慢性肾功能不全患者治疗前低蛋白饮食治疗的有效及安全的再认识

低蛋白饮食(LPD)用于透析前慢性肾衰(CRF)患者的治疗已有50余年，许多文献报道低蛋白饮食治疗可以减轻尿毒症、延缓肾衰进展，同时亦有学者质疑其安全性以及对以后替代治疗预后的影响。本文着重综述2000年以后发表的文献，从LPD治疗可以延缓CRF进展、不同LPD治疗方案对透析前CRF患者的作用及其安全性、LPD治疗不影响替代治疗预后等方面，论证其有效性和营养安全性。     

慢性肾功能不全患者治疗前低蛋白饮食治疗的有效及安全的再认识

低蛋白饮食 (LPD)用于透析前慢性肾衰 (CRF)患者的治疗已有 5 0余年 ,许多文献报道低蛋白饮食治疗可以减轻尿毒症、延缓肾衰进展 ,同时亦有学者质疑其安全性以及对以后替代治疗预后的影响。本文着重综述 2 0 0 0年以后发表的文献 ,从LPD治疗可以延缓CRF进展、不同LPD治疗方案对透析前CRF患者的作用及其安全性、LPD治疗不影响替代治疗预后等方面 ,论证其有效性和营养安全性。     

慢性肾功能衰竭营养疗法研究与应用的进展

慢性肾功能衰竭营养疗法研究与应用的进展郑法雷慢性肾功能衰竭（ＣＲＦ）营养治疗，已有约半个世纪的历史。６０年代以前，ＣＲＦ营养治疗一般仅限于应用低盐低蛋白饮食，这种治疗可使尿毒症患者的临床症状获得短期缓解；但易发生营养不良，也较少用于早期ＣＲＦ患者。６...     

复杂性肾结石并慢性肾功能不全47例的治疗

目的 提高复杂性肾结石并慢性肾功能不全的治疗水平。方法 收集47例复杂性肾结石并慢性肾功能不全的病例,比较几种不同的方法对肾功能恢复的影响,其中不阻断血流取石18例(A组),原位低温阻断肾血流取石22例(B组),保守治疗7例(C组)。结果 治疗后3月血Cr下降人数比:A组100％,B组81.8％,其中4例术后出现肾功能衰竭,C组28.6％。治疗后6月血Cr平均下降值: A组232.3μmol·L-1, B组87.2μmol·L-1, C组10.6μmol·L-1。结论 不阻断肾血流的取石肾脏损害轻,预后较为理想。阻断肾血流取石,多数病例预后较好,但少数加重肾脏的损害,导致术后肾功能衰竭,应警惕。消极等待不如积极治疗。     

采用低蛋白饮食并α酮酸治疗在延缓慢性肾功能不全进展的作用

目的 观察低蛋白饮食加α酮酸制剂是否具有延缓慢性肾功能不全患者肾功能减退、改善酸中毒的疗效。方法 观察未行透析的慢性肾功能不全患者26例，采用低蛋白饮食加α酮酸制剂平均28个月后，患者肾功能、血常规、电解质、肝功能以及内生肌酐清除率(Ccr)的改变。结果 治疗后患者血常规、电解质、肝功能无明显改变，血肌酐值虽然较治疗前上升但无统计学意义，而血碳酸氢盐水平较治疗前显著升高(P＜0．05)。结论 慢性肾功能不全患者长期采用低蛋白饮食加α酮酸制剂具有保护残余肾功能的作用，可减慢肾功能恶化速度，部分纠正酸中毒。     

低蛋白质饮食在延缓肾功能不全中的作用

慢性肾脏病（chronic kidney disease，CI〈D）已经成为全球关注的公共健康问题，虽然干预CKD进展的手段越来越多，但最终步人替代治疗的患者仍持续上升。积极控制患者的血糖和血压对延缓CKD进展的作用似乎并不令人满意，而蛋白营养治疗在其中发挥的重要作用却逐渐达成共识。     

慢性肾功能衰竭患者的个体化营养模式探讨

当前，低蛋白饮食（LDP）是慢性肾衰竭治疗的一个重要手段，但一直存在争议，争议的主要焦点在于LDP可能诱发营养不良。本研究探讨能够最大限度地减轻肾脏负担，又能防治LDP造成营养不良的个体化营养治疗模式。     

