Chronic Kidney Di Ea E Mineral And Bone Di Order Pdf
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- Low-protein diets for chronic kidney disease patients: the Italian experience
- Low-protein diets for chronic kidney disease patients: the Italian experience
- Parathyroid Hormone Measurement in Chronic Kidney Disease: From Basics to Clinical Implications
- Chronic Kidney Disease – Mineral and Bone Disorder: pathophysiology and treatment
Magnesium is an essential mineral and a cofactor for hundreds of enzymes. Magnesium is involved in many physiologic pathways, including energy production, nucleic acid and protein synthesis , ion transport, cell signaling , and also has structural functions. More information. Severe magnesium deficiency can impede vitamin D and calcium homeostasis.
Low-protein diets for chronic kidney disease patients: the Italian experience
In children with chronic kidney disease CKD , optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease.
Complications of mineral bone disease MBD are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium Ca and phosphate P in children with CKD.
The Pediatric Renal Nutrition Taskforce PRNT is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations CPRs for the nutritional management of various aspects of renal disease management in children.
The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian.
The provision of adequate calcium Ca and phosphate P is an important part of chronic kidney disease CKD management [ 1 ]. However, excess intake of Ca and P is also detrimental, and may lead to nephrocalcinosis and vascular calcification [ 4 ]. Dietary management in CKD is an area fraught with uncertainties, with wide variations in practice, and where expert dietetic input, even in tertiary pediatric nephrology centers, is often lacking.
The PRNT recognizes that there are few studies in children with CKD that provide high-level evidence and have undertaken a process of developing clinical practice recommendations CPRs for their nutritional management. Existing guidelines on the nutritional requirements of healthy children of all ages were reviewed and requirements for children with CKD proposed. Our CPRs are based on an in-depth review of the available evidence, but in the absence of applicable studies, guidance is based on the opinion of experienced dietitians and nephrologists from the PRNT.
These recommendations are designed to provide information and assist in decision-making in order to reduce uncertainty and improve patient outcome. They are not intended to define a standard of care and should not be interpreted as an exclusive course of management.
We also provide research recommendations. Following guideline publication the PRNT have planned a dissemination phase to guide practical day-to-day management of calcium and phosphate intake. This will involve developing material written information in the form of leaflets and charts, mobile phone Apps, videos, etc. Regional variations in diet will be addressed. Translation of this information into different languages will also be performed.
The development process for the CPRs, including the group composition and task distribution, is described in the Supplementary material.
Recommendations in CPRs are most useful when they provide specific actionable advice on choosing between alternative approaches in particular clinical situations [ 5 ]. Our PICO terms were as follows:. Outcomes: Growth, bone disease, fracture risk, Ca balance, bone mineralization on imaging or biopsies, development of hypo- or hypercalcemia, hypo- or hyper-phosphatemia or hyperparathyroidism, and development of vascular calcification.
The choice of P binder treatment is not within the scope of this document. We have not discussed dietary sources of vitamin D as natural non-fortified foods provide only a negligible amount of vitamin D [ 9 ] and do not significantly alter the serum levels of 25OHD or Ca [ 10 ].
Details on the literature search are described in Supplemental Table 1. After critically reviewing the literature for each question, we derived CPRs and graded them as suggested by the American Academy of Pediatrics Supplemental Table 2 [ 11 ]. The strength of a recommendation is graded as strong, moderate, weak, or discretionary when no recommendation can be made. The quality of evidence is graded high A , moderate B , low C , or very low D.
Grade X refers to exceptional situations where validating studies cannot be performed and benefit or harm clearly predominate: in that case, a moderate or a strong recommendation may be given. Using the Delphi method, voting group members were sent an e-questionnaire to provide a level of agreement on a 5-point scale strongly disagree, disagree, neither agree nor disagree, agree, strongly agree and given the opportunity for re-wording of recommendations if appropriate. The main dietary sources of Ca for children are milk, milk products, breast milk and manufactured infant formulas.
Statutory or voluntary fortification of foods with Ca can increase the contribution from other foods. The main natural dietary sources of P for children are milk including milk products, breast milk and manufactured infant formulas , cereal grains and cereal products, and meat and meat products. Inorganic P added to some processed foods is readily absorbed and can significantly increase P intake. The contribution of foods to average daily intake of Ca at different ages is presented in Table 1.
