Transcript CKD 11/3

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
Dietary 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 ?
Volume
330:877-884
March 31,
Number 13
1994
The Effects of Dietary Protein Restriction and Blood-Pressure
Control on the Progression of Chronic Renal Disease
Saulo 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*
MDRD study
• 研究設計
Study A
GFR 25-55 mL/min (mean SCr 1.9±0.5)
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 3.4±0.9)
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
.62 - .68
.68 - .75
Meta-Analysis of Low Protein
Diet in Progression of CKD
Cochrane systematic review and
meta-analysis
Fouque 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 analysis
2. Dietary recall
3. 24 hr urine collection for urea- N
Duplicate meal & ash analysis
• Good 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 patients
Dietary recall
Advantage:
•
Best practice
•
ample time for personel – patient interaction
•
Patients have more freedom to express their physical
and emotional constraint
Barrier
•
•
•
•
•
•
Need qualified dietitian
Need patient’s understanding & cooperation
Inadequate informative about nutritional value of
local foods
Calculation is uneasy
Subject to biological variation
May not be practical for nation-wide implementation
Monitoring of dietary protein
from urine urea N
DPI
= 6.25 [ total u. urea-N + 0.031 KgBW ]
+ urine protein
Benefit of 24h urine collection for DPI
monitoring
1. Cheap
2. Slightly inconvenient but acceptable by most
patients
3. Accurate and reliable feedback (to patient)
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 ?
Low protein diet : effect on progression of CRF
in diabetic CKD patients : meta-analysis
 Dietary protein restriction significantly reduces the risk of decline
in GFR or creatinine clearance in patients with diabetic nephropathy.
PEDRINI et al. (1996): Effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases:
a meta-analysis. Ann Intern Med, 124, 627-632
Low Protein Diet
Incidence of ESRD/death in diabetic nephropathy
 A protein restriction improves prognosis in type 1 diabetic patients
with progressive diabetic nephropathy in addition to the beneficial
effect of antihypertensive treatment.
HANSEN et al. (2002): Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy
Kidney Int, 62, 220-228
何謂 Supplemented Very Low
Protein Diet (SVLPD) ?
Dietary management in CKD
Composition of a Keto Acid Therapy
Caloric supply (kcal/kg bw/day)
% from carbohydrates
% from lipids
% from proteins
30-35
67
30
3
Protein content (g/kg bw/day)
0.3-0.4 (max. 0.6)
Phosphorus content (mg/kg bw/day)
5-7
Supplemented with:
KA/AA (Ketosteril®)
Calcium (g/day)
100 mg/kg bw/day
Vitamin D (IU/day)
Iron (mg/day)
1,000
10-15
0.5-1.0
Mechanisms of Protective Effects
of LPD+KS in CKD
Improves
Abnormal Renal
Hemodynamic
Minerals
CHO and Lipid
Nephro
Protective
Reduces
Proteinuria
Retards
Progression
Ameliorates
Symptoms
Improves outcome
Reduces
Proimflammatory
Cytokines
Acidosis
catabolic
Metabolic
Disorrders
Correction
Specific Dietary Requirements for Patients with Chronic Kidney Disease
Patients
Protein requirement
Normal adults or those
with uncomplicated CKD
Recommended Daily Allowance:
0.8 g protein/kg/day
Symptomatic CKD patients,
those with complications
Minimum: 0.6 g protein/kg/day or
0.3 g/kg/day + ketoacids
CKD patients with
loss of muscle mass
0.8 g protein/kg/day
CKD patients
proteinuria
<0.8 g protein/kg/day plus
1g protein per gram proteinuria
(possibly, less protein is needed)
with
Notes
30-35 Kcal/kg/day needed
to utilize dietary protein
efficiently
Adjustments for specific
problems (diabetes,
hyperphosphatemia)
This is
needed
the
maximum
Even less dietary protein
may be sufficient