Criteria for choosing amino acid therapy in acute renal failure.

Metabolic studies were performed on 19 patients with acute renal failure. Therapy included intravenous hyperalimentation using 15 to 20 g of essential amino acids or 20 to 40 g of essential plus nonessential amino acids and hypertonic glucose (37 to 50%). The effect of this parenteral feeding appears to be primarily pharmacological. Hypertonic glucose promotes the hyperinsulinemia important to be membrane function, the operation of the sodium pump, and cell metabolism. Administration of high biological value crystalline amino acdis potentiates the effect of insulin by inhibiting protein breakdown and promoting protein synthesis, particularly in muscle. This reduces tissue catabolism and urea formation, and promotes potassium, magnesium, and phosphate homeostasis. The branched-chain ketogenic amino acids valine, leucine, and isoleucine may be of particular importance. When indicated, administration of renal failure hyperalimentation and peritoneal or hemodialysis can be expected to complement each other and accelerate recovery. This intravenous fluid therapy, in turn, must be coordinated with proper hemodynamics, usually requiring a colloidal solution to maintain intravascular volume, and cardiotrophic agents such as digitalis and dopamine. Early use of renal failure can be expected to demonstrate the most striking response in terms of survival, early recovery from acute renal failure, and the preservation of physiological homeostasis.     

慢性肾功能衰竭血液透析患者发生医院感染的临床特点及相关危险因素分析

目的 探讨慢性肾功能衰竭血液透析患者发生医院感染的临床特点及相关危险因素,为提高慢性肾衰竭患者血液透析的安全性提供参考.方法 医院2008年1月-2009年1月收治的慢性肾功能衰竭行血液透析患者124例,按照是否发生医院感染分为:感染组75例和非感染组49例,将两组患者的资料、实验室诊断、医疗差异、住院环境等进行对比分析,总结慢性肾衰竭行血液透析患者发生医院感染的危险因素.结果 两组患者血肌酐、甘油三酯及尿素清除指数,组间比较,差异均无统计学意义;感染组与非感染组各项资料分别为:年龄(66.4±11.5)岁、(54.3±15.5)岁,住院天数为(25.6±10.7)d、(14.7±14.3)d,白蛋白为(25.3±10.2)g/L、(36.1±11.3)g/L,血红蛋白为(77.4±13.4)g/L、(89.5±17.6)g/L,组间比较差异均有统计学意义(P＜0.05);抗菌药物使用、病房环境、责任护士组间比较差异均有统计学意义(P＜0.05);患者医院感染的好发部位为呼吸系统占43.6％、胃肠道占21.3％、导管感染占17.0％.结论 慢性肾功能衰竭血液透析患者发生医院感染的危险因素,主要是患者自身及医疗因素;在治疗过程中,应加强医院感染控制管理,同时注意合理使用抗菌药物,尽量减少医院感染的危险因素.     

Low protein diet and ketosteril in predialysis patients with renal failure

After a short review of the contemporary understanding of amino acid supplementation to low protein diets in patients with uremia we present the results of administration of ketosteril in 20 low-protein-diet patients on such a diet. MATERIAL AND METHODS: Twenty patients (10 men and 10 women) with stable II and III stage chronic renal failure were assigned to a low protein diet (protein up to 40 g/day). Ketosteril (6 tablets a day) were added to the diet. Some of the basic markers of protein metabolism and nitrogen balance were followed. RESULTS: No evidence of deteriorated protein synthesis was found in the therapy thus administered. Serum urea and creatinine values did not change and even tended to decrease. Glomerular filtration was found to increase insignificantly more markedly in the patients with renal failure in the early stages. CONCLUSIONS: A low protein diet with increased content of essential amino acids and their keto-analogues does not deteriorate the nitrogen balance of patients with chronic renal failure. By adding essential amino acids and keto-analogues a normal protein metabolism is maintained in spite of the reduce intake of protein substances with the diet. Supplementation of the diet of chronic renal failure patients with essential amino acids and keto-analogues allows a considerable reduction of the protein intake to be achieved which brings about reduction of glomerular hyperfiltration which actually retards the progression of renal failure and improves its short-term prognosis.     

