Effect of a low-protein diet on urinary albumin excretion in uremic patients

Fifteen patients with advanced renal failure (creatinine clearance less than 25 ml/mn) and with severe albuminuria (greater than 1.5 g/24 h) were put on a low-protein (0.3 g/kg body weight), low-phosphorus (5-7 mg/kg body weight) diet supplemented with essential amino acids and ketoanalogues. During the 6-month follow-up, urinary albumin excretion and fractional renal albumin clearance were reduced significantly while serum albumin concentration increased; no nutritional change occurred during the study.     

Effect of a low-protein diet on chemiluminescence production by leukocytes from uremic patients

Chemiluminescence (CL) emission from leukocytes was studied in 20 uremic patients after ingestion of opsonized zymosan. CL production was impaired when compared with control groups. Six months after a low-protein, low-phosphorus diet supplemented with essential amino acids and ketoanalogues (SD) was started, a significant improvement in CL production was observed. SD may be expected to decrease the susceptibility of uremic patients to bacterial infections.     

慢性肾脏病患者低蛋白饮食依从性评估方法的研究进展

综述了非透析慢性肾脏病患者低蛋白饮食依从性评估的方法,其中主观方法包括饮食日记法、膳食回顾法、问卷法、访谈法;客观方法有测定24 h尿尿素氮或随机尿尿素氮浓度,详细阐述各评估方法、局限性以及应用发展。提出在临床护理实践时考虑不同人群的实际情况,选择合适的评估方法,以促进临床慢性肾脏病患者的饮食管理,提高营养治疗效果。     

Adaptive response to a low-protein diet in predialysis chronic renal failure patients

Arandomized, controlled study of 12 patients with mild chronic renal failure was designed to assess the metabolic effects of a low-protein diet supplemented (n = 6) or not (n = 6) with ketoanalogs of amino acids. The protein intake was prescribed so that both groups were isonitrogenous. The dietary survey each month included a 3-d food record and a 24-h urine collection for urea measurement. After a 4- to 6-wk equilibrium period (standard occidental diet, 1.11 g of protein and 32 kcal/kg per d), patients reduced their protein intake to reach 0.71 g of protein/kg per d during the third month. Energy intake was kept constant (31 kcal/kg per d) during the 3-mo period. Compliance to the diet was achieved after 2 mo of training. Leucine turnover measurement was performed before and at the end of the 3-mo low-protein period. There was no clinical change, whereas total body flux decreased by 8% (P < 0.05) and leucine oxidation by 18% (P < 0.05). No difference could be attributed to the ketoanalogs themselves. Thus, under sufficient energy intake, a low-protein diet is nutritionally and metabolically safe during chronic renal failure. The nitrogen-sparing effect of a low-protein diet is still present during mild chronic renal insufficiency.     

The effect of a low-protein diet on serum levels of ceruloplasmin and transferrin in patients with chronic renal failure

In patients with chronic renal failure the administration of a diet providing 20 g protein per day for five weeks caused a significant rise in the serum ceruloplasmin level. A low dietary copper content (0.8 mg/day) may have been the limiting factor for any further rise of the ceruloplasmin level. The rise of ceruloplasmin was associated with a continuous decline of total iron binding capacity. The temporarily raised serum iron levels and the continuous decline of unsaturated iron binding capacity suggested enhanced iron mobilization caused by the raised ceruloplasmin level. The rise of ceruloplasmin correlated with the decline of UIBC.     

A low-protein diet does not necessarily lead to malnutrition in peritoneal dialysis patients.

BACKGROUND: The Dialysis Outcomes Quality Initiative (DOQI) group guideline recommends that the dietary protein intake (DPI) for peritoneal dialysis patients should be more than 1.2 g/kg/d. However, this target is not realistic for many Chinese peritoneal dialysis patients. In the present study, we investigated the impact of a low-protein diet on patients' nutritional status in a longitudinal cohort study in peritoneal dialysis patients. METHODS: Forty-seven peritoneal dialysis patients who had been on peritoneal dialysis for at least 3 months by the end of 2002 were included in the present study. All of the patients were followed up for 1 year. The patients were asked to collect their 3-day dietary record once every 3 months, and dialysis adequacy was evaluated once every 6 months. Subjective global assessment was performed at the beginning and by the end of the study. Comorbidities occurring during the follow-up were recorded. Fluid status was assessed once every 3 months. Patients were divided into three groups, with patients having a consistent DPI > or = 0.8 g/kg/d in group 1, patients with a variable DPI in group 2, and patients with a consistent DPI < 0.8 g/kg/d in group 3. RESULTS: There were 12, 18, and 17 patients in groups 1, 2, and 3, respectively. At the beginning of the study, 53.2% of the patients were malnourished. During the follow-up, nutritional status had improved in 12 patients, did not change in 32 patients, and had worsened in 3 patients. By the end of the follow-up, 34% of the patients were malnourished with only one severely malnourished patient. Malnourished patients by the end of the study had a significantly higher incidence of new comorbidities, more inflammation, and a higher incidence of fluid overload. There were no significant differences in the dialysis adequacy index among the three groups. CONCLUSIONS: Our study suggests that (1) many Chinese peritoneal dialysis patients did not achieve a high protein intake as recommended by the DOQI, but the low-protein diet does not necessarily lead to malnutrition in these patients, and (2) comorbidities occurring during the follow-up and volume overload may be the important risk factors for malnutrition in peritoneal dialysis patients.     

