La valutazione dello stato nutrizionale nella malnutrizione proteico energetica

La malnutrizione proteico energetica \ue8 una condizione di perdita di massa muscolare e adiposa associata, o meno, a modificazioni delle proteine viscerali, conseguente a patologie di tipo acuto e cronico e tale da influenzare la morbilit\ue0, la mortalit\ue0 e la prognosi dei pazienti. Negli ultimo decennio la ricerca ha notevolmente approfondito i meccanismi fisiopatologici dei quadri di malnutrizione evidenziando in particolare il ruolo della risposta infiammatoria o dello stress ossidativo. Inoltre \ue8 emersa l\u2019importanza di attuare uno screening nutrizionale sistematico precoce in tutti i pazienti al momento del ricovero e a cadenze determinate nel follow-up. Nei casi di screening positivo va attuata una valutazione diagnostica secondo criteri ben definiti. Il laboratorio clinico mantiene un ruolo centrale nella definizione dello stato nutrizionale attraverso la valutazione dii numerosi indicatori biochimici: dal bilancio dell\u2019azoto, utile anche nella terapia di supporto nutrizionale, al dosaggio delle proteine sieriche e di metaboliti correlati alla massa muscolare. I markers di infiammazione e di stress ossidativo possono fornire informazioni sull\u2019andamento del quadro clinico, sulla gravit\ue0 della malnutrizione e sulla risposta alla terapia. In quest\u2019ambito sono necessari ulteriori definizioni e messa a punto di metodiche sufficientemente sensibili e specifiche. Una valutazione dello stato dei micronutrienti, minerai e vitamine pu\uf2 essere necessaria in alcune situazioni

Clinical Nutrition

There is scientific evidence that nutritional treatment can prevent or delay the progression of CKD, control symptoms and prevent or reduce the development of complications such as protein energy malnutrition (PEM) and cardiovascular disease (CVD). PEM is a common clinical finding in renal disease and has a negative bearing on quality of life, morbidity and mortality and therefore it should be adequately prevented, diagnosed and treated. Nutritional prescriptions in renal patients are complex because nutritional goals are multiple, and at time conflicting, yet the prescribed diets should be as realistic and practical as possible. Nutritional support is needed when spontaneous food intake is inadequate to cover nutrient requirements. The main topics of the chapter are: the physiopathology of acute and chronic renal failure, a review of the literature on the role of different nutrients on progression of kidney disease, diagnosis and classification of protein energy malnutrition, which is steel controversial, dietary treatment according to the most recent guidelines, nutritional practical tips, nutrition in dialysis and transplant patients

The kidney

The purpose of the chapter is to offer a review of the physiopathology of kidney diseases related to multiple nutritional factors. These include not only protein and phosphate intake, but also dietary fats, excessive energy intake, nutrients related to hypertension, including sodium, alcohol and excess calories, bearing a negative impact and potassium, with a protective action. Metabolic disorders, such as dyslipidemia, obesity and a diabetes mellitus and low physical activity all have a role. Obesity is an independent risk factor for both chronic kidney and diabetic kidney diseases (obesity related glomerulopathy, ORG). Predialysis medical nutrition therapy has a role in delaying progression to stage 5 of kidney failure and in decreasing mortality after initiation of renal replacement therapy. Protein energy malnutrition and the inflammatory processes are frequent before and during dialysis. Kidney transplant is associated with metabolic complications. In the chapter current recommendations for screening, diagnosis, and treatment of clinically relevant nutritional problems are critically reviewed for application in clinical practice

