饮食治疗对以蛋白尿为主的原发性肾小球疾病的疗效
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摘要
目的：评价饮食治疗对原发性肾小球疾病(CKD1-2期)的疗效及安全性
方法：按照入选及排除标准选取于大连医科大学附属一院肾内科门诊及病房就诊的CKD1-2期的30例原发性肾小球疾病患者,随机分为2组：低蛋白饮食组(LPD group:18例,给予饮食蛋白摄入量0.7g/kg/d并服用a-酮酸片0.09g/kg/d)；正常蛋白饮食组(NPD group:12例,饮食蛋白摄入量1.0g/kg/d)。随访12个月,动态观察血肌酐、eGFR.尿蛋白定量、血清白蛋白(Alb)、前白蛋白(PAB)、转铁蛋白(TRF)、胆固醇(TC)、甘油三脂(TG)、低密度脂蛋白(LDL)、体重指数(BMI)、上臂围、腰围等指标变化,随访结束后通过以上相关指标评价临床疗效(包括完全缓解、部分缓解及未缓解)以及营养状态。随访终点包括：治疗后达完全缓解；血肌酐值倍增或eGFR<30ml／min.1.73m-2;患者死亡。结果采用SPSS 16.0统计学软件进行统计分析,计量资料用均数±标准差(x±s)表示,计数资料采用χ2检验,计量资料采用t检验。
结果：30例患者随访4-12个月不等(平均随访9个月)。随访结束时两组共有12例达到完全缓解(LPD组9例,NPD组3例),无其他终点事件发生。LPD组完全缓解率为50%,总缓解率89%；NPD组完全缓解率25%,总缓解率67%,两组之间比较无显著差异(p＞0.05)。LPD组血肌酐水平在9个月(75.60±16.09μml/l)、12个月(72.84±15.21μml/l)时较基础值(89.27±11.18μmol/l)明显下降,与NPD组相比,有显著差异(p＜0.05)。LPD组eGFR较治疗前明显上升,在9个月(94.51±25.43ml/min·1.73m-2)、12个月(101.55±23.65ml/min·1.73m-2)时升高显著,与NPD组相比有显著差异(p＜0.05)。LPD组尿蛋白水平在3个月(3955.80±2521.23 mg/d)、6个月(2102.334±1050.34 mg/d)、9个月(1568.95±664.33mg/d)和12个月(985.63±717.65mg/d)时较基线值(5121.00±2486.09mg/d)均有明显下降(p<0.05),与NPD组比较6、9、12个月时,差异有统计学意义(p＜0.05)。LPD组治疗后血清白蛋白水平明显上升,在6个月(38.54.4±6.93 g/l)、9个月(42.47±6.71 g/l)、12个月(43.55±7.36 g/l)时与NPD组比较,有显著差异(p＜0.05)；LPD组前白蛋白、转铁蛋白水平较治疗前呈轻度上升趋势,与NPD组相比,无显著差异(p＞0.05)。LPD组胆固醇、甘油三脂、低密度脂蛋白水平较治疗前均有不同程度下降,在9、12个月时胆固醇和低密度脂蛋白下降明显,与NPD组比较有统计学差异(p＜0.05)；治疗前后两组患者BMI、上臂围、腰围均无明显变化。
结论：低蛋白饮食联合酮酸治疗可显著减少原发性肾小球疾病的蛋白尿水平,改善肾脏功能,同时维持良好的营养状态。
Objects:To evaluate the efficacy and safety of dietary intervention in patients with primary glomerular diseases.
