate of eGFR decline changed from −2.71 ± 2.38 to −2.01 ± 2.26 ml/min/1.73 m2 per year in the treatment group and from −2.18 ± 2.01 to −2.04 ± 2.18 ml/min/1.73 m2 per year in the control group. Only in the treatment group the difference was significant (p = 0.04 and p = 0.6). Standardized effect size for intervention was significant in treatment group: −0.3 (of pooled SD), 95 % CI −0.58 ÷ −0.02 and non-significant in control group: −0.07 (−0.35 ÷ +0.22). The univariate and multivariate analysis of EAA/KA therapy effect demonstrated that it was probably more effective in patients of older age, with higher time-averaged proteinuria (PU), lower phosphate level, in patients with glomerular v. interstitial diseases, and in females. Only the latter factor was significant at pre-specified level (<0.05). Conclusions LPD combined with EAA/KA supplementation lead to the decrease of the CKD progression both in well-designed clinical study and in real nephrology practice in wide variety diseases and settings. Registry data can be helpful to reveal patients with optimal chances for beneficial effect of LPD supplemented by EAA/KA. Trial registration ISRCTN28190556 06/05/2016.
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Affiliation(s)
- Alexander Zemchenkov
- City Mariinsky Hospital - City Nephrology Center, Liteiny pr., 56, 191104, Saint Petersburg, Russian Federation. .,North-Western State Medical University n.a. I.I. Mechnikov, Internal Diseases and Nephrology Chair, Kirochnaya str., 41, 191015, Saint Petersburg, Russian Federation. .,First St.-Petersburg State Medical University n.a. I.P.Pavlov, Nephrology and Dialysis Chair, L'va Tolstogo str., 6-8, 197022, Saint Petersburg, Russian Federation.
| | - Irina N Konakova
- City Mariinsky Hospital - City Nephrology Center, Liteiny pr., 56, 191104, Saint Petersburg, Russian Federation. .,North-Western State Medical University n.a. I.I. Mechnikov, Internal Diseases and Nephrology Chair, Kirochnaya str., 41, 191015, Saint Petersburg, Russian Federation.
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24
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Fouque D, Chen J, Chen W, Garneata L, Hwang SJ, Kalantar-Zadeh K, Kopple JD, Mitch WE, Piccoli G, Teplan V, Chauveau P. Adherence to ketoacids/essential amino acids-supplemented low protein diets and new indications for patients with chronic kidney disease. BMC Nephrol 2016; 17:63. [PMID: 27388899 PMCID: PMC4936289 DOI: 10.1186/s12882-016-0278-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 06/14/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low protein diets (LPD) have long been prescribed to chronic kidney disease patients with the goals of improving metabolic abnormalities and postpone the start of maintenance dialysis. METHODS We reviewed the recent literature addressing low protein diets supplemented with ketoacids/essential aminoacids prescribed during chronic kidney disease and their effects on metabolic, nutritional and renal parameters since 2013. RESULTS We show new information on how to improve adherence to these diets, on metabolic improvement and delay of the dialysis needs, and preliminary data in chronic kidney disease associated pregnancy. In addition, data on incremental dialysis have been reviewed, as well as potential strategies to reverse protein energy wasting in patients undergoing maintenance dialysis. CONCLUSION These recent data help to better identify the use of low protein diets supplemented with ketoacids/essential aminoacids during chronic kidney disease.
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Affiliation(s)
- Denis Fouque
- UCBL, Centre Hospitalier Lyon-Sud, University Lyon, Carmen, Cens, F-69622, Lyon, France. .,Department Nephrology, Centre Hospitalier Lyon Sud, Chemin du grand revoyet, 69495, Pierre Bénite, France.