Acacia gum supplementation of a low-protein diet in children with end-stage renal disease

Patients with end-stage renal disease (ESRD) die in the absence of renal replacement therapy (RRT). In developing countries RRT is not uniformly available and treatment often relies on conservative management and intermittent peritoneal dialysis (IPD). This study investigates the possibility of using acacia gum supplementation to improve the quality of life and provide children with ESRD with a dialysis-free period. Three patients referred to our hospital with ESRD during a 3-month period were enrolled in a therapeutic trial to investigate the efficacy of acacia gum (1 g/kg per day in divided doses) as a complementary conservative measure aimed at improving the quality of life. Inclusion criteria included a pre-dialysis creatinine clearance of <5 ml/min, current dietary restrictions and supplementation, at least one dialysis session to control uremic symptoms, absence of life-threatening complications, and sufficient motivation to ensure compliance with the study protocol. One patient complied with the protocol for only 10 days and died after 6 months, despite IPD. Two patients completed the study. Both reported improved well-being. Neither became acidotic or uremic, and neither required dialysis during the study period. Both patients maintained urinary creatinine and urea levels not previously achieved without dialysis. In conclusion, dietary supplementation with acacia gum may be an alternative to renal replacement therapy to improve the quality of life and reduce or eliminate the need for dialysis in children with ESRD in some developing countries.     

Effect of low-protein, very-low-phosphorus diet on diabetic renal insufficiency with proteinuria

We describe the clinical outcome of 13 patients with non-insulin-dependent diabetes mellitus (NIDDM), renal insufficiency, and proteinuria, treated for 12.2 +/- 12.9 months (mean +/- SD) with a low-protein, very-low-phosphorus diet (LPVLP) containing 30 g protein and 11.3 mmol (350 mg) phosphorus. After a control period of 18.2 +/- 20.4 months, LPVLP therapy was initiated and serum urea nitrogen, uric acid, and phosphate, as well as urinary excretion of protein, creatinine, urea nitrogen, uric acid, and phosphate, decreased significantly. There was no change in mean blood pressure, hemoglobin, blood pH, and HCO3-, as well as in serum creatinine, protein, albumin, calcium, magnesium, cholesterol, triglyceride, beta-lipoprotein, and high-density lipoprotein (HDL)-cholesterol. Nitrogen balances were measured over 5 weeks in nine patients. Nitrogen balance increased significantly from a negative balance of -0.795 +/- 1.367 g/d in the first week, to almost neutral in the fourth week, and later, was neutral or positive. Neither uremic symptoms nor signs of malnutrition appeared during the LPVLP period. These results suggest that negative nitrogen balance during the initial few weeks does not predict future nutritional status of patients with diabetic renal failure.     

Anaphylaxis during anaesthesia. Results of a two-year survey in France

Between January 1, 1997 and December 31, 1998, 467 patientswere referred to one of the allergo-anaesthesia centres of theFrench GERAP (Groupe d’Etudes des Réactions AnaphylactoïdesPeranesthésiques) network and were diagnosed as havinganaphylaxis during anaesthesia. Diagnosis was established onthe basis of clinical history, skin tests and/or a specificIgE assay. The most frequent cause of anaphylaxis was a neuromuscularblocking agent (69.2%). Latex was less frequently incriminated(12.1%) than in previous reports. A significant difference wasobserved between the incidence of anaphylactic reactions observedwith each neuromuscular blocking agent and the number of patientswho received each drug during anaesthesia in France throughoutthe study period (P<0.0001). Succinylcholine and rocuroniumwere most frequently incriminated. Clinical reactions to neuromuscularblocking drugs were more severe than to latex. The diagnosticvalue of specific IgE assays was confirmed. These results areconsistent with changes in the epidemiology of anaphylaxis relatedto anaesthesia and are an incentive for the further developmentof allergo-anaesthesia clinical networks. Br J Anaesth 2001; 87: 549–58     

