1、慢性腎臟病與低蛋白飲食Chronic Kidney Disease and Low Protein Diet腎臟科陳冠興Factors Associated with Loss of Kidney Function in CKD Slow the progression of kidney disease Have been proven to be effective Strict glucose control in diabetes Strict blood pressure control ACEI or ARB Have been studied but inconclusive D
2、ietary protein restriction Lipid-lowering therapy Partial correction of anemia Frequent causes of acute decline in GFR Volume depletion;contrast;NSAID;antimicrobial agents;ACEI/ARB;cyclosporine;obstruction uropathy什麼時候開始認為低蛋白飲食可能會延緩腎臟病的惡化?The Effects of Dietary Protein Restriction and Blood-Pressure
3、 Control on the Progression of Chronic Renal DiseaseSaulo Klahr,Andrew S.Levey,Gerald J.Beck,Arlene W.Caggiula,Lawrence Hunsicker,John W.Kusek,Gary Striker,for The Modification of Diet in Renal Disease Study Group*Volume 330:877-884 March 31,1994 Number 13MDRD study 研究設計 Study A GFR 25-55 mL/min(mea
4、n SCr 1.90.5)Usual protein 1.3 g/kg/d;low protein diet 0.58 g/kg/d N=585 Study B GFR 13-24 mL/min(mean Scr 3.40.9)Low protein diet;very low protein diet N=255 論文發表 N Engl J Med 330:877-884,1994 J Am Soc Nephrol 7:2616-2626,1996 AJKD 27(5):652-663,1996 J Am Soc Nephrol 10:2426-2439,1999.75 g/Kg/d.62.
5、62-.68.68-.75Meta-Analysis of Low Protein Diet in Progression of CKDCochrane systematic review and meta-analysisFouque D,et al,Cochrane Database Syst Rev 2006;19:CD001892.如何確定病人是否有執行低蛋白飲食?1.Duplicate meal&ash analysis2.Dietary recall3.24 hr urine collection for urea-NDuplicate meal&ash analysis Good
6、 for research study Barrier Need accurate collection of duplicate meals by patients or research assistant Need lab methods to process specimens:blender,freezing,burning,acid digestion N2 analyzer Costly No clinical application for individual patientsDietary recall Advantage:Best practiceample time f
7、or personel patient interactionPatients have more freedom to express their physical and emotional constraint Barrier Need qualified dietitianNeed patients understanding&cooperationInadequate informative about nutritional value of local foods Calculation is uneasy Subject to biological variation May
8、not be practical for nation-wide implementationMonitoring of dietary protein from urine urea NDPI =6.25 total u.urea-N+0.031 KgBW +urine protein Benefit of 24h urine collection for DPImonitoring 1.Cheap 2.Slightly inconvenient but acceptable by most patients 3.Accurate and reliable feedback(to patie
9、nt)4.Body language is more convincing persuasive 5.achieve more compliance to the guideline Proper monitoring 1.U.protein :surrogate marker for glomerular permselecturity 2.Body weight :calorie intake (dry)3.24h Urine urea N+BW :nPNA(nDPI)4.24h U.Na :salt intake 低蛋白飲食會造成病人營養不良嗎?低蛋白飲食對糖尿病腎病變有幫忙嗎?Diet
10、ary protein restriction significantly reduces the risk of decline in GFR or creatinine clearance in patients with diabetic nephropathy.Low protein diet:effect on progression of CRF in diabetic CKD patients:meta-analysisPEDRINI et al.(1996):Effect of dietary protein restriction on the progression of
11、diabetic and nondiabetic renal diseases:a meta-analysis.Ann Intern Med,124,627-632Low Protein DietIncidence of ESRD/death in diabetic nephropathyHANSEN et al.(2002):Effect of dietary protein restriction on prognosis in patients with diabetic nephropathyKidney Int,62,220-228 A protein restriction imp
12、roves prognosis in type 1 diabetic patients with progressive diabetic nephropathy in addition to the beneficial effect of antihypertensive treatment.何謂 Supplemented Very Low Protein Diet(SVLPD)?Caloric supply(kcal/kg bw/day)30-35%from carbohydrates67%from lipids30%from proteins 3Protein content (g/k
13、g bw/day)0.3-0.4(max.0.6)Phosphorus content (mg/kg bw/day)5-7Supplemented with:Calcium(g/day)0.5-1.0Vitamin D(IU/day)1,000Iron(mg/day)100 mg/kg bw/day10-15Dietary management in CKDComposition of a Keto Acid TherapyKA/AA(Ketosteril)Mechanisms of Protective Effects of LPD+KS in CKDReduces Proimflammat
14、oryCytokinesMetabolicDisorrders CorrectionCHO and Lipid AcidosiscatabolicImprovesAbnormal Renal HemodynamicReduces ProteinuriaNephroProtectiveRetardsProgressionAmeliorates SymptomsImproves outcomeMineralsSpecific Dietary Requirements for Patients with Chronic Kidney DiseasePatientsProtein requiremen
15、tNotesNormal adults or those with uncomplicated CKDSymptomatic CKD patients,those with complicationsRecommended Daily Allowance:0.8 g protein/kg/dayMinimum:0.6 g protein/kg/day or0.3 g/kg/day+ketoacids30-35 Kcal/kg/day needed to utilize dietary protein efficientlyAdjustments for specific problems(diabetes,hyperphosphatemia)CKD patients with loss of muscle mass 0.8 g protein/kg/dayCKD patients with proteinuria0.8 g protein/kg/day plus1g protein per gram proteinuria(possibly,less protein is needed)This is the maximum neededEven less dietary protein may be sufficient
