极低蛋白饮食治疗严重慢性肾功能不全的安全性和有效性

Safety and efficacy of very low protein diet in the treatment of patients with severe chronic renal insufficiency

目的观察在不补充必需氨基酸或其酮酸情况下,极低蛋白饮食对严重慢性肾功能不全患者营养状态及肾功能的影响。方法37例慢性肾功能不全患者犤Scr(588.2±123.5)μmol/L,Ccr(9.77±3.48)ml·min-1·(1.73m2)-1犦按实际蛋白摄入量分成两组:极低蛋白饮食治疗组犤VLPD,蛋白摄入量(0.33±0.04)g·kg-1·d-1犦,20例;低蛋白饮食治疗组犤LPD,蛋白质摄入量为(0.60±0.11)g·kg-1·d-1犦,17例。观察患者的顺应性、营养相关生化指标及肾功能进展。结果(1)患者对极低蛋白饮食有较好的耐受性,无一例患者出现蛋白营养不良征象,观察期间患者血清白蛋白浓度稳定。和低蛋白饮食相比,极低蛋白饮食患者血清白蛋白浓度升高(P<0.05)。5例VLPD患者虽然蛋白质摄入量持续低于0.3g·kg-1·d-1,但经过最长53个月治疗,血清白蛋白仍能维持正常范围。(2)虽然两组患者血清转铁蛋白浓度有下降趋势,但仍保持在正常范围。(3)和VLPD组比较,LPD组患者血HCO3-水平明显降低(P<0.05),且VLPD组患者为治疗代谢性酸中毒所使用的碳酸氢盐剂量明显低于LPD组(P<0.05)。(4)两组患者血清磷浓度保持正常,LPD组增高趋势较明显,但差异无显著性意义(P>0.05)。VLPD组服用肠道磷结合剂的剂量明显小于LPD组(P<0.05)。(5)VLPD及LPD组患者肾功能不全进展速度分别?

Objective To investigated the effects of long term use of very low protein diet(VLPD,0 3 g·kg-1·d-1) treatment on patients with chronic renal insufficiency without essential amino acids(EAAs) or related ketoacids supplement.Methods Thirty seven patients with established severe chronic renal failure (CRF)[Scr(588 2±123 5)μmol/L, Ccr(9 77±3 48)ml·min-1·(1 73m2)-1]were divided into 2 groups according to their actual protein intake: 20 patients with protein intake of (0 33±0 04)g·kg-1·d-1 were used as VLPD group, while other 17 CRF patients whose protein intake was 0 6 g·kg-1·d-1 were served as low protein diet group (LPD). Results All patients in VLPD group showed good compliance to this very low protein diet,and no one presented signs of protein malnutrition during the observation. The concentrations of serum albumin and transferrin were maintained in normal ranges during the follow up period despite the transferrin levels in both groups gradually decreased as time went on. The serum concentration of transferrin was higher in VLPD patients than that in LPD patients at the end of study (P< 0 05). LPD group showed more obvious tendency to develop severe metabolic acidosis and had higher concentration of serum phosphate than VLDP group. Lower doses of sodium bicarbonate and phosphate binding agents were needed to correct these metabolic disturbances in VLPD than in LPD group. The mean decrease in GFR during the observation was (0 125±0 072)ml·min-1·month-1 in VLPD patients, slower than that in LPD group (0 214±0 017)ml·min-1·month-1(P< 0 01). At the time of initiating renal replacement treatment, the Ccr was lower in VLPD patients than that in LPD patients [(3 70±1 17) vs(8 46±2 57)ml·min-1·(1 73m2)-1]. The time course of initiating dialysis in VLPD group was significantly longer than that of LPD group. The time course of initiating dialysis in VLPD group was significantly longer than that of LPD group[(72 0±33 5),(33 4±6 52) months,respectively,P< 0 01). Indeed, the kidney replacement treatment was postponed for about 4 to 5 years with very low protein diet treatment compared with classical LPD regime. Conclusions Long term treatment with very low protein diet without supplement of EAAs in chronic renal insufficiency is safe and effective. Some metabolic disturbances accompanied with renal disease, such as metabolic acidosis, hyperphosphatemia, secondary hyperparathyroidism and renal osteopathy can be effectively improved and the renal death event rate can be significantly reduced.