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慢性腎臟病與低蛋白飲食ChronicKidneyDiseaseandLowProteinDiet腎臟科陳冠興慢性腎臟病與低蛋白飲食ChronicKidneyDis1FactorsAssociatedwithLossofKidneyFunctioninCKDSlow the progression of kidney diseaseHavebeenproventobeeffectiveStrictglucosecontrolindiabetesStrictbloodpressurecontrolACEIorARBHavebeenstudiedbutinconclusiveDietary protein restrictionLipid-loweringtherapyPartialcorrectionofanemiaFrequent causes of acute decline in GFRVolumedepletion;contrast;NSAID;antimicrobialagents;ACEI/ARB;cyclosporine;obstructionuropathyFactorsAssociatedwithLosso2什麼時候開始認為低蛋白飲食可能會延緩腎臟病的惡化?什麼時候開始認為低蛋白飲食可能會延緩腎臟病的惡化?3The Effects of Dietary Protein Restriction and Blood-Pressure 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 330:877-884March 31,1994Number 13Volume330:877-884March314MDRDstudy研究設計StudyAGFR25-55mL/min(meanSCr1.90.5)Usualprotein1.3g/kg/d;lowproteindiet0.58g/kg/dN=585StudyBGFR13-24mL/min(meanScr3.40.9)Lowproteindiet;verylowproteindietN=255論文發表NEnglJMed330:877-884,1994JAmSocNephrol7:2616-2626,1996AJKD27(5):652-663,1996JAmSocNephrol10:2426-2439,1999MDRDstudy研究設計5.75 g/Kg/d.75g/Kg/d.62.62-.68.686Meta-Analysis of Low Protein Diet in Progression of CKDMeta-AnalysisofLowProteinD7Cochrane systematic review and meta-analysisFouque D,et al,Cochrane Database Syst Rev 2006;19:CD001892.Cochranesystematicreviewand8如何確定病人是否有執行低蛋白飲食?如何確定病人是否有執行低蛋白飲食?91.Duplicate meal&ash analysis2.Dietary recall3.24 hr urine collection for urea-NDuplicatemeal&ashanalysis10Duplicatemeal&ashanalysisGood 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 patientsDuplicatemeal&ashanalysis11Dietary recall Advantage:Best practiceample time for 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 not be practical for nation-wide implementationDietaryrecall12Monitoring of dietary protein from urine urea NDPI =6.25 total u.urea-N+0.031 KgBW +urine protein Monitoringofdietaryprotein13Benefit of 24h urine collection for DPImonitoring 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 Benefitof24hurinecollectio14Proper 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 Propermonitoring1.U.prote15低蛋白飲食會造成病人營養不良嗎?低蛋白飲食會造成病人營養不良嗎?16低蛋白飲食對糖尿病腎病變有幫忙嗎?低蛋白飲食對糖尿病腎病變有幫忙嗎?17DietaryproteinrestrictionsignificantlyreducestheriskofdeclineinGFRorcreatinineclearanceinpatientswithdiabeticnephropathy.Low protein diet:effect on progression of CRF in diabetic CKD patients:meta-analysisPEDRINIetal.(1996):Effectofdietaryproteinrestrictionontheprogressionofdiabeticandnondiabeticrenaldiseases:ameta-analysis.AnnInternMed,124,627-632Dietaryproteinrestriction18Low Protein DietIncidence of ESRD/death in diabetic nephropathyHANSENetal.(2002):EffectofdietaryproteinrestrictiononprognosisinpatientswithdiabeticnephropathyKidneyInt,62,220-228Aproteinrestrictionimprovesprognosisintype1diabeticpatientswithprogressivediabeticnephropathyin additiontothebeneficialeffectofantihypertensivetreatment.LowProteinDietHANSENetal.19何謂SupplementedVeryLowProteinDiet(SVLPD)?何謂SupplementedVeryLowProte20Caloric supply(kcal/kgbw/day)30-35%fromcarbohydrates67%fromlipids30%fromproteins 3Protein content (g/kgbw/day)0.3-0.4(max.0.6)Phosphorus content (mg/kgbw/day)5-7Supplemented with:Calcium(g/day)0.5-1.0VitaminD(IU/day)1,000Iron(mg/day)100mg/kgbw/day10-15Dietary management in CKDComposition of a Keto Acid TherapyKA/AA(Ketosteril)Caloricsupply(kcal/kgbw/day21MechanismsofProtectiveEffectsofLPD+KSinCKDReducesProimflammatoryCytokinesMetabolicDisorrdersCorrectionCHOandLipidAcidosiscatabolicImprovesAbnormalRenalHemodynamicReducesProteinuriaNephroProtectiveRetardsProgressionAmeliorates SymptomsImproves outcomeMineralsMechanismsofProtectiveEffec22Specific Dietary Requirements for Patients with Chronic Kidney DiseasePatientsProtein requirementNotesNormal 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 sufficientSpecificDietaryRequirements23
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