Zusammenfassung
Ernährungsempfehlungen bei Nierenerkrankungen richten sich nach dem Krankheitsstadium
(CKD-Stadien [CKD: chronische Nierenerkrankung]), den Begleiterkrankungen und den
Sekundärfolgen der Niereninsuffizienz. Diätetische Maßnahmen verfolgen primär präventive
Ziele wie die Progressionshemmung der Niereninsuffizienz, die Aufrechterhaltung eines
adäquaten Ernährungszustands und die Verhinderung von Hyperphosphatämie oder Hyperkaliämie.
Zur Progressionshemmung chronischer Nierenerkrankungen wird neben den etablierten
medikamentösen Interventionen nur noch in den CKD-Stadien 1–3 eine diätetische Eiweißrestriktion
auf 0,6–0,8 g / kg / d empfohlen. Für das Management einer Hyperphosphatämie stehen
sowohl diätetische als auch medikamentöse (Phosphatbinder) Behandlungsoptionen zur
Verfügung. Diätetische Phosphatrestriktionen dürfen den Ernährungszustand allerdings
nicht negativ beeinflussen. In den CKD-Stadien 4 und 5 besteht ein hohes Risiko für
die Entwicklung einer Mangelernährung, die durch einen gesteigerten Proteinkatabolismus
bei gleichzeitig gehemmter Proteinsynthese charakterisiert ist. Die Entwicklung einer
Malnutrition muss frühzeitig erkannt und konsequent behandelt werden. Das Ziel ernährungsmedizinischer
Maßnahmen bei Mangelernährung ist die komplette Abdeckung des individuellen Energie-
und Eiweißbedarfs, im Bedarfsfall auch durch orale oder enterale (PEG [perkutane endoskopische
Gastrostomie]) Verabreichung eiweißreicher und hochkalorischer Zusatznahrung.
Abstract
Dietary recommendations for patients with chronic renal disease need to take into
consideration the CKD stage, the variety of comorbidities, and the plethora of secondary
consequences of renal insufficiency. Primary aims of dietary interventions in kidney
disease include retardation of disease progression, maintenance of a good nutritional
state and prevention of hyperphosphatemia or hyperkalemia. In CKD stages 1–3 retardation
of disease progression can be achieved by medicinal interventions in combination with
dietary protein restriction to 0.6–0.8 g / kg / day. The management of hyperphosphatemia
includes dietary as well as medicinal (phosphate binders) measures. However, dietary
phosphate control should not compromise protein intake. There is an increased risk
for development of malnutrition in CKD stages 4 and 5, which is characterized by stimulation
of muscle proteolysis and inhibition of protein synthesis. The development of malnutrition
needs to be recognized early and addressed with scrutiny. Any dietary interventions
for the management of malnutrition aim at improving energy and protein intake, either
by dietary counselling or, if required, by prescription of oral or enteral (PEG / PEJ)
energy and protein supplements.
Schlüsselwörter
Mangelernährung - Hyperphosphatämie - arterielle Hypertonie - Hyperlipidämie
Keywords
malnutrition - hyperphosphatemia - arterial hypertension - hyperlipidemia
Literatur
- 1
Levey A S, Coresh J, Balk E et al.
National Kidney Foundation practice guidelines for chronic kidney disease: evaluation,
classification, and stratification.
Ann Intern Med.
2003;
139
137-147
- 2
Manjunath G, Sarnak M J, Levey A S.
Prediction equations to estimate glomerular filtration rate: an update.
Curr Opin Nephrol Hypertens.
2001;
10
785-792
- 3
Hallan S I, Coresh J, Astor B C et al.
International comparison of the relationship of chronic kidney disease prevalence
and ESRD risk.
J Am Soc Nephrol.
2006;
17
2275-2284
- 4 Bello A, Kawar B, El Kossi M et al. Epidemiology and pathophysiology of chronic
kidney disease.. In: Floege J, Johnson R J, Feehally J, eds Comprehensive clinical
nephrology.. 4th ed. St Louis, Missouri: Elsevier Inc; 2010: 907-918
- 5
Levin N W, Gotch F A, Kuhlmann M K.
