Sunday, March 7, 2010

LOW-PROTEIN DIET AND THE USE OF PROTEIN NABATI IN CKD (Chronic kidney disease)

Triyani Kresnawan *, HMS Markun ** * Installation of Nutrition Nutritionist RSCM Jakarta ** Division of Hypertension Kidney. Internist FKUI-RSCM INTRODUCTION Chronic kidney disease (ckd) grouped according to stages, ie stage I, II, III, and IV. At stations where a decline in IV renal function but not heavy replacement therapy dialysis so-called pre dialysis conditions. Generally the patient was given conservative treatment that includes diet and medical therapy in order to maintain the remaining kidney function would gradually entered the stage V or stage renal failure. Nutritional status is still a lot less experienced CKD patients. Research state of nutrition of patients with CKD Kliren Creatinine Test (TKK) ≤ 25 ml / mt  given therapy conservative in Renal Hypertension Clinic RSCM, found 50% of 14 patients with less nutritional status. Factors causing less nutrition include lack of food intake as a result of not appetite, nausea and vomiting. 

To prevent the decline and maintain the nutritional status, needs attention through monitoring and evaluation of health status and intake of food by the health team. In the service an integrated team consisting of doctors, nurses, nutritionists and other health workers needed to necessary therapy to patients optimally. Parenting nutrition (Nutrition Care) aims to meet the nutrient needs in order to achieve optimal nutritional status, patients can move normally, keeping balance fluids and electrolytes, which in turn has a quality of life is pretty good. Diet Management of Chronic Kidney Disease Patients pre dialysis stage IV with TKK <25 ml / mt is basically trying to slow the decline in kidney function in a way further reduce Nephron workload and lower levels of blood urea. Standard diet in Chronic Kidney Disease Pre Dialysis with conservative therapy is as follows: 1. Conditions in Developing Diet Energy 35 kcal / kg BW, at which the geriatric age> 60 years is 30 kcal / kg BW, with conditions and the following composition: �� carbohydrates as a source of energy, 50-60% of total calories �� protein for tissue maintenance and replace cells damaged by about 0.6 g / kg BW. If energy intake is not reached, the protein can be given up to 0.75 g / kg BW. Given protein is lower than the normal requirements, therefore diet This so-called Low-Protein Diet. In the past, the suggestion of the protein value high biology / animal until ≥ 60%, but at this moment the suggestion is 50%. When This animal protein can be substituted with vegetable proteins derived from processed soybeans as a side dish for the menu variety. �� fats to satisfy the energy needs required ± 30% preferred unsaturated fats. The need for fluid �� adjusted by the number of urine a day plus expenses IWL ± 500 ml. Salt �� adapted to the presence or absence of hypertension and fluid retention in the body. Salt restricted range 2,5-7,6 g / day equivalent to 1000-3000 mg Na / day. Potassium �� adapted to conditions of existence of hyperkalemia 40-70 mEq / day Phosphorus is recommended �� ≤ 10 mg / kg BW / day �� Calcium 1400-1600 mg / day 2. Suggested Food Source �� Carbohydrates: rice, vermicelli, noodles, macaroni, jagng, bread, kwethiau, potatoes, starchy, honey, syrup, candy, and sugar. �� Animal Protein Source: eggs, milk, meat, fish, chicken. Substitute Food Animal Protein The results are processed soybean tempeh, tofu, soybean milk, can be used as a substitute for animal protein for patients who likes a variety of menus or to the patient as long vegetarians is included in calculating protein needs. Some of the good and the weakness of vegetable protein source for patients with chronic kidney disease will be discussed. Fat �� Source: coconut oil, corn oil, soybean oil, low-salt margarine, butter. �� Vitamin and Mineral Sources All vegetables and fruit, unless the patient has hipekalemi should avoid fruits and vegetables have high potassium and special management by soaking fruits and vegetables in warm water for 2 hours, after which the soaking water discarded, vegetables / fruits are washed again with water flowing and for the fruit can be cooked into stup fruit / fruit coktail. 