(Journal Article): Low-Protein Vegetarian Diet with Alpha-Chetoanalogues Prior to Pre-emptive Pancreas-Kidney Transplantation
 
Piccoli GB, Motta D, Martina G, Consiglio V, Gai M, Mezza E, Maddalena E, Burdese M, Colla L, Tattoli F, Anania P, Rossetti M, Soragna G, Grassi G, Dani F, Jeantet A, Segoloni GP (Chair of Nephrology, Department of Internal Medicine, University of Turin, Corso Dogliotti 16, 10126 Torino, Italy, giorgina.piccoli(at)unito.it )
 
IN: Rev Diabetic Stud 2004; 1(2):95-102
Impact Factor(s) of Rev Diabetic Stud: 0.125 (2006)

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ABSTRACT: BACKGROUND: Pre-emptive pancreas-kidney transplantation is increasingly considered the best therapy for irreversible chronic kidney disease (CKD) in type 1 diabetics. However, the best approach in the wait for transplantation has not yet been defined. AIM: To evaluate our experience with a low-protein (0.6 g/kg/day) vegetarian diet supplemented with alpha-chetoanalogues in type 1 diabetic patients in the wait for pancreas-kidney transplantation. METHODS: Prospective study. Information on the progression of renal disease, compliance, metabolic control, reasons for choice and for drop-out were recorded prospectively; the data for the subset of patients who underwent the diet while awaiting a pancreas-kidney graft are analysed in this report. RESULTS: From November 1998 to April 2004, 9 type 1 diabetic patients, wait-listed or performing tests for wait-listing for pancreas-kidney transplantation, started the diet. All of them were followed by nephrologists and diabetologists, in the context of integrated care. There were 4 males and 5 females; median age 38 years (range 27.9-45.5); median diabetes duration 23.8 years (range 16.6-33.1), 8/9 with widespread organ damage; median creatinine at the start of the diet: 3.2 mg/dl (1.2-7.2); 4 patients followed the diet to transplantation, 2 are presently on the diet, 2 dropped out and started dialysis after a few months, 1 started dialysis (rescue treatment). The nutritional status remained stable, glycaemia control improved in 4 patients in the short term and in 2 in the long term, no hyperkalaemia, acidosis or other relevant side effect was recorded. Proteinuria decreased in 5 cases, in 3 from the nephrotic range. Albumin levels remained stable; the progression rate was a loss of 0.47 ml/min of creatinine clearance per month (ranging from an increase of 0.06 to a decrease of 2.4 ml/min) during the diet period (estimated by the Cockroft-Gault formula). CONCLUSIONS: Low-protein supplemented vegetarian diets may be a useful tool to slow CKD progression whilst awaiting pancreas-kidney transplantation.

TYPE OF PUBLICATION: Case Report

REFERENCES:

