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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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Torreggiani M, Fois A, Moio MR, Chatrenet A, Mazé B, Lippi F, Vigreux J, Beaumont C, Santagati G, Paulin N, Piccoli GB. Spontaneously Low Protein Intake in Elderly CKD Patients: Myth or Reality? Analysis of Baseline Protein Intake in a Large Cohort of Patients with Advanced CKD. Nutrients 2021; 13:nu13124371. [PMID: 34959922 PMCID: PMC8707092 DOI: 10.3390/nu13124371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 11/16/2022] Open
Abstract
The recent guidelines on nutritional management of chronic kidney disease (CKD) advise a reduction in protein intake as early as CKD stage 3, regardless of age, to slow kidney function impairment. However, since elderly patients are usually considered as having a spontaneously reduced protein intake, nutritional interventions to reduce protein intake are often considered futile. This study aimed to assess the baseline protein intake of elderly CKD patients referred for nephrology care, and explore the need for dietary evaluations, focusing on the current recommendations for protein restriction in CKD. This is an observational study of CKD patients followed in the unit dedicated to advanced CKD patients in Le Mans, France. Patients with stages 3 to 5 not on dialysis were included. All patients were evaluated by an expert dietician to assess their baseline protein intake, whenever possible on the basis of a 7-days diet journal; when this was not available, dietary recall or analysis of delivered meals was employed. Demographic characteristics, underlying kidney disease, Charlson Comorbidity Index (CCI), Malnutrition-Inflammation Score (MIS), Subjective Global Assessment (SGA) and clinical and laboratory data were recorded. Between 15 November 2017 and 31 December 2020, 436 patients were evaluated in the unit. Their age distribution was as follows: "young": <60 (n = 62), "young-old": 60-69 (n = 74), "old": 70-79 (n = 108), "old-old": 80-89 (n = 140) and "oldest-old": ≥90 (n = 54). The prevalence of vascular nephropathies was higher in patients older than 70 years compared to younger ones, as did CCI and MIS (p < 0.001). Moderate nutritional impairment (SGA: B) was higher in elderly patients, reaching 53.7% at ≥90, while less than 3% of patients in the overall cohort were classified as SGA C (p < 0.001). The median protein intake was higher than the recommended one of 0.8 g/kg/day in all age groups; it was 1.2 g/kg/day in younger patients and 1.0 thereafter (p < 0.001). Patient survival depended significantly on age (p < 0.001) but not on baseline protein intake (p = 0.63), and younger patients were more likely to start dialysis during follow-up (p < 0.001). Over half of the patients, including the old-old and oldest-old, were still on follow-up two years after referral and it was found that survival was only significantly associated with age and comorbidity and was not affected by baseline protein intake. Our study shows that most elderly patients, including old-old and extremely old CKD patients, are spontaneously on diets whose protein content is higher than recommended, and indicates there is a need for nutritional care for this population.
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Kelly JT, Campbell KL, Carrero JJ. Primary Versus Secondary Prevention of Chronic Kidney Disease: The Case of Dietary Protein. J Ren Nutr 2019; 28:225-228. [PMID: 29935606 DOI: 10.1053/j.jrn.2018.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jaimon T Kelly
- Faculty of Health Sciences and Medicine, Bond University, Australia
| | | | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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Otero Alonso P, Pérez Fontán M, López Iglesias A, García Falcón T, Rodríguez-Carmona A. High rates of protein intake are associated with an accelerated rate of decline of residual kidney function in incident peritoneal dialysis patients. Nephrol Dial Transplant 2019; 34:1394-1400. [PMID: 30615149 DOI: 10.1093/ndt/gfy393] [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: 08/30/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preservation of residual kidney function (RKF) is a relevant objective in peritoneal dialysis (PD) patients. The influence of dietary protein intake (PI) on this variable has not been adequately investigated. METHODS Following an observational design, we studied 336 patients incident on PD, with a minimum follow-up of 6 months. The main study variable was the mean PI [normalized rate of protein nitrogen appearance (nPNA)] during the first 4 months on PD. The main outcome variables were the absolute rate of decline of RKF and the proportion of patients presenting a >50% decay of their RKF during the first year of follow-up. We applied univariate and multivariate strategies of analysis, taking into consideration the main control variables bearing a correlation with nPNA and/or RKF. RESULTS Mean nPNA (first 4 months) was 1.23 ± 0.33 g/kg/day, while the overall rate of decline of RKF was -0.13 ± 0.29 mL/min/month; 69 patients (25.1%) had lost >50% of their initial RKF by the end of the first year. Univariate analysis disclosed consistent associations between the main study variable on one hand and baseline RKF (r = 0.32, P < 0.0005) and its rate of decline (r = -0.23, P < 0.0005) on the other. The latter two variables were also significantly correlated (r = -0.36, P < 0.0005). Multivariate analysis identified mean nPNA as an independent predictor of the rate of decline of RKF [odds ratio 1.09 per 0.10 g/kg/day, 95% confidence interval (CI) 0.99-1.19, P = 0.058] and, in particular, of the probability of losing >50% of the baseline RKF during the first year of treatment (odds ratio 1.15 per 0.10 g/kg/day, 95% CI 1.04-1.27, P = 0.006). CONCLUSION Higher rates of PI during the first months of therapy are associated with a faster decline of RKF among patients incident on PD. Our results underline the convenience of keeping an adequate balance between sufficient protein ingestion, to prevent malnutrition and wasting, and sensible restriction in stable, adequately nourished individuals with rates of intake in the higher range or above-recommended allowances.
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Di Micco L, Di Lullo L, Bellasi A, Di Iorio BR. Very Low Protein Diet for Patients with Chronic Kidney Disease: Recent Insights. J Clin Med 2019; 8:jcm8050718. [PMID: 31137545 PMCID: PMC6572310 DOI: 10.3390/jcm8050718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/30/2022] Open
Abstract
Use of nutritional therapy (NT) in chronic kidney disease (CKD) patients is still debated among nephrologists, but it represents a fundamental point in the conservative treatment of CKD. It has been used for years and it has new goals today, such as (1) the reduction of edema, diuretics, and blood pressure values with a low sodium-content diet; (2) the dose reduction of phosphate levels and phosphate binders; (3) the administration of bicarbonate with vegetables in order to correct metabolic acidosis and delay CKD progression; (4) the reduction of the number and the doses of drugs and chemical substances; and (5) the lowering of urea levels, the cure of intestinal microbioma, and the reduction of cyanates levels (such as indoxyl-sulphate and p-cresol sulphate), which are the most recent known advantages achievable with NT. In conclusion, NT and especially very low protein diet (VLPD) have several beneficial effects in CKD patients and slows the progression of CKD.
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Affiliation(s)
- Lucia Di Micco
- Nefrology and Dialysis, AORN "San Giuseppe Moscati, 83100 Avellino AV, Italy.
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Rome, Italy.
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, 24127 Bergamo BG, Italy.
| | - Biagio R Di Iorio
- Nephrology and Dialysis, AORN "Antonio Cardarelli", 80131 Napoli, Italy.
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