3. Raw Food Saved �� Vitamin and Mineral Sources Avoid fruits and vegetables high potassium if the patient has hiperkalemi. High-potassium foods such as the spinach, squash, cassava leaves, lychees, papaya leaves, young coconut, banana, durian, and jackfruit. Avoid / limit foods high in sodium if the patient's hypertension, and ascites udema. High-sodium foods such as the salt, MSG, flavor / broth dried, preserved foods, canned and salted. DISCUSSION Source of Protein in Chronic Kidney Disease Protein derived from the Greek, which means that the main proteos or precedence. The number and type of a given protein CKD in pre dialysis patients in the form of low protein diet is important to note that the protein useful for replacing damaged tissue, making antibody substances, enzymes and hormones, maintaining acid base balance, water, electrolytes, and also contributed a number of energy body. Proteins are made of 20 amino acids making up proteins, 11 of which can be synthesized by the body, and the remaining 9 essential amino acids is derived from food materials, namely Leucine, Isoleucine, Valine, Tryptophan, Phenylalanine, Methionine, Threonine, Lysine and histidine. Of amino acids, 8 of them needed by adults, while the histidine is needed by children who are in a period of growth. Raw foods contain all the amino acids is called a complete protein, like eggs, meat, fish, milk, poultry, cheese. Therefore, animal proteins commonly referred to as high biological value protein. Plant foods, such as rice and beans, contain essential amino acids is limited or incomplete. Therefore, said protein low biological value. Soybeans and their processed products, ie tempeh, tofu and soy milk, contain essential amino acids, although there was 1 amino acid less, limited to the maintenance function only, not for growth (Limiting Amino Acid) is methionine. Similarly, essential amino acids lysine less on rice and less on corn triptopan, but when food containing limited amino acid consumed simultaneously in the daily meal, can complement each other deficiencies in essential amino acids. For example, lysine limited rice eaten together with a limited Tempe methionine mixture obtained that allows the complementary amino acids for growth and maintenance of body tissues. Protein quality assessment methods used to using the Protein Efficiency Ratio (PER) is based on growth response in providing a number of proteins. Currently, quality assessment of protein used Protein Digestibility Corrected Amino Acid Score (PDCAAS) which describes the number of amino acids from the protein and the level of human resources at cernanya. With this method, soy protein has the same value in comparison with egg white and milk protein, except amino acids that must be added methionin. Source of protein from beans and soy products, like tempeh, tofu, milk acang also contains potassium and phosphorus are high enough to prevent hyperkalemia and hiperfosfatemia still needed phosphorus and potassium binder adequate. Soy products safe enough to break instead of animal protein as a variation on the menu with the recommended amount. But not for the additional supplements or that exceed the requirements. Soybean milk can also be used as a substitute for cow's milk. Positive things that come from vegetable protein contains phytoestrogens which are called isoflavones that provide many benefits to PGK. Studies have been conducted didapatan of soy protein can reduce proteinuria, hiperfiltrasi, and the estimated proinflamato cytokines can inhibit the decrease in lebuh renal function further. Other studies on diet with vegetable protein in patients are able to reduce the CKD ekresi urea, serum total cholesterol and LDL as the prevention of heart defects in patients often experienced PGK. In animal experiments with