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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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Ben Hmida M, Mechichi T, Piccoli GB, Ksibi M. Water implications in dialysis therapy, threats and opportunities to reduce water consumption: a call for the planet. Kidney Int 2023; 104:46-52. [PMID: 37116701 DOI: 10.1016/j.kint.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
Water is a dwindling natural resource, and potable water is wrongly considered an unlimited resource. Dialysis, particularly hemodialysis, is a water-hungry treatment that impacts the environment. The global annual water use of hemodialysis is approximately 265 million m3/yr. In this reference estimate, two-thirds of this water is represented by reverse osmosis reject water discharged into the drain. In this review, we would like to draw attention to the complexity and importance of water saving in hemodialysis. We propose that circular water management may comply with the "3R" concept: reduce (reduce dialysis need, reduce dialysate flow, and optimize reverse osmosis performance), reuse (reuse wastewater as potable water), and recycle (dialysis effluents for agriculture and aquaponic use). Awareness and sustainability should be integrated to create positive behaviors. Effective communication is crucial for water savings because local perspectives may lead to global opportunities. Besides the positive environmental impacts, planet-friendly alternatives may have significant financial returns. Innovative policies based on the transition from linear to circular water management may lead to a paradigm shift and establish a sustainable water management model. This review seeks to support policymakers in making informed decisions about water use, avoiding wasting, and finding solutions that may be planet friendly and patient friendly in dialysis, especially in hemodialysis treatments.
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Affiliation(s)
- Mohamed Ben Hmida
- Department of Nephrology, Hédi Chaker University Hospital, Sfax, Tunisia; Research Laboratory of Renal Pathology LR19ES11, Faculty of Medicine, University of Sfax, Sfax, Tunisia.
| | - Tahar Mechichi
- Laboratory of Biochemistry and Enzymatic Engineering of Lipases, National Engineering School of Sfax, University of Sfax, Sfax, Tunisia
| | | | - Mohamed Ksibi
- Laboratory of Environmental Engineering and Eco-technology, National Engineering School of Sfax (LGEET-ENIS), University of Sfax, Sfax, Tunisia
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Huynh TNP, Nguyen TM, Povero M, Pradelli L. Economic Analysis of a Ketoanalogue-supplemented Very Low-protein Diet in Patients With Chronic Kidney Disease in Vietnam. Clin Ther 2023; 45:649-654. [PMID: 37365045 DOI: 10.1016/j.clinthera.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/21/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE The aim of this study was to estimate the cost-effectiveness of a very low-protein diet (VLPD) supplemented with ketoanalogues of essential amino acids compared with a conventional low-protein diet (LPD) in Vietnam. METHODS The study was conducted from payer (base case), patient, and societal perspectives. A Markov model simulated costs and quality-adjusted life-years (QALYs) for patients with chronic kidney disease stage 4 or 5 (CKD4+) who were followed up during their lifetimes. Patients received a VLPD (0.3- to 0.4-g/kg/d diet) supplemented with ketoanalogues (5 kg/d [1 tablet]) versus LPD (0.6 g/kg/d, mixed proteins). In each model cycle, patient transitions among the health states-CKD4+ (nondialysis), dialysis, and death-were based on transition probabilities taken from the published literature. The time horizon covered the cohort's lifetime. Utilities and costs were estimated from literature review and projected for the lifespan considered in the model. Probabilistic and deterministic sensitivity analyses were performed. FINDINGS The ketoanalogue-supplemented VLPD increased survival and QALYs compared with the LPD. From a payer's perspective, total cost of care in Vietnam was ₫216,854,268 (€8684/$9242) per patient with LPD versus ₫200,928,819 (€8046/$8563) per patient with a supplemented VLPD (sVLPD) (difference, -₫15,925,449 [-€638/-$679]). From a patient's perspective, total cost of care in Vietnam was ₫217,872,043 (€8724/$9285) per patient with LPD versus ₫116,015,672 (€4646/$4944) per patient with sVLPD (difference, -₫101,856,371 [-€4,079/ -$4341]). From a societal perspective, total cost of care in Vietnam was ₫434,726,312 (€17,408/-$18,527) per patient with LPD versus ₫316,944,491 (€12,692/ $13,508) per patient with sVLPD (difference, -₫117,781,820 [-€4716 €/$5020). IMPLICATIONS Ketoanalogue-supplemented VLPD lowered costs compared with LPD in all 3 perspectives considered.