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei Chen
- Department of Parenteral and Enteral Nutrition, Peking Union Medical College Hospital, Beijing, China
| | - Liliana Garneata
- Department Nephrology and Internal Medicine, Dr Carol Davila Hospital of Nephrology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - S J Hwang
- Division Nephrology, Kaohsiung Medical University Hospital, Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kamyar Kalantar-Zadeh
- Division Nephrology and Hypertension, University of California Irvine School of Medicine, Irvine, CA, USA.,Deparment Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Joel D Kopple
- Division Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.,David Geffen School of Medicine at UCLA, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - William E Mitch
- Nephrology Division, Baylor College of Medicine, Houston, TX, USA
| | - Giorgina Piccoli
- SS Nephrology, ASOU San Luigi, Departmentt of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Vladimir Teplan
- Department Nephrol, Institute Clin Exp Med, Transpl Centre, Prague, Czech Republic
| | - Philippe Chauveau
- Service de Néphrologie, CHU de Bordeaux & Aurad-Aquitaine, Bordeaux, France
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25
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Garneata L, Stancu A, Dragomir D, Stefan G, Mircescu G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. J Am Soc Nephrol 2016; 27:2164-76. [PMID: 26823552 PMCID: PMC4926970 DOI: 10.1681/asn.2015040369] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/24/2015] [Indexed: 01/23/2023] Open
Abstract
Dietary protein restriction may improve determinants of CKD progression. However, the extent of improvement and effect of ketoanalogue supplementation are unclear. We conducted a prospective, randomized, controlled trial of safety and efficacy of ketoanalogue-supplemented vegetarian very low-protein diet (KD) compared with conventional low-protein diet (LPD). Primary end point was RRT initiation or >50% reduction in initial eGFR. Nondiabetic adults with stable eGFR<30 ml/min per 1.73 m(2), proteinuria <1 g/g urinary creatinine, good nutritional status, and good diet compliance entered a run-in phase on LPD. After 3 months, compliant patients were randomized to KD (0.3 g/kg vegetable proteins and 1 cps/5 kg ketoanalogues per day) or continue LPD (0.6 g/kg per day) for 15 months. Only 14% of screened patients patients were randomized, with no differences between groups. Adjusted numbers needed to treat (NNTs; 95% confidence interval) to avoid composite primary end point in intention to treat and per-protocol analyses in one patient were 4.4 (4.2 to 5.1) and 4.0 (3.9 to 4.4), respectively, for patients with eGFR<30 ml/min per 1.73 m(2) Adjusted NNT (95% confidence interval) to avoid dialysis was 22.4 (21.5 to 25.1) for patients with eGFR<30 ml/min per 1.73 m(2) but decreased to 2.7 (2.6 to 3.1) for patients with eGFR<20 ml/min per 1.73 m(2) in intention to treat analysis. Correction of metabolic abnormalities occurred only with KD. Compliance to diet was good, with no changes in nutritional parameters and no adverse reactions. Thus, this KD seems nutritionally safe and could defer dialysis initiation in some patients with CKD.
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Affiliation(s)
- Liliana Garneata
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Alexandra Stancu
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Diana Dragomir
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Stefan
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
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Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
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Beto JA, Schury KA, Bansal VK. Strategies to promote adherence to nutritional advice in patients with chronic kidney disease: a narrative review and commentary. Int J Nephrol Renovasc Dis 2016; 9:21-33. [PMID: 26893578 PMCID: PMC4749088 DOI: 10.2147/ijnrd.s76831] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Chronic kidney disease (CKD) requires extensive changes to food and lifestyle. Poor adherence to diet, medications, and treatments has been estimated to vary between 20% and 70%, which in turn can contribute to increased mortality and morbidity. Delivering effective nutritional advice in patients with CKD coordinates multiple diet components including calories, protein, sodium, potassium, calcium, phosphorus, and fluid. Dietary intake studies have shown difficulty in adhering to the scope and complexity of the CKD diet parameters. No single educational or clinical strategy has been shown to be consistently effective across CKD populations. Highest adherence has been observed when both diet and education efforts are individualized to each patient and adapted over time to changing lifestyle and CKD variables. This narrative review and commentary summarizes nutrition education literature and published strategies for providing nutritional advice in CKD. A cohort of practical and effective strategies for increasing dietary adherence to nutritional advice are provided that include communicating with "talking control" principles, integrating patient-owned technology, acknowledging the typical food pattern may be snacking rather than formal meals, focusing on a single goal rather than multiple goals, creating active learning and coping strategies (frozen sandwiches, visual hands-on activities, planting herb gardens), and involving the total patient food environment.