α－酮酸配伍低蛋白饮食对长期腹膜透析患者营养状况影响的临床研究

随着腹膜透析技术的不断改进，患者的生存期已相应延长，但其长期并发症也越显突出，尤其蛋白质营养不良已成为影响患者存活率的最主要因素。使用低蛋白饮食加α-酮酸疗法可改善非透析肾功能衰竭患者的代谢紊乱，降低尿毒症毒素水平。并使患者保持良好的营养状况。因此，在低蛋白饮食的基础上配伍α-酮酸治疗，进一步探讨其对CAPD患者营养状况的影响有着积极的临床价值。     

Body composition in patients treated with peritoneal dialysis

Background: Malnutrition is a common complication in uremia and during maintenance dialysis. Several factors contribute to its development. Different modes of dialysis treatment may differ in their effects on nutritional status. Methods: In order to analyse the nutritional consequences of peritoneal dialysis (PD), body composition analyses were performed in PD patients between February 1993 and March 1996. Body cell mass (BCM) was estimated from measurements of total body potassium (TBK) in a whole-body counter. Total body water (TBW) was determined by measurement of tritiated water. Body fat (BF) was calculated from body weight (BW), TBK and TBW. Observed values were related to predicted (o/p) derived from local population studies. Results: Sixty patients were repeatedly investigated during the study period. Of these, 34 were investigated during the first year of PD. At the start of dialysis, TBK o/p was 0.94 and BF o/p 0.76. No change in body composition was seen during the observation period in the group as a whole. However, within the group individual changes in BW were strongly correlated with individual changes in BF (r=0.66, P=0.0001). Twenty-six patients were examined during the second and third year of PD. In this group, BW o/p remained constant over time. However, there was a small but significant decline of TBK o/p and a concomitant increase of BF o/p (P<0.05). No correlation was observed between changes in TBK and changes in serum albumin. Conclusions: The results of this study indicate, that there may be a risk for further reduction of body cell mass during long-term PD treatment, while body energy stores are maintained or even increased.     

EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators.

OBJECTIVE: The aim of this study was to determine the effects of quality improvement programs for pressure ulcer prevention by conducting a follow-up survey in a hospital in Sweden. DESIGN: A cross-sectional survey design with comparison between data collected in 2002 and 2004. SETTING AND SUBJECTS: All inpatient areas were surveyed in the surgical, medical, and geriatric departments in a university hospital. A total of 369 patients were included. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form including some additional questions. METHODS: The 1-day survey was conducted on March 23, 2004. Each patient was visited by 2 registered nurses, who inspected the patient's skin for any pressure ulcer classified according to the EPUAP grading system. RESULTS: There were no significant differences in gender, age, or Braden score between the patients in surgical, medical, or geriatric care in 2002 and 2004. The overall prevalence of pressure ulcers was 33.3% (grade 1 excluded: 10.9%) in 2002 and 28.2% (grade 1 excluded: 14.1%) in 2004. In surgical care, the prevalence was reduced from 26.8% to 17.3% (P = .051). In medical care, the prevalence was 23.6% in 2002 and 26.7% in 2004. Corresponding prevalence figures for geriatric care were 59.3% and 50.0%. A quarter of the patients in surgical care, a third in medical care, and more than half in geriatric care had a pressure ulcer upon arrival at the ward. The use of pressure-reducing mattresses had increased significantly from 16.0% to 42.7% in medical care (P = .000). CONCLUSIONS: The EPUAP methodology has facilitated the introduction of pressure ulcer as a quality indicator at hospital level. Pressure ulcer prevalence surveys with a standardized methodology should be repeated on a regular basis in order to stimulate quality improvement.     

Body composition and cardiovascular risk in hemodialysis patients.

Death rate is unacceptably elevated in end-stage renal disease patients treated with hemodialysis. Excessive body fat, or obesity, is the well-known risk factor for cardiovascular disease and other health problems in the general population. However, hemodialysis patients with a higher body mass index (BMI) have a lower risk of death, as shown by many studies. There are several explanations for the paradox of BMI in dialysis patients. First, although body mass is composed of fat mass and fat-free mass (lean mass), it is unknown which is more important, fat mass or lean mass, in predicting outcome of hemodialysis patients. Second, it is also possible that functions of adipose tissue are altered in renal failure so that accumulation of body fat leads to less atherogenicity and beneficial properties become predominant. Third, an increased fat mass may be protective against death after harmful events. In this article, we explore these possibilities using either the data of our own cohort of hemodialysis patients or the existing registry data of Japan. We conclude that in hemodialysis patients, fat mass rather than lean mass plays a protective role against mortality, that the fat mass-adipocytokine relationship is altered, and that a low BMI is associated with increased risk of fatality after cardiovascular events rather than the risk of occurrence of such events.