INFLUENCE OF LOW PROTEIN DIET IN IMPROVING ANEMIA TREATED WITH ERYTHROPOETIN

Transcription

1 INFLUENCE OF LOW PROTEIN DIET IN IMPROVING ANEMIA TREATED WITH ERYTHROPOETIN, Idrizi A, Barbullushi M, Gjyzari A, Duraku A Department of Nephrology, University Hospital Center, Tirana, Albania

2 Introduction Anemia is a major complication of chronic renal failure. The use of Erythropoetin (EPO) in recent years improved in a radical way the life quality, cardiovascular complications and mortality in uremic patients.

3 Background Whether pts with CKD should be described a restricted dietary protein has been a matter of much debate. MDRD study showed that a low versus usual protein diet (0.58 vs. 1.3 g/kg/d) did not result in slower decline of kidney function. Other meta-analysed studies in CKD stage 1-3 found no reduction in mortality or ESRD after LPD. Because present data are not firmly conclusive,dietary protein restriction are not firmly recommended as a rutine kidney protective strategy for pts with CKD.

4 Background However the reported safety of LPD and their beneficial effect on uremic symptoms are obvious and justified for most CKD pts. KDIGO guidelines suggest the consumption of a high quality protein diet of around 0.8 g/kg/day among individuals with CKD stages 3-5 who are motivated to follow such a diet. Others suggest a lower range of protein restrictions to g/kg/day, provided that the signs of malnutrition are not present.

5 Aim of the study To evaluate the role of low protein diet in improvement of renal anemia treated with EPO.

6 Methods: We studies two groups of patients with advanced chronic renal disease (creatinine clearance <25 ml/min) treated with EPO for one year. The first group (42 patients),received a low protein diet ( gr/kg.w./day ). The second group (46 patients)received a very low protein diet ( gr/kg.w. /day)plus ketoanalogs of essential aminoacids (ketosteril). The target of Hb.level was gr/dl).

7 Patients demographic data Demographic variable Total number of patients N 88 Sex (M/F) 47/41 Age (years) 36.3±10.7 (27-68) Weight (kg) 64.2±6.7 (54-96) Height (cm) 152.7±7.4 ( )

8 Results At the end of the study period the level of Hb was similar in both groups (11.6 ± 0.4 gr/dl and 11.7 ± 0.3 gr/dl respectively). The dose of EPO was similar in both groups in the begining (55.3 ± 8.2 UI/kg.w./week and 54.8 ± 9.7 UI/kg.w./week respectively). This dose did not changed in the first group but was diminished progressively in the second group until it was 45.7 ± 8.4 UI/kg.w./week at the end of the study period (p < 0.001).

9 Results after 1 year treatment

10 Discussion: Hyperparathyroidism is usually listed among the possible reasons for impaired response to recombinant human erythropoietin (rhuepo) in patients with renal disease. Possible pathogenic links between anaemia and parathyroid hormone (PTH) include reduced erythropoiesis due to calcitrol deficiency, and direct or indirect effects of PTH on erythropoietin release, red blood cell (RBC) production, survival, and loss.

11 Causes of inadequate ESA response Causes for inadequate ESA Causes for inadequate ESA response Number * response Number * Infection/inflammation 41 Haemolysis 0 Blood loss 16 Pure red cell aplasia 1 Hyperparathyroidism/alumini um toxicity 10 Malignancy 7 Haemoglobinopathy 2 Graft/shunt problems 14 Folate/vitamin B12 deficiency 1 Operation 8 Multiple myeloma/myelofibrosis/myel odysplastic syndrome 6 Suspected noncompliance 9 Malnutrition 5 Medication ( bone marrow suppress) 4 Inadequate dialysis 2 Unknown 2 Anaemia Management in Chronic Kidney Disease: Partial Update 2015 [Internet]. NICE Guideline, No. 8. National Clinical Guideline Centre (UK).

12 Figure 1 Erythropoietin (EPO) dose (bars) and hemoglobin concentration (line) at baseline and during follow-up in very low protein diet (VLPD) (A) and low protein diet (LPD) (B) patients. Kidney International Copyright , International DOI: Society ( /j x) of Kidney International Volume 64, Issue 5, Pages (November 2003)

13 Linear regression between Figure the 2 percentage changes of parathyroid hormone (PTH) level and erythropoietin (EPO) dose at 18 months in low protein diet (LPD) and very low protein diet (VLPD) patients Kidney International , DOI: ( /j x) Copyright 2003 International Society of Nephrology Kidney International Volume 64, Issue 5, Pages (November Koroshi 2003) A

14 From: Very low-protein diet plus ketoacids in chronic kidney disease and risk of death during end-stage renal disease: a historical cohort controlled study Nephrol Dial Transplant. 2014;30(1): doi: /ndt/gfu251 Nephrol Dial Transplant The Author Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

15 From: Very low-protein diet plus ketoacids in chronic kidney disease and risk of death during end-stage renal disease: a historical cohort controlled study Nephrol Dial Transplant. 2014;30(1): doi: /ndt/gfu251 Nephrol Dial Transplant The Author Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

16 Conclusions In advanced chronic renal disease, reducing dietary proteins allows a lower dose of EPO in order to maintain the same level of Hb. We support the idea that this effect is linked with reduced level of phosphates in the diet and consequently with reduced production of PTH.