Factors for increased morbidity and mortality in uremia: hyperphosphatemia.
Semin Nephrol.
2004;
24
396-400
- 6
Bailey J L, Wang X, England B K et al.
The acidosis of chronic renal failure activates muscle proteolysis in rats by augmenting
transcription of genes encoding proteins of the ATP-dependent ubiquitin-proteasome
pathway.
J Clin Invest.
1996;
97
1447-1453
- 7
Fouque D, Kalantar-Zadeh K, Kopple J D et al.
A proposed nomenclature and diagnostic criteria for protein – energy wasting in acute
and chronic kidney disease.
Kidney Int.
2008;
73
391-398
- 8
Stenvinkel P, Ketteler M, Johnson R J et al.
IL-10, IL-6, and TNF-alpha: central factors in the altered cytokine network of uremia
– the good, the bad, and the ugly.
Kidney Int.
2005;
67
1216-1233
- 9
Ikizler T A, Greene J H, Wingard R L et al.
Spontaneous dietary protein intake during progression of chronic renal failure.
J Am Soc Nephrol.
1995;
6
1386-1391
- 10
Ikizler T A, Pupim L B, Brouillette J R et al.
Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation.
Am J Physiol Endocrinol Metab.
2002;
282
E107-E116
- 11
Enia G, Sicuso C, Alati G et al.
Subjective global assessment of nutrition in dialysis patients.
Nephrol Dial Transplant.
1993;
8
1094-1098
- 12
Moissl U M, Wabel P, Chamney P W et al.
Body fluid volume determination via body composition spectroscopy in health and disease.
Physiol Meas.
2006;
27
921-933
- 13
Fouque D, Aparicio M.
Eleven reasons to control the protein intake of patients with chronic kidney disease.
Nat Clin Pract Nephrol.
2007;
3
383-392
- 14
Klahr S, Levey A S, Beck G J et al.
The effects of dietary protein restriction and blood-pressure control on the progression
of chronic renal disease. Modification of Diet in Renal Disease Study Group.
N Engl J Med.
1994;
330
877-884
- 15
Clinical practice guidelines for nutrition in chronic renal failure. K / DOQI, National
Kidney Foundation.
Am J Kidney Dis.
2000;
35
1-140
- 16
Hansen H P, Tauber-Lassen E, Jensen B R et al.
Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy.
Kidney int.
2002;
62
220-228
- 17
Fouque D, Vennegoor M, Ter Wee P et al.
EBPG guideline on nutrition.
Nephol Dial Transplant.
2007;
22
(S 02)
ii45-ii87
- 18
Brunori G, Viola B F, Parrinello G et al.
Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly:
a prospective randomized multicenter controlled study.
Am J Kidney Dis.
2007;
49
569-580
- 19
Steiber A L, Kopple J D.
Vitamin Status and Needs for People with Stages 3–5 Chronic Kidney Disease.
J Ren Nutr.
2011;
21
355-368
- 20
Boaz M, Smetena S, Weinstein T et al.
Secondary prevention with antioxidants of cardiovascular disease in end stage renal
disease (SPACE): randomized placebo-controlled trials.
Lancet.
2000;
356
1213-1218
- 21
Mann J FE, Lonn E M, Yi Q et al.
Effects of vitamin E on cardiovascular outcomes in people with mild- to-moderate renal
insufficiency: results of the HOPE study.
Kidney Int.
2004;
65
1375-1380
- 22
Kopple J D, Feroze U.
The effect of obesity on chronic kidney disease.
J Ren Nutr.
2011;
21
66-71
- 23
Baigent C, Landray M J, Reith C et al.
The effects of lowering LDL cholesterol with simvastatin and ezetimibe in patients
with chronic kidney disease (Study of Heart an Renal Protection): a randomised placebo-controlled
trial.
Lancet.
2011;
377
2181-2192
- 24
Wanner C, Krane V, Maerz W et al.
Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis.
N Engl J Med.
2005;
353
238-248
- 25
Kuhlmann M K.