α-酮酸联合低蛋白饮食治疗慢性乙型肝炎并发慢性肾脏病的疗效和安全性

目的 探讨α-酮酸联合低蛋白饮食治疗慢性乙型肝炎(乙肝)并发慢性肾脏病(CKD)的疗效和安全性.方法 采用前瞻性随机对照试验.17例慢性乙肝并发CKD患者按数字随机法分为两组:对照组:蛋白质0.6～0.8 g·kg-1·d-1+24 h尿蛋白量;治疗组:复合α-酮酸制剂(开同,北京费森尤斯卡比公司)0.1g·kg-1·d-1+蛋白质0.6～0.8 g·kg-1·d-1+24 h尿蛋白量.饮食中优质蛋白比例超过2/3,热量为125.52～146.44 kJ·kg-1·d-1.随访3个月,观察比较两组的疗效和安全性.结果 随访期内,两组患者的组间及组内Scr、肾小球滤过率差异无统计学意义.在随访开始后的第1个月,治疗组患者的尿微量白蛋白开始持续下降[基线值(2855.43±248.03)mg/L,第1个月(2157.14±218.15) mg/L,第2个月(1681.57±146.18)mg/L,第3个月(924.29±83.33) mg/L,P＜0.05];第3个月时,两组患者的尿微量白蛋白水平差异有统计学意义;治疗组24 h尿蛋白总量也显著降低[基线值(4.52±1.74)g,第1个月(3.19±1.52)g,第2个月(2.19±1.10)g,第3个月(1.64±0.77)g,P＜0.05],与对照组差异有统计学意义.从第1个月开始,治疗组和对照组的血钙水平差异有统计学意义,但治疗组各随访点的血钙没有持续上升,各时间点间差异无统计学意义.第3个月时,治疗组组内及两组间的血浆白蛋白水平差异都有统计学意义.随访期间,安全性指标均在正常范围内.结论 α-酮酸制剂联合低蛋白饮食能有效地改善慢性乙肝并发CKD患者的血白蛋白水平,降低患者尿蛋白量.随访期间未见不良反应.     

Dietary protein and growth in infants with chronic renal insufficiency: a report from the Southwest Pediatric Nephrology Study Group and the University of California,San Francisco

This report describes growth and nutrition data from the feasibility phase of a clinical trial that was designed to evaluate the effect of diet protein modification in infants with chronic renal insufficiency (CRI). The purpose of the proposed trial was to compare the safety (effect on growth in length) and efficacy [effect on glomerular filtration rate (GFR)] of a diet with a low protein:energy (PE) ratio versus a control diet in such patients. Twenty-four infants with GFRs less than 55 ml/min per 1.73 m² were randomly assigned at 8 months of age to receive either a low-protein (PE ratio 5.6%) or control protein (PE ratio 10.4%) formula, which resulted in average protein intakes of 1.4 and 2.4 g/kg per day in the low and control groups, respectively. Overall energy intakes over a 10-month period of study averaged 92%±12% recommended dietary allowance (RDA) for length in the low-protein group and 92±15% RDA in the control group. Weight for age standard deviation scores (SDS) were comparably low in both groups at the time of randomization (low-protein —2.0±1.3, control –1.9±1.1) and at the end of the study (low –1.9±1.2, control –1.7±0.9). Length for age SDS at entry tended to be lower in the low-protein group but were not significantly different in the two groups (low –2.2±1.4 vs. control –1.7±1.4). However, at 18 months the low-protein group had a significantly lower SDS for length (–2.6±1.2 vs. –1.7±1.4). The length velocity SDS from 12 to 18 months were also different, with the low-protein group remaining strongly negative (–1.0±0.9) while the control group improved (–0.1±1.1). We conclude from this feasibility study that there is a need for caution in advising the use of low-protein intake in infants with CRI. However, our findings should be regarded as preliminary because of the small number of patients and the observation that the weight gains were the same in the two groups.Southwest Pediatric Nephrology Study Group centers/participantsBaylor College of Medicine, Houston, Tex.Phillip L. Berry, M. D., Andrea Forbes, R. N.Baylor University Medical Center, Dallas, Tex.Ronald J. Hogg, M. D., Tracy Shuck, R. N., Kaye GreenTulane University Medical Center, New Orleans, La.Frank Boineau, M. D., Karen Welling, R. N.University of Arkansas, Little Rock, Ark.Watson C. Arnold, M. D., Donna Floyd-Gimon, R.N.University of Colorado, Denver, Colo.Gary M. Lum, M.D., Leff Paulsen, R. N., Gail D'Amico, R. N.University of Tennessee, Memphis, Tenn.F. Bruder Stapleton, M. D., Patti Lawson, R. N., Judy Vinson, R. N.University of Texas Medical Branch, Galveston, Tex.Ben H. Brouhard, M. D., Lisa Hollander, R. N., Susan Gemma, R. D.University of Texas Medical School, Houston, Tex.Susan B. Conley, M. D., Ann InceUniversity of Texas Southwestern Medical Center, Dallas, Tex.Ricardo Uauy, M. D., Ph. D., Joan Reisch, Ph. D., Steven Alexander,M. D., Nancy Simonds, R. N., Cynthia Cunningham, R. D.University of Utah, Salt Lake City, UtahEileen Brewer, M. D., Miriam Turner, M. D., Jean Tealey, R. N.,Greg Done, R. N., Patricia Reading, R. D., Cynthia Terrill, R. D.University of California at San Francisco participants:Malcolm Holliday, M. D., Jon Block, Ph. D., Martin Glasser, M. D.,Jane Turner, Suzanne Young, R. N., Julie DuBois, R. N., Jon Hidayat, Jean Harrah(Note that the location of the individual investigators reflects their institution during the time period of this study)     