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Affiliation(s)
- Judith A Beto
- Division of Nephrology and Hypertension, Loyola University Healthcare System, Loyola University of Chicago, Maywood, IL, USA
| | - Katherine A Schury
- Division of Nephrology and Hypertension, Loyola University Healthcare System, Loyola University of Chicago, Maywood, IL, USA
| | - Vinod K Bansal
- Division of Nephrology and Hypertension, Loyola University Healthcare System, Loyola University of Chicago, Maywood, IL, USA
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Shah B, Kirpalani A, Sunder S, Gupta A, Khanna U, Chafekar D, Tan LP, Sirivongs D, Pahari D, Nath G, Ikizler TA. A prospective, multi-centre, observational study to examine kidney disease progression in adults with chronic kidney disease - CKDOD - Study design and preliminary results. BMC Nephrol 2015; 16:215. [PMID: 26696239 PMCID: PMC4687357 DOI: 10.1186/s12882-015-0191-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 11/24/2015] [Indexed: 11/29/2022] Open
Abstract
Background The objective of this article is to describe the organisation of an international, clinical registry, the Chronic Kidney Disease Observational Database (CKDOD), the processes of enrolling patients and entering data and preliminary results to date. Design The Chronic Kidney Disease Observational Database (CKDOD) is designed to assess the association between different factors with a known influence on chronic kidney disease (CKD) progression as well as treatment strategies such as dietary modifications, blood pressure control and pharmacological interventions in Asian countries (India, China, Malaysia and Thailand). The only inclusion criterion is the presence of CKD stage 2 or higher as defined by the KDIGO guidelines. Demographic and clinical information are collected by a standardised electronic questionnaire, available in English and Chinese. The data are transferred to the CKDOD database either by e-mail or via web access. All data are checked for consistency and missing values. Collection of data started in September 2011 and by April 2015, data on 1323 individual patients had been submitted. The mean age at inclusion was 57 ± 14 years, 67 % were male and 36 % were diabetic. The baseline estimated glomerular filtration rate was 26 ml/min/1.73 m2. Of all enrolled patients, 324 (24 %) received ketoanalogue supplementation during at least one recorded visit. Discussion The CKDOD is a very large and comprehensive data repository, currently focused in subjects recruited from Asia. The database is expected to provide important long-term information on CKD progression, nutritional and metabolic derangements that accompany CKD progression and treatment strategies to ameliorate progression and complications of CKD. Trial Registration Clinical Trial Registry – India: CTRI/2012/06/002743; 25th July 2012 Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0191-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Sham Sunder
- Department of Nephrology, RML (Ram Manohar Lohiya) hospital, New Delhi, India.
| | | | | | | | - Li Ping Tan
- University Malaya Medical Centre, Renal unit, Faculty of Medicine, Kuala Lumpur, Malaysia.
| | - Dhavee Sirivongs
- Department of Medicine, Khon Kaen Medical School, Khon Kaen City, Thailand.
| | - Dilip Pahari
- Dr. Medica Institute of Kidney Diseases, Kolkata, India.
| | - Gokul Nath
- Department of Nephrology, St. John's Medical College & Hospital, Bangalore, India.
| | - Talat Alp Ikizler
- Vanderbilt University Medical Center, Division of Nephrology, 1161 21st Avenue South, S-3223 Medical Center North, Nashville, TN, 37232-2372, USA.
