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The impact of known and unknown dietary components to phosphorus intake
No full textThe pathogenesis of CKD-MBD is multifactorial but the tendency towards phosphorus retention due to an excessive dietary intake for the residual renal function plays a central role. The dietary phosphorus is absorbed in the intestine as inorganic free phosphorus. The share of intestinal absorption (about 60% on average) is negligible for plant phosphorus (in the form of phytate), while it is maximal for phosphate or polyphosphates contained in food additives. The latter represent a dangerous extra load of phosphorus because they are poorly recognized by patients and widely used in modern nutrition, in particular in low-cost food. In a free mixed diet, the phosphorus content is directly related to that of proteins. It follows that protein-rich foods are the main source of phosphorus. This is a favorable condition for CKD patients in conservative therapy when a low-protein diet is implemented, while it represents a huge problem for dialysis patients, who need a high-protein diet. A simple and effective approach to reduce the load of dietary phosphorus without reducing protein intake is to educate patients to avoid foods high in phosphorus (cheese, egg yolk, nuts, etc.), and particularly those containing phosphorus additives. In addition, they should prefer boiling (resulting also in a decrease in sodium and potassium) to other methods of cooking. Counseling by a dietician is important for successful patient care. The dietician provides nutritional education, can help the patient with the choice of food, and may favor the adherence to dietary prescriptions, which is a crucial aspect in an integrated approach to CKD-MBD
Fiducia nel diritto, fiducia nel giudice, teoria democratica (con uno sguardo su Hayek: 'The Political Order of a Free People')
No full textFunzione "espressiva" del rimedio: un dialogo tra giudice e comunità
No full textIl saggio esamina il rapporto tra risarcimento del danno non patrimoniale e punitive damages, approfondendo alcune ipotesi di rimedi alternativi, tra cui l'idea di un risarcimento in forma specifica del danno non patrimoniale
L’introduzione del principio costituzionale di equilibrio nel bilancio dello Stato: per un ripensamento dei valori nell’ ordinamento della giustizia pubblica
No full textItalian Association of Comparative Law (AIDC) - XXIV Colloquium
Assessment of habitual physical activity and energy expenditure in dialysis patients and relationships to nutritional parameters
No full textBACKGROUND AND AIM: Assessment of physical activity level and of energy expenditure is important in the clinical and nutritional care of dialysis patients, but it is not so easy to accomplish. The SenseWearTM Armband (SWA) is a novel multisensory device that is worn on the upper arm and collects a variety of physiologic data related to physical activity. Thus, duration and intensity of physical activity is recorded and expressed as METs (Metabolic Equivalent Task), and energy expenditure is estimated. The aim of our study was to assess interdialytic spontaneous physical activity in stable chronic hemodialysis (HD) patients and the relation to nutritional status and dietary nutrient intake.
PATIENTS AND METHODS: In 50 stable patients on maintenance hemodialysis treatment and 33 normal subjects (control group), level of spontaneous physical activity and estimated daily energy expenditure was assessed by SWA and related to biochemistry and anthropometry data, bioelectric impedance vector analysis, and energy and nutrient intake information coming from a 3-day food recall.
RESULTS: In respect to controls, HD patients showed lower mean daily METs value (1.3 ± 0.3 vs. 1.5 ± 0.2, p 3 METs (89 ± 85 vs. 143 ± 104 min/day, p < 0.05), lower number of steps per day (5,584 ± 3,734 vs. 11,735 ± 5,130, p < 0.001), resulting in a lower estimated energy expenditure (2,190 ± 629 vs. 2,462 ± 443 Kcal/day, p < 0.05). 31 out of the 50 HD patients (62%) had a mean daily value < 1.4 METs and hence were defined as sedentary. They differed from the active patients for higher age (63 ± 12 vs. 54 ± 12 y, p < 0.01), lower energy intake (26.1 ± 6.4 vs. 32.4 ± 11.3 Kcal/day, p < 0.05) and lower phase angle (5.5 ± 1.0 vs. 6.3 ± 0.9, p < 0.05). SWA-based estimation of daily energy expenditure was negatively related to age (r = -0.31, p < 0.05), whereas positive relations were observed with BMI (r = 0.51, p < 0.001), phase angle (r = 0.40, p < 0.01), serum phosphate (r = 0.49, p < 0.001) and albumin (r = 0.41, p < 0.01). The mean daily METs values were strongly related to normalized energy intake (r = 0.47, p < 0.001) and also to protein intake (r = 0.33, p < 0.05) and to phase angle (r = 0.38, p < 0.01). Multiple regression analysis showed that energy intake and dietary protein intake were independently related to the intensity of physical activity.