The typical Ca content per portion of Ca-rich foods is shown in Table 2. The Ca content of reduced-fat dairy products is comparable to whole milk—derived products. Hard water from taps and some mineral waters can be important sources of Ca [ 19 , 20 ], with a bioavailability similar to dairy products [ 21 ]. This mainly reflects the contribution from Ca-fortified flour in cereals in the UK, particularly in older children [ 22 ]. The variation in foods eaten in different countries or cultures may alter the relative Ca intake from specific food groups.
The most recent NDNS reports that the average dietary Ca intake has significantly decreased in young children aged 1.
Calcium may be added to foods, either for fortification or as a food additive. Some countries mandate Ca fortification of foods, such as Ca fortification of bread and wheat flour except wholemeal in the UK [ 24 ].
Ca is also added voluntarily by manufacturers to some breakfast cereals and drinks to increase the Ca content. Nutrient composition tables include the contribution from naturally occurring Ca and some fortified products e.
However, the calculated estimates of dietary Ca intake using nutrient databases and dietary assessment software packages are considered reasonably accurate when compared to direct chemical analyses [ 26 ]. There are international recommendations on Ca intake for healthy children Table 6. Dietary P is available in two forms, organic and inorganic, with inorganic phosphates added during food processing. Data from the USA for all age groups also indicate that the highest contributors to P intake are milk, meat, and grains [ 27 , 28 ].
Breast milk is relatively low in phosphate, having a concentration about half of most standard whey-based formulas and one-third of casein-based infant formulas.
The relative contribution of foods to average daily intake of P at different ages in the UK is presented in Table 3 , but data on food P content are often incomplete due to the inability to accurately quantify the contribution from P additives. Table 4 shows the typical P content per portion of foods with high P content. Phosphate additives, such as phosphoric acid and sodium phosphate, are used by the food industry to improve the texture, taste, appearance, and shelf-life of many processed foods and their presence, but not quantity, may be indicated on the food ingredient list as an E number Table 5.
Manufacturers are not legally required to list the total P content on the food label or the contribution to daily P requirements, despite increasing pressure for this to be mandatory [ 30 ]. Processed foods with significant amounts of added inorganic P include meat, dairy, and bakery products, as well as a growing number of drinks such as colas and some flavored drinks, bottled water, malted drinks and sterilized, ultra-heat treated, and thickened or powdered milks [ 31 , 32 ] Table 4.
In addition, inorganic phosphates are added to several medications, such as antacids and many anti-hypertensive medications, as an excipient that aids in dispersion of the active drug ingredient once ingested [ 33 , 34 ]; these can vary between manufacturers and across different formulations of the same medication. The P load from medications can make a meaningful contribution to the daily P intake, and thus should be reviewed carefully, particularly in patients receiving anti-hypertensive medications.
Nutrient databases and dietary assessment software packages are used to assess P intake, but they do not include the amount of inorganic P derived from P additives. This is especially relevant for children, who may have a high intake of processed foods [ 31 ]. There are international recommendations on P intake in healthy children Table 6. However, as formulas have a higher concentration of Ca than breast milk, this comparison in bioavailability may not be important [ 37 ], and absorption values similar to breast milk have been reported for some specialized formulas [ 38 ].
Thus, although some cereals and green leafy vegetables and fruit may be rich in Ca and also low in phosphate , given the low bioavailability of Ca from these sources, children with CKD are unlikely to consume sufficient quantities in order to meet nutritional requirements.
The amount of Ca absorbed from P-binders is not fully understood [ 41 ]. The absorption of P from foods depends on whether it is in an organic or inorganic form, and on vitamin D status. Given that children often consume processed foods, the potential for high intake of bioavailable inorganic P additives is significant. A list of P-containing food additives approved in Europe [ 48 ] are presented in Table 5.
Foods with comparable P loads may contribute significantly different nutritional values. However, the nutrient-rich egg provides an excellent source of protein, fat, B-vitamins, and selenium, compared to the nutrient-poor empty-calories in the cola. We suggest that in healthy children and those with CKDD a diet history of a typical h period be used to rapidly identify the main dietary sources of Ca and P, including P additives in processed foods.