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Pregnancy in Chronic Kidney Disease: questions and answers in a changing panorama. Best Pract Res Clin Obstet Gynaecol 2015; 29:625-42. [DOI: 10.1016/j.bpobgyn.2015.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 02/18/2015] [Accepted: 02/23/2015] [Indexed: 01/10/2023]
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Pan Z, Huang X, Zhong Y, Wang L, Zhu D, Li L. Three-phase hollow-fiber microextraction combined with ion-pair high-performance liquid chromatography for the simultaneous determination of five components of compound α-ketoacid tablets in human urine. J Sep Sci 2015; 38:1499-506. [PMID: 25693965 DOI: 10.1002/jssc.201401497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 01/25/2015] [Accepted: 02/03/2015] [Indexed: 01/08/2023]
Abstract
The determination of α-ketoacid concentration is demanded to evaluate the absorption and metabolic behavior of compound α-ketoacid tablets taken by chronic kidney disease patients. To eliminate the interference of endogenous substance of urine and enrich the analytes, a three-phase hollow-fiber liquid-phase microextraction combined with ion-pair high-performance liquid chromatography method was established for the determination of d,l-α-hydroxymethionine calcium, d,l-α-ketoisoleucine calcium, α-ketovaline calcium, α-ketoleucine calcium, and α-ketophenylalanine calcium of compound α-ketoacid tablets in human urine samples. The extraction parameters, such as organic solvent, pH of donor phase and acceptor phase, stirring rate, and extraction time were optimized. Under the optimal conditions, the obtained enrichment factors were up to 11-, 110-, 198-, 202-, and 50-fold, respectively. The calibration curves for these analytes were linear over the range of 0.1-10 mg/L for α-ketovaline calcium, d,l-α-ketoisoleucine calcium, and α-ketoleucine calcium, 0.5-10 mg/L for d,l-α-hydroxymethionine calcium, and α-ketophenylalanine calcium with r > 0.99. The relative standard deviations (n = 5) were less than 6.27% and the LODs were 100.7, 10.0, 5.8, 7.8, and 8.6 μg/L (based on S/N = 3), respectively. Good recoveries from spiked urine samples (92-118%) were obtained. The proposed method demonstrated excellent sample clean-up and analytes enrichment to determine the five components in human urine.
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Affiliation(s)
- Zaifa Pan
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, P. R. China
| | - Xiaoya Huang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, P. R. China
| | - Yuan Zhong
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, P. R. China
| | - Lili Wang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, P. R. China
| | - Danhua Zhu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of Medical College, Zhejiang University, Hangzhou, Zhejiang, P. R. China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of Medical College, Zhejiang University, Hangzhou, Zhejiang, P. R. China
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Piccoli GB, Vigotti FN, Leone F, Capizzi I, Daidola G, Cabiddu G, Avagnina P. Low-protein diets in CKD: how can we achieve them? A narrative, pragmatic review. Clin Kidney J 2015; 8:61-70. [PMID: 25713712 PMCID: PMC4310428 DOI: 10.1093/ckj/sfu125] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/01/2014] [Indexed: 12/31/2022] Open
Abstract
Low-protein diets (LPDs) have encountered various fortunes, and several questions remain open. No single study, including the famous Modification of Diet in Renal Disease, was conclusive and even if systematic reviews are in favour of protein restriction, at least in non-diabetic adults, implementation is lagging. LPDs are considered difficult, malnutrition is a threat and compliance is poor. LPDs have been reappraised in this era of reconsideration of dialysis indications and timing. The definition of a normal-adequate protein diet has shifted in the overall population from 1 to 1.2 to 0.8 g/kg/day. Vegan-vegetarian diets are increasingly widespread, thus setting the groundwork for easier