CONCLUSION: Our findings indicate that poor physical activity is highly prevalent in stable dialysis patients even when free from physical or neurological disabilities or severe comorbid conditions. The level and intensity of physical activity is positively related to body composition and to dietary nutrient intake. This confirms the strong interrelationship between exercise and nutrition, which in turn are associated with survival, rehabilitation and quality of life in dialysis patient
Dietary habits and counseling focused on phosphate intake in hemodialysis patients with hyperphosphatemia
No full textOBJECTIVE: To evaluate the dietary habits of hemodialysis patients with hyperphosphatemia and the effects of a dietetic intervention focused on limiting dietary phosphate load.
DESIGN: Cross-sectional dietary evaluation and prospective intervention study.
SETTING: Hospital hemodialysis units of Pisa and Pistoia, Italy. Subjects Forty-three stable adult hemodialysis patients, 20 of whom had phosphorus serum levels >5.5 mg/dL.
INTERVENTION: Analysis of dietary composition and of the effects of individual dietetic counseling in an attempt to reduce phosphorus intake while preserving the same protein intake.
MAIN OUTCOME MEASURES: Differences in nutrient intake between normophosphatemic and hyperphosphatemic patients, and changes in dietary phosphorus and phosphorus-protein ratio, serum phosphate, and calcium-phosphate product after dietetic intervention.
RESULTS: No major differences in nutrient intake were detected between hyperphosphatemia and normophosphatemia patients, apart from a lower phosphorus-protein ratio (13.1 +/- 1.7 versus 14.1 +/- 2.1 mg/g, P < .05) in the former. After dietetic intervention in the hyperphosphatemia patients, phosphate and calcium intake decreased significantly (by 100 mg on average), whereas dietary protein did not change. A further decrease of the dietary phosphate-protein ratio (12.5 +/- 1.8 mg/g, P < .05) also occurred. Serum phosphate showed a trend to decrease in the intervention group, whereas the serum calcium-phosphate product decreased significantly (from 66.8 +/- 13.1 to 61.0 +/- 13.8 mg2 /dL2 , P < .05).
CONCLUSIONS: In compliant and motivated patients, individual dietetic counseling may be useful in reducing phosphate load and in limiting the phosphate burden related to an adequate protein intake, with a potentially favorable impact on calcium-phosphate retention. A phosphate-controlled diet has a role in an integrated therapeutic approach to hyperphosphatemia and positive calcium-phosphorus balance in hemodialysis patients
Physical activity and renal transplantation.
No full textRenal transplantation is burdened by high cardiovascular risk because of increased prevalence of traditional and disease-specific cardiovascular risk factors and, consequently, patients are affected by greater morbidity and mortality. In renal transplanted patients, healthy lifestyle and physical activity are recommended to improve overall morbidity and cardiovascular outcomes. According to METs (Metabolic Equivalent Task; i.e. the amount of energy consumed while sitting at rest), physical activities are classified as sedentary (= 6.0 METs). Guidelines suggest for patients with chronic kidney disease an amount of physical activity of at least 30 minutes of moderate-intensity activity five times per week (min 450 MET-minutes/week). Data on physical activity in renal transplanted patients, however, are limited and have been mainly obtained by mean of non-objective methods. Available data suggest that physical activity is low either at the start or during renal transplantation and this may be associated with poor patient and graft outcomes. Therefore, in renal transplanted patients more data on physical activity obtained with objective, accelerometer-based methods are needed. In the meanwhile, physical activity have to be considered as an essential part of the medical care for renal transplanted recipient
Effect of telmisartan on the proteinuria and circadian blood pressure profile in chronic renal patients
No full textTelmisartan is a type 1 angiotensin II (AT(1)) receptor blocker, effective and safe in the treatment of arterial hypertension. However, data with respect to circadian blood pressure (BP) monitoring and urinary protein (uP) excretion are lacking in normotensive or mild hypertensive patients with chronic renal diseases. This study