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Deng X, Tang C, Fang T, Li T, Li X, Liu Y, Zhang X, Sun B, Sun H, Chen L. Disruption of branched-chain amino acid homeostasis promotes the progression of DKD via enhancing inflammation and fibrosis-associated epithelial-mesenchymal transition. Metabolism 2024:156037. [PMID: 39317264 DOI: 10.1016/j.metabol.2024.156037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 09/12/2024] [Accepted: 09/18/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND AND AIMS The disrupted homeostasis of branched-chain amino acids (BCAAs, including leucine, isoleucine, and valine) has been strongly correlated with diabetes with a potential causal role. However, the relationship between BCAAs and diabetic kidney disease (DKD) remains to be established. Here, we show that the elevated BCAAs from BCAAs homeostatic disruption promote DKD progression unexpectedly as an independent risk factor. METHODS AND RESULTS Similar to other tissues, the suppressed BCAAs catabolic gene expression and elevated BCAAs abundance were detected in the kidneys of type 2 diabetic mice and individuals with DKD. Genetic and nutritional studies demonstrated that the elevated BCAAs from systemic disruption of BCAAs homeostasis promoted the progression of DKD. Of note, the elevated BCAAs promoted DKD progression without exacerbating diabetes in the animal models of type 2 DKD. Mechanistic studies demonstrated that the elevated BCAAs promoted fibrosis-associated epithelial-mesenchymal transition (EMT) by enhancing the activation of proinflammatory macrophages through mTOR signaling. Furthermore, pharmacological enhancement of systemic BCAAs catabolism using small molecule inhibitor attenuated type 2 DKD. Finally, the elevated BCAAs also promoted DKD progression in type 1 diabetic mice without exacerbating diabetes. CONCLUSION BCAA homeostatic disruption serves as an independent risk factor for DKD and restoring BCAA homeostasis pharmacologically or dietarily represents a promising therapeutic strategy to ameliorate the progression of DKD.
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Affiliation(s)
- Xiaoqing Deng
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Chao Tang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China; Affiliated Huzhou Hospital, Zhejiang University School of Medicine, China
| | - Ting Fang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Ting Li
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Xiaoyu Li
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Yajin Liu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Xuejiao Zhang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Bei Sun
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China
| | - Haipeng Sun
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China; Center for Cardiovascular Diseases, The Province and Ministry Co-Sponsored Collaborative Innovation Center for Medical Epigenetics, Tianjin Medical University, Tianjin, China.
| | - Liming Chen
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300134, China.
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Ding Z, Wu X, Liu C, Ying R, Zhang Y, Zhang S, Zhang Q, Hu H, Dai F. Associations between dietary patterns and renal impairment in individuals with diabetes: a cross-sectional study. J Hum Nutr Diet 2024; 37:193-202. [PMID: 37795524 DOI: 10.1111/jhn.13245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND A variety of chronic diseases are affected by diet. To our knowledge, few studies have investigated the relationship between dietary patterns and renal impairment in individuals with diabetes within an Asian population. This study aimed to assess the relationship between renal impairment and dietary patterns in individuals with diabetes within a Chinese population. METHODS In this cross-sectional survey, we analysed data on 1522 participants with diabetes aged 18 years or older who took part in the China National Diabetic Chronic Complications Study. We utilised the Chinese Diabetes Complications Questionnaire, including the semiquantitative food frequency questionnaire (SQFFQ). We identified three dietary patterns using factor analysis: Chinese traditional, healthy and plant-based dietary patterns, and these dietary patterns were used to classify participants into four groups based on the quartiles of their scores. A decrease in the estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2 ) and an increase in the albumin-to-creatinine ratio (ACR; ≥3 mg/mmol) were used as indicators of renal impairment. Binary logistic regression models were used to estimate the odds ratio (OR) of the highest quartile (Q4: high intake levels of each dietary pattern) for renal impairment compared to the lowest quartile (Q1: low intake levels of each dietary pattern). RESULTS Among the 1522 participants, there was a 5.5% prevalence of low eGFR, with prevalence rates of 5.2% in men and 5.9% in women, yet the prevalence of albuminuria was as high as 47.9%. After adjusting for confounders, participants in Q4 of the plant-based dietary pattern had a smaller OR for renal impairment than those in Q1. CONCLUSIONS Our findings demonstrated that a plant-based dietary pattern is associated with a reduced risk of renal impairment in a population with diabetes.