慢性肾病病人营养模式的研究

目的：探讨既能最大限度地减轻慢性肾病病人的肾负担,又能防治低蛋白饮食（LPD）造成的营养不良和营养素失调的个体化营养治疗模式。方法：选择非糖尿病肾病肾小球滤过率（GFR）下降的稳定期慢性肾病病人68例。比较普通低蛋白饮食和个体化营养治疗模式的效果。结果：普通低蛋白饮食和个体化营养模式对病人肾功能均无明显影响。普通低蛋白饮食对慢性肾病病人营养治疗前后营养状况比较发现,病人血清总蛋白（TP）和清蛋白（ALB）等营养指标水平明显下降（P〈0．05）;其自我感觉耐受率由35．5％下降至28．3％（P〈0．05）。个体化营养模式对慢性肾病病人营养治疗前后营养状况比较发现,病人TP和ALB等营养指标水平明显上升（P〈0．05）;其自我感觉耐受率由35．5％上升至70．8％（P〈0．01）。结论：对于慢性肾病病人的营养治疗应根据每个病人的病情,设计不同的个体化营养模式。     

Mass balance: a quantitative guide to clinical nutritional therapy. I. The predialysis patient with renal disease.

Mass balance principles can be readily applied to the patient with chronic renal failure for the more structured management of his/her nutritional and clinical course. Urine values provide valuable information with respect to rates of protein catabolism and sodium intake; creatinine excretion rates provide a ready check on data accuracy and lean body mass; urea and creatinine clearance can be calculated, if blood levels of these solutes are known. With accurate data on creatinine generation and the ratio of urea to creatinine clearance, creatinine clearance, urea generation, and protein catabolism rates can be estimated from blood levels alone. These techniques then provide quantitative guidance for the nutritional/medical staff in its efforts to control the clinical course of the patient with severly diminished renal function.     

The metabolic conversion of phenylalanine into tyrosine in the human kidney: does it have nutritional implications in renal patients?

Recent evidence provided by the in vivo measure of the activity of phenylalanine hydroxylase in humans indicates that the kidney plays a role greater than previously presumed in phenylalanine conversion to tyrosine, an amino acid which has been considered nonessential so far. Homeostasis of tyrosine pools is only partially restored by a reduced uptake of the same amino acid by splanchnic organs in the well-nourished noncatabolic patient with chronic renal failure. Tyrosine pools in uremia can also be restored by an increase in endogenous net protein catabolism, because it occurs during treatment with nonbiocompatible membranes or during acidosis. However, these are trade-offs that are associated with a progressive decrease in muscle mass. Based on these findings, one can argue that with progressively declining renal function and kidney metabolic activity, the nutritional requirements for tyrosine increase progressively. This mechanism could in part account for the increased protein requirements in dialysis-treated end-stage renal disease patients, as compared with predialysis patients.     

Effects of dietary protein on renal function and lipid metabolism in five-sixths nephrectomized rats

The objective of the present experiment was to examine the effect of substituting different quantities of soyabean protein for casein on renal function and lipid metabolism in rats with chronic renal failure induced by a five-sixths nephrectomy. Experimental animals were subjected to a nephrectomy and fed either casein or soyabean protein (200 or 100 g/kg diet). The diets were isoenergetic with identical fat, Na, K and P contents. Rats ingesting 200 g casein/kg diet showed a significantly (P<0.05) accelerated course of chronic renal failure, while the soyabean-protein groups showed retarded progression of the experimentally induced renal disease and hypercholesterolaemic effects. Rats in the low-soyabean-protein diet (100 g/kg) also demonstrated increased serum albumin and decreased serum triacylglycerol, total cholesterol concentrations and blood urea-N; however, the low-casein diet significantly (P<0.05) increased serum triacylglycerol. Results of the present study show that the replacement of casein by soyabean protein was related to the rate of progression of renal failure and improvement in lipid profiles in serum of five-sixths nephrectomized rats.     

Energy metabolism in acute and chronic renal failure

Energy metabolism was measured by indirect calorimetry in 86 patients with various forms of renal failure and in 24 control subjects. In patients with acute renal failure with sepsis, oxygen consumption, carbon dioxide production, and resting energy expenditure were increased (P less than 0.05). In other groups with renal failure (acute renal failure without sepsis, chronic renal failure with conservative treatment or hemodialysis, and severe untreated azotemia) these indices were not different from those of control subjects. Urea nitrogen appearance was decreased in patients with chronic renal failure undergoing conservative treatment, in those with severe untreated azotemia, and in hemodialysis patients (P less than 0.05). We conclude that renal failure has no influence on energy expenditure as long as septicemia is absent. Reduced urea nitrogen appearance rates in chronic renal failure are due to a reduced energy and protein intake. Wasting is a consequence of decreased food intake but not of hypermetabolism in chronic renal failure.     

