晚期糖尿病肾病合并大量蛋白尿患者的低盐低蛋白饮食与血压控制

Low-salt low-protein diet and blood pressure control in patients with advanced diabetic kidney disease and heavy proteinuria.

作者信息

Mihalache Andreea, Garneata Liliana, Mocanu Carmen Antonia, Simionescu Tudor-Petrisor, Mircescu Gabriel

机构信息

"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.

Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, 4 Calea Grivitei, Sector 1, 010731, Bucharest, Romania.

出版信息

Int Urol Nephrol. 2021 Jun;53(6):1197-1207. doi: 10.1007/s11255-020-02717-2. Epub 2021 Jan 2.

DOI:10.1007/s11255-020-02717-2

PMID:33389459

Abstract

PURPOSE

To assess the associations between effects of low salt, low protein diet supplemented with keto-analogues (sLPD)-on salt intake, blood pressure (BP) and cardiovascular events (CVEs) in patients with advanced diabetic kidney disease (DKD) and heavy proteinuria.

METHODS

Prospective, single-center study (total duration of 15 months), enrolling 92 patients with advanced DKD (median eGFR 11.7 ml/min) and heavy proteinuria (median 4.8 g/g creatininuria). The intervention consisted in a low salt-low protein (0.6 g/kg-day) diet (sLPD) under intensive nutritional counselling, and adjustment of antihypertensive therapy. The endpoints of this sub-analysis were a salt intake ≤ 5 g/day, a mean blood pressure (MAP) ≤ 97 mmHg, corresponding to KDIGO target of 130/80 mmHg, and the rate of CVEs.

RESULTS

Salt intake decreased with 2.5 g/day and the proportion of patients reaching the salt intake endpoint increased with 58%. A salt intake ≤ 5 g/day was associated with a reduced MAP, BMI, proteinuria, fractional excretion of sodium, and eGFR, suggesting a salt-related volume contraction but was not related to protein intake. Mean arterial pressure decreased with 13 mmHg. MAP ≤ 97 mmHg was associated with lower proteinuria, salt, and protein intake, but the contribution of salt intake cannot be differentiated from that of protein intake. CVEs occurred in 20% of patients and were independently related to a lower age and MAP, and increased comorbidities. eGFR only minimally declined and no renal adverse events were noted. sLPD was nutritionally safe.

CONCLUSIONS

The multifactorial personalized intervention allowed a stable MAP reduction to KDIGO recommended levels (≤ 97 mmHg), related to the decrease in salt and protein intake. However, BP lower than 130/80 mmHg increased the cardiovascular but not the renal risk in heavy proteinuric patients with advanced DKD.

TRIAL REGISTRATION NUMBER

0341507433: NCT03415074. Registered 02/02/2015 in US National Library of Medicine, ClinicalTrials.gov (NCT).

摘要

目的

评估补充酮类似物的低盐、低蛋白饮食（sLPD）对晚期糖尿病肾病（DKD）合并大量蛋白尿患者盐摄入量、血压（BP）及心血管事件（CVE）的影响。

方法

前瞻性单中心研究（总时长15个月），纳入92例晚期DKD患者（估算肾小球滤过率[eGFR]中位数为11.7 ml/min）及大量蛋白尿患者（肌酐尿中位数为4.8 g/g）。干预措施包括在强化营养咨询下采用低盐低蛋白（0.6 g/kg·天）饮食（sLPD），以及调整降压治疗。该亚组分析的终点为盐摄入量≤5 g/天、平均血压（MAP）≤97 mmHg（对应KDIGO目标值130/80 mmHg）及CVE发生率。

结果

盐摄入量每日减少2.5 g，达到盐摄入终点的患者比例增加58%。盐摄入量≤5 g/天与MAP、体重指数（BMI）、蛋白尿、钠排泄分数及eGFR降低相关，提示与盐相关的容量收缩，但与蛋白质摄入量无关。平均动脉压下降13 mmHg。MAP≤97 mmHg与较低的蛋白尿、盐及蛋白质摄入量相关，但盐摄入量的作用无法与蛋白质摄入量的作用区分开来。20%的患者发生了CVE，且与较低年龄、MAP及合并症增加独立相关。eGFR仅轻微下降，未观察到肾脏不良事件。sLPD在营养方面是安全的。