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Affiliation(s)
- Ziling Ding
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xingzhe Wu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chao Liu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ruixue Ying
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yi Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Shiqi Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Qiu Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Honglin Hu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Fang Dai
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Chen M, Chen Y, Zhu W, Yan X, Xiao J, Zhang P, Liu P, Li P. Advances in the pharmacological study of Chinese herbal medicine to alleviate diabetic nephropathy by improving mitochondrial oxidative stress. Biomed Pharmacother 2023; 165:115088. [PMID: 37413900 DOI: 10.1016/j.biopha.2023.115088] [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: 06/01/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023] Open
Abstract
Diabetic nephropathy (DN) is one of the serious complications of diabetes mellitus, primarily arising from type 2 diabetes (T2DM), and can progress to chronic kidney disease (CKD) and end stage renal disease (ESRD). The pathogenesis of DN involves various factors such as hemodynamic changes, oxidative stress, inflammatory response, and lipid metabolism disorders. Increasing attention is being given to DN caused by oxidative stress in the mitochondrial pathway, prompting researchers to explore drugs that can regulate these target pathways. Chinese herbal medicine, known for its accessibility, rich historical usage, and remarkable efficacy, has shown promise in ameliorating renal injury caused by DN by modulating oxidative stress in the mitochondrial pathway. This review aims to provide a reference for the prevention and treatment of DN. Firstly, we outline the mechanisms by which mitochondrial dysfunction impairs DN, focusing on outlining the damage to mitochondria by oxidative stress. Subsequently, we describe the process by which formulas, herbs and monomeric compounds protect the kidney by ameliorating oxidative stress in the mitochondrial pathway. Finally, the rich variety of Chinese herbal medicine, combined with modern extraction techniques, has great potential, and as we gradually understand the pathogenesis of DN and research techniques are constantly updated, there will be more and more promising therapeutic targets and herbal drug candidates. This paper aims to provide a reference for the prevention and treatment of DN.
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Affiliation(s)
- Ming Chen
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China
| | - Yao Chen
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China
| | - Wenhui Zhu
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China
| | - Xiaoming Yan
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China
| | - Jing Xiao
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China
| | - Peiqing Zhang
- Renal Division, Department of Medicine, Heilongjiang Academy of Chinese Medicine Sciences, Harbin, China.
| | - Peng Liu
- Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China.
| | - Ping Li
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing, China.
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Torreggiani M, Wang AYM, Fois A, Piccoli GB. Personalized Low-Protein Diet Prescription in CKD Population: Merging Evidence From Randomized Trials With Observational Data. Semin Nephrol 2023; 43:151402. [PMID: 37536057 DOI: 10.1016/j.semnephrol.2023.151402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Nutritional therapy is a cornerstone of the clinical management of chronic kidney disease (CKD). Nevertheless, randomized controlled trials often have failed to show a relevant benefit of low-protein diets in nonselected CKD populations in terms of slowing the progression of kidney disease and need for dialysis. The more the target population is selected, the less the results can be generalizable to implement in clinical practice. On the contrary, observational studies, especially if performed with patient-centered, flexible approaches, point toward an extensive implementation of dietary protein restriction in different and unselected CKD populations. The observational evidence cannot be disregarded anymore. The most recent guidelines advise implementing low-protein diets or even very-low-protein diets in all CKD patients as early as stage 3. However, the lack of data from large randomized controlled trials on unselected CKD populations as well as on specific subpopulations, such as diabetic or obese patients, which nowadays comprise the majority of CKD subjects, reduces the generalizability of the recommendations. For some patient populations, such as those encompassing very old, nephrotic, or pregnant patients, the literature is even more limited because of the lower prevalence of these conditions and diffused prejudices against reducing protein intake. This pragmatic review discusses the need for integrating information derived from randomized trials with evidence derived from observational studies to guide feasible strategies for more successful implementation of low-protein diets in the treatment of all segments of the CKD population.