Whole body protein turnover in malnourished cystic fibrosis patients and its relationship to pulmonary disease

To investigate the effect of pulmonary disease in cystic fibrosis (CF), total body protein synthesis and catabolism were determined in eight CF children with acute exacerbations of pulmonary infection at the time of study (CF I), a group of CF children (n = 7) with chronic but stable pulmonary disease (CF II) and a group (n = 8) of healthy children. Protein synthesis was determined by the method of Waterlow et al (1978) using a single oral dose of 15N glycine and protein catabolism derived from nitrogen balance. Protein synthesis was markedly decreased (p less than 0.001) in the CF I group (1.01 +/- 0.10 g kg-1 10 h-1) compared with that of controls (2.02 +/- 0.08) and with CF children with chronic but stable pulmonary disease (CF II) (2.36 +/- 0.17). Protein catabolism was increased (p less than 0.01) in the CF II group compared with both controls and CF I. These findings contrast strongly to studies in normal children and those with mild protein-energy malnutrition (PEM) and infection, where infection increased protein synthesis, but are consistent with the observed decrease in protein turnover where severe PEM is accompanied by infection. We conclude that repeated pulmonary infection can adversely affect protein-energy balance and that adequate nutritional support should be considered in management during and after each episode.     

Immunity to poliomyelitis, diphtheria and tetanus in pediatric patients before and after renal or liver transplantation.

Few studies have considered the safety, efficacy and appropriateness of vaccinations in pediatric patients before and after solid organ transplantation. The aim of this study was to evaluate the immune status after primary vaccination to diphtheria, tetanus and poliomyelitis in pediatric patients before and after hepatic transplantation and to poliomyelitis in pediatric patients before and after renal transplantation. All the patients had received a complete primary immunization schedule for diphtheria and tetanus and poliomyelitis. Immunity to the three polioviruses was evaluated in 56 patients with renal transplant, 27 on chronic dialysis and 33 controls and in 39 patients with hepatic transplant, 25 with chronic hepatic failure and their 36 controls. Immunity to diphtheria and tetanus was evaluated in 52 liver transplant patients, 29 children with chronic hepatic failure and 54 healthy children. Renal transplant patients were less protected and had lower antibody geometric mean titers than healthy controls for polioviruses 1 and 2. Whereas, protection in the children liver transplant patients was similar to that in their controls. Patients with chronic hepatic failure had higher antibody geometric mean titers to diphtheria and polioviruses 1 and 3 than their control group. Immunosuppression after transplantation has a negative influence on the immune status after primary vaccination in children with renal transplant. Whereas children with chronic hepatic failure have higher antibodies than a normal population. When possible, it could be advisable to individualize immunization schedules in patients at high risk.     

慢性肾衰竭患者腹水高迁移率族蛋白检测及其意义

目的研究高迁移率族蛋白B1(HMGB1)在慢性肾衰竭及并发感染患者腹水中的水平变化及其临床意义。方法采用ELISA法对35例临床腹水标本(其中慢性肾衰竭无并发症10例,肾衰竭并发肺炎12例,肾衰竭并发腹膜炎13例)进行HMGB1检测,同时检测所有研究对象血液中的CRP水平。结果肾衰竭并发腹膜炎(C)组腹水(渗出液)HMGB1水平明显高于慢性肾衰竭无并发症(A)组及肾衰并发肺炎(B)组(漏出液),差异有统计学意义(P<0.01),A组与B组腹水中HMGB1水平的差异无统计学意义;B组和C组血液中的CRP水平明显高于A组,差异有统计学意义(P<0.01),提示体内存在感染。结论腹水HMGB1检测对慢性肾衰竭患者腹水性质的鉴别有较好的临床意义,若联合血液CRP指标的检测对临床鉴别诊断慢性肾衰竭有无并发其他感染性疾病也具有一定意义。     

营养治疗慢性肾功能衰竭效果的初步观察

在非透析综合疗法中膳食治疗的原则,应是在限制低蛋白质摄入量的基础上设法提高必需氨基酸的摄入水平,以纠正体内氨基酸代谢紊乱。根据此原则我们为慢性肾功能衰竭患者制备了低蛋白麦淀粉膳食(蛋白质限制在20～40g/24hr,总热量2000～3000kcal/24hr),麦淀粉含蛋白质量甚低(0.4—0.6g％),故以其代替大米,面粉做为主食,既可减少植物蛋白质的进量,又可在低蛋白限量范围内适当增加含必需氨基酸丰富的食品,如蛋,奶、瘦肉等;并使优质蛋白质占膳食中总蛋白质量的50～70％。本组30例病人经治疗1—2个月后,除6例(2例无效,4例因故未坚持治疗)外,病人氮质血症均有减轻,临床症状得到改善,营养状况有所改进,延长了生命,根据6例氮平衡实验结果,提示慢性肾衰病人(Ccr5—10ml/min)的饮食在充足热量摄入的基础上,蛋白质摄入量至少0.5g/kg/24hr,(其中优质蛋白占50—70％),才可达到氮的平衡。     