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Affiliation(s)
- Thao Ngoc Phuong Huynh
- Medicine Faculty, University of Medicine and Pharmacy at Ho Chi Minh City, Ho chi Minh City, Vietnam; Nephrology and Hemodialysis Department, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam.
| | - Tuan Minh Nguyen
- Department of Dialysis, Cho Ray Hospital, Hochiminh City, Vietnam
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Praditpornsilpa K, Garneata L, Lin YC, Povero M, Pradelli L, Susantitaphong P, Wu CH. Economic Analysis of a Ketoanalogue-Supplemented Very Low-Protein Diet in Patients With Chronic Kidney Disease in Taiwan and Thailand. J Ren Nutr 2023; 33:269-277. [PMID: 36179957 DOI: 10.1053/j.jrn.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/12/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE A vegetarian very low-protein diet (VLPD) supplemented with ketoanalogues of essential amino acids Ketoanalogue-supplemented very low-protein diet (sVLPD) delays dialysis initiation in patients with chronic kidney disease (CKD). In this cost-effectiveness analysis, we compare an sVLPD with a conventional low-protein diet (LPD) in patients with CKD stage 4-5 using data from Taiwan and Thailand. DESIGN AND METHODS A Markov model simulated health outcomes and care costs in patients receiving an sVLPD (0.3-0.4 g/kg-day, vegetarian diet) supplemented with ketoanalogues (1 tablet/5 kg-day) or an LPD (0.6 g/kg-day, mixed proteins). Health state transition probability and resource cost inputs were based on published literature and local sources, respectively. RESULTS An sVLPD increased survival and quality-adjusted life years (QALYs) at a lower cost than an LPD. Total cost of care in Taiwan was 2,262,592.30 New Taiwan dollars (NTD) (68,059.35 EUR) with an LPD and 1,096,938.20 NTD (32,996.18 EUR) with an sVLPD (difference -1,165,654.10 NTD; -35,063.17 EUR). Total cost of care in Thailand was 500,731.09 Thai baht (THB) (14,584.12 EUR) with an LPD and 421,019.22 THB (12,262.46 EUR) with an sVLPD (difference -79,711.86 THB; -2,321.66 EUR). CONCLUSION A ketoanalogue-supplemented vegetarian sVLPD increased QALYs and lowered lifetime care costs versus an LPD in patients with predialysis CKD in Taiwan and Thailand. These data, together with the new KDOQI Guidelines for nutrition in CKD, support dietary intervention using ketoanalogue-supplemented vegetarian sVLPDs to prevent CKD progression and postpone dialysis as a cost-effective approach, with beneficial effects for patients and health care providers.