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Affiliation(s)
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Antioco Fois
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
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Jiang S, Fang J, Li W. Protein restriction for diabetic kidney disease. Cochrane Database Syst Rev 2023; 1:CD014906. [PMID: 36594428 PMCID: PMC9809923 DOI: 10.1002/14651858.cd014906.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Diabetic kidney disease (DKD) continues to be the leading cause of kidney failure across the world. For decades dietary protein restriction has been proposed for patients with DKD with the aim to retard the progression of chronic kidney disease (CKD) towards kidney failure. However, the relative benefits and harms of dietary protein restriction for slowing the progression of DKD have not been addressed. OBJECTIVES To determine the efficacy and safety of low protein diets (LPD) (0.6 to 0.8 g/kg/day) in preventing the progression of CKD towards kidney failure and in reducing the incidence of kidney failure and death (any cause) in adult patients with DKD. Moreover, the effect of LPD on adverse events (e.g. malnutrition, hyperglycaemic events, or health-related quality of life (HRQoL)) and compliance were also evaluated. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs in which adults with DKD not on dialysis were randomised to receive either a LPD (0.6 to 0.8 g/kg/day) or a usual or unrestricted protein diet (UPD) (≥ 1.0 g/kg/day) for at least 12 months. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. Summary estimates of effect were obtained using a random-effects model. Results were summarised as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised MD (SMD) with 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified eight studies involving 486 participants with DKD. The prescribed protein intake in the intervention groups ranged from 0.6 to 0.8 g/kg/day. The prescribed protein intake in the control groups was ≥ 1.0 g/kg/day, or a calculated protein intake ≥ 1.0 g/kg/day if data on prescribed protein intake were not provided. The mean duration of the interventions was two years (ranging from one to five years). Risks of bias in most of the included studies were high or unclear, most notably for allocation concealment, performance and detection bias. All studies were considered to be at high risk for performance bias due to the nature of the interventions. Most studies were not designed to examine death or kidney failure. In low certainty evidence, a LPD may have little or no effect on death (5 studies, 358 participants: RR 0.38, 95% CI 0.10 to 1.44; I² = 0%), and the number of participants who reached kidney failure (4 studies, 287 participants: RR 1.16, 95% CI 0.38 to 3.59; I² = 0%). Compared to a usual or unrestricted protein intake, it remains uncertain whether a LPD slows the decline of glomerular filtration rate over time (7 studies, 367 participants: MD -0.73 mL/min/1.73 m²/year, 95% CI -2.3 to 0.83; I² = 53%; very low certainty evidence). It is also uncertain whether the restriction of dietary protein intake impacts on the annual decline in creatinine clearance (3 studies, 203 participants: MD -2.39 mL/min/year, 95% CI -5.87 to 1.08; I² = 53%). There was only one study reporting 24-hour urinary protein excretion. In very low certainty evidence, a LPD had uncertain effects on the annual change in proteinuria (1 study, 80 participants: MD 0.90 g/24 hours, 95% CI 0.49 to 1.31). There was no evidence of malnutrition in seven studies, while one study noted this condition in the LPD group. Participant compliance with a LPD was unsatisfactory in nearly half of the studies. One study reported LPD had no effect on HRQoL. No studies reported hyperglycaemic events. AUTHORS' CONCLUSIONS Dietary protein restriction has uncertain effects on changes in kidney function over time. However, it may make little difference to the risk of death and kidney failure. Questions remain about protein intake levels and compliance with protein-restricted diets. There are limited data on HRQoL and adverse effects such as nutritional measures and hyperglycaemic events. Large-scale pragmatic RCTs with sufficient follow-up are required for different stages of CKD.
