Kalantar-Zadeh Kamyar, Rhee Connie M, Joshi Shivam, Brown-Tortorici Amanda, Kramer Holly M
University of California Irvine (UCI), Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, Orange.
Tibor Rubin VA Long Beach Healthcare System, Long Beach, California.
Curr Opin Nephrol Hypertens. 2022 Jan 1;31(1):26-35. doi: 10.1097/MNH.0000000000000761.
Nearly half of all Americans with chronic kidney disease (CKD) also have type-2-diabetes (T2D). Whereas traditional and emerging pharmacotherapies are increasingly frequently used for the management of CKD in diabetes (CKD/DM), the role of integrated or multimodal interventions including the potentially synergistic and additive effect of diet and lifestyle modifications in addition to pharmacotherapy has not been well examined, in sharp contrast to the well-known integrated approaches to heart disease.
Low-carbohydrate low-fat diets are often recommended in T2D, whereas low-protein diets (LPD) are recommended by guidelines for nondiabetic CKD with increasing emphasis on plant-based protein sources. High-protein diets with greater animal protein lead to glomerular hyperfiltration, especially in patients with T2D, and faster decline in renal function. Guidelines provide differing recommendations regarding the amount (low vs high) and source (plant vs animal) of dietary protein intake (DPI) in CKD/DM. Some such as KDIGO recommend 0.8 g/kg/day based on insufficient evidence for DPI restriction in CKD/DM, whereas KDOQI and ISRNM recommend a DPI of 0.6 to <0.8 g/kg/day. A patient-centered plant-focused LPD for the nutritional management of CKD/DM (PLAFOND), a type of PLADO diet comprising DPI of 0.6 to <0.8 g/kg/day with >50% plant-based sources, high dietary fiber, low glycemic index, and 25-35 Cal/kg/day energy, can be implemented by renal dietitians under Medical Nutrition Therapy.
Potential risks vs benefits of high vs low protein intake in CKD/DM is unknown, for which expert recommendations remain opinion based. Randomized controlled studies are needed to examine safety, acceptability and efficacy of PLAFOND.
在所有患有慢性肾脏病（CKD）的美国人中，近一半同时患有2型糖尿病（T2D）。尽管传统和新兴药物疗法越来越频繁地用于糖尿病合并慢性肾脏病（CKD/DM）的治疗，但与广为人知的心脏病综合治疗方法形成鲜明对比的是，包括饮食和生活方式改变的潜在协同和累加效应在内的综合或多模式干预措施在药物治疗之外的作用尚未得到充分研究。
T2D患者通常推荐低碳水化合物低脂饮食，而非糖尿病CKD指南则推荐低蛋白饮食（LPD），且越来越强调植物性蛋白质来源。高蛋白饮食尤其是动物蛋白含量高的饮食会导致肾小球高滤过，特别是在T2D患者中，并使肾功能下降更快。关于CKD/DM患者饮食蛋白质摄入量（DPI）的量（低与高）和来源（植物与动物），指南提供了不同的建议。例如，KDIGO基于CKD/DM中DPI限制证据不足，推荐每日摄入量为0.8 g/kg；而KDOQI和ISRNM则推荐DPI为0.6至<0.8 g/kg/天。一种以患者为中心、以植物为重点的用于CKD/DM营养管理的LPD（PLAFOND），这是一种PLADO饮食，其DPI为0.6至<0.8 g/kg/天，植物性来源>50%，膳食纤维含量高，血糖指数低，能量为25 - 35 Cal/kg/天，可由肾脏营养师在医学营养治疗下实施。
CKD/DM中高蛋白摄入与低蛋白摄入的潜在风险与益处尚不清楚，专家建议仍基于观点。需要进行随机对照研究来检验PLAFOND的安全性、可接受性和有效性。
