D) Le alterazioni della ghiandola paratiroide: L’iperplasia della
3.4 Dieta e terapia nutrizionale in nefropatia diabetica(basse proteine)
La nefropatia diabetica è la causa principale nel progresso della malattia renale cronica e la fine della terapia sostitutiva renale.Gli inibitori dell’enzima convertibile dell’angiotensina o il bloccante del recettore hanno dimostrato di avere un gran effetto nel rallentamento della progressione ma lo stesso non si arriva a inibire totalmente la progressione.
La dieta con basso contenuto di proteine si pensa di essere un intervento nutrizionale efficace nel rallentamento della progressione.L’Emodinamica anormale intraglomerulare assieme alla malattia primaria contribuiscono nella progressione .Studi preclinici che hanno usato una dieta con poche proteine hanno dimostrato che questa dieta ha effetti renoprottetivi171
.Lo stesso ci sono state finalità controverse nell’efficacità di questa dieta.La dieta con poche proteine asseconda degli studi fatti in animali ha dimostrato che migliora l’emodinamica intraglomerulare con alcuni meccanismi:
169Schwartz MM, Lewis EJ, Leonard-Martin T, et al. Renal pathology patterns in type II diabetes mellitus: relationship with retinopathy. The Collaborative Study Group. Nephrol Dial Transplant 1998; 13:2547
170Mauer M, Zinman B, Gardiner R, et al. Renal and retinal effects of enalapril and losartan in type 1 diabetes. N Engl J Med 2009; 361:40
171Premen AJ.protein-mediated elevation in renal hemodynamics:existence of a hepatorenal axis?Med hypotheses 1986;19:295-309
A. L’Effetto Ormonale ,il sovvracarico di proteine aumenta l’escrezione di glucagono che induce indirettamente la dilatazione dell’arteriola afferente che di conseguenza aumenta la pressione intraglomerulare. 172
.Cosi anche il carico di proteine aumenta insulin like growth factor(IGF-1) prodotta in fegato che è vasidilatatore dei vasi renali173
.
B. L’Influenza nel flusso renale e nella filtrazione glomerulare,un altro effetto importante è che questa dieta inibisce il sistema renino angiotezino .Peters et.al.rapportò che la combinazione di ACE/ARB con una dieta con poche proteine,rallenta di piú la progressione sicchè ad una ad una174
.9.Le proteine in aggiunta aumentano l’escrezione degli aminoacidi dai glomeruli che porta anche l’aumento e il riassorbimento dei medesimi insieme con il sodio nei tubi proximali,questo tipo di trasportazione aumenta anche il trasporto dell cloruro di sodio il quale risulta in defficienza della cloride che va nel apparato iuxtaglomerulare, come conseguenza del sistema di feed-back per regolare la concentrazione di cloro ,aumenta GFR.175
172Ueda J, Nakanishi H, Miyazaki M. Abe Y. Effects of glucagon on the renal hemodynamics in the dog. Jpn Circ J. 1977;41:991- 8.
173Fontana L., Weiss EP, Villareal DT. Klein S. Holloszy JO. Long-term effects of calorie on protein restriction on serim IGF-1 and IGFBP-3 concentration in humans. Aging Cell.. 200/;7:681-7.
174Peters H. Border WA, Noble NA. Angiotensin II blockade and low-protein diet produce additive therapeutic effects in experimental glomerulonephritis. Kidney Int. 2000;57:1493-501.
175Sallstrom J. Carlstrom M, Olerud J, Fredholm BB, Kouzmine M, Sandles S, et al. High-protein-induced glomerular hyperfiltration is independent of the tubuloglomerular feedback mechanism and nitric oxide synthases. Am J physiol Regul Integr Comp Physiol.2010;299:R1263-8.
IMG-Meccanismi GFR in sovvracarico di proteine.176
C. Si pensa anche che ci siano altri meccanismi tranne a quelli emodinamici come p.es.l’inibizione di citochina fibrogenica riducendo nefroschlerosa ,anche quando la dieta è ricca di proteine accade l’aumento dei fenoli,acido urico,acido di fosfato177.
Diversi studi fatti in persone hanno dimostrato l’efficacità della dieta con poche proteine nel calo di albuminuria e la progressione di nefropatia p.es.Walker et al. negli anni 1989 e Zellers et al. 1991 rapportarono che la dieta con 0.6 gr/chg proteine può ridurre la progressione di insufficienza renale fino al 75% dei pazienti con nefropatia diabetica DM tipo 1 entro un periodo annuale178 179
.In base a molti studi che rivelavano il beneficio della dieta è stato inserito come un intervento nutrizionale nel 2012 da (NKF KDOQI) la quale l’ha inserito nella linea guida e raccomanda la dieta con poche proteine.