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Affiliation(s)
- Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Jinying Fang
- China-Japan Friendship Institute of Clinical Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
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Yen CL, Fan PC, Kuo G, Chen CY, Cheng YL, Hsu HH, Tian YC, Chatrenet A, Piccoli GB, Chang CH. Supplemented Low-Protein Diet May Delay the Need for Preemptive Kidney Transplantation: A Nationwide Population-Based Cohort Study. Nutrients 2021; 13:nu13093002. [PMID: 34578879 PMCID: PMC8467708 DOI: 10.3390/nu13093002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although several studies suggest the benefit of a low-protein diet supplemented with amino acids and keto acids (sLPD) in delaying the initiation of hemodialysis, evidence on whether these nutritional approaches could delay the timing of preemptive transplantation is lacking. METHODS Retrospective nationwide cohort study, from Taiwan's National Health Insurance Research Database. Patients having undergone a first preemptive kidney transplantation between 2001 and 2017 were identified and divided into two groups according to the presence of sLPD treatment or not. The primary outcome was the time between the diagnosis of advanced CKD and transplantation. Secondary outcomes were post-transplantation adverse events. RESULTS A total of 245 patients who received their first preemptive kidney transplantation were identified from the nationwide database; 63 of them had been on an sLPD prior to transplantation (sLPD group). The duration between the day of advanced CKD diagnosis and the day of transplantation was significantly longer in the sLPD group compared with the non-sLPD group (median duration: 345 vs. 220 days, p = 0.001). The risk of post-transplantation adverse events did not differ between the two groups. CONCLUSIONS Within the limits of its observational, retrospective design, this is the first study to suggest that nutritional management with sLPDs can safely delay the timing of preemptive kidney transplantation.
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Affiliation(s)
- Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Chao-Yu Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Ya-Lien Cheng
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Hsiang-Hao Hsu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Ya-Chun Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
| | - Antoine Chatrenet
- Néphrologie, Centre Hospitalier du Mans, 72037 Le Mans, France; (A.C.); (G.B.P.)
| | - Giorgina Barbara Piccoli
- Néphrologie, Centre Hospitalier du Mans, 72037 Le Mans, France; (A.C.); (G.B.P.)
- Dipartimento di Scienze Cliniche e Biologiche, Universitàdi Torino, 10100 Torino, Italy
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-L.Y.); (P.-C.F.); (G.K.); (C.-Y.C.); (Y.-L.C.); (H.-H.H.); (Y.-C.T.)
- Correspondence: or ; Tel.: +886-3-3281200 (ext. 8181)
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Santoro D, Torreggiani M, Pellicanò V, Cernaro V, Messina RM, Longhitano E, Siligato R, Gembillo G, Esposito C, Piccoli GB. Kidney Biopsy in Type 2 Diabetic Patients: Critical Reflections on Present Indications and Diagnostic Alternatives. Int J Mol Sci 2021; 22:5425. [PMID: 34063872 PMCID: PMC8196671 DOI: 10.3390/ijms22115425] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
Roughly 3% of patients worldwide with a new diagnosis of type 2 diabetes mellitus (T2DM) already have an overt nephropathy at diagnosis and about 20-30% of the remaining ones develop a complication of this kind later in life. The early identification of kidney disease in diabetic patients is important as it slows its progression, which is important not only because this reduces the need for renal replacement therapy, but also because it decreases the high rate of mortality and morbidity associated with a reduction in kidney function. The increasing prevalence of type 2 diabetes and the consequent greater probability of finding different types of kidney diseases in diabetic patients frequently gives rise to overlapping diagnoses, a definition encompassing the differential diagnosis between diabetic and non-diabetic kidney disease. The issue is made more complex by the acknowledgement of the increasing frequency of presentations of what is termed "diabetic kidney disease" without relevant proteinuria, in particular in T2DM patients. Distinguishing between diabetes related and non-diabetes related forms of kidney disease in diabetic patients is not only a semantic question, as different diseases require different clinical management. However, while the urologic and macrovascular complications of diabetes, as well as overlapping parenchymal damage, can be diagnosed by means of imaging studies, often only a kidney biopsy will make a differential diagnosis possible. In fact, the coexistence of typical diabetic lesions, such as nodular glomerulopathy or glomerulosclerosis, with different glomerular, vascular and tubulo-interstitial alterations has been extensively described, and an analysis of the dominant histological pattern can contribute to determining what therapeutic approach should be adopted. However, due to the high frequency of kidney diseases, and to the fact that T2DM patients are often affected by multiple comorbidities, a kidney biopsy is not generally performed in T2DM patients. What follows is a review aiming to discuss the diagnostic work-up, on the base of clinical, laboratory and imaging criteria, and evaluate the present indications and alternatives to renal biopsy.