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Affiliation(s)
- Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
| | - Liliana Garneata
- "Carol Davila" University of Medicine and Pharmacy, Dept of Internal Medicine and Nephrology, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Yen-Chung Lin
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei Medical University Hospital, TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei, Taiwan
| | | | | | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Che-Hsiung Wu
- Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Probiotics-Supplemented Low-Protein Diet for Microbiota Modulation in Patients with Advanced Chronic Kidney Disease (ProLowCKD): Results from a Placebo-Controlled Randomized Trial. Nutrients 2022; 14:nu14081637. [PMID: 35458199 PMCID: PMC9025298 DOI: 10.3390/nu14081637] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 02/01/2023] Open
Abstract
The probiotics-supplemented low-protein diet in chronic kidney disease (ProLowCKD) was a single-centre, double-blind, placebo-controlled, randomised trial that was conducted to investigate whether the association between a low protein diet (LPD) and a new formulation of probiotics (Bifidobacterium longum and Lactobacillus reuteri) was effective at reducing traditional uremic, microbiota-derived, and proatherogenic toxins in sixty patients affected by advanced CKD. After 2 months of a LPD—a reduction in blood urea nitrogen (52 ± 17 vs. 46 ± 15 mg/dL, p = 0.003), total cholesterol (185 ± 41 vs. 171 ± 34 mg/dL, p = 0.001), and triglycerides (194 ± 148 vs. 161 ± 70 mg/dL, p = 0.03) was observed; 57 subjects were then randomized to receive probiotics or a placebo for the subsequent 3 months. A total of 27 patients in the placebo group showed increased serum values of total cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.01), LDL cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.02), lipoprotein-associated phospholipase A2 (155.4 ± 39.3 vs. 167.5 ± 51.4 nmol/mL/min, p = 0.006), and indoxyl-sulphate (30.1 ± 17.6 vs. 34.5 ± 20.2 μM, p = 0.026), while the 24 subjects in the probiotics group showed a trend in the reduction of microbiota toxins. A reduction of antihypertensive and diuretic medications was possible in the probiotics group. This study shows that associating probiotics to LPD may have an additional beneficial effect on the control and modulation of microbiota-derived and proatherogenic toxins in CKD patients.
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Food as medicine? Exploring the impact of providing healthy foods on adherence and clinical and economic outcomes. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 5:100129. [PMID: 35478519 PMCID: PMC9032066 DOI: 10.1016/j.rcsop.2022.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Methods Results Conclusion
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De Mauri A, Carrera D, Vidali M, Bagnati M, Rolla R, Riso S, Torreggiani M, Chiarinotti D. Compliance, Adherence and Concordance Differently Predict the Improvement of Uremic and Microbial Toxins in Chronic Kidney Disease on Low Protein Diet. Nutrients 2022; 14:nu14030487. [PMID: 35276846 PMCID: PMC8839589 DOI: 10.3390/nu14030487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/06/2023] Open
Abstract
Background. In medicine, “compliance” indicates that the patient complies with the prescriber’s recommendations, “adherence” means that “the patient matches the recommendations” and “concordance” means “therapeutic alliance” between patient and clinician. While a low protein diet (LPD) is a cornerstone treatment of chronic kidney disease (CKD), monitoring the actual performance of LPD is a challenge. Patients. Fifty-seven advanced CKD adult patients were enrolled and LPD prescribed. Compliance was evaluated through the normalized protein catabolic rate (nPCR), adherence by the dietitian by means of a 24-h dietary recall and concordance by the nephrologist during consultations. Traditional parameters as well as total p-Cresyl Sulphate (t-PCS), total Indoxyl Sulphate (t-IS) and Lipoprotein-associated phspholipase A2 (Lp-PLA2) were compared between adherent/not adherent and concordant/not concordant subjects at enrolment and after two months. Results. nPCR, blood urea nitrogen, cholesterol and triglycerides significantly decreased in all patients. t-PCS and t-IS decreased among adherent subjects. Lp-PLA2, t-PCS, free-PCS and t-IS decreased among concordant subjects, while these increased in non-concordant ones. Conclusion. This study demonstrates that LPD may improve the control of traditional uremic toxins and atherogenic toxins in “adherent” and “concordant” patients. A comprehensive and multidisciplinary approach is needed to evaluate the compliance/adherence/concordance to LPD for optimizing nutritional interventions.
