Ernährung bei Nierenerkrankungen

Zusammenfassung

Ernährungsempfehlungen bei Nierenerkrankungen richten sich nach dem Krankheitsstadium (CKD-Stadien [CKD: chronische Nierenerkrankung]), den Begleiterkrankungen und den Sekundärfolgen der Niereninsuffizienz. Diätetische Maßnahmen verfolgen primär präventive Ziele wie die Progressionshemmung der Niereninsuffizienz, die Aufrechterhaltung eines adäquaten Ernährungszustands und die Verhinderung von Hyperphosphatämie oder Hyperkaliämie. Zur Progressionshemmung chronischer Nierenerkrankungen wird neben den etablierten medikamentösen Interventionen nur noch in den CKD-Stadien 1–3 eine diätetische Eiweißrestriktion auf 0,6–0,8 g / kg / d empfohlen. Für das Management einer Hyperphosphatämie stehen sowohl diätetische als auch medikamentöse (Phosphatbinder) Behandlungsoptionen zur Verfügung. Diätetische Phosphatrestriktionen dürfen den Ernährungszustand allerdings nicht negativ beeinflussen. In den CKD-Stadien 4 und 5 besteht ein hohes Risiko für die Entwicklung einer Mangelernährung, die durch einen gesteigerten Proteinkatabolismus bei gleichzeitig gehemmter Proteinsynthese charakterisiert ist. Die Entwicklung einer Malnutrition muss frühzeitig erkannt und konsequent behandelt werden. Das Ziel ernährungsmedizinischer Maßnahmen bei Mangelernährung ist die komplette Abdeckung des individuellen Energie- und Eiweißbedarfs, im Bedarfsfall auch durch orale oder enterale (PEG [perkutane endoskopische Gastrostomie]) Verabreichung eiweißreicher und hochkalorischer Zusatznahrung.

Abstract

Dietary recommendations for patients with chronic renal disease need to take into consideration the CKD stage, the variety of comorbidities, and the plethora of secondary consequences of renal insufficiency. Primary aims of dietary interventions in kidney disease include retardation of disease progression, maintenance of a good nutritional state and prevention of hyperphosphatemia or hyperkalemia. In CKD stages 1–3 retardation of disease progression can be achieved by medicinal interventions in combination with dietary protein restriction to 0.6–0.8 g / kg / day. The management of hyperphosphatemia includes dietary as well as medicinal (phosphate binders) measures. However, dietary phosphate control should not compromise protein intake. There is an increased risk for development of malnutrition in CKD stages 4 and 5, which is characterized by stimulation of muscle proteolysis and inhibition of protein synthesis. The development of malnutrition needs to be recognized early and addressed with scrutiny. Any dietary interventions for the management of malnutrition aim at improving energy and protein intake, either by dietary counselling or, if required, by prescription of oral or enteral (PEG / PEJ) energy and protein supplements.