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Affiliation(s)
- Domenico Santoro
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France;
| | - Vincenzo Pellicanò
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Valeria Cernaro
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Roberta Maria Messina
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Elisa Longhitano
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Rossella Siligato
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Guido Gembillo
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, Department of Internal Medicine, ICS Maugeri S.p.A. SB, University of Pavia, 27100 Pavia, Italy;
| | - Giorgina Barbara Piccoli
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France;
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Fois A, Torreggiani M, Trabace T, Chatrenet A, Longhitano E, Mazé B, Lippi F, Vigreux J, Beaumont C, Moio MR, Piccoli GB. Quality of Life in CKD Patients on Low-Protein Diets in a Multiple-Choice Diet System. Comparison between a French and an Italian Experience. Nutrients 2021; 13:nu13041354. [PMID: 33919635 PMCID: PMC8073895 DOI: 10.3390/nu13041354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022] Open
Abstract
Prescribing a low-protein diet (LPD) is part of the standard management of patients in advanced stages of chronic kidney disease (CKD). However, studies on the quality of life (QoL) of patients on LPDs are lacking, and the impact these diets have on their QoL is often given as a reason for not prescribing one. We, therefore, decided to assess the QoL in a cohort of CKD stage 3–5 patients followed up by a multiple-choice diet approach in an outpatient nephrology clinic in France. To do so, we used the short version of the World Health Organization’s quality of life questionnaire and compared the results with a historical cohort of Italian patients. We enrolled 153 patients, managed with tailored protein restriction in Le Mans, and compared them with 128 patients on similar diets who had been followed in Turin (Italy). We found there were no significant differences in terms of age (median 73 vs. 74 years, respectively), gender, CKD stage, and comorbidities (Charlson’s Comorbidity Index 7 vs. 6). French patients displayed a greater body mass index (29.0 vs. 25.4, p < 0.001) and prevalence of obesity (41.2 vs. 15.0%, p < 0.001). Baseline protein intake was over the target in France (1.2 g/kg of real body weight/day). In both cohorts, the burden of comorbidities was associated with poorer physical health perception while kidney function was inversely correlated to satisfaction with social life, independently of the type of diet. Our study suggests that the type of LPD they follow does not influence QoL in CKD patients and that a personalized approach towards protein restriction is feasible, even in elderly patients.