integration of moderate protein restriction in Chronic Kidney Disease. There are four main moderately restricted LPDs (0.6 g/kg/day). Two of them require careful planning of quantity and quality of food: a 'traditional' one, with mixed proteins that works on the quantity and quality of food and a vegan one, which integrates grains and legumes. Two further options may be seen as a way to simplify LPDs while being on the safe side for malnutrition: adding supplements of essential amino and keto acids (various doses) allows an easier shift from omnivorous to vegan diets, while protein-free food intake allows for an increase in calories. Very-low-protein diets (vLPDs: 0.3 g/kg/day) combine both approaches and usually require higher doses of supplements. Moderately restricted LPDs may be adapted to virtually any cuisine and should be tailored to the patients' preferences, while vLPDs usually require trained, compliant patients; a broader offer of diet options may lead to more widespread use of LPDs, without competition among the various schemas.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Nephrology, Clinical and Biological Sciences Department, S. Luigi Gonzaga Hospital, University of Turin, Italy
| | - Federica Neve Vigotti
- Nephrology, Clinical and Biological Sciences Department, S. Luigi Gonzaga Hospital, University of Turin, Italy
| | - Filomena Leone
- Dietetics, Surgical Sciences Department, S. Anna Hospital, University of Torino, Turin, Italy
| | - Irene Capizzi
- Nephrology, Clinical and Biological Sciences Department, S. Luigi Gonzaga Hospital, University of Turin, Italy
| | - Germana Daidola
- Nephrology, S. Giovanni Battista Hospital, University of Turin, Italy
| | | | - Paolo Avagnina
- Clinical Nutrition, Clinical and Biological Sciences Department, S. Luigi Gonzaga Hospital, University of Turin, Italy
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Piccoli GB, Clari R, Vigotti FN, Leone F, Attini R, Cabiddu G, Mauro G, Castelluccia N, Colombi N, Capizzi I, Pani A, Todros T, Avagnina P. Vegan-vegetarian diets in pregnancy: danger or panacea? A systematic narrative review. BJOG 2015; 122:623-33. [PMID: 25600902 DOI: 10.1111/1471-0528.13280] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although vegan-vegetarian diets are increasingly popular, no recent systematic reviews on vegan-vegetarian diets in pregnancy exist. OBJECTIVES To review the literature on vegan-vegetarian diets and pregnancy outcomes. SEARCH STRATEGY PubMed, Embase, and the Cochrane library were searched from inception to September 2013 for pregnancy and vegan or vegetarian Medical Subject Headings (MeSH) and free-text terms. SELECTION CRITERIA Vegan or vegetarian diets in healthy pregnant women. We excluded case reports and papers analysing vegan-vegetarian diets in poverty and malnutrition. Searching, paper selection, and data extraction were performed in duplicate. DATA COLLECTION AND ANALYSIS The high heterogeneity of the studies led to a narrative review. MAIN RESULTS We obtained 262 full texts from 2329 references; 22 selected papers reporting maternal-fetal outcomes (13) and dietary deficiencies (nine) met the inclusion criteria. None of the studies reported an increase in severe adverse outcomes or in major malformations, except one report of increased hypospadias in infants of vegetarian mothers. Five studies reported vegetarian mothers had lower birthweight babies, yet two studies reported higher birthweights. The duration of pregnancy was available in six studies and was similar between vegan-vegetarians and omnivores. The nine heterogeneous studies on microelements and vitamins suggest vegan-vegetarian women may be at risk of vitamin B12 and iron deficiencies. AUTHOR'S CONCLUSIONS The evidence on vegan-vegetarian diets in pregnancy is heterogeneous and scant. The lack of randomised studies prevents us from distinguishing the effects of diet from confounding factors. Within these limits, vegan-vegetarian diets may be considered safe in pregnancy, provided that attention is paid to vitamin and trace element requirements.