An estimate of the total Ca and P intake should consider contributions from diet, nutritional supplements, dialysate, and medications, including P binders grade C, weak recommendation. An estimate of usual Ca and P intake can be made using a variety of tools Supplemental Table 3 , each with advantages and disadvantages. Many of these have been developed for research purposes or for particular population groups, and vary in their accuracy as well as respondent and interviewer burden [ 50 , 51 ].
FFQs tend to overestimate daily dietary nutrient intake, although this depends on the number of food categories included in the tool [ 53 , 54 , 55 ].
Supplemental Table 3 lists the relative advantages and disadvantages of the different methods of dietary assessment. Clinicians may prefer to rapidly estimate calcium intake from a retrospective diet history of a typical h period.
This is a detailed dietary assessment technique consisting of questions about food and drinks consumed at meals and snacks through a typical h period. The history is usually taken from morning to night, capturing information on usual meal pattern and types, frequency, and quantity of foods consumed. Any additional nutrient source e. Tools that can assist in estimation of portion sizes include use of common household measures e. A more detailed account of the frequency of consumption of specific dietary sources of Ca or P such as milk, cereals, and additive-rich foods can be ascertained by direct questioning.
If a more accurate assessment is required, the portion sizes for each dietary item can be converted into weights and used with country specific food composition databases FCDB or dietary analysis software, supplemented by other sources, such as information from manufacturers, if required. Importantly, the Ca intake from P binders can contribute significantly to dietary Ca intake and must be included when calculating total daily Ca intake in CKD patients.
There is little data on the Ca absorption from binders, particularly the effects of age and residual kidney function. We describe the Ca and P requirements for healthy children as background and justification for estimating the requirements for children with CKDD; specific recommendations for healthy children are outside the scope of this document. Adequate dietary Ca intake during childhood and adolescence is essential for normal skeletal mineralization [ 59 ].
The normal levels of serum Ca and P have been previously described [ 41 , 61 , 62 ]. Balance studies indicate that dietary Ca absorption is the main driver of net Ca retention in infants and adolescents [ 63 , 64 ]. The highest Ca requirements are during periods of rapid growth, including in the first year of life and during puberty, dropping after puberty to normal adult requirements [ 65 ].
Randomized controlled trials RCTs in healthy children have shown that children require a higher Ca intake than adults, presumably for bone mineral accrual and growth [ 60 , 66 , 67 , 68 ]. A further RCT has shown that in year-old girls an increase in milk intake led to an increase in bone mineral density BMD and bone mineral content as measured by dual-energy x-ray absorptiometry DXA scan [ 67 ].
In fact, bone mineral accrual continues up to the end of the second or early in the third decade of life, depending on the skeletal site, when peak bone mass is achieved [ 60 ]. There is limited data on the Ca intake and health outcomes in normal children or suitable biomarkers of bone mineralization that can be used to derive suggested dietary requirements.
An estimate of requirements for healthy infants is based on the Ca and P from breast milk. This method accounts for the total quantity of mineral needed for bone accretion, growth, and replacement of obligatory losses from stool, urine, and skin , and is adjusted for percentage absorption. National recommendations for Ca and P intake for normal children have been reported by many countries [ 69 , 70 , 71 , 72 , 73 , 74 ] Table 6.
The international publications referenced in Table 6 use the most reliable methods for assessing mineral status. Since these recommendations for dietary adequacy have different definitions and have used different methods in their derivation, some of the resulting recommendations differ widely.
We have taken a pragmatic approach and quoted the range of the published values for our recommendations. The lower and upper limits of the SDI lie within the international published values for Ca and P intake in healthy children Table 6 , which represent the required average amounts of a nutrient plus 2 standard deviations.
Low-protein diets for chronic kidney disease patients: the Italian experience
Within each recommendation, the strength of recommendation is indicated as Level 1 , Level 2 , or not graded , and the quality of the supporting evidence is shown as A , B , C , or D. This Clinical Practice Guideline Update is based upon systematic literature searches last conducted in September supplemented with additional evidence through February It is designed to assist decision making. It is not intended to define a standard of care, and should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians consider the needs of individual patients, available resources, and limitations unique to an institution or type of practice.
Download PDF [PDF] Keywords Mineral bone disorder, renal osteodystrophy, calcium, phosphorus, Moreover, the histologic nomenclature of CKD-related bone disease is not Seibert, E., Levin, N.W., Kuhlmann, M.K. Immunomodulating effects of González, E.A., Sachdeva, A., Oliver, D.A., Martin, K.J. Vitamin D.
