CKD: Progression and Diabetes (2001)
Articles based on adults with chronic renal failure. Other criteria not specified.
Other criteria not specified.
Recruitment: article selection methods not specified.
Design: Narrative Review.
Blinding Used (if applicable): not specified.
Intervention (if applicable): not specified.
Statistical Analysis: not specified.
Timing of Measurements: not specified.
Dependent Variables: not specified.
Independent Variables: not specified.
Control Variables: not specified.
Initial N: not specified, 40 references included.
Attrition (Final N): not specified.
Age: not specified.
Ethnicity: not specified.
Other relevant demographics: not specified.
Anthropometrics: not specified.
Location: not specified.
Categories of Renal Function
1. Normal Renal Function Serum creatinine: 70 – 106 µmol/L Blood urea nitrogen: 3.6 – 7.1 mmol/L Creatinine clearance: 120 – 140 mL/min (decrease of 10 mL/min/decade after 50 yr)
2. Renal Insufficiency Serum creatinine: 140 – 880 µmol/L Blood urea nitrogen: 15 - 30 mmol/L Clinical signs/symptoms: decreased appetite, nausea, fatigue, ammonia breath
Polycystic kidney disease increases rapid deterioration of kidney function despite strict dietary and hypertension control.
In diabetes, early onset of microalbuminuria is often followed by nephrotic syndrome and lipid abnormalities.
There is a relationship between the level of proteinuria and the rate of renal insufficiency progession.
3. End-Stage Renal Disease Creatinine clearance: 10 mL/min Uremia which is death threatening without dialysis.
Types of treatment modalities
Renal insufficiency
1. Renal insufficiency
Once GFR is decreased to below 25 mL/min, progression to ESRD is usually rapid.
More rapid decline in GFR is common in blacks and those with polycystic kidney disease (autosomal dominant)
Dietary parameters
Renal insufficiency
a. Protein restriction
A meta-analysis of controlled low-protein diets in patients with chronic renal insufficiency found that protein levels 0.4 to 0.6 g/kg/day delayed renal failure, but the analysis was inconclusive regarding the role of diet in progression.
MDRD Study: used 3 levels of protein (1.3, 0.58, or 0.28 g/kg/d + ketoacid supplements) and was unable to demonstrate a clear relationship between the level of protein intake and rate of progression.
b. Pharmacologic intervention: In insulin dependent diabetes mellitus, angiotensin- converting enzyme inhibitors have a renal protective effect by reducing indicators of diabetic nephropathy.
c. Blood pressure control
The MDRD Study and DCCT underscored the importance of normalizing blood pressure.
A consensus conference on management of renal disease recommended mean arterial pressure of 100 or 110/70 mm Hg. Moderate sodium restriction (4 g) also recommended.
Kidney transplant
d. Glycemic control in diabetes The DCCT demonstrated that tight control of glycemia in patients with type 1 diabetes had a clearly positive effect on nephropathy.
Dietary parameters for kidney transplant
1.Protein :
0.6 – 0.8 g/kg/d, >50% - 60% HBV
0.8 – 1.0 g/kg in nephrotic syndrome
2. Energy: 30-35 kcal/kg/d
3. Sodium: 2.0 – 4.0 g/d; variable with disease etiology/ urine output
4. Potassium: Not usually restricted until GFR <10 mL/min.
Usually not restricted in renal insufficiency.
5. Phosphorus: 10-12 mg/g dietary protein
When the serum phosphorus level is >1.80 mmol/L, phosphate binders are required to maintain normal serum levels (can be calcium supplements)
6. Calcium: 1.0-1.5 g/d
7. Fluid: Unrestricted until urine output decreases
8. Vitamins/minerals:
Daily RDI of vitamins B, C, and D, Iron, zinc; Folic acid: 900 to 1,000 µg/d to support red blood cell production
Do not supplement vitamin A or magnesium
1. The success of a transplant depends on many factors including match of the donor and recipients antigens, effect of rejection episodes and compliance with a posttransplant regimen of long-term use of immunosuppressive drugs. Nutritional status at the time of transplant is an important determinant of postsurgical rates of recovery and complication.
1. Protein
a. immediately post-transplant: 1.3-1.5 g/kg/d
b.chronic with stable kidney function: 1.0 g/kg/d
2. Kcal (Energy)
a. 25-35 kca;/kg/d to maintain desired body weight
b. limit fat to 30% total energy and cholesterol to <300 mg/d
3. Sodium
a. immediately post-transplant: 2-4 g/d
b. chronic with stable kidney function: 3-4 g/d
4. Potassium
a. unrestricted, monitor drug effects.
5. Phosphorus
a. unrestricted, monitor drug effects
6. Calcium: 1-1.5 g/d
7. Fluid: unrestricted unless urine output decreases or fluid overload occurs
8. Vitamins and minerals: Daily RDA
This review is targeted to general and nonrenal specialty practitioners. THe review's scope is limited to adults with chronic renal disease.
Early intervention may delay or prevent rapid progression of renal disease in some patients. Treatment modalities need to be individualized to maintain nutritional status.
| University/Hospital: | Rosary College |
This review included Pre-End Stage Renal Disease as well as dialysis and post transplant. However, the summary includes only Pre-End Stage Renal Disease.
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Quality Criteria Checklist: Review Articles
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| Relevance Questions | |||
| 1. | Will the answer if true, have a direct bearing on the health of patients? | Yes | |
| 2. | Is the outcome or topic something that patients/clients/population groups would care about? | Yes | |
| 3. | Is the problem addressed in the review one that is relevant to dietetics practice? | Yes | |
| 4. | Will the information, if true, require a change in practice? | Yes | |
| Validity Questions | |||
| 1. | Was the question for the review clearly focused and appropriate? | Yes | |
| 2. | Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? | No | |
| 3. | Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? | No | |
| 4. | Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? | No | |
| 5. | Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? | Yes | |
| 6. | Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? | Yes | |
| 7. | Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? | No | |
| 8. | Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? | Yes | |
| 9. | Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? | No | |
| 10. | Was bias due to the review's funding or sponsorship unlikely? | Yes | |