低蛋白饮食在改善蛋白尿和推迟透析开始方面的作用:新与旧
The role of low protein diet in ameliorating proteinuria and deferring dialysis initiation: what is old and what is new.
作者信息
Wang Mengjing, Chou Jason, Chang Yongen, Lau Wei L, Reddy Uttam, Rhee Connie M, Chen Jing, Hao Chuanming, Kalantar-Zadeh Kamyar
机构信息
Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, CA, USA.
Division of Nephrology, Fudan University, Huashan Hospital, Shanghai, China.
出版信息
Panminerva Med. 2017 Jun;59(2):157-165. doi: 10.23736/S0031-0808.16.03264-X. Epub 2016 Oct 19.
In the management of patients with chronic kidney diseases (CKD), a low-protein diet usually refers to a diet with protein intake of 0.6 to 0.8 grams per kilogram of body weight per day (g/kg/day) and should include at least 50% high-biologic-value protein. It may be supplemented with essential acids or nitrogen-free ketoanalogues if <0.6 g/kg/d. Low-protein diet can reduce proteinuria especially in non-diabetic CKD patients. In hypoalbuminemic patients it may lead to an increase in serum albumin level. By lowering proteinuria, decreasing nitrogen waste products, ameliorating metabolic burden, mitigating oxidative stress and acidosis, and lowering phosphorus burden, a low-protein diet can help delay dialysis start in advanced CKD. Low-protein diet is safe, since most CKD patients can maintain nitrogen balance by mechanisms of decreasing amino acid oxidation and protein degradation in addition to increased utilization of amino acids for protein synthesis. We suggest a dietary protein intake below 1.0 g/kg/day when estimated glomerular filtration rate (eGFR) falls below 60 mL/min/1.73 m2 or when there is solitary kidney or proteinuria at any level of GFR. Protein intake should be reduced progressively based on severity and progression of CKD and patient's nutritional status with a target of 0.6-0.8 g/kg/d in most patients with eGFR <45 mL/min/1.73 m2. The risk of protein-energy wasting can be overcome by careful attention to quantity and quality of the ingested proteins, sufficient energy intake of 30-35 Kcal/kg/d, and use of dietary supplements. Long-term observations and individualized approaches are needed to further demonstrate the benefits and safety of low-protein diet.
在慢性肾脏病(CKD)患者的管理中,低蛋白饮食通常是指每天每千克体重蛋白质摄入量为0.6至0.8克(g/kg/天)的饮食,且应包含至少50%的高生物价蛋白质。如果蛋白质摄入量<0.6 g/kg/天,可补充必需氨基酸或无氮酮类似物。低蛋白饮食可减少蛋白尿,尤其是在非糖尿病CKD患者中。在低白蛋白血症患者中,它可能会导致血清白蛋白水平升高。通过降低蛋白尿、减少氮废物产物、减轻代谢负担、缓解氧化应激和酸中毒以及降低磷负担,低蛋白饮食有助于延缓晚期CKD患者开始透析。低蛋白饮食是安全的,因为大多数CKD患者除了增加氨基酸用于蛋白质合成的利用率外,还可通过减少氨基酸氧化和蛋白质降解的机制来维持氮平衡。当估计肾小球滤过率(eGFR)低于60 mL/min/1.73 m² 或存在孤立肾或在任何GFR水平出现蛋白尿时,我们建议饮食蛋白质摄入量低于1.0 g/kg/天。应根据CKD的严重程度和进展以及患者的营养状况逐步减少蛋白质摄入量,大多数eGFR<45 mL/min/1.73 m² 的患者目标为0.6 - 0.8 g/kg/天。通过仔细关注摄入蛋白质的数量和质量、充足的能量摄入(30 - 35千卡/千克/天)以及使用膳食补充剂,可以克服蛋白质 - 能量消耗的风险。需要长期观察和个体化方法来进一步证明低蛋白饮食的益处和安全性。