Parathyroid Hormone Measurement in Chronic Kidney Disease: From Basics to Clinical Implications
Metrics details. Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD.
In children with chronic kidney disease CKD , optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease MBD are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium Ca and phosphate P in children with CKD.
Due to the variability of PTH assays, preanalytical sample errors, and the phenomenon of end-organ PTH hyporesponsiveness, current CKD-MBD guidelines recommend a wide range for serum PTH targets 2—9 the upper normal limit of the intact PTH assay in dialysis patients to diminish the risk of developing adynamic bone disease.
Chronic Kidney Disease – Mineral and Bone Disorder: pathophysiology and treatment
The Journal publishes articles on basic or clinical research relating to nephrology, arterial hypertension, dialysis and kidney transplants. It is governed by the peer review system and all original papers are subject to internal assessment and external reviews. The journal accepts submissions of articles in English and in Spanish languages.
Emphasis is now placed on the need to start therapy early in the course of CKD. This article will outline the main mechanisms involved in CKD-MBD and the therapeutic interventions that aim to control this complication. In normal bone, the remodelling process is tightly controlled.
Это приказ. Чатрукьян пнул ногой урну и выругался вслух - благо лаборатория была пуста: - Диагностика, черт ее дери. С каких это пор заместитель директора начал действовать в обход фильтров. Сотрудникам лаборатории платили хорошие деньги, чтобы они охраняли компьютерные системы АНБ, и Чатрукьян давно понял, что от него требуются две вещи: высочайший профессионализм и подозрительность, граничащая с паранойей. Черт возьми! - снова мысленно выругался .
Вы сами это знаете. Он никогда не оставил бы жучков в своей программе. - Их слишком много! - воскликнула Соши, выхватив распечатку из рук Джаббы и сунув ее под нос Сьюзан. - Смотрите. Сьюзан кивнула. Так и есть, примерно через каждые двадцать строк появляется произвольный набор четырех знаков. Сьюзан пробежала все их глазами.
Огромный лист гофрированного металла слетел с капота автомобиля и пролетел прямо у него над головой. С гулко стучащим сердцем Беккер надавил на газ и исчез в темноте. ГЛАВА 84 Джабба вздохнул с облегчением, припаяв последний контакт. Выключив паяльник, он отложил в сторону фонарик и некоторое время отдыхал, лежа под большим стационарным компьютером. Затекшая шея причиняла ему сильную боль. Такая работа была непростой, особенно для человека его комплекции.
А у ее клиентов по крайней мере есть деньги. Они ее не бьют, им легко угодить. Росио натянула ночную рубашку, глубоко вздохнула и открыла дверь в комнату.
Когда она вошла, глаза немца чуть не вывалились из орбит. На ней была черная ночная рубашка; загорелая, орехового оттенка кожа светилась в мягком свете ночника, соски призывно выделялись под тонкой прозрачной тканью. - Komm doch hierher, - сказал немец сдавленным голосом, сбрасывая с себя пижаму и поворачиваясь на спину. Росио через силу улыбнулась и подошла к постели.
Сьюзан восхитилась спектаклем, который на ее глазах разыгрывал коммандер. - ТРАНСТЕКСТ работает с чем-то очень сложным, фильтры никогда ни с чем подобным не сталкивались. Боюсь, что в ТРАНСТЕКСТЕ завелся какой-то неизвестный вирус. - Вирус? - снисходительно хмыкнул Стратмор, - Фил, я высоко ценю твою бдительность, очень высоко. Но мы с мисс Флетчер проводим диагностику особого рода.
Увидев выгравированные знаки, Беккер страшно удивился. Он совсем забыл про кольцо на пальце, забыл, для чего приехал в Севилью. Он посмотрел на приближающуюся фигуру, затем перевел взгляд на кольцо.
Он солгал. Бринкерхофф не знал, что на это ответить. - Ты утверждаешь, что Стратмор намеренно запустил в ТРАНСТЕКСТ вирус. - Нет! - отрезала. - Не думаю, что он знал, что имеет дело с вирусом.
Соши прочитала снова: - …Искусственно произведенный, обогащенный нейтронами изотоп урана с атомным весом 238. - Двести тридцать восемь? - воскликнула Сьюзан. - Разве мы не знаем, что в хиросимской бомбе был другой изотоп урана.