Methods:Total 30 patients with dominant proteinuria caused by primary glomerular diseases (CKD1-2) were enrolled from Nephrology Department of the First Affiliated Hospital of Dalian Medical University between July 2008 and February 2010. They were randomly assigned to LPD group (dietary protein intake 0.7g/kg/day+ketoacids 0.09g/kg/d) or NPD group (dietary protein intake 1.Og/kg/day). Follow up for 12 months. Serum creatinine, eGFR, urinary protein excretion,serum albumin, prealbumin, transferrin, cholesterol, triglyceride, low-density lipoprotein cholesterol and anthropometric index (BMI, waistline, mid-arm circumference) were tested during the follow-up period. End points included doubling of the serum creatinine concentration, eGFR<30 ml/min·1.73m-2, death and complete remission. All analyses were carried out with SPSS 16.0 statistical software, the results are presented as mean±SD. Chi-square test and t-test were used respectively for numeration and measurement data. p<0.05 was considered statistically significant.
Results:The mean follow-up was 9 months (range 4 to 12 months).Total 12 patients were complete remission (LPD 9 and NPD 3) without other end points. The entire remission rate were 89% in LPD and 67% in NPD, while complete remission rate were 50% and 25% respectively, with no significant difference between groups (p>0.05). Serum creatinine declined significantly from the 9th month in group LPD (75.60±16.09 at the 9th month,72.84±15.21 at the 12th month, p<0.05). A significant increase in eGFR was observed in LPD (p<0.05). Urinary protein excretion started to decline significantly from the 3th month (3955.80±2521.23 mg/d) in group LPD, and a statistically significant difference was found between groups (2102.33±1050.34mg/d at the 6th month,1568.95±664.33mg/d at the 9th month, 985.63±717.65mg/d at the 12th month,p<0.05). Serum albumin increased significantly from baseline in LPD (p<0.05), but not in NPD. Cholesterol and low-density lipoprotein cholesterol declined significantly form the 9th month, while it remained in NPD (p<0.05). No statistically significant difference was found between groups in prealbumin, transferrin and anthropometric index (BMI, waistline, mid-arm circumference) (p＞0.05).
Conclusion:Low protein diet with Keto acids have benefit effects on reducing proteinuria, improving renal function and maintaining nutritional status.
方法：按照入选及排除标准选取于大连医科大学附属一院肾内科门诊及病房就诊的CKD1-2期的30例原发性肾小球疾病患者,随机分为2组：低蛋白饮食组(LPD group:18例,给予饮食蛋白摄入量0.7g/kg/d并服用a-酮酸片0.09g/kg/d)；正常蛋白饮食组(NPD group:12例,饮食蛋白摄入量1.0g/kg/d)。随访12个月,动态观察血肌酐、eGFR.尿蛋白定量、血清白蛋白(Alb)、前白蛋白(PAB)、转铁蛋白(TRF)、胆固醇(TC)、甘油三脂(TG)、低密度脂蛋白(LDL)、体重指数(BMI)、上臂围、腰围等指标变化,随访结束后通过以上相关指标评价临床疗效(包括完全缓解、部分缓解及未缓解)以及营养状态。随访终点包括：治疗后达完全缓解；血肌酐值倍增或eGFR<30ml／min.1.73m-2;患者死亡。结果采用SPSS 16.0统计学软件进行统计分析,计量资料用均数±标准差(x±s)表示,计数资料采用χ2检验,计量资料采用t检验。
结果：30例患者随访4-12个月不等(平均随访9个月)。随访结束时两组共有12例达到完全缓解(LPD组9例,NPD组3例),无其他终点事件发生。LPD组完全缓解率为50%,总缓解率89%；NPD组完全缓解率25%,总缓解率67%,两组之间比较无显著差异(p＞0.05)。LPD组血肌酐水平在9个月(75.60±16.09μml/l)、12个月(72.84±15.21μml/l)时较基础值(89.27±11.18μmol/l)明显下降,与NPD组相比,有显著差异(p＜0.05)。LPD组eGFR较治疗前明显上升,在9个月(94.51±25.43ml/min·1.73m-2)、12个月(101.55±23.65ml/min·1.73m-2)时升高显著,与NPD组相比有显著差异(p＜0.05)。LPD组尿蛋白水平在3个月(3955.80±2521.23 mg/d)、6个月(2102.334±1050.34 mg/d)、9个月(1568.95±664.33mg/d)和12个月(985.63±717.65mg/d)时较基线值(5121.00±2486.09mg/d)均有明显下降(p<0.05),与NPD组比较6、9、12个月时,差异有统计学意义(p＜0.05)。LPD组治疗后血清白蛋白水平明显上升,在6个月(38.54.4±6.93 g/l)、9个月(42.47±6.71 g/l)、12个月(43.55±7.36 g/l)时与NPD组比较,有显著差异(p＜0.05)；LPD组前白蛋白、转铁蛋白水平较治疗前呈轻度上升趋势,与NPD组相比,无显著差异(p＞0.05)。LPD组胆固醇、甘油三脂、低密度脂蛋白水平较治疗前均有不同程度下降,在9、12个月时胆固醇和低密度脂蛋白下降明显,与NPD组比较有统计学差异(p＜0.05)；治疗前后两组患者BMI、上臂围、腰围均无明显变化。