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Affiliation(s)
- Andreana De Mauri
- Nephrology and Dialysis Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy;
- Correspondence:
| | - Deborah Carrera
- Nutritional Science and Dietetic, Maggiore della Carità University Hospital, 28100 Novara, Italy; (D.C.); (S.R.)
| | - Matteo Vidali
- Clinical Chemistry Unit, Fondazione IRCCS Ca’ Granda Maggiore Policlinico Hospital, 20122 Milano, Italy;
| | - Marco Bagnati
- Clinical Chemistry Laboratory, Maggiore della Carità University Hospital, 28100 Novara, Italy; (M.B.); (R.R.)
| | - Roberta Rolla
- Clinical Chemistry Laboratory, Maggiore della Carità University Hospital, 28100 Novara, Italy; (M.B.); (R.R.)
- Department of Health Sciences, Amedeo Avogadro University of Eastern Piedmont, 28100 Novara, Italy
| | - Sergio Riso
- Nutritional Science and Dietetic, Maggiore della Carità University Hospital, 28100 Novara, Italy; (D.C.); (S.R.)
| | | | - Doriana Chiarinotti
- Nephrology and Dialysis Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy;
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Wang AYM, Okpechi IG, Ye F, Kovesdy CP, Brunori G, Burrowes JD, Campbell K, Damster S, Fouque D, Friedman AN, Garibotto G, Guebre-Egziabher F, Harris D, Iseki K, Jha V, Jindal K, Kalantar-Zadeh K, Kistler B, Kopple JD, Kuhlmann M, Lunney M, Mafra D, Malik C, Moore LW, Price SR, Steiber A, Wanner C, ter Wee P, Levin A, Johnson DW, Bello AK. Assessing Global Kidney Nutrition Care. Clin J Am Soc Nephrol 2022; 17:38-52. [PMID: 34980675 PMCID: PMC8763143 DOI: 10.2215/cjn.07800621] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Nutrition intervention is an essential component of kidney disease management. This study aimed to understand current global availability and capacity of kidney nutrition care services, interdisciplinary communication, and availability of oral nutrition supplements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas Committee, developed this Global Kidney Nutrition Care Atlas. An electronic survey was administered among key kidney care stakeholders through 182 ISN-affiliated countries between July and September 2018. RESULTS Overall, 160 of 182 countries (88%) responded, of which 155 countries (97%) answered the survey items related to kidney nutrition care. Only 48% of the 155 countries have dietitians/renal dietitians to provide this specialized service. Dietary counseling, provided by a person trained in nutrition, was generally not available in 65% of low-/lower middle-income countries and "never" available in 23% of low-income countries. Forty-one percent of the countries did not provide formal assessment of nutrition status for kidney nutrition care. The availability of oral nutrition supplements varied globally and, mostly, were not freely available in low-/lower middle-income countries for both inpatient and outpatient settings. Dietitians and nephrologists only communicated "sometimes" on kidney nutrition care in ≥60% of countries globally. CONCLUSIONS This survey reveals significant gaps in global kidney nutrition care service capacity, availability, cost coverage, and deficiencies in interdisciplinary communication on kidney nutrition care delivery, especially in lower-income countries.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Feng Ye
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Csaba P. Kovesdy
- University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Giuliano Brunori
- Division of Nephrology and Dialysis, Santa Chiara Hospital, Trento, Italy
| | - Jerrilynn D. Burrowes
- Department of Biomedical, Health and Nutritional Sciences, Long Island University Post, Greenvale, New York
| | - Katrina Campbell
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | | | - Denis Fouque
- University Claude Bernard Lyon1, Hospital Lyon Sud - Lyon-France, South Lyon, France
| | - Allon N. Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Fitsum Guebre-Egziabher