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Affiliation(s)
- G B Piccoli
- SS Nephrology, Department of Biological and Clinical Sciences, University of Torino, Torino, Italy
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Piccoli GB, Guzzo G, Vigotti FN, Capizzi I, Clari R, Scognamiglio S, Consiglio V, Aroasio E, Gonella S, Veltri A, Avagnina P. Tailoring dialysis and resuming low-protein diets may favor chronic dialysis discontinuation: Report on three cases. Hemodial Int 2014; 18:590-5. [DOI: 10.1111/hdi.12168] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Giorgina Barbara Piccoli
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Gabriella Guzzo
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Federica Neve Vigotti
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Irene Capizzi
- SS Clinical Nutrition, ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Roberta Clari
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Stefania Scognamiglio
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Valentina Consiglio
- SS Nephrology ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Emiliano Aroasio
- SCDU Laboratory ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Silvana Gonella
- SCDU Laboratory ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Andrea Veltri
- SCDU Radiology ASOU San Luigi; Department of Oncology; University of Torino; Torino Italy
| | - Paolo Avagnina
- SS Clinical Nutrition, ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
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Chronic dialysis discontinuation: a systematic narrative review of the literature in the new millennium. Int J Artif Organs 2014; 37:556-62. [PMID: 24811304 DOI: 10.5301/ijao.5000321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND AIMS Renal function recovery (RFR), defined as the discontinuation of dialysis after 3 months of replacement therapy, is an uncommon occurrence. At a time when the "too early" start of dialysis is in discussion, a systematic review of the literature for cases in which patients recovered renal function after starting dialysis with chronic indications, including single cases and large series, may lead to attention being focused on this interesting issue. METHODS The search strategy was built in Medline on Pubmed, in EMBASE and in the Cochrane Collaboration (August 2013) combining Mesh, Emtree and free terms: dialysis or hemodialysis, kidney function, renal function and recovery (publication date 2000-2013). The following tasks were performed in duplicate: titles and abstracts were manually screened, the data were extracted: title, author, objective, year, journal, period of study, multi-center, country, type of study. RESULTS The systematic review retrieved 1,894 titles; 58 full papers were retrieved and the final selection included 24 papers: 11 case series or Registry data (4 from ANZdata) and 13 case reports. In spite of the high heterogeneity of the studies, overall they suggest that RFR occurs in about 1% of patients, without differences between PD and HD. RFR appears to be more frequent in elderly patients with renal vascular disease (up to 10% RFR in cholesterol emboli or scleroderma), but is reported in all types of primary and secondary kidney diseases. CONCLUSIONS RFR is a clinical event that should be looked for, particularly in elderly patients with vascular comorbidity.
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Piccoli GB, Leone F, Attini R, Parisi S, Fassio F, Deagostini MC, Ferraresi M, Clari R, Ghiotto S, Biolcati M, Giuffrida D, Rolfo A, Todros T. Association of low-protein supplemented diets with fetal growth in pregnant women with CKD. Clin J Am Soc Nephrol 2014; 9:864-73. [PMID: 24578333 DOI: 10.2215/cjn.06690613] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Women affected by CKD increasingly choose to get pregnant. Experience with low-protein diets is limited. The aim of this study was to review results obtained from pregnant women with CKD on supplemented vegan-vegetarian low-protein diets. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a single-arm, open intervention study between 2000-2012 of a low-protein diet in pregnant patients with stages 3-5 CKD or severe proteinuria (>1 g/d in the first trimester or nephrotic at any time). Stages 3-5 CKD patients who were not on low-protein diets for clinical, psychologic, or logistic reasons served as controls. The setting was the Obstetrics-Nephrology Unit dedicated to kidney diseases in pregnancy. The treated group included 24 pregnancies--21 singleton deliveries, 1 twin pregnancy, 1 abortion, and 1 miscarriage. Additionally, there were 21 controls (16 singleton deliveries, 5 miscarriages). The diet was a vegan-vegetarian low-protein diet (0.6-0.8 g/kg per day) with keto-acid supplementation and 1-3 protein-unrestricted meals allowed per week. RESULTS Treated patients and controls were comparable at baseline for median age (35 versus 34 years), referral week (7 versus 8), eGFR (59 versus 54 ml/min), and hypertension (43.5% versus 33.3%); median proteinuria was higher in patients on the low-protein diet (1.96 [0.1-6.3] versus 0.3 [0.1-2.0] g/d; P<0.001). No significant differences were observed in singletons with regard to gestational week (34 versus 36) or Caesarean sections (76.2% versus 50%). Kidney function at delivery was not different, but proteinuria was higher in the diet group. Incidence of small for gestational age babies was significantly lower in the diet group (3/21) versus controls (7/16; chi-squared test; P=0.05). Throughout follow-up (6 months to 10 years), hospitalization rates and prevalence of children below the third percentile were similar in both groups. CONCLUSION Vegan-vegetarian supplemented low-protein diets in pregnant women with stages 3-5 CKD may reduce the likelihood of small for gestational age babies without detrimental effects on kidney function or proteinuria in the mother.