1. Stratta RJ, Taylor RJ, Ozaki CF, Bynon JS, Miller SA, Knight TF, Fischer JL, Neumann TV, Wahl TO, Duckworth WC. A comparative analysis of results and morbidity in type I diabetics undergoing pre-emptive versus postdialysis combined pancreas-kidney transplantation. Transplantation 1993. 55:1097-1103.
2. Sudan D, Sudan R, Stratta R. Long-term outcome of simultaneous kidney-pancreas transplantation: analysis of 61 patients with more than 5 years follow-up. Transplantation 2000. 69:550-555.
3. Gross CR, Limwattananon C, Matthees B, Zehrer JL, Savik K. Impact of transplantation on quality of life in patients with diabetes and renal dysfunction. Transplantation 2000. 70:1736-1746.
4. Kessler M, Frimat L, Panescu V, Briancon S. Impact of nephrology referral on early and midterm outcomes in ESRD: EPidemiologie de l'Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study. Am J Kidney Dis 2003. 42:474-485.
5. Chantrel F, Enache I, Bouiller M, Kolb I, Kunz K, Petitjean P, Moulin B, Hannedouche T. Abysmal prognosis of patients with type 2 diabetes entering dialysis. Nephrol Dial Transplant 1999. 14:129-136.
6. Stoves J, Bartlett CN, Newstead CG. Specialist follow up of patients before end stage renal failure and its relationship to survival on dialysis. Postgrad Med J 2001. 77:586-588.
7. Harvey JN. Diabetic nephropathy. BMJ 2002. 325: 59-60.
8. Cupisti A, Licitra R, Chisari C, Stampacchia G, D'Alessandro C, Galetta F, Rossi B, Barsotti G. Skeletal muscle and nutritional assessment in chronic renal failure patients on a protein-restricted diet. J Intern Med 2004 255:115-124.
9. Aparicio M, Chauveau P, De Precigout V, Bouchet JL, Lasseur C, Combe C. Does nutrition affect the prognosis of aged hemodialysis patients? Nephrologie 2002 23:77-83.
10. Kopple JD, Berg R, Houser H, Steinman TI, Teschan P. Nutritional status of patients with different levels of chronic renal insufficiency. Modification of Diet in Renal Disease (MDRD) Study Group. Kidney Int 1989. 27: S184-194.
11. Waugh NR, Robertson AM. Protein restriction for diabetic renal disease. Cochrane Database Syst Rev 2000. 2:CD002181.
12. Barsotti G, Navalesi R, Giampietro O, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Effects of a vegetarian, supplemented diet on renal function, proteinuria, and glucose metabolism in patients with 'overt' diabetic nephropathy and renal insufficiency. Contrib Nephrol 1988. 65:87-94.
13. Barsotti G, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Nutritional treatment of renal failure in type 1 diabetic nephropathy. Clin Nephrol 1988. 29:280-287.
14. Piccoli GB, Grassi G, Mezza E, Gai M, Iacuzzo C, Bechis F, Biancone L, Jeantet A, Dani F, Cavallo Perin P, Segoloni GP. Early referral of Type 2 diabetic patients: are we ready for the assault? Nephrol Dial Transplant 2002. 17:1241-1247.
15. Piccoli GB, Soragna G, Mezza E, Putaggio S, Motta D, Gai M, Anania P, Fop F, Bermond F, Burdese M, et al. Lost to follow-up: the bottleneck of early referral to renal units? Med Sci Monit 2003. 9:493-499.
16. Laszlo J. Oncology in Wyngaarden JB, Smith LH Jr, (eds.). Cecil Textbook of Medicine. WB Saunders, PA 1988, pp 1082-1089.
17. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987. 11:8-13.
18. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 2002. 39 (Suppl 1):S1-S266.
19. Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int 1985. 27:58-65.
20. Viberti GC, Mogensen CE, Passa P, Bilous R, Mangili R. St Vincent Declaration, 1994. Guidelines for the prevention of diabetic renal failure in the kidney and hypertension in diabetes mellitus. In: Mogensen CE (ed). Kluwer Academic Publishers, Boston, 1994; pp 527-551.
21. Ritz E, Rychlik I, Locatelli F, Halimi S. End-stage renal failure in type 2 diabetes: A medical catastrophe of worldwide dimensions. Am J Kidney Dis 1999. 34:795-808.
22. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997. 14 (Suppl. 5):S1-S85.
23. Teschan PE, Beck GJ, Dwyer JT, Greene T, Klahr S, Levy AS, Mitch WE, Snetselaar LG, Steinman TI, Walser M. Effect of a ketoacid-aminoacid-supplemented very low protein diet on the progression of advanced renal disease: a reanalysis of the MDRD feasibility study. Clinical Nephrol 1998. 50:273-83.
24. Joss N, Paterson KR, Deighan CJ, Simpson K, Boulton-Jones JM. Diabetic nephropathy: how effective is treatment in clinical practice? Q J Med 2002. 95:41-49.