结论：低蛋白饮食联合酮酸治疗可显著减少原发性肾小球疾病的蛋白尿水平,改善肾脏功能,同时维持良好的营养状态。
Objects:To evaluate the efficacy and safety of dietary intervention in patients with primary glomerular diseases.
Methods:Total 30 patients with dominant proteinuria caused by primary glomerular diseases (CKD1-2) were enrolled from Nephrology Department of the First Affiliated Hospital of Dalian Medical University between July 2008 and February 2010. They were randomly assigned to LPD group (dietary protein intake 0.7g/kg/day+ketoacids 0.09g/kg/d) or NPD group (dietary protein intake 1.Og/kg/day). Follow up for 12 months. Serum creatinine, eGFR, urinary protein excretion,serum albumin, prealbumin, transferrin, cholesterol, triglyceride, low-density lipoprotein cholesterol and anthropometric index (BMI, waistline, mid-arm circumference) were tested during the follow-up period. End points included doubling of the serum creatinine concentration, eGFR<30 ml/min·1.73m-2, death and complete remission. All analyses were carried out with SPSS 16.0 statistical software, the results are presented as mean±SD. Chi-square test and t-test were used respectively for numeration and measurement data. p<0.05 was considered statistically significant.
Results:The mean follow-up was 9 months (range 4 to 12 months).Total 12 patients were complete remission (LPD 9 and NPD 3) without other end points. The entire remission rate were 89% in LPD and 67% in NPD, while complete remission rate were 50% and 25% respectively, with no significant difference between groups (p>0.05). Serum creatinine declined significantly from the 9th month in group LPD (75.60±16.09 at the 9th month,72.84±15.21 at the 12th month, p<0.05). A significant increase in eGFR was observed in LPD (p<0.05). Urinary protein excretion started to decline significantly from the 3th month (3955.80±2521.23 mg/d) in group LPD, and a statistically significant difference was found between groups (2102.33±1050.34mg/d at the 6th month,1568.95±664.33mg/d at the 9th month, 985.63±717.65mg/d at the 12th month,p<0.05). Serum albumin increased significantly from baseline in LPD (p<0.05), but not in NPD. Cholesterol and low-density lipoprotein cholesterol declined significantly form the 9th month, while it remained in NPD (p<0.05). No statistically significant difference was found between groups in prealbumin, transferrin and anthropometric index (BMI, waistline, mid-arm circumference) (p＞0.05).
Conclusion:Low protein diet with Keto acids have benefit effects on reducing proteinuria, improving renal function and maintaining nutritional status.
引文
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1. Jafar TH, Stark PC, Schmid CH, Landa M, Maschio G, Marcantoni C, de Jong PE, de Zeeuw D, Shahinfar S, Ruggenenti P, Remuzzi G, Levey AS; AIPRD Study Group.Angiotensin-Converting Enzymne Inhibition and Progression of Renal Disease. Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int.2001 Sep; 60(3):1131-40.