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Affiliation(s)
- Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Massimo Torreggiani
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Tiziana Trabace
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.O.U. “G. Martino”, University of Messina, 98124 Messina, Italy;
| | - Béatrice Mazé
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Francoise Lippi
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Jerome Vigreux
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Coralie Beaumont
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Maria Rita Moio
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Giorgina Barbara Piccoli
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
- Correspondence: ; Tel.: +33-66-973-3371
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Zhang PN, Zhou MQ, Guo J, Zheng HJ, Tang J, Zhang C, Liu YN, Liu WJ, Wang YX. Mitochondrial Dysfunction and Diabetic Nephropathy: Nontraditional Therapeutic Opportunities. J Diabetes Res 2021; 2021:1010268. [PMID: 34926696 PMCID: PMC8677373 DOI: 10.1155/2021/1010268] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022] Open
Abstract
Diabetic nephropathy (DN) is a progressive microvascular diabetic complication. Growing evidence shows that persistent mitochondrial dysfunction contributes to the progression of renal diseases, including DN, as it alters mitochondrial homeostasis and, in turn, affects normal kidney function. Pharmacological regulation of mitochondrial networking is a promising therapeutic strategy for preventing and restoring renal function in DN. In this review, we have surveyed recent advances in elucidating the mitochondrial networking and signaling pathways in physiological and pathological contexts. Additionally, we have considered the contributions of nontraditional therapy that ameliorate mitochondrial dysfunction and discussed their molecular mechanism, highlighting the potential value of nontraditional therapies, such as herbal medicine and lifestyle interventions, in therapeutic interventions for DN. The generation of new insights using mitochondrial networking will facilitate further investigations on nontraditional therapies for DN.
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Affiliation(s)
- Ping Na Zhang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Meng Qi Zhou
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Jing Guo
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Hui Juan Zheng
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Jingyi Tang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Chao Zhang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Yu Ning Liu
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Wei Jing Liu
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
- Institute of Nephrology and Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, China
| | - Yao Xian Wang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
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10
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Nutritional Aspects in Diabetic CKD Patients on Tertiary Care. ACTA ACUST UNITED AC 2019; 55:medicina55080427. [PMID: 31374951 PMCID: PMC6723094 DOI: 10.3390/medicina55080427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022]
Abstract
Background and objectives: Diabetes is largely prevalent in the chronic kidney disease (CKD) population. Both conditions have metabolic and nutritional abnormalities that affect body composition and the presence of diabetes makes the dietary management of CKD patients more difficult. The aim of this study was to assess peculiar nutritional and functional aspects of diabetic patients in an adult/elderly CKD population, and their predictive significance. Materials and methods: This prospective cohort study included 144 out-patients aged >55 years, affected by stage 3b-4 CKD, on tertiary care clinic; 48 (40 males) were type 2 diabetics and 96 (80 males) were nondiabetics. The two groups have similar age, gender, and residual renal function (30 ± 9 vs. 31 ± 11 mL/min×1.73). All patients underwent a comprehensive nutritional and functional assessment and were followed for 31 ± 14 months. Results: Diabetic CKD patients showed higher waist circumference and fat body mass, lower muscle mass, and lower number of steps per day and average daily METs. Meanwhile, resting energy expenditure (REE), as assessed by indirect calorimetry, and dietary energy intake were similar as well as hand-grip and 6 min walking test. Diabetic patients did not show a greater risk for all-cause mortality and renal death with respect to nondiabetics. Middle arm muscle circumference, phase angle, serum cholesterol, and serum albumin were negatively related to the risk of mortality and renal death after adjustment for eGFR. Conclusions: CKD diabetic patients differed from nondiabetics for a greater fat mass, lower muscle mass, and lower physical activity levels. This occurred at the same REE and dietary energy intake. The outcome of diabetic or nondiabetic CKD patients on tertiary care management was similar in terms of risk for mortality or renal death. Given the same residual renal function, low levels of muscle mass, phase angle, serum albumin, and cholesterol were predictive of poor outcome. Overall, a malnutrition phenotype represents a major predictor of poor outcome in diabetic and nondiabetic CKD patients.