decreased kidney function that given casein compared with soy protein after a 1-3 week delay didapatkab kidney fungal decline further. Sample Menu (Modification) PGK patients with conservative treatment composition of animal protein: vegetable = 50%: 50%. Menu created for pre PGK HD patients 62 years old man with 66 kg of BB and TB 173 cm. Nutritional Value: Energy ± 2000 kcal, protein ± 40 g, ± 58 g fat, KH ± 335 g. Amount Time Menu G URT * Morning Rice Sauteed Tofu Honey Milk Sugar 100 75 40 15 13 ¾ GLS 1 ptg centrein 2 sachets 3 tablespoons 1 tbsp Pk 10:00 Cake salver Tea Sugar 50 13 1 servings 1 tbsp Day Rice Rolade Meat Cap-cay Fry Stup Pineapple 150 50 50 100 1 GLS 1 pcs centrein ½ GLS 1st ptg Pk 16:00 Pastry Bowl Fla. Syrup 50 30 1 pcs centrein 3 tablespoons Afternoon Rice fried chicken Stup Beans-Carrot Papaya Cocktail 150 40 50 100 1 GLS 1 pcs centrein ½ GLS 1st ptg * URT = household size, tbsp = tablespoon, ptg = cut, GLS = glass, centrein = moderate, btr = grain, BKS = pack Sample Menu Conventional CKD patients with conservative treatment of animal protein composition ≥ 60%. Menu created for male patients pre HD PGK 61 years with BB and TB 66 kg 173 cm. Nutritional Value: Energy ± 2030 kcal, protein ± 40 g, ± 60 g fat, KH ± 336 g. Amount Time Menu G URT * Morning Rice Egg Balado Honey Milk Sugar 100 75 40 20 13 ¾ GLS 1 btr KCl 2 sachets 4 tbsp 1 tbsp Pk 10:00 Cake salver Tea Sugar 50 13 1 servings 1 tbsp Siang Rice 150 1 GLS Beefsteak Meat Beans + Carrots Stup Stup Pineapple 50 50 100 1 ptg centrein ½ GLS 1st ptg Pk 16:00 Pudding Syrup 50 30 1 ptg centrein 3 tablespoons Afternoon Rice Baked Chicken Cap Cay Goreng Papaya 150 40 50 100 1 GLS 1 ptg centrein ½ GLS 1st ptg * URT = household size, tbsp = tablespoon, ptg = cut, GLS = glass, centrein = moderate, btr = grain, BKS = pack Conclusion: • conservative therapy, ie diet and medication given to patients who have not PGK replacement therapy, where TKK <25 ml / mt (stations IV PGK). • Diet low given the high protein. Caitan and electrolytes adjusted to the patient's condition. • In the Low Protein Diet, the source of protein as a side dish is not only derived from animal protein, can be processed soybeans for replacement of animal protein as a variation to the menu or vegetarian adherents to consider all the advantages and disadvantages. • protein intake is consistent and controlled is essential. • Organize food and meet the recommendations can improve the quality of the patient. Bibliography 1. Paulo Fanti, Soyfood in Chronic Renal Disease, University of Kentucky. Third 2. Annual Soyfoods Symposium Proceedings. http://www.soyfoods.com/ 3. Soy & Health. Incorporating Optimal Levels of Protein in the Diet. United Soybean Board. www.talksoy.com 4. Dietary protein and chronic Kidney Disease (CKD)-Davita 2004-2007 5. Joan Brookhyser, Eating a Vegetarian Diet While Living with Kidney Disease. Vegetarian Journal 2004. 6. Nutrition and Chronic Kidney Disease. National Kidney Foundation, 1998-2006. www.kidney.org 7. Denise E. Fair, Malcolm R. Ogbom, at all. Doetary Soy Protein Attenauates Renal Disease Proression After 1 and 3 weeks in Han: SPRD-cy Weanling Rats. Ametican Society for Nutrition Sciences. 2004 8. RSCM and Nutrition Section PERSAGI, Diet Guide, PT. Gramedia, Jakarta, 2004 9. K / DOQI, Clinical Practice Executive Summery. Guideline for Nutrition in Clinical Renal Failure Adult & Pediatric. Nutrition Kidney Foundation, USA. 2000 10. National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (K / DOQI) Advisory Board: K / DOQI Clinical practice guidelines for chronic kidney disease: evaluation, classification, and Stratification. Kisney Disease Outcome Quality Initiative. Am J Kidney Dis 39 (Suppl 1): S246, 2000 11. Adamasco, et al, Vegetarian Diet Alternated with Conventional Low-Protein Diet for Patient with Chronic Renal Failure. National Kidney Foundation. 2002 12. Koople and Massry's Nutrition Management of Renal Disease, second edition. Lippincott William & Wilkins, A Wolters Kluwers Company. 2004