Flaxseed oil supplementation decreases C-reactive protein levels in chronic hemodialysis patients

Malnutrition and chronic inflammation in dialysis patients negatively impact their survival prognosis, and nutrients, such as omega-3 oils, are postulated to reduce proinflammatory response. In this randomized, double-blind, multicenter, placebo-controlled trial, we investigated the effects of flaxseed oil (FO) on the inflammatory state of patients with chronic renal failure undergoing renal replacement therapy with hemodialysis (HD). We hypothesized that FO supplementation lowers C-reactive protein (CRP) levels. One hundred sixty patients with chronic renal failure who received HD therapy of 3 dialysis units over a 3-month period in South Brazil were included. The patients received blind doses of FO (1 g twice a day) and placebo (mineral oil, 1 g twice a day) for a period of 120 days. Inflammation was observed in 89 patients (61%) at the beginning of the study. There was a correlation between CRP and the body mass index (R_s = 0.22; P = .022) and high-density lipoprotein cholesterol (R_s = −0.23; P = .032), and the CRP levels decreased significantly over time in the group that received FO compared with the control group (P < .001). During the study period, 33.3% of the FO group changed from an inflamed to a not-inflamed category, whereas only 16.9% changed in the mineral oil group (P = .04). We conclude that the administration of FO decreases the CRP levels and that inflammation in HD patients appears to be correlated to their body mass index and reduced high-density lipoprotein cholesterol levels. Studies with a larger number of patients and over a longer duration are necessary to corroborate these findings.     

The effect of different intravenous nutritional regimens on renal function during acute renal failure in the rat

Acute renal failure in the surgical patient is accompanied by a state of hypermetabolism and increased catabolism. Nutritional therapy is therefore directed at the preservation of body cell mass and protein synthesis for repair of wounds and damaged renal tubuli and for maintenance of host defense mechanisms. We examined the effect of two levels of protein intake (18.4 +/- 1.4 and 30.8 +/- 2.4 mg N/100 g BW/day) and three different amino acid formulations (Freamine III, Nephramine, and a made-up mixture of Nephramine + Freamine HBC) on renal function following mercury chloride-induced acute renal failure in the rat. All animals suffered severe renal failure manifested by increased plasma urea and creatinine levels, decreased creatinine clearance, and increased fractional excretion of sodium. On day 4 of acute renal failure, rats receiving low dose amino acids had better-preserved renal function than those receiving high dose amino acids. However, the type of solution infused did not affect recovery of renal function.     

慢性肾功能衰竭患者超声心动图改变临床分析

目的探讨慢性肾功能衰竭患者超声心动图改变的临床意义。方法根据肌酐清除率水平，将49例慢性肾功能衰竭患者分为三组（肾功能代偿期组11例；肾功能失代偿期组16例和肾功能衰竭组22例），并以20例正常人作对照，分别用彩色多普勒超声心动图进行心脏腔径及心功能参数的测定。结果CRF患者心脏彩超异常者占80%，主要为左心损害。随着肌酐清除率水平的下降，慢性肾功能衰竭各组患者左室（LV）、左房（LA）、室间隔（IVS）、左室后壁厚度（LVPWT）和左室心肌重量指数（LVMI）均显著增加（p〈0.05，p〈0.01），而E/A比值则呈下降趋势，与对照组比较差异显著（p〈0.05）。结论通过超声心动图对慢性肾功能衰竭患者心脏改变进行严密监测，控制以上因素，有助于减少心血管病变的发生。     