- Department of Nephrology, Dialysis and Hypertension, Hospices Civils de Lyon, Hospital Edouard Herriot, Lyon, France,CarMeN Laboratory, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1060, Lyon East Faculty of Medicine, University Claude Bernard Lyon 1, Lyon, France
| | - David Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Kunitoshi Iseki
- Clinical Research Support Center, Nakamura Clinic, Okinawa, Japan
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales, New Delhi, India,School of Public Health, Imperial College, London, United Kingdom,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Kailash Jindal
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine Medical Center, Orange, California
| | - Brandon Kistler
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | - Joel D. Kopple
- Division of Nephrology and Medicine and the Lundquist Research Institute at Harbor–University of California Los Angeles (UCLA) Medical Center, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Denise Mafra
- Federal University Fluminense, Rio de Janeiro, Brazil
| | - Charu Malik
- International Society of Nephrology, Brussels, Belgium
| | - Linda W. Moore
- Houston Methodist Hospital, Department of Surgery, Houston, Texas
| | - S. Russ Price
- Departments of Internal Medicine and Biochemistry-Molecular Biology, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Alison Steiber
- Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Christoph Wanner
- Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Pieter ter Wee
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David W. Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia,Translational Research Institute, Brisbane, Australia,Metro South and Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Rusli C, Bukhari A, A Taslim N, As'ad S, Rasyid H. Nutrition Therapy in Critically Ill Overweight Elderly Patient with Heart Failure, Myocardial Infarction, Pneumonia, and Chronic Kidney Disease. J Nutr Sci Vitaminol (Tokyo) 2021; 66:S25-S31. [PMID: 33612605 DOI: 10.3177/jnsv.66.s25] [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: 11/27/2022]
Abstract
Overweight or obesity will increase the risk of morbidity and mortality from cardiovascular disease. In older people, the risk is higher, but also paradoxically associated with lower mortality rates. Overweight patients vary in body composition and when it coupled with limited reliable sources to make caloric requirements estimation will make nutrition therapy extremely challenging. This case study reveals the nutrition therapy support in critically ill overweight elderly patient with heart failure, myocardial infarction, pneumonia, and chronic kidney disease. An 80-year old moderate malnourished male patient (body mass index 24.6 kg/m2) with acute lung edema, cardiogenic shock, myocardial infarction, pneumonia, and chronic kidney disease was admitted in the cardiovascular intensive-care unit. The patient was treated with diuretics, vasopressor support, and antibiotics. Oral intake was reduced due to shortness of breath and loss of appetite. The physical examination revealed basal lung rales, wheezing, muscle wasting, edema. Blood tests showed hyperkalemia, leucocytosis, depletion of the immune system, hyperuricemia, hypoalbuminemia, and dyslipidemia. The patient was on stage 5 renal failure (GFR 6.2 mL/min) but refused hemodialysis treatment. Nutritional therapy was given gradually with calorie target 1900 kcal and protein 0.6-1.2 g/ideal body weight/d using normal foods, oral nutrition supplement, and amino acids parenteral nutrition. After 13 d of nutritional treatment, the patient was discharged from the hospital with no shortness of breath, adequate nutrition intake, increased renal function (GFR 22.4 mL/min), and improvement of the blood test results (immune status, uric acid, albumin, and lipid profile). Critically ill overweight elderly patients are hypercatabolic and have increased nutrient demands. Nutritional support in these patients is required to provide necessary nutrient substrates and to alter the course and outcome of the disease.