2. Valmadrid CT, Klein R, Moss SE, Klein BE. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med.2000 Apr 24; 160(8):1093-100.
3. Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease:the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med.1982 Sep 9; 307(11):652-9. Review.
4. Ricardo SD, Bertram JF, Ryan GB. Reactive oxygen species in puromycin Aminonucleoside nephrosis:in vitro studies. Kidney Int.1994 Apr; 45(4): 1057-69.
5. Chobanian MC, Julin CM, Molteni KH, Brazy PC. Growth hormone regulates ammoniagenesis in canine renal proximal tubule segments. Am J Physiol.1992 May;262(5 Pt 2):F878-84.
6. Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of estricting dietary protein on the progression of renal failure in patients with nsulin-dependent diabetes mellitus. N Engl J Med.1991 Jan 10; 324(2):78-84.
7. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency:meta-analysis. BMJ.1992 Jan 25; 304(6821):216-20.
8. Pedrini MT, Levey AS, Lau J, Chalmers TC, Wang PH. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med.1996 Apr 1; 124(7):627-32.
9. Kasiske BL, Lakatua JD, Ma JZ, Louis TA. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function. Am J Kidney Dis.1998 Jun; 31 (6):954-61.
10.李素蘋,许菲菲.Maroni公式评估慢性肾脏病患者饮食蛋白质摄入在国人中
的应用.浙江临床医学,2008；10(10)：1310-1312.
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12. Aparicio M, Bouchet JL, Gin H, Potaux L, Morel D, de Precigout V, Lifermann F, Gonzalez R. Effect of a low-protein diet on urinary albumin excretion in uremic patients. Nephron.1988; 50(4):288-91.
13. Walser M, Hill S, Tomalis EA. Treatment of nephrotic adults with a supplemented, very low-protein diet. Am J Kidney Dis.1996 Sep; 28(3):354-64.
14. Andrew S. Levey, Sharon Adler, Arlene W. Caggiula, et al. Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study. American Journal of Kidney Disease,1996; 27(5):652-663.
15. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency:meta-analysis. BMJ.1992 Jan 25; 304(6821):216-20.
16. Lowrie EG, Lew NL. Death risk in hemodialysis patients:the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis.1990 May; 15(5):458-82.
17. Pifer TB, McCullough KP, Port FK, Goodkin DA, Maroni BJ, Held PJ, Young EW. Mortality risk in hemodialysis patients and changes in nutritional indicators: DOPPS. Kidney Int.2002 Dec; 62(6):2238-45.
18.董捷 王海燕.腹膜透析患者慢性炎症状态与营养不良及心血管病的关系[J].中华肾脏病杂志,2002,18(5)：317-321
19. Bergstrom J.Why are dialysis patients malnourished? Am J Kidney Dis.1995 Jul;26(1):229-41. Review.
20. Bistrian BR, McCowen KC, Chan S. Protein-energy malnutrition in dialysis patients. Am J Kidney Dis.1999 Jan; 33(1):172-5. Review.
21. Tizianello A,Deferrari G, Gabribotto G, et al. Is amino acid imblance harmful to patients in chronic renal failure? [J]. Kidney Int Suppl,1985,17:S79-S83.
22.林善琰.重视对慢性肾功能衰竭的“一体化”治疗.临床肾脏病杂志,2001,1：6-8.
23.唐知还 郝静 虞茜 袁伟杰.运用主观评估法评价α酮酸对老年透析患者营养的改善作用[J].中国血液净化,2008,7(6)：307-310
24. Rosman JB, ter Wee PM, Meijer S, Piers-Becht TP, Sluiter WJ, Donker AJ.Prospective randomised trial of early dietary protein restriction in chronic renal failure. Lancet.1984 Dec 8;2(8415):1291-6.