慢性乙型肝炎合并肾功能不全患者抗病毒治疗研究进展

慢性乙型肝炎(Chronic hepatitis B,CHB)是一种以肝脏损害为主要表现的感染性疾病,可进展为肝纤维化、肝硬化、肝衰竭或肝癌,危及患者生命。CHB患者易并发乙型肝炎病毒(Hepatitis B virus,HBV)相关性肾小球肾炎,或合并其他肾脏疾病,这类患者的抗病毒治疗需要充分考虑药物的肾脏安全性。根据目前相关指南推荐,合并肾功能不全或者有潜在肾功能损害的患者应优先选用替比夫定、恩替卡韦或丙酚替诺福韦,但这几种抗HBV药物各有利弊,如何在CHB合并肾脏损害的患者中进行抗病毒治疗值得进一步深入探究。同时,抗病毒治疗过程中应定期监测肾功能,以便早期识别肾功能损害。本文就CHB合并肾功能损害的原因,抗HBV治疗引起肾脏损害的风险,抗病毒治疗方案的选择,以及患者肾功能监测等作一综述。     

Carbonic adsorbent AST-120 retards progression of renal failure by additive effect with ACEI and protein restriction diet

Background. In order to slow the progression of chronic renal failure (CRF), a multimodal approach should be applied if the efficacy is proved. Although compelling evidence of a beneficial effect exists for the use of angiotensin-converting enzyme inhibitors (ACEIs) and low-protein diets, there is little evidence on whether carbon adsorbent has an effect on retardation of the progression of CRF.Methods. In experiment 1, we examined whether the oral carbon adsorbent, AST-120, conferred an additive effect with captopril and an 80% restriction diet on the survival rate of 3/4 nephrectomized rats (3/4 NX). The 3/4 NX rats were divided into three groups (C, control, n = 7; AD, captopril (an ACEI) +80% restriction diet (RD), n = 8; and ADK, ACEI + RD + AST-120, n = 8) and survival was observed for 72 weeks. In experiment 2, 3/4 NX rats were divided into four groups (C, control, n = 4; D, 80% restriction diet, n = 4; AD, temocapril + RD, n = 9; and ADK, temocapril + RD + AST-120, n = 9) for the examination of renal function, blood pressure, hematocrit (Ht), serum albumin, and proteinuria every month. We analyzed morphological changes in the kidney at 48 weeks.Results. In experiment 1, ADK did not improve the survival rate compared with AD, although ADK prolonged the survival significantly compared with C (C vs AD, P = 0.24; C vs ADK, P = 0.0007; AD vs ADK, P = 0.073). In experiment 2, renal function and proteinuria were significantly ameliorated in the ADK group compared with AD at 48 weeks. Concomitantly with the preservation of renal function, pathological indices, including the glomerular sclerosis index and the interstitial fibrosis index, were significantly improved in ADK compared with AD. In the ADK group, Ht and serum albumin did not change over the 48 weeks.Conclusions. Administration of AST-120 in addition to an ACEI and a restriction diet preserves renal function independently of blood pressure control, angiotensin II inhibition, and protein restriction in 3/4 NX rats at 48 weeks, but does not improve the survival significantly.     