Management of Hyperphosphatemia.
Hemodial Int.
2006;
10
338-345
- 26
Noori N, Kalantar-Zadeh K, Kovesdy C P et al.
Association of dietary phosphorus intake and phosphorus-to-protein ratio with mortality
in hemodialysis patients.
Clin J Am Soc Nephrol.
2010;
5
683-692
- 27
Kalantar-Zahed K, Gutekunst L, Mehrotra R et al.
Understanding sources of dietary phosphorus in the treatment of patients with chronic
kidney disease.
Clin J Am Soc Nephrol.
2010;
5
519-530
- 28
Moe S M, Zidehsarai M P, Chambers M A et al.
Vegetarian compared with meat dietary protein source and phosphorus homeostasis in
chronic kidney disease.
Clin J Am Soc Nephrol.
2011;
6
257-264
- 29
Kuhlmann M K, Hoechst S, Landthaler I.
Patient empowerment in the management of hyperphosphatemia.
Int J Artif Organs.
2007;
30
1008-1013
- 30
Ahlenstiel T, Pape L, Ehrich J H et al.
Self-adjustment of phosphate binder dose to meal phosphorus content improves management
of hyperphosphataemia in children with chronic kidney disease.
Nephrol Dial Transplant.
2010;
25
3241-3249
- 31
Sullivan C, Sayre S S, Leon J B et al.
Effect of food additives on hyperphosphatemia among patients with end-stage renal
disease: a randomized controlled trial.
JAMA.
2009;
301
629-635
- 32 Committee to Review Dietary Reference Intakes for Vitamin D and Calcium, Food and
Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium and
Vitamin D.. Washington, DC: National Academy Press; 2010
- 33
Pupim L B, Flakoll P J, Levenhagen D K et al.
Exercise augments the acute anabolic effects of intradialytic parenteral nutrition
in chronic hemodialysis patients.
Am J Physiol Endocrinol Metab.
2004;
286
E589-597
- 34
Kuhlmann M K, Schmidt F, Koehler H.
High protein / energy vs. standard protein / energy nutritional regimen in the treatment
of malnourished hemodialysis patients.
Mineral Electrolyte Metabolism.
1999;
25
306-310
- 35
Stratton R J, Bircher G, Fouque D et al.
Multinutrient oral supplements and tube feeding in maintenance dialysis: a systematic
review and meta-analysis.
Am J Kidney Dis.
2005;
46
387-405
- 36
Cano N J, Fouque D, Roth H et al.
Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis
patients: a 2-year multicenter, prospective, randomized study.
J Am Soc Nephrol.
2007;
18
2583-2591
- 37
Johansen K L, Painter P L, Sakkas G K et al.
Effects of resistance exercise training and nandrolone decanoate on body composition
and muscle function among patients who receive hemodialysis: A randomized, controlled
trial.
J Am Soc Nephrol.
2006;
17
2307-2314
- 38
Feldt-Rasmussen B, Lange M, Sulowicz W et al.
Growth hormone treatment during hemodialysis in a randomized trial improves nutrition,
quality of life, and cardiovascular risk.
J Am Soc Nephrol.
2007;
18
2161-2171
- 39
Kuhlmann M K, Levin N W.
Potential interplay between nutrition and inflammation in dialysis patients.
Contrib Nephrol.
2008;
161
76-82
- 40
Nafar M, Noori N, Jalali-Farahani S et al.
Mediterranean diets are associated with a lower incidence of metabolic syndrome one
year following renal transplantation.
Kidney Int.
2009;
76
1199-1206
- 41 D-A-CH .Referenzwerte für die Nährstoffzufuhr.. 1. Aufl. 3. korrigierter Nachdruck.
Neustadt an der Weinstraße: Neuer Umschau Buchverlag; 2008
Prof. Dr. med. Martin K. Kuhlmann
Innere Medizin – Nephrologie, Vivantes Klinikum im Friedrichshain
Landsberger Allee 49
10249 Berlin
eMail: Martin.kuhlmann@vivantes.de