25. Giordano M, De Feo P, Lucidi P, DePascale E, Giordano G, Cirillo D, Dardo G, Signorelli SS, Castellino P. Effects of dietary protein restriction on fibrinogen
26. Jiang N, Qian J, Sun W, Lin A, Cao L, Wang Q, Ni Z, Wan Y, Linholm B, Axelsson J, Yao Q.Better preservation of residual renal function in peritoneal dialysis patients treated with a low-protein diet supplemented with keto acids:a prospective, randomized trial. Nephrol Dial Transplant.2009 Aug; 24(8): 2551-8.Epub 2009 Mar 3.
27.李英 吴文清等.脂代谢异常与肾脏损害[J].临床荟萃,2002,17(6)：372-372,F003
28. Castelli WP. Lipids, risk factors and ischaemic heart disease. Atherosclerosis. 1996 Jul; 124 Suppl:S1-9.
29. Bernard S, Fouque D, Laville M, Zech P. Effects of low-protein diet supplemented with ketoacids on plasma lipids in adult chronic renal failure. Miner Electrolyte Metab.1996; 22(1-3):143-6.
30. D'Amico G, Gentile MG, Manna G, Fellin G, Ciceri R, Cofano F, Petrini C,Lavarda F, Perolini S, Porrini M. Effect of vegetarian soy diet on hyperlipidaemia in nephrotic syndrome. Lancet.1992 May 9; 339(8802):1131-4.
2. Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease:the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal abiation, and intrinsic renal disease.N Engl J Med.1982 Sep 9;307(11):652-9. Review.
3. Ricardo SD, Bertram JF, Ryan GB. Reactive oxygen species in puromycin Aminonucleoside nephrosis:in vitro studies. Kidney Int.1994 Apr;45(4):1057-69.
4. Jafar TH, Stark PC, Schmid CH, Landa M, Maschio G, Marcantoni C, de Jong PE, de Zeeuw D, Shahinfar S, Ruggenenti P, Remuzzi G, Levey AS; AIPRD Study Group.Angiotensin-Converting Enzymne Inhibition and Progression of Renal Disease. Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int.2001 Sep;60(3):1131-40.
5. Valmadrid CT, Klein R, Moss SE, Klein BE. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med.2000 Apr 24;160(8):1093-100.
6. Friedman AN. High-protein diets:potential effects on the kidney in renal health and disease. Am J Kidney Dis.2004 Dec;44(6):950-62.
7. Aparicio M, Bouchet JL, Gin H, Potaux L, Morel D, de Precigout V, Lifermann F, Gonzalez R. Effect of a low-protein diet on urinary albumin excretion in uremic patients. Nephron.1988;50(4):288-91.
8. Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of estricting dietary protein on the progression of renal failure in patients with nsulin-dependent diabetes mellitus. N Engl J Med.1991 Jan 10;324(2):78-84.
9. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency:meta-analysis. BMJ.1992 Jan 25;304(6821):216-20.
10. Pedrini MT, Levey AS, Lau J, Chalmers TC, Wang PH. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med.1996 Apr 1;124(7):627-32.
11. Kasiske BL, Lakatua JD, Ma JZ, Louis TA. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function. Am J Kidney Dis.1998 Jun;31(6):954-61.
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17. Bernard S, Fouque D, Laville M, Zech P. Effects of low-protein diet supplemented with ketoacids on plasma lipids in adult chronic renal failure.Miner Electrolyte Metab.1996;22(1-3):143-6.
18. Peuchant E, Delmas-Beauvieux MC, Dubourg L, Thomas MJ, Perromat A, Aparicio M, Clerc M, Combe C. Antioxidant effects of a supplemented very low protein diet in chronic renal failure. Free Radic Biol Med.1997;22(1-2):313-20.
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24. Levey AS, Greene T, Beck GJ, Caggiula AW, Kusek JW, Hunsicker LG, Klahr S.Dietary protein restriction and the progression of chronic renal disease:what have all of the results of the MDRD study shown? Modification of Diet in Renal Disease Study group. J Am Soc Nephrol.1999 Nov;10(11):2426-39. Review.