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11
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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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12
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Lee SW, Kim YS, Kim YH, Chung W, Park SK, Choi KH, Ahn C, Oh KH. Dietary Protein Intake, Protein Energy Wasting, and the Progression of Chronic Kidney Disease: Analysis from the KNOW-CKD Study. Nutrients 2019; 11:nu11010121. [PMID: 30626166 PMCID: PMC6356719 DOI: 10.3390/nu11010121] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023] Open
Abstract
Studies on the effect of dietary protein intake (DPI) on chronic kidney disease (CKD) progression, along with the potential hazard of protein-energy wasting (PEW), are scarce. We evaluated the association between DPI and kidney function both cross-sectionally and longitudinally, particularly emphasizing the role of PEW, in a large-scale, observational, multicenter, prospective study. We enrolled 1572 patients with non-dialysis CKD between 2011 and 2016. CKD progression was defined by a >50% estimated glomerular filtration rate (eGFR) decrease, serum creatinine doubling, or dialysis initiation. A Cox proportional hazard regression analysis was conducted. During the mean follow-up period of 41.6 months, CKD progression was observed in 296 patients. Cross-sectionally, increased DPI was significantly associated with increased eGFR. Similarly, increased DPI tertile was significantly associated with increased renal survival in a Kaplan–Meier curve analysis. In the multivariate Cox proportional hazard regression analysis, the statistical significance of the DPI tertile group in CKD progression was lost when PEW-related variables were added as covariates. In penalized spline curve analysis, the adjusted odds ratio of PEW significantly increased as DPI decreased. DPI, per se was not a major determinant of CKD progression. An intimate association between reduced DPI and PEW may be a more important predictor of CKD progression than DPI.
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Affiliation(s)
- Sung Woo Lee
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea.
| | - Yong-Soo Kim
- Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul 06591, Korea.
| | - Yeong Hoon Kim
- Department of Internal Medicine, Inje University, Busan Paik Hospital, Busan 47392, Korea.
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon 21565, Korea.
| | - Sue K Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul 03082, Korea.
- Cancer Research Institute, Seoul National University, Seoul 08826, Korea.
- Department of Biomedical Science, Seoul National University Graduate School, Seoul 03081, Korea.
| | - Kyu Hun Choi
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul 03722, Korea.
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.
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13
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Moderate Protein Restriction in Advanced CKD: A Feasible Option in An Elderly, High-Comorbidity Population. A Stepwise Multiple-Choice System Approach. Nutrients 2018; 11:nu11010036. [PMID: 30586894 PMCID: PMC6356994 DOI: 10.3390/nu11010036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/08/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Protein restriction may retard the need for renal replacement therapy; compliance is considered a barrier, especially in elderly patients. Methods: A feasibility study was conducted in a newly organized unit for advanced kidney disease; three diet options were offered: normalization of protein intake (0.8 g/kg/day of protein); moderate protein restriction (0.6 g/kg/day of protein) with a “traditional” mixed protein diet or with a “plant-based” diet supplemented with ketoacids. Patients with protein energy wasting (PEW), short life expectancy or who refused were excluded. Compliance was estimated by Maroni-Mitch formula and food diary. Results: In November 2017–July 2018, 131 patients started the program: median age 74 years (min–max 24-101), Charlson Index (CCI): 8 (min-max: 2–14); eGFR 24 mL/min (4–68); 50.4% were diabetic, BMI was ≥ 30 kg/m2 in 40.4%. Normalization was the first step in 75 patients (57%, age 78 (24–101), CCI 8 (2–12), eGFR 24 mL/min (8–68)); moderately protein-restricted traditional diets were chosen by 24 (18%, age 74 (44–91), CCI 8 (4–14), eGFR 22 mL/min (5–40)), plant-based diets by 22 (17%, age 70 (34–89), CCI 6.5 (2–12), eGFR 15 mL/min (5–46)) (p < 0.001). Protein restriction was not undertaken in 10 patients with short life expectancy. In patients with ≥ 3 months of follow-up, median reduction of protein intake was from 1.2 to 0.8 g/kg/day (p < 0.001); nutritional parameters remained stable; albumin increased from 3.5 to 3.6 g/dL (p = 0.037); good compliance was found in 74%, regardless of diets. Over 1067 patient-months of follow-up, 9 patients died (CCI 10 (6–12)), 7 started dialysis (5 incremental). Conclusion: Protein restriction is feasible by an individualized, stepwise approach in an overall elderly, high-comorbidity population with a baseline high-protein diet and is compatible with stable nutritional status.