Gli studi di MDRD : Coinvolti 585 pazienti con GFR mediamente 39 ml/min e sono stati comparati gli effetti della dieta con poche proteine in conrfonto alla dieta normale 0.58 g/chg/gg verso 1.3 g/chg/gg.L’Osservazione media era di 2.2 anni .In questo studio la ricezione della proteine è stata monitorata tramite l’urea escretata in 24 ore.I pazienti in dieta con basse proteine hanno avuto un calo della GFR nei primi 4 mesi,dopo questo periodo in modo notevole alla fine delo studio i pazienti con restrinzione delle proteine hanno avuto una progressione piú lenta 2,8
ml/min/anno con 3,9 ml/min/anno,quindi il vantaggio è stato di 1,1
ml/min/anno.Nell’osservazione di 12 anni,nei primi 6 anni questa dieta ha avuto effetti renoprottetivi e ha ridotto la mortalità poi questi effetti sono scomparsi nei secondi 6 anni . 180
181
.
176Sallstrom J. Carlstrom M, Olerud J, Fredholm BB, Kouzmine M, Sandles S, et al. High-protein-induced glomerular hyperfiltration is independent of the tubuloglomerular feedback mechanism and nitric oxide synthases. Am J physiol Regul Integr Comp Physiol.2010;299:R1263-8.
177Cottini EP, Gallina DL, Dominguez JM. Urea excretion in adult humans with varying degrees of kidney malfunction fed milk, egg or an amino acid mixture: assessment of nitrogen balance. J Nutr. 1973;103:11-9.
178Walker JD, Bending JJ, Dodds RA, Mattock MB, Murells TJ, Keen H, et al. Restriction of dietary protein and progression of renal failure in diabetic nephropathy. Lancet. 1989;2:1411-5
179Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of restricting dietary protein on the progression of renal failure in patiens with insulin-dependent diabetes mellitus. N Engl J Med. 1991;324:78-84.
180Beck GJ, Berg RL, Coggins CH, Gassman JJ, Hunsicker LG, Schluchter MD, et al. Design and statistical issues of the Modification of Diet in renal Disease Trial. The Modification of Diet in Renal Disease Study Group. Control Clin Trials. 1991;12:566-86.
181Lebey AS, Greene T, Samak MJ, Wang X, Beck GJ, Kusek JW, et al. Effect of dietary protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study. Am J Kidney Dis Off J Natl Kidney Found. 2006;48:879-88.
Un altro studio di Hansen considerato importante,basato nella grandezza dello studio ,partecipanti erano 82 pazienti con nefropatia diabetica DM tipo 1(calo medio della GFR 7.1 ml/anno).Il conseguimento in ESRD o la morte è successa nel 27%dei pazienti con dieta normale(1.02g/chg)e in 10 %dei pazienti con restrinzione delle proteine (0.6g/chg) 182
.
Valutazione assunzione di proteine: è necessario per valutare il nitrogeno totale escretato nell’urina di 24 ore che serve per misurare l’assunzione delle proteine .Si usa la formula di Maroni:183
. in una situazione stabile l’assunzione di nitrogeno è uguale al nitrogeno escretato in urina (l’assunzione di nitrogeno=urine urea nitrogeno+urina nonurea nitrogeno.
Non urea nitrogeno non dipende motlo dall’assunzione delle proteine ma dal peso corporeo e massa muscolare 184 e mediamente è 31mg/chg/gg,il fattore convertibile del nitrogeno in proteine è 6,25.Di conseguenza l’assunzione delle proteine si calcola con la formula:
182Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int. 2002;62:220-8.
183Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int. 1985;27:58-65
184Borah Mf, Schoenfeld PY, Gotch FA, Sargent JA, Wolfsen M, Humphreys MH, Nitrogen balance during intermittent dialysis therapy of uremia. Kidney Int. 1978;14:491-500
Conclusioni
Su questo lavoro abbiamo fatto un analisi basandoci sugli studi più recenti della letteratura scientifica , al riguardo della diabete nella malattia renale cronica, il trattamento convenzionale farmacologico. gli aspetti dietetici nutrizionali delle malattie sopracitate e in specifico di nefropatia diabetica.
La tesi aveva lo scopo di porre in focus gli aspetti dietetici e la loro importanza come parte integrante della terapia, i suoi benefit nella prognosi, nella mortalità e nel rallentamento della riduzione del GFR.
Sicuramente servirebbe uno studio più ampio delle scuole del pensiero che supportano solamente a terapia farmacologica , in modo da fare un confronto più preciso, vedere i vantaggi di una o del altro metodo di trattamento.
Questa tesi non cerca di essere esaustiva sulla letteratura o dei vantaggi della terapia dietetica ma vuole essere un punto di partenza basandosi su una vasta bibliografia per produrre studi utili, nel futuro, su questo problema.
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