Nutrizione nell insufficienza renale cronica; quattro luoghi comuni: il sale, il peso, le proteine e l acqua. Luca Gabutti Bellinzona

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1 Nutrizione nell insufficienza renale cronica; quattro luoghi comuni: il sale, il peso, le proteine e l acqua Luca Gabutti Bellinzona

2 Lose weight! Eat less proteins!

3 Malattia renale cronica e rischio di ulteriore peggioramento Come filtra Quanto filtra

Salt intake per person per day for adults in the WHO European Regions from individual countrybased surveys,

5 TUR HUN HRV MKD CZE BGR SVN PRT ROU SWE EST ESP ITA LUX FRA CHE LTU IRL GBR DNK NOR AUT NLD SVK FIN ISL DEU AND LVA BEL ISR POL CYP ALB ARM AZE BLR BIH GEO GRC KAZ KGZ MLT MCO MNE MDA RUS SMR SRB TJK TKM UKR UZB Grams Salt intake per person per day for adults in the WHO European Regions from individual countrybased surveys, various years WHO/FAO RECOMMENDATION <5 grams No data 2 g Na Country

6 The Swiss Survey on Salt (SSS) Study population: 1624 subjects (729 men, 777 women) from 3 linguistic regions (11 centers) 4.2 g Na 3.1 g Na

7 Estimated 24-Hour Urinary Excretion of Sodium and CV Death, Myocardial Infarction, Hospitalization for Congestive Heart Failure, and Stroke 11.2 g Na (g) x 2.5 = NaCl (g) NaCl (g) x 16.7 = NaCl (mmol) JAMA, 2011

8 8.7g NaCl Mills. JAMA. 2016

¼ of hypertensive patients with CKD have resistant hypertension BP 130/80 mm Hg despite 3 antihypertensive drugs including a diuretic or 4 drugs regardless of BP level Condition

9 ¼ of hypertensive patients with CKD have resistant hypertension BP 130/80 mm Hg despite 3 antihypertensive drugs including a diuretic or 4 drugs regardless of BP level Condition more common in patients not adhering to a low-salt regimen De Nicola. Prevalence and prognostic role of resistant hypertension in chronic kidney disease patients. J Am Coll Cardiol 2013

10 Prevalence and determinants of chronic kidney disease in the Swiss population G3a A1; G1 and G2 A2 G3b A1; G3a A2; G1 and G2 A3 G4 and G5; G3aA3; G3bA2 and A3 Forni Ogna, Swiss Med Wkly. 2016;146:w14313

11 Prevalence and determinants of chronic kidney disease in the Swiss population Decline slope (SE): 0.79 (0.03) ml/min/1.73 m2/year for men, 0.80 (0.03) ml/min/1.73 m2/year for women Forni Ogna, Swiss Med Wkly. 2016;146:w14313

12 Intervention trials, Nomura, Kidney International (2017) 92, 67 78

13 Intervention trials, Nomura, Kidney International (2017) 92, 67 78

14 Meta-regression analysis of the percentage difference in the renal outcome plotted versus the duration of the intervention in 6 trials Intervention trials, Nomura, Kidney International (2017) 92, 67 78

Ragazzo 18enne Nefropatia congenita malformativa con ipomagnesemia e ipocalciuria CKD: egfr 70, non albuminuria PA 118/74 mmhg BMI 15 (47 Kg 177 cm)

15 Ragazzo 18enne Nefropatia congenita malformativa con ipomagnesemia e ipocalciuria CKD: egfr 70, non albuminuria PA 118/74 mmhg BMI 15 (47 Kg 177 cm) Debolezza/affaticabilità Consumo di NaCl 6g/24 ore e di proteine 61g (1.3 g/kg)/24 ore (consigliato in passato di contenere il consumo di sale e di proteine) Che cosa gli consigliate?

16 Troppo sale è > 5g per la WHO ma più probabilmente più di 10g (?) nella popolazione generale e più di 7.5g (?) nella CKD Nell ipertensione resistente (e se proteinuria, iperfostatemia o sovraccarico di sodio ) considerare il target della WHO Individualizzare il target!