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27. Kopple JD. National kidney foundation K/DOQI chinical protein guidelines for nutrition in chronic renal failure. Am J Kidney Dis,2001,37(1,suppl2):S66-70
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32.李燕,蔡东联,陈小莉,胡同杰.大豆异黄酮对实验性肾病综合征疗效观察[J].中华肾脏病杂志,2002,18(3)：207-210
33.孙莉静.大豆蛋白饮食在肾脏疾病中的应用[J].肾脏病与透析肾移植杂志,2001,(4)：373-376
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35. Ricardo SD, Bertram JF, Ryan GB. Reactive oxygen species in puromycin Aminonucleoside nephrosis:in vitro studies. Kidney Int.1994 Apr;45(4):1057-69.
36. Chobanian MC, Julin CM, Molteni KH, Brazy PC. Growth hormone regulates ammoniagenesis in canine renal proximal tubule segments. Am J Physiol.1992 May;262(5 Pt 2):F878-84.
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39. Okuda S, Nakamura T, Yamamoto T, Ruoslahti E, Border WA. Dietary protein restriction rapidly reduces transforming growth factor beta 1 expression in experimental glomerulonephritis. Proc Natl Acad Sci USA.1991 Nov 1;88(21): 9765-9.
40. Uribarri J, Tuttle KR. Advanced glycation end products and nephrotoxicity of high-protein diets. Clin J Am Soc Nephrol.2006 Nov;1(6):1293-9. Epub 2006 Sep 27
41. Peters H, Border WA, Noble NA. Tandem antifibrotic actions of L-arginine supplementation and low protein diet during the repair phase of experimental glomerulonephritis. Kidney Int.2000 Mar;57(3):992-1001.
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43. Giordano M, De Feo P, Lucidi P, DePascale E, Giordano G, Cirillo D, Dardo G, Signorelli SS, Castellino P. Effects of dietary protein restriction on fibrinogen and albumin metabolism in nephrotic patients. Kidney Int.2001 Jul; 60(1): 235-42.
44. Walser M, Hill S, Tomalis EA. Treatment of nephrotic adults with a supplemented, very low-protein diet. Am J Kidney Dis.1996 Sep;28(3):354-64.
1. Jafar TH, Stark PC, Schmid CH, Landa M, Maschio G, Marcantoni C, de Jong PE, de Zeeuw D, Shahinfar S, Ruggenenti P, Remuzzi G, Levey AS; AIPRD Study Group.Angiotensin-Converting Enzymne Inhibition and Progression of Renal Disease. Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int.2001 Sep; 60(3):1131-40.
2. Valmadrid CT, Klein R, Moss SE, Klein BE. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med.2000 Apr 24; 160(8):1093-100.
3. Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease:the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med.1982 Sep 9; 307(11):652-9. Review.
4. Ricardo SD, Bertram JF, Ryan GB. Reactive oxygen species in puromycin Aminonucleoside nephrosis:in vitro studies. Kidney Int.1994 Apr; 45(4): 1057-69.
5. Chobanian MC, Julin CM, Molteni KH, Brazy PC. Growth hormone regulates ammoniagenesis in canine renal proximal tubule segments. Am J Physiol.1992 May;262(5 Pt 2):F878-84.
6. Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of estricting dietary protein on the progression of renal failure in patients with nsulin-dependent diabetes mellitus. N Engl J Med.1991 Jan 10; 324(2):78-84.
7. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency:meta-analysis. BMJ.1992 Jan 25; 304(6821):216-20.
8. Pedrini MT, Levey AS, Lau J, Chalmers TC, Wang PH. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med.1996 Apr 1; 124(7):627-32.
9. Kasiske BL, Lakatua JD, Ma JZ, Louis TA. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function. Am J Kidney Dis.1998 Jun; 31 (6):954-61.
10.李素蘋,许菲菲.Maroni公式评估慢性肾脏病患者饮食蛋白质摄入在国人中
的应用.浙江临床医学,2008；10(10)：1310-1312.