慢性肾功能衰竭患者的高同型半胱氨酸血症

目的 研究慢性肾功能衰竭（ＣＲＦ）患者血浆同型半胱氨酸（Ｈｃｙ）水平、影响因素以及与心、脑血管疾病的关系。方法 采用荧光偏振免疫分析法测定１６０例ＣＲＦ患者血浆总同型半胱氨酸（ｔＨｃｙ）水平，以３１例冠心病患者和４５例正常人为对照。结果 以正常组血浆ｔＨｃｙｘ±２ｓ为９５％可信度上限，ＣＲＦ患者高同型半胱氨酸血症的发生率为８２．５０％，明显高于冠心病组（２２．５８％）（Ｐ＜０．０１）；血液透析（ＨＤ）组血浆ｔＨｅｙ水平［（２４．１３±１２．６８）μｍｏｌ／Ｌ，ｎ＝７３］明显高于持续性非卧床腹膜透析（ＣＡＰＤ）组［（１６．４３ ±５．５８）μｍｏｌ／Ｌ，ｎ＝１９］、冠心病组［（１１．１３±４．９７）μｍｏｌ／Ｌ，ｎ＝３１］以及正常组（７．９７±２．６５）μｍｏｌ／Ｌ，ｎ＝４５，Ｐ均＜０．０１。９２例透析治疗的ＣＲＦ患者中有明确心、脑血管病者的血浆ｔＨｃｙ水平［（２７．１２±１５．９４）μｍｏｌ／Ｌ，ｎ＝３０］明显高于无此类病史的患者［（２０．１７±８．７１）μｍｏｌ／Ｌ，ｎ＝６２］。未经透析的 ＣＲＦ患者血浆 ｔＨｃｙ水平与内生肌酐清除率呈负相关（ｒ＝－０．３７４，Ｐ＜０．０１），与患者年龄、血葡萄糖、血脂及血浆白     

Low protein diet causes a decrease in serum concentrations of leptin and tumour necrosis factor-alpha in patients with conservatively treated chronic renal failure

BACKGROUND: Chronic renal failure (CRF) provokes derangement in various hormonal regulations of food intake and energy expenditure. In the present study, we have examined the effect of a low protein, low phosphorus diet on circulating levels of leptin, tumour necrosis factor (TNF)-alpha, and insulin in patients with CRF. METHODS: Seventeen male, non-diabetic subjects with conservatively treated CRF (estimated creatinine clearance 39.5 +/- 11.1 mL/min), and proteinuria below 2 g/day were prospectively studied. Measurements of hormonal, metabolic and anthropometric parameters were performed before and after 16 weeks of dietary treatment (protein 0.6 g/kg of ideal body mass, 30% of calories derived from fat, 62% of calories derived from carbohydrates and 10 mg/kg of phosphorus). Actual dietary intake in patients was measured by using 3-day food records and was supervised by the dietician. RESULTS: Body mass index and body fat mass remained unchanged during the 4 months of dietary treatment. Urea, leptin, and TNF-alpha serum concentrations decreased significantly. CONCLUSIONS: A low protein, low phosphorus diet reduces TNF-alpha and leptin levels in plasma. The effect on leptin appears not to be mediated by an insulin-dependent mechanism.     

慢性肾衰竭患者继发甲状旁腺功能亢进外科治疗进展

随着透析技术的进步,慢性肾衰竭患者的生存时间逐渐延长,但影响患者生活质量甚至严重威胁患者生命的许多并发症也随之出现.继发性甲状旁腺功能亢进(SHPT)是血液透析患者的常见并发症之一,并且有一定的发病率和病死率,特征性表现主要有:低钙、高磷和高甲状旁腺激素.大多数患者可以通过药物治疗而痊愈,然而,药物治疗并不是都能很好地调节甲状旁腺功能的紊乱,部分患者需要外科干预.本文对慢性肾衰竭血透患者SHPT外科治疗的现状做一综述.