17 Lose weight!

18 2% risk increase for every increment of 1 kg/m2 of body mass index 39 cohorts covering participants,garofalo,kidney International (2017) 91,

nutritional habits in patients with incident CKD In Western countries the excess of protein, salt and phosphate intake impair the effectiveness of RAAS inhibitors and antihypertensive drugs,

19 nutritional habits in patients with incident CKD In Western countries the excess of protein, salt and phosphate intake impair the effectiveness of RAAS inhibitors and antihypertensive drugs, increases proteinuria, contributes to mineral bone disease and metabolic acidosis. Severely reduced renal function induces retention of nitrogen-derived toxins, which causes loss of appetite, taste abnormality, and anorexia Kovesdy. Am J Clin Nutr 2013

20 Criteria for the diagnosis of protein-energy wasting (at least one criterion in 3 out of 4 categories). The International Society of Renal Nutrition and Metabolism. 1) Reduced levels of biochemical markers of nutritional status: pre-albumin (<28 mg/dl), albumin (<38 g/l), cholesterol 2) Reduced body mass: BMI<23 kg/m 2 or unintentional weight loss of >5% in 3 months or 10% in 6 months, reduced fat mass <10%) 3) Reduced muscle mass: reduction of muscle mass by 5% in 3 months or 10% in 6 months, reduced arm muscle area by 10% as compared to the 50th percentile of the reference population 4) Inadequate nutritional intake: spontaneous intake of protein and calories of <0.8 g/kg/d and <25 kcal/kg/d, respectively, for at least 2 months Fouque. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008

21 Accuracy of BMI in assessing nutritional status and risk of malnutrition in catabolic diseases such as CKD A BMI < 23 kg/m 2 in CKD is compatible with a normal nutritional status Obesity is not exempt from PEW Leal. Is a body mass index of 23 kg/m² a reliable marker of protein-energy wasting in hemodialysis patients? Nutrition 2012 Carrero. Pros and cons of body mass index as a nutritional and risk assessment tool in dialysis patients. Semin Dial 2015

22 Il sovrappeso è un fattore di rischio per sviluppare una malattia renale cronica Nell insufficienza renale, attenzione al sovrappeso con sarcopenia

23 Eat less proteins!

24 dietary protein restriction is the basis of the nutritional therapy for CKD Guidelines on CKD advise 0.8 g/kg/d in adults with GFR <30 ml/min/1.73 m 2, and < 1.3 g/kg/d in all patients at risk of CKD progression KDIGO Guidelines, Chapter 3. Management of progression and complications of CKD. Kidney Int 2013

25 in Italy, the mean protein intake is 1.3±0.6 g/kg/d Cirillo M Lombardi C Chiricone D et al. Protein intake and kidney function in the middle-age population: contrast between cross-sectional and longitudinal data. Nephrol Dial Transplant 2014

In CKD stages 3b or advanced, a protein prescription of 0.6-0.

26 In CKD stages 3b or advanced, a protein prescription of g/kg/d could improve uremia, metabolic acidosis, and hyperparathyroidism Cianciaruso B Pota A Pisani A et al. Metabolic effects of two low protein diets in chronic kidney disease stage IV-V: a randomized controlled trial. Nephrol Dial Transpl 2008

In diabetes, a decrease in protein intake leads to a decrease in proteinuria (chicken better then red meat) De Mello VDF Zelmanovitz T Perassolo MS et al.

27 In diabetes, a decrease in protein intake leads to a decrease in proteinuria (chicken better then red meat) De Mello VDF Zelmanovitz T Perassolo MS et al. Withdrawal of red meat from the usual diet reduces albuminuria and improves serum fatty acid profile in type 2 diabetes patients with macroalbuminuria. Am J Clin Nutr 2006

28 Red meat is associated with an higher risk of ESRD Lew QLJ Jafar TH Koh HWL et al. Red meat intake and risk of ESRD. J Am Soc Nephrol 2016

Vegetarian diets are associated with decreased acid load which produces a lower risk of renal fibrosis and lower progression of renal insufficiency Scialla.