11.张道友,叶任高,李幼姬,李惠群.静注人体白蛋白对肾病综合征的不利影响[J].中华肾脏病杂志,1996,12(3)：144-146
12. Aparicio M, Bouchet JL, Gin H, Potaux L, Morel D, de Precigout V, Lifermann F, Gonzalez R. Effect of a low-protein diet on urinary albumin excretion in uremic patients. Nephron.1988; 50(4):288-91.
13. Walser M, Hill S, Tomalis EA. Treatment of nephrotic adults with a supplemented, very low-protein diet. Am J Kidney Dis.1996 Sep; 28(3):354-64.
14. Andrew S. Levey, Sharon Adler, Arlene W. Caggiula, et al. Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study. American Journal of Kidney Disease,1996; 27(5):652-663.
15. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency:meta-analysis. BMJ.1992 Jan 25; 304(6821):216-20.
16. Lowrie EG, Lew NL. Death risk in hemodialysis patients:the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis.1990 May; 15(5):458-82.
17. Pifer TB, McCullough KP, Port FK, Goodkin DA, Maroni BJ, Held PJ, Young EW. Mortality risk in hemodialysis patients and changes in nutritional indicators: DOPPS. Kidney Int.2002 Dec; 62(6):2238-45.
18.董捷 王海燕.腹膜透析患者慢性炎症状态与营养不良及心血管病的关系[J].中华肾脏病杂志,2002,18(5)：317-321
19. Bergstrom J.Why are dialysis patients malnourished? Am J Kidney Dis.1995 Jul;26(1):229-41. Review.
20. Bistrian BR, McCowen KC, Chan S. Protein-energy malnutrition in dialysis patients. Am J Kidney Dis.1999 Jan; 33(1):172-5. Review.
21. Tizianello A,Deferrari G, Gabribotto G, et al. Is amino acid imblance harmful to patients in chronic renal failure? [J]. Kidney Int Suppl,1985,17:S79-S83.
22.林善琰.重视对慢性肾功能衰竭的“一体化”治疗.临床肾脏病杂志,2001,1：6-8.
23.唐知还 郝静 虞茜 袁伟杰.运用主观评估法评价α酮酸对老年透析患者营养的改善作用[J].中国血液净化,2008,7(6)：307-310
24. Rosman JB, ter Wee PM, Meijer S, Piers-Becht TP, Sluiter WJ, Donker AJ.Prospective randomised trial of early dietary protein restriction in chronic renal failure. Lancet.1984 Dec 8;2(8415):1291-6.
25. Giordano M, De Feo P, Lucidi P, DePascale E, Giordano G, Cirillo D, Dardo G, Signorelli SS, Castellino P. Effects of dietary protein restriction on fibrinogen
26. Jiang N, Qian J, Sun W, Lin A, Cao L, Wang Q, Ni Z, Wan Y, Linholm B, Axelsson J, Yao Q.Better preservation of residual renal function in peritoneal dialysis patients treated with a low-protein diet supplemented with keto acids:a prospective, randomized trial. Nephrol Dial Transplant.2009 Aug; 24(8): 2551-8.Epub 2009 Mar 3.
27.李英 吴文清等.脂代谢异常与肾脏损害[J].临床荟萃,2002,17(6)：372-372,F003
28. Castelli WP. Lipids, risk factors and ischaemic heart disease. Atherosclerosis. 1996 Jul; 124 Suppl:S1-9.
29. Bernard S, Fouque D, Laville M, Zech P. Effects of low-protein diet supplemented with ketoacids on plasma lipids in adult chronic renal failure. Miner Electrolyte Metab.1996; 22(1-3):143-6.
30. D'Amico G, Gentile MG, Manna G, Fellin G, Ciceri R, Cofano F, Petrini C,Lavarda F, Perolini S, Porrini M. Effect of vegetarian soy diet on hyperlipidaemia in nephrotic syndrome. Lancet.1992 May 9; 339(8802):1131-4.