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Affiliation(s)
- Giorgina B Piccoli
- SS Nephrology, Department of Clinical and Biological Sciences, San Luigi Hospital, and, †Gynecology and Obstetrics 2U, Department of Surgical Sciences, University of Turin, Turin, Italy
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Piccoli GB, Deagostini MC, Vigotti FN, Ferraresi M, Moro I, Consiglio V, Scognamiglio S, Mongilardi E, Clari R, Aroasio E, Versino E, Porpiglia F. Which low-protein diet for which CKD patient? An observational, personalized approach. Nutrition 2014; 30:992-9. [PMID: 25102817 DOI: 10.1016/j.nut.2014.01.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/17/2013] [Accepted: 01/03/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Low protein diets (LPDs) are milestones in chronic kidney disease (CKD). Concerns over compliance and safety limit their use. The aim of this study was to test the feasibility and main results of a multiple-choice approach to LPDs, adapted to patient preferences. METHODS From December 2007 to January 2013, all CKD patients (stages 4/5; progressive stage 3) without contraindications (malnutrition, short life expectancy), were offered two main LPDs (proteins 0.6 g/kg daily): Vegan supplemented (LPD-KA) or with "aproteic" commercial food (LPD-ACF). LPDs followed a qualitative approach based on forbidden and allowed food; one to three free meals per week, and flexible control policy (1-3 mo). Start of dialysis, death, and combined outcome (death-dialysis) were analyzed by Kaplan-Meier curves and Cox model. Comparison with dialysis in patients with glomerular filtration rate (GRF) <15 mL/min, (corresponding to "early" dialysis start) employed standardized mortality rates, with respect to the Italian and the United States Dialysis Registry. RESULTS One hundred eighty-five patients (222 patient-years) started at least a trial of LPD-KA, 122 (177 patients-years) LPD-ACF; only 3 patients with GFR <30 mL/min denied an LPD trial. Patients who chose LPD-KA were younger than those on LPD-ACF (63 versus 74 y), had less comorbidity (82% versus 93%), higher proteinuria (1.4 versus 0.7 g/d) and lower GFR (17 versus 23 mL/min) (P < 0.001). Median daily protein intake was 0.7 g/kg on both diets (Maroni-Mitch formula). The combined outcome (death or dialysis) was not influenced by the diet chosen (Cox analysis). Relative risk for death on the diet (patients with GFR <15 mL/min) was 0.5 with respect to the Italian Registry and 0.3 to the United States Dialysis Registry. The diets had comparable costs (1 y on dialysis: 50 patient-years on LPD). CONCLUSIONS The choice of diet is strictly linked to patient characteristics, thus supporting a multiple-choice offer. Once corrected for baseline data, both LPDs led to similar results, suggesting at least survival equivalence with dialysis, at lesser cost.
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Affiliation(s)
- Giorgina B Piccoli
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy.
| | - Maria Chiara Deagostini
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Federica Neve Vigotti
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Martina Ferraresi
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Irene Moro
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Valentina Consiglio
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Stefania Scognamiglio
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Elena Mongilardi
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Roberta Clari
- SS Nephrology, Department of Clinical and Biological Sciences ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Emiliano Aroasio
- General Laboratory, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Elisabetta Versino
- Epidemiology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
| | - Francesco Porpiglia
- Urology Department of Oncology, ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
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