29 Vegetarian diets are associated with decreased acid load which produces a lower risk of renal fibrosis and lower progression of renal insufficiency Scialla. Plant protein intake is associated with fibroblast growth factor 23 and serum bicarbonate levels in patients with CKD: the Chronic Renal Insufficiency Cohort Study. J Ren Nutr Goraya Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int 2012

30 Ketoanalogue-Supplemented Vegetarian Very Low Protein Diet and CKD Progression (0.6 vs g/kg per day) Garneata, J Am Soc Nephrol 27: , 2016

31 approach to hyperphosphatemia 1) Increase efficiency of antialbuminuric therapy by low-salt diet and renin-angiotensin system blockade 2) Reduce protein intake to 0.8 g/kg/d (that per se limits phosphate intake to mg/d) 3) Provide nutritional counseling aimed at limiting phosphate loads (cola drinks, processed sausages and cheese, industrial food with phosphoruscontaining additives) and at reducing phosphorus content by preferring boiling as type of cooking D Alessandro C Piccoli GB Cupisti A The phosphorus pyramid : a visual tool for dietary phosphate management in dialysis and CKD patients. BMC Nephrol 2015

32 The intestinal absorption rate of phosphate is lower with plant protein. Less meat processed food leads to a decrease in phosphate additives. Moe SM Zidehsaraj MP Chambers MA et al. Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin J Am Soc Nephrol 2011

33 Dietary protein intake and chronic kidney disease Ko; Curr Opin Clin Nutr Metab Care 2017, 20:77 85

34 To avoid a negative nitrogen balance >50% of proteins have to be of high biological value and the energy intake should be normal-high (30-35 kcal/kg/d) D Alessandro C Piccoli GB Calella P et al. Dietaly : practical issues for the nutritional management of CKD patients in Italy. BMC Nephrol 2016

35 The biological value of a protein is a measure of the % of the protein that can be incorporated into the proteins of the human body Protein food Biological value Egg 94 Milk 90 Rice 83 Quinoa 83 Fish 76 Beef 74 Soybeans 73 Whole wheat 64 Bellizzi. (ERA-EDTA) European Renal Nutrition Working Group of the European Renal Association. point care 2016

36 The case (2012): 59 year old woman, known proteinuric nephropathy (egfr EPI: 39 ml/min, proteinuria 330mg/mmol -> G3bA3) and hypertension (first diagnosis 1981) No symptoms Home BP about 130/80 mmhg BMI 25 kg/m 2

37 Follow-up visit after 5 years: 64 year old No symptoms; vegetarian diet BMI 21 (25) kg/m 2 (75 -> 65 kg) Home BP about 150/85 (130/75)

38 egfr EPI 2012: 39 ml/min egfr EPI 2017: 20 ml/min (G4A3) She lost 19 ml/min in 5 years; 3.8 ml/year; she will probably require dialysis/transplantation in about 3 years

Sodio 2.8 g/24 ore ; (((urea 220) x 28/1000) + 1.7)/0.

39 Sodio 2.8 g/24 ore ; (((urea 220) x 28/1000) + 1.7)/ > proteine 51 g/24 ore (0.78 g/kg) meducator3.net

40 New anthropometry-based age- and sex-specific reference values for urinary 24-hour creatinine excretion based on the adult Swiss population Forni Ogna, BMC Medicine 2015, 13:40

41 Diminure l apporto di proteine protegge la funzione renale Le proteine vegetali potrebbero essere più favorevoli Attenzione al rischio di malnutrizione proteica; monitorare l apporto calorico

43 Association between Water Intake and Chronic Kidney Disease: Cross-Sectional Analysis of NHANES CKD was higher among those with the lowest (<2.0 l/day) vs. highest total water intake (>4.3 l/day) (adjusted odds ratio 2.52; 95% confidence interval Sontrop, Am J Nephrol 2013;37:

44 Fluid and nutrient intake and risk of chronic kidney disease Number of participants who completed the survey CKD in % of the men and % of the women (ages y). the highest quintile of fluid intake (3.2 L/day) had a significantly lower risk of CKD (odds ratio 0.5, 95%CI 0.32 to 0.77, P = 0.003). Strippoli. Nephrology (Carlton) 16: , 2011

45 High Water Intake and Progression of Chronic Kidney Diseases despite the encouraging association between high water intake and preserved egfr in the two large observational studies, causal relationships between increased water intake and reduced GFR loss among individuals with CKD remain speculative. Choi, Electrolyte Blood Press 13:46-51, 2015

46 Suggerire un grande apporto di acqua come protettivo è (per ora) speculativo

47 La vera sfida è essere coscienti dell individualità e della specificità dei bisogni

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