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Affiliation(s)
- Christina Rusli
- Clinical Nutrition Specialist Program, Faculty of Medicine, Hasanuddin University
| | - Agussalim Bukhari
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Nurpudji A Taslim
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Suryani As'ad
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Haerani Rasyid
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University.,Department of Internal Medicine, Faculty of Medicine, Hasanuddin University
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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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De Mauri A, Carrera D, Bagnati M, Rolla R, Chiarinotti D, Mogna L, Pane M, Amoruso A, Del Piano M. Probiotics-addicted low-protein diet for microbiota modulation in patients with advanced chronic kidney disease (ProLowCKD): A protocol of placebo-controlled randomized trial. J Funct Foods 2020. [DOI: 10.1016/j.jff.2020.104133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Yen CL, Fan PC, Lee CC, Kuo G, Tu KH, Chen JJ, Lee TH, Hsu HH, Tian YC, Chang CH. Advanced Chronic Kidney Disease with Low and Very Low GFR: Can a Low-Protein Diet Supplemented with Ketoanalogues Delay Dialysis? Nutrients 2020; 12:nu12113358. [PMID: 33142717 PMCID: PMC7694025 DOI: 10.3390/nu12113358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated that dietary therapy can delay the initiation of dialysis, but little research has investigated whether patients with very poor renal function would benefit from a dietary therapy. METHODS This study was performed by using the Chang Gung Research Database (CGRD), which is based on the largest medical system in Taiwan. Patients with estimated glomerular filtration rates (eGFR) < 15 mL/min/1.73 m2 between 2001 and 2015 with more than 3 months of low-protein diet supplemented with ketoanalogues (sLPD) were extracted (Ketosteril group). We then assigned five patients without any sLPD to match one patient of the Ketosteril group (comparison group). Both groups were followed up for 1 year for the initiation of dialysis and rates of major adverse cardiac and cerebrovascular events (MACCEs). RESULTS The Ketosteril group (n = 547), compared with the comparison group (n = 2735), exhibited a lower incidence of new-onset dialysis (40.2% vs. 44.4%, subdistribution hazard ratio (SHR): 0.80, 95% confidence interval (CI): 0.70-0.91) and MACCEs (3.7% vs. 5.9%, HR: 0.61, 95% CI: 0.38-0.97). The beneficial effect of an sLPD did not differ in patients with a baseline eGFR < 5 mL/min/1.73 m2. CONCLUSION Even among patients with extremely low eGFR, sLPD treatment can safely delay the need for dialysis.
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Affiliation(s)
- Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Kun-Hua Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Tao-Han Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Hsiang-Hao Hsu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Ya-Chun Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33341, Taiwan; (C.-L.Y.); (P.-C.F.); (C.-C.L.); (G.K.); (K.-H.T.); (J.-J.C.); (T.-H.L.); (H.-H.H.); (Y.-C.T.)
- College of Medicine, Chang Gung University, Taoyuan 33341, Taiwan
- Correspondence: or ; Tel.: +886-3-3281200 (ext. 8181) or +0033669733371
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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: 21] [Impact Index Per Article: 4.2] [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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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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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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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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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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Rysz J, Franczyk B, Ciałkowska-Rysz A, Gluba-Brzózka A. The Effect of Diet on the Survival of Patients with Chronic Kidney Disease. Nutrients 2017; 9:E495. [PMID: 28505087 PMCID: PMC5452225 DOI: 10.3390/nu9050495] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/14/2017] [Accepted: 05/10/2017] [Indexed: 12/20/2022] Open
Abstract
The prevalence of chronic kidney disease (CKD) is high and it is gradually increasing. Individuals with CKD should introduce appropriate measures to hamper the progression of kidney function deterioration as well as prevent the development or progression of CKD-related diseases. A kidney-friendly diet may help to protect kidneys from further damage. Patients with kidney damage should limit the intake of certain foods to reduce the accumulation of unexcreted metabolic products and also to protect against hypertension, proteinuria and other heart and bone health problems. Despite the fact that the influence of certain types of nutrients has been widely studied in relation to kidney function and overall health in CKD patients, there are few studies on the impact of a specific diet on their survival. Animal studies demonstrated prolonged survival of rats with CKD fed with protein-restricted diets. In humans, the results of studies are conflicting. Some of them indicate slowing down of the progression of kidney disease and reduction in proteinuria, but other underline significant worsening of patients' nutritional state, which can be dangerous. A recent systemic study revealed that a healthy diet comprising many fruits and vegetables, fish, legumes, whole grains, and fibers and also the cutting down on red meat, sodium, and refined sugar intake was associated with lower mortality in people with kidney disease. The aim of this paper is to review the results of studies concerning the impact of diet on the survival of CKD patients.
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Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
| | - Aleksandra Ciałkowska-Rysz
- Palliative Medicine Unit, Chair of Oncology, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
| | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, WAM Teaching Hospital of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
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