Schlüsselwörter

Mangelernährung - Hyperphosphatämie - arterielle Hypertonie - Hyperlipidämie

Keywords

malnutrition - hyperphosphatemia - arterial hypertension - hyperlipidemia

Literatur

• 1 Levey A S, Coresh J, Balk E et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.  Ann Intern Med. 2003;  139 137-147
• 2 Manjunath G, Sarnak M J, Levey A S. Prediction equations to estimate glomerular filtration rate: an update.  Curr Opin Nephrol Hypertens. 2001;  10 785-792
• 3 Hallan S I, Coresh J, Astor B C et al. International comparison of the relationship of chronic kidney disease prevalence and ESRD risk.  J Am Soc Nephrol. 2006;  17 2275-2284
• 4 Bello A, Kawar B, El Kossi M et al. Epidemiology and pathophysiology of chronic kidney disease.. In: Floege J, Johnson R J, Feehally J, eds Comprehensive clinical nephrology.. 4th ed. St Louis, Missouri: Elsevier Inc; 2010: 907-918
• 5 Levin N W, Gotch F A, Kuhlmann M K. Factors for increased morbidity and mortality in uremia: hyperphosphatemia.  Semin Nephrol. 2004;  24 396-400
• 6 Bailey J L, Wang X, England B K et al. The acidosis of chronic renal failure activates muscle proteolysis in rats by augmenting transcription of genes encoding proteins of the ATP-dependent ubiquitin-proteasome pathway.  J Clin Invest. 1996;  97 1447-1453
• 7 Fouque D, Kalantar-Zadeh K, Kopple J D et al. A proposed nomenclature and diagnostic criteria for protein – energy wasting in acute and chronic kidney disease.  Kidney Int. 2008;  73 391-398
• 8 Stenvinkel P, Ketteler M, Johnson R J et al. IL-10, IL-6, and TNF-alpha: central factors in the altered cytokine network of uremia – the good, the bad, and the ugly.  Kidney Int. 2005;  67 1216-1233
• 9 Ikizler T A, Greene J H, Wingard R L et al. Spontaneous dietary protein intake during progression of chronic renal failure.  J Am Soc Nephrol. 1995;  6 1386-1391
• 10 Ikizler T A, Pupim L B, Brouillette J R et al. Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation.  Am J Physiol Endocrinol Metab. 2002;  282 E107-E116
• 11 Enia G, Sicuso C, Alati G et al. Subjective global assessment of nutrition in dialysis patients.  Nephrol Dial Transplant. 1993;  8 1094-1098
• 12 Moissl U M, Wabel P, Chamney P W et al. Body fluid volume determination via body composition spectroscopy in health and disease.  Physiol Meas. 2006;  27 921-933
• 13 Fouque D, Aparicio M. Eleven reasons to control the protein intake of patients with chronic kidney disease.  Nat Clin Pract Nephrol. 2007;  3 383-392
• 14 Klahr S, Levey A S, Beck G J et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group.  N Engl J Med. 1994;  330 877-884
• 15 Clinical practice guidelines for nutrition in chronic renal failure. K / DOQI, National Kidney Foundation.  Am J Kidney Dis. 2000;  35 1-140
• 16 Hansen H P, Tauber-Lassen E, Jensen B R et al. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy.  Kidney int. 2002;  62 220-228
• 17 Fouque D, Vennegoor M, Ter Wee P et al. EBPG guideline on nutrition.  Nephol Dial Transplant. 2007;  22 (S 02) ii45-ii87
• 18 Brunori G, Viola B F, Parrinello G et al. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study.  Am J Kidney Dis. 2007;  49 569-580
• 19 Steiber A L, Kopple J D. Vitamin Status and Needs for People with Stages 3–5 Chronic Kidney Disease.  J Ren Nutr. 2011;  21 355-368
• 20 Boaz M, Smetena S, Weinstein T et al. Secondary prevention with antioxidants of cardiovascular disease in end stage renal disease (SPACE): randomized placebo-controlled trials.  Lancet. 2000;  356 1213-1218
• 21 Mann J FE, Lonn E M, Yi Q et al. Effects of vitamin E on cardiovascular outcomes in people with mild- to-moderate renal insufficiency: results of the HOPE study.  Kidney Int. 2004;  65 1375-1380
• 22 Kopple J D, Feroze U. The effect of obesity on chronic kidney disease.  J Ren Nutr. 2011;  21 66-71
• 23 Baigent C, Landray M J, Reith C et al. The effects of lowering LDL cholesterol with simvastatin and ezetimibe in patients with chronic kidney disease (Study of Heart an Renal Protection): a randomised placebo-controlled trial.  Lancet. 2011;  377 2181-2192
• 24 Wanner C, Krane V, Maerz W et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis.  N Engl J Med. 2005;  353 238-248
• 25 Kuhlmann M K. Management of Hyperphosphatemia.  Hemodial Int. 2006;  10 338-345
• 26 Noori N, Kalantar-Zadeh K, Kovesdy C P et al. Association of dietary phosphorus intake and phosphorus-to-protein ratio with mortality in hemodialysis patients.  Clin J Am Soc Nephrol. 2010;  5 683-692
• 27 Kalantar-Zahed K, Gutekunst L, Mehrotra R et al. Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease.  Clin J Am Soc Nephrol. 2010;  5 519-530
• 28 Moe S M, Zidehsarai M P, Chambers M A et al. Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.  Clin J Am Soc Nephrol. 2011;  6 257-264
• 29 Kuhlmann M K, Hoechst S, Landthaler I. Patient empowerment in the management of hyperphosphatemia.  Int J Artif Organs. 2007;  30 1008-1013
• 30 Ahlenstiel T, Pape L, Ehrich J H et al. Self-adjustment of phosphate binder dose to meal phosphorus content improves management of hyperphosphataemia in children with chronic kidney disease.  Nephrol Dial Transplant. 2010;  25 3241-3249
• 31 Sullivan C, Sayre S S, Leon J B et al. Effect of food additives on hyperphosphatemia among patients with end-stage renal disease: a randomized controlled trial.  JAMA. 2009;  301 629-635
• 32 Committee to Review Dietary Reference Intakes for Vitamin D and Calcium, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D.. Washington, DC: National Academy Press; 2010
• 33 Pupim L B, Flakoll P J, Levenhagen D K et al. Exercise augments the acute anabolic effects of intradialytic parenteral nutrition in chronic hemodialysis patients.  Am J Physiol Endocrinol Metab. 2004;  286 E589-597
• 34 Kuhlmann M K, Schmidt F, Koehler H. High protein / energy vs. standard protein / energy nutritional regimen in the treatment of malnourished hemodialysis patients.  Mineral Electrolyte Metabolism. 1999;  25 306-310
• 35 Stratton R J, Bircher G, Fouque D et al. Multinutrient oral supplements and tube feeding in maintenance dialysis: a systematic review and meta-analysis.  Am J Kidney Dis. 2005;  46 387-405
• 36 Cano N J, Fouque D, Roth H et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study.  J Am Soc Nephrol. 2007;  18 2583-2591
• 37 Johansen K L, Painter P L, Sakkas G K et al. Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: A randomized, controlled trial.  J Am Soc Nephrol. 2006;  17 2307-2314
• 38 Feldt-Rasmussen B, Lange M, Sulowicz W et al. Growth hormone treatment during hemodialysis in a randomized trial improves nutrition, quality of life, and cardiovascular risk.  J Am Soc Nephrol. 2007;  18 2161-2171
• 39 Kuhlmann M K, Levin N W. Potential interplay between nutrition and inflammation in dialysis patients.  Contrib Nephrol. 2008;  161 76-82
• 40 Nafar M, Noori N, Jalali-Farahani S et al. Mediterranean diets are associated with a lower incidence of metabolic syndrome one year following renal transplantation.  Kidney Int. 2009;  76 1199-1206
• 41 D-A-CH .Referenzwerte für die Nährstoffzufuhr.. 1. Aufl. 3. korrigierter Nachdruck. Neustadt an der Weinstraße: Neuer Umschau Buchverlag; 2008