解毒泄浊法保留灌肠治疗慢性肾衰98例

目的本研究主要就解毒泄浊法保留灌肠治疗慢性肾衰(CRF)的临床效果进行分析探讨。方法选择该院2009年3月—2013年3月被确诊为慢性肾衰的98例患者作为研究对象,将所有患者随机均分为观察组与对照组,对照组的患者给予爱西特片治疗,观察组的患者给予解毒泄浊法保留灌肠治疗,对两组患者的治疗有效率进行比较。结果两组患者的治疗有效率比较差异具有统计学意义,P<0.05。结论与传统的治疗方法相比,采用中药保留灌肠与解毒泄浊法相结合的方式来对慢性肾衰进行治疗,可以取得更好的临床效果,因此,可以在临床治疗慢性肾衰竭方面进行推广。     

A controlled study of supplementation with essential amino acids and α-keto acids in the conservative management of patients with chronic renal failure

Oral therapy with essential amino acids (EAA) or α-keto acids (α-KA) has been recommended in patients with renal failure, but quality and quantity of optimal protein intake are still controversial. This study compares sequentially the effect of supplementation with EAA, and with α-KA versus placebo in 15 ambulatory patients with chronic renal failure (average creatinine clearance 10.8 ml/min), maintained on a protein diet of 0.57 g/kg body weight (40 g for a 70-kg patient). The actual dietary intake averaged 0.55 g protein/kg and 27 kcal/kg according to repeated 7-day dietary recordings. After a 6-week baseline period on this diet, all patients received additionally 0.112 g EAA/kg for 6 weeks followed by a double-blind cross-over study of 0.105 g α-KA/kg versus placebo supplementation for 6 weeks each. Fasting blood samples for multiple parameters, including 15 indicators for protein deficiency, as well as anthropometric and clinical data were evaluated every 3 weeks. Laboratory data revealed no indications of protein deficiency. Therapy with α-KA diminished serum phosphate concentration (p<0.05), however no other significant beneficial effects could be demonstrated during supplementation with either EAA or α-KA. Therefore, such supplementation to a 0.55-g/kg-protein diet appears superfluous in stable ambulatory patients with renal insufficiency.     

Mass balance: a quantitative guide to clinical nutritional therapy. II. The dialyzed patient.

The concepts of mass balance are extended to the nutritional management of the patient with chronic renal failure on dialysis. The use of these concepts permits estimation of protein catabolism from calculated rates of urea generation, using measurement of blood urea levels. Protein catabolic rate will equal intake in the stable patient (zero nitrogen balance), allowing for accurate nutritional screening in a large dialysis population for whom these values are available without individual dietary surveys. This has resulted in a four-fold reduction in routine monitoring of protein nutrition in such patients, freeing the dietitian to concentrate on specific problems. These concepts also comprise a key aspect of the National Cooperative Dialysis Study which seeks to maintain BUN at different levels in four carefully controlled modes of dialysis therapy. With these methods, the monitoring and control of BUN and protein intake has made the dietitian a pivotal member of this study staff.     

Nutritional support in the patient with acute renal failure.

Nutritional support in the patient with acute renal failure is of great importance in lessening the degree of catabolism when energy demands are high and may also result in salutary metabolic effects. Overall treatment considerations in the posttraumatic or postsurgical patient with acute renal failure will be discussed, including fluid and electrolyte balance and energy and nutritional considerations. The application of the Giordano and Giovannetti principles to the field of parenteral nutritional support enables modifications of treatment programs of total parenteral nutrition to be applied to patients with acute renal failure. Utilizing an intravenous mixture of eight essential l-amino acids, hypertonic dextrose, and vitamins, we observed salutary biochemical effects in surgical patients. A prospective, randomized double-blind study of that treatment regimen compared to patients receiving hypertonic dextrose and vitamins alone resulted in improved survival and a decreased duration of renal failure in the treated group. Management considerations of these patients and possible application of these principles to other patients in renal failure will be discussed.     

Nutritional support in the patient with acute renal failure

Nutritional support in the patient with acute renal failure is of great importance in lessening the degree of catabolism when energy demands are high and may also result in salutary metabolic effects. Overall treatment considerations in the posttraumatic or postsurgical patient with acute renal failure will be discussed, including fluid and electrolyte balance and energy and nutritional considerations. The application of the Giordano and Giovannetti principles to the field of parenteral nutritional support enables modifications of treatment programs of total parenteral nutrition to be applied to patients with acute renal failure. Utilizing an intravenous mixture of eight essential l-amino acids, hypertonic dextrose, and vitamins, we observed salutary biochemical effects in surgical patients. A prospective, randomized double-blind study of that treatment regimen compared to patients receiving hypertonic dextrose and vitamins alone resulted in improved survival and a decreased duration of renal failure in the treated group. Management considerations of these patients and possible application of these principles to other patients in renal failure will be discussed.