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14
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Does a Supplemental Low-Protein Diet Decrease Mortality and Adverse Events After Commencing Dialysis? A Nationwide Cohort Study. Nutrients 2018; 10:nu10081035. [PMID: 30096785 PMCID: PMC6115816 DOI: 10.3390/nu10081035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/20/2022] Open
Abstract
Background: A beneficial effect of a ketoanalogue-supplemented low-protein diet (sLPD) in postponing dialysis has been demonstrated in numerous previous studies. However, evidence regarding its effect on long-term survival is limited. Our study assessed the long-term outcomes of patients on an sLPD after commencing dialysis. Methods: This retrospective study examined patients with new-onset end-stage renal disease with permanent dialysis between 2001 and 2013, extracted from Taiwan’s National Health Insurance Research Database. Patients who received more than 3 months of sLPD treatment in the year preceding the start of dialysis were extracted. The outcomes studied were all-cause mortality, infection rate, and major cardiac and cerebrovascular events (MACCEs). Results: After propensity score matching, the sLPD group (n = 2607) showed a lower risk of all-cause mortality (23.1% vs. 27.6%, hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.70–0.84), MACCEs (19.2% vs. 21.5%, HR 0.86, 95% CI 0.78–0.94), and infection-related death (9.9% vs. 12.5%, HR 0.76, 95% CI 0.67–0.87) than the non-sLPD group did. Conclusion: We found that sLPD treatment might be safe without long-term negative consequences after dialysis treatment.
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15
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Kitada M, Ogura Y, Monno I, Koya D. A Low-Protein Diet for Diabetic Kidney Disease: Its Effect and Molecular Mechanism, an Approach from Animal Studies. Nutrients 2018; 10:nu10050544. [PMID: 29702558 PMCID: PMC5986424 DOI: 10.3390/nu10050544] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 12/15/2022] Open
Abstract
A low-protein diet (LPD) can be expected to retard renal function decline in advanced stages of chronic kidney disease (CKD), including diabetic kidney disease (DKD), and is recommended in a clinical setting. Regarding the molecular mechanisms of an LPD against DKD, previous animal studies have shown that an LPD exerts reno-protection through mainly the improvement of glomerular hyperfiltration/hypertension due to the reduction of intraglomerular pressure. On the other hand, we have demonstrated that an LPD, particularly a very-LPD (VLPD), improved tubulo-interstitial damage, inflammation and fibrosis, through the restoration of autophagy via the reduction of a mammalian target of rapamycin complex 1 (mTORC1) activity in type 2 diabetes and obesity animal models. Thus, based on animal studies, a VLPD may show a more beneficial effect against advanced DKD. Previous clinical reports have also shown that a VLPD, not a moderate LPD, slows the progression of renal dysfunction in patients with chronic glomerular nephritis. However, there is insufficient clinical data regarding the beneficial effects of a VLPD against DKD. Additionally, the patients with CKD, including DKD, are a high-risk group for malnutrition, such as protein–energy wasting (PEW), sarcopenia, and frailty. Therefore, an LPD, including a VLPD, should be prescribed to patients when the benefits of an LPD outweigh the risks, upon consideration of adherence, age, and nutritional status. As the future predicts, the development of a VLPD replacement therapy without malnutrition may be expected for reno-protection against the advanced stages of DKD, through the regulation of mTORC1 activity and adequate autophagy induction. However, further studies to elucidate detailed mechanisms by which a VLPD exerts reno-protection are necessary.
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Affiliation(s)
- Munehiro Kitada
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Yoshio Ogura
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Itaru Monno
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
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16
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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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17
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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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