Cập nhật về
dinh dưỡng
trong bệnh thận
đái tháo đường
theo
KDIGO 2021
Prof Pham Van Bui
Univ. of Medicine Pham Ngoc Thach
Nguyen Tri Phuong Hospital
President, Society of the Dialysis Therapies
Invited Professor, Liege Univ. of Medicine, Belgium


KDOQI CLINICAL PRACTICE GUIDELINE FOR
NUTRITION IN CKD: 2020 UPDATE

During progression of chronic kidney disease
(CKD), the requirements and utilization of
different nutrients change significantly. →
ultimately place patients with kidney disease at
higher risk for nutritional and metabolic
abnormalities.
AJKD Vol 76 | Iss 3 | Suppl 1 | September 2020





KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease OCT 2020

Kidney–Heart Risk Factor Management

1.1 Comprehensive diabetes and CKD management
Practice Point 1.1.1: Patients with diabetes and chronic kidney disease (CKD) should be treated with a
comprehensive strategy to reduce risks of kidney disease progression and cardiovascular disease


NUTRITION

Nutrition therapy can decrease
HbA1c levels at levels similar to, or
better than, antihyperglycemic
medications.
KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease 2020


NUTRITION
• Recommendation 3.1.1. We suggest maintaining protein intake of 0.8 g
protein/kg(weight)/day for those with diabetes and non-dialysis CKD (2C).
• Practice Point 3.1.1. Patients with diabetes and CKD should consume a diet
high in vegetables, fruits, whole grains, fiber, legumes, plant-based
proteins, unsaturated fats, and nuts and lower in processed meats,
refined carbohydrates, and sweetened beverages.

• WHO recommends: protein intake of 0.8 g/kg/d for healthy people.
• Neither lower nor higher protein intake appears beneficial, and
each is associated with potential harms
KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease 2020


Protein

• An essential part of the diet: Needed for
good health
• Repairs and replaces tissues and cells.

“BUILD BLOCKS”


NUTRITION: Why protein intake of 0.8 g ?
• Patients who are in advanced CKD may naturally
decrease their oral intake → malnutrition.
• Limiting protein intake < 0.8 g/kg/d in a person with
diabetes, who also may have been counseled to limit
carbohydrates, fat, and alcohol →↓ caloric content of
the diet → significant weight loss →↓ quality of life
• Protein intake on a diabetic diet is especially crucial
to avoid episodes of hypoglycemia
KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease 2020


NUTRITION
• Dietary recommendations should take into
account individual nutrition needs ( age, weight,
physical activity, and comorbidities),
• Higher protein diet at early stages to allow for
a reduction of carbohydrates to better
manage their diabetes.
KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease 2020


NUTRITION: Why Plant-based protein ?

Observational studies:
• High consumption of red and processed meat is
associated with increased risk of CKD
progression & mortality,
• Plant-based protein, fruits & vegetable intake
were associated with decline in progression of
kidney disease
KDIGO Clinical Practice Guideline on Diabetes Management in Chronic Kidney Disease 2020


（μmol/l)
５００
４００
３００

２００

Aminogram of chronic kidney
disease
(plasma)
EAA
NEAA
*

Normal person
EAA：NEAA = 50：50, (ratio 1)
CKD
EAA：NEAA = 37：63 (ratio 0.59)

*


*

CKD （ｎ＝8）
ＨＤ （ｎ＝6）

HD
EAA：NEAA = 40：60 (ratio 0.67)

*P＞0.05

*
*

１００

*

*

*

*
０

Ｖａｌ

Ｌｙｓ Ｌｅｕ Ｔｈｒ Ｉｌｅ

Ｈｉｓ


*

Ｐｈｅ Ｔｒｐ Ｍｅｔ Ｇｌｎ Ａｌａ Ｇｌｙ Ｐｒｏ Ｓｅｒ Ｔａｕ

Decreased
Essential amino-acids

Ａｒｇ Ａｓｎ Ｏｒｎ Ｔｙｒ Ｇｌｕ Ｃｉｔ

Increased
Non Essential amino-acids
原陽子他：臨床栄養 ＶＯＬ．83 Ｎｏ.7 1993.12


• Để tổng hợp protein, cơ thể cần phải có đầy đủ
các loại axit amin(thiết yếu + không thiết yếu)
với tỉ lệ cân đối:
• Trong đó, có 8 loại axit amin thiết yếu không
thể tổng hợp trong cơ thể, rất cần cung cấp từ
nguồn dinh dưỡng bên ngoài.


Appetite decreases as CKD progresses
Starts when eGFR
<10-25% of normal

Retention of uremic
toxins - suppress
appetite


eGFR
eGFR
eGFR
eGFR
<90 mL/mi<60 mL/min<30 mL/min <15 mL/min
Carrero JJ. J Ren Nutr. 2009;19:10-15.

Initiation of dialysis
improves feeding
behavior

Dialysis
begins

Repletion by Milk
Which Milk ?


PROSOURCE
• Tiêu chuẩn chất lượng axit amin PDCAAS100
• Cung cấp lượng đạm tinh khiết và các axit amin
trong :
• Suy dinh dưỡng đạm
• Suy nhược cơ thể
• Có nguy cơ / suy giảm thể trọng do bệnh lý
(vd: CKD)
• Bổ sung đạm giúp nâng nồng độ Albumine
• Nhu cầu bổ sung hàm lượng đạm cao trong
thể tích nước thấp



PROSOURCE
Ít Kali
Ít Natri
Ít Photpho
• Dễ hồ tan trong thức ăn và nước uống
• Hơn 17 năm tín nhiệm tại các bệnh viện
ở Hoa Kỳ


• Prosource cung cấp 20 loại axit amin, đặc
biệt bổ sung đầy đủ 8 loại axit amin thiết
yếu với tỉ lệ cân đối cần thiết cho cơ thể
• Đạm Whey/Prosource còn đạt tiêu chuẩn
PDCAAS 100 về bổ sung và hấp thu
protein


RENAMENT







↓Nguy cơ chạy thận sớm ESRD?.
↑ cường sức đề kháng CKD-ESRD-Dialysis.
Bệnh nhân ăn uống kém.

Bệnh nhân suy kiệt.
Người lớn tuổi
Người ăn kiêng, biếng ăn


RENAMENT
Hỗ trợ điều trị bệnh thận - lọc máu

 Ít Kali
 Ít Natri
 Ít Photpho





Giàu năng lượng
Hịa tan hồn tồn trong thể tích nước thấp
Giàu đạm sinh học, tiêu chuẩn PDCAAS 100
Vị trái cây dễ sử dụng.


Đạm Sinh Học giúp tăng nồng độ Albumin
ở bệnh nhân suy thận-lọc máu
Mục tiêu Đánh giá hiệu quả bổ sung đạm sinh học đối với nồng
độ Albumin ở BN suy thận lọc máu.
Đối
BN suy thận lọc máu 3 lần/tuần. Độ tuổi 31 - 90
tượng
Thiết kế


NC thực nghiệm, thử nghiệm lâm sàng có nhóm chứng

Phương
pháp
Kết quả

Đánh giá nồng độ Albumin trong máu
Sau 3 tháng, nhóm BN sử dụng đạm sinh học 3
lần/tuần, mỗi lần 15g có nồng độ Albumin tăng rõ rệt
so với nhóm chứng khơng sử dụng đạm sinh học.

Pittaoulis A, Phillip E. (2007). Can oral supplementation with a collagen-casein based hydrolyzed liquid protein improve
serum albumin levels in hypoalbuminemic hemodialysis paitents? Dialysis & Transplantation; 36, 5: 258-265


Đạm Sinh Học giúp tăng nồng độ Albumin
ở bệnh nhân suy thận-lọc máu

Pittaoulis A, Phillip E. (2007). Can oral supplementation with a collagen-casein based hydrolyzed liquid protein improve
serum albumin levels in hypoalbuminemic hemodialysis paitents? Dialysis & Transplantation; 36, 5: 258-265


PDCAAS100 ?
• Protein Digestibility-Corrected Amino Acid Scores
• is a measure of a protein's ability to provide adequate levels
of essential amino acids for human needs.
• Soy protein had high quality proteins comparable to meat, egg
and dairy proteins with a truncated PDCAAS of 1.00/100
(absorption100%)

• Soy protein is recognized as a high quality plant protein, but
published PDCAAS values may vary based on the soy protein
ingredient as well as the reproducibility and accuracy of the
testing methods.


Effects of whey protein supplement in the
elderly submitted to resistance training:
systematic review and meta-analysis
• Aging process → biopsychological changes(eg skeletal
muscle mass reduction)
• If amino acids/body insufficient → negative protein balance
→ harmful side effects( such as loss of muscle mass & late
recovery
• Whey protein: a dietary supplement for building muscle
mass thanks to its rapid digestion & absorption,
Tamy Colonetti et al(2016). International Journal of Food Sciences and Nutrition, 68:3, 257-264, DOI:
10.1080/09637486.2016.1232702


Effects of whey protein supplement in the elderly
submitted to resistance training: systematic review
and meta-analysis
• 05 studies, involving 391 patients met the criteria & were analyzed.
• ♂ & ♀ mean ages: 67.4 to 78.0 years.

Results: compared to control, Whey prot supplementation:
• Lean mass ↑ 26% (95% CI: 0.43 to 0.95)
• ↑ Mixed muscle protein fractional synthesis rate:
• Fat mass ↓12% (95% CI: 0.87–0.64)

• Glomerular filtration rate unchanged
Tamy Colonetti et al(2016). International Journal of Food Sciences and Nutrition, 68:3, 257-264, DOI:
10.1080/09637486.2016.1232702