Waugh N R, Robertson A M
Wessex Institute of Health Research and Development, University of Southampton, Mailpoint 728 Boldrewood, Southampton, UK, SO16 7PX.
Cochrane Database Syst Rev. 2000(2):CD002181. doi: 10.1002/14651858.CD002181.
To determine whether protein restriction slows or prevents progression of diabetic nephropathy towards renal failure.
Computerised databases MEDLINE (1976-1996) and EMBASE (1974-1996) were searched using keywords diabetes mellitus, diabetic nephropathy, dietary proteins, diet, protein restricted and uremia. Recent issues of selected journals (Diabetic Medicine, Diabetologia, Diabetes Care, Kidney International, Nephrology Dialysis and Transplantation) were handsearched for papers not yet in the computerised databases. Reference lists of papers were also checked.
This review was not limited to randomised controlled trials. All trials involving people with insulin-dependent diabetes following a lower protein diet for at least 4 months were considered since the straight line nature of progression as reflected by GFR means that patients can act as their own controls in a before and after comparison.
Data were extracted for length of follow up, level of protein restriction, renal function and dietary compliance. No studies of the impact of protein restriction on outcomes such as the need for dialysis or transplantation were found. The trials reported only the effect on short-term indicators such as creatinine clearance.
Overall a protein restricted diet (0.3-0. 8g/kg) does appear to slow the progression of diabetic nephropathy towards renal failure.
REVIEWER'S CONCLUSIONS: The results show that reducing protein intake appears to slow progression to renal failure, but some questions remain unanswered. The first is what level of protein restriction we should be used? The trials aimed for a daily intake of between 0.3 to 0.8g/kg of protein. The second concerns compliance in routine care - what level would be acceptable to patients? The third concerns long term outcomes -the present trials use proxy indicators such as creatinine clearance rather than outcomes such as time to dialysis or prevention of ESRF. All trials were carried out in subjects with insulin-dependent diabetes. It remains to be seen if a lower protein intake would slow the progression of nephropathy affecting the non-insulin dependent diabetic population.
确定蛋白质限制是否能减缓或预防糖尿病肾病向肾衰竭的进展。
使用关键词糖尿病、糖尿病肾病、膳食蛋白质、饮食、蛋白质限制和尿毒症检索计算机数据库MEDLINE（1976 - 1996年）和EMBASE（1974 - 1996年）。对选定期刊（《糖尿病医学》《糖尿病学》《糖尿病护理》《国际肾脏杂志》《肾病透析与移植》）的近期期刊进行手工检索，以查找尚未收录在计算机数据库中的论文。还检查了论文的参考文献列表。
本综述不限于随机对照试验。所有涉及胰岛素依赖型糖尿病患者采用低蛋白饮食至少4个月的试验均被纳入考虑，因为肾小球滤过率所反映的疾病进展的直线性质意味着患者在前后比较中可作为自身对照。
提取随访时间、蛋白质限制水平、肾功能和饮食依从性的数据。未发现关于蛋白质限制对诸如透析或移植需求等结局影响的研究。这些试验仅报告了对肌酐清除率等短期指标的影响。
总体而言，蛋白质限制饮食（0.3 - 0.8克/千克）似乎确实能减缓糖尿病肾病向肾衰竭的进展。
结果表明，减少蛋白质摄入似乎能减缓向肾衰竭的进展，但一些问题仍未得到解答。第一个问题是应采用何种蛋白质限制水平？这些试验的目标是每日蛋白质摄入量在0.3至0.8克/千克之间。第二个问题涉及常规护理中的依从性——患者可接受的水平是多少？第三个问题涉及长期结局——目前的试验使用肌酐清除率等替代指标，而非诸如透析时间或预防终末期肾衰竭等结局指标。所有试验均在胰岛素依赖型糖尿病患者中进行。低蛋白摄入是否会减缓影响非胰岛素依赖型糖尿病人群的肾病进展仍有待观察。