Disvitaminosi. In Trattato di Medicina Interna

Il capitolo prende in esame i diversi aspetti delle vitamine e ha l\u2019obiettivo di rivedere, alla luce della pi\uf9 recente letteratura, le modalit\ue0 di classificazione, il metabolismo, le funzioni, i fabbisogni, in condizioni fisiologiche , nelle diverse et\ue0 e nei due sessi, e nelle situazioni di disvitaminosi, oggi spesso subcliniche, ma comunque presenti e talora di difficile definizione, i quadri clinici di carenza, le pi\uf9 aggiornate indagini diagnostiche, le principali sorgenti alimentari e le interazioni tra farmaci e nutrienti. Le funzioni svolte delle vitamine si sono rivelate pi\uf9 complesse rispetto al passato, intervenendo nella regolazione della crescita dei tessuti, nella differenziazione cellulare, nella regolazione epigenetica dell\u2019espressione genica, come antiossidanti, antiinfiammatori e regolatori del sistema immunitario, e nella patogenesi di diverse patologie. Il testo comprende anche una descrizione della tossicit\ue0 di vitamine assunte in sovradosaggio, sostenuta da un diffuso e frequente ricorso a supplementi e integratori alimentari di vario tipo, assunti talora in modo indiscriminato o per funzioni non ancora confermate sul piano sperimentale

Nutrition in Renal Disease

Nutrition has a fundamental role in the management of kidney patients, acute and chronic, on conservative or on substitutive dialysis treatment or after kidney transplantation. In chronic kidney disease (CKD), independently from the cause of the original renal damage there is a progressive and irreversible loss of nephrons and organ function leading to the final stages of kidney failure (ESRD) when dialysis treatment needs to be started. Some nutritional intervention may be useful to prevent or delay the development of kidney disease associated with some chronic conditions such as overweight (leading to Obesity-related glomerulopathy, ORG), diabetes mellitus. or hypertension or to delay the progression toward the end stages of kidney disease. In later stages of CKD, dietary modifications (protein, phosphate, calcium, potassium and sodium) are part of the management of some uremic complications. Since protein-energy malnutrition (PEM) is a common finding in CRF and its presence at the beginning of dialysis caries a bad prognosis, with higher mortality and complication rates, the nutritional status of the patient needs to be constantly monitored and every effort should be taken be prevented or to control malnutrition. In patients with CRF the rationale, the goals and the modalities of nutritional prescriptions change with the degree of loss of renal function, the etiology of kidney disease, the nutritional status of the subjects, the presence and the severity of clinical complications or co-morbidities and the need for dialysis treatment. When CRF patients start substitutive treatment the nutritional requirements change considerably. The big challenge for the nutritionist is to preserve the nutritional status, threatened by chronic nutrient losses and catabolism induced by dialysis, while at the same time controlling some of the symptoms not corrected by the dialysis sesions. Acute kidney failure(ARF) is associated with an acute type of PEM and nutritional interventions are generally similar to those for the acute hypercatabolic patients, with normal renal function.. In acute kidney patients however special substrates may be useful. Finally kidney transplant subjects require special care to counteract the effects on the nutritional status and nutrient requirements at first from the surgery and later from the post-transplant drug treatment

The Kidney

Dietary therapy has a role in renal disease to control the symptoms and the metabolic consequences of renal dysfunction. Protein and phosphate intake modification may decrease the rate of kidney failure patients. Protein-energy malnutrition is a common clinical finding in kidney patients from a number of cause, including iatrogenic factors from inadequate diets. Malnutrition may with a negative bearing in morbidity, mortality, quality of life and costs and also in the rate of progression of renal disease The indices to evaluate may be influenced by renal failure and may therefore not be as reliable as in subjects with normal renal function. The nutritional status of the patient needs to be monitored to prevent or treat malnutrition and regular follow up procedure are relevant. Acute and chronic kidney disease require specific nutritional treatments according the stage or the severity of renal failure, associated clinical conditions and the need of renal replacement therapy. In chronic patients personalized modified diets are prescribed after a careful assessment of the nutrient requirements. The compliance may be low and patient need to be educated and adequately informed. In some patients special substrates may be required . Finally kidney transplant subjects require special dietary treatment according to the different clinical stages and the type of medical treatment required by patients