Abstract：

With the development of the dialysis technology,the survival time of patients with chronic renal failure is prolonged,while more complications which affect the quality of life or even threat the life of patients are followed.Secondary hyperparathyroidism(SHPT)with a certain incidence and mortality is one of the common complications,and its main characteristic performances ale hyperphosphatemia,hypocalcemia and high level of parathyroid hormone.Most patients Can be cured by the treatment of medicine while surgical treatment is still required by some cases in which the disorder of the parathyroid function can not be well regulated through medicine treatment.The purpose of this paper is to make a review of the recent studies of surgical treatment in patients with SHPT.     

Dietary protein restriction benefits patients with chronic kidney disease

The prevalence of chronic kidney disease (CKD) is rapidly increasing so every strategy should be used to avoid the complications of CKD. Most CKD symptoms or uraemia are caused by protein intolerance; symptoms arise because the patient is unable to excrete metabolic products of dietary protein and the ions contained in protein-rich foods. Consequently, CKD patients accumulate salt, phosphates, uric acid and many nitrogen-containing metabolic products, and secondary problems of metabolic acidosis, bone disease and insulin resistance become prominent. These problems can be avoided with dietary planning. Protein-restricted diets do not produce malnutrition and with these diets even patients with advanced CKD maintain body weight, serum albumin and normal electrolyte values. Non-compliance is a problem, but this can be detected using standard techniques to provide the patient with appropriate responses. The role of dietary protein restriction in the progression of CKD has not been proven, but it can reduce albuminuria and will prevent uraemic symptoms. Until a means of preventing kidney disease or progression is found, safe methods of management such as dietary manipulation should be available for CKD patients.     

别嘌呤醇对慢性肾衰竭患者肾脏保护作用及机制

目的观察别嘌呤醇对慢性肾衰竭（CRF）患者肾功能的保护作用。方法将入选的86例CRF（除外尿酸性肾病）患者分成对照组和治疗组,对照组给予CRF常规非透析疗法治疗;治疗组则在对照组基础上加用别嘌呤醇治疗;观察4周。测定2组治疗前后患者的尿素氮（BUN）、血肌酐（SCr）、血尿酸、一氧化氮（NO）,内皮素1（ET-1）,血栓素B2（TXB2）、6-酮-前列腺素F1α（6-keto-PGF-1α）及超敏C反应蛋白（hs-CRP）。结果治疗组治疗后,BUN、SCr及血尿酸较同组治疗前显著降低（P〈0．05）,与对照组比较有统计学差异（P〈0．05）;ET-1和NO分别较同组治疗前降低和升高（P〈0．05）,TXB2和6-keto-PGF-1α分别较治疗前降低和升高（P〈0．05）,hs-CRP较同组治疗前下降（P〈0．05）,与对照组比较均有统计学差异（P〈0．05）。结论别嘌呤醇对CRF患者肾功能具有保护作用,其可能是通过抗微炎症状况和改善血管内皮功能的作用。     

Low protein diets delay end-stage renal disease in non-diabetic adults with chronic renal failure.

BACKGROUND: The objective of this study was to determine the efficacy of low protein diets in delaying the need to start maintenance dialysis based on an analysis of published literature. METHODS: The search strategy involved a Medline and Embase search from January 1966 through to June 1999, congress abstracts (American Society of Nephrology since 1990, European Dialysis Transplant Association since 1985, International Society of Nephrology since 1987) and direct contacts with investigators. The selection criteria included randomized trials comparing two different levels of protein intake in adult patients suffering from moderate to severe renal failure, followed for at least 1 year. Patients with diabetic nephropathy were excluded. Seven trials were selected from 40 studies since 1975. A total of 1494 patients were analysed: 753 had received reduced protein intake and 741 a higher protein intake. The numbers of 'renal deaths' (defined as the need for starting dialysis, the death of a patient or kidney transplant during the trial) were collected. RESULTS: 242 renal deaths were recorded, 101 in the low protein diet and 141 in the higher protein diet group, giving an odds ratio of 0.61 with a 95% confidence interval of 0.46 to 0.83 (P=0.006). CONCLUSION: Reducing protein intake in patients with chronic renal failure reduces the occurrence of renal death by about 40% as compared with larger or unrestricted protein intake. The optimal level of protein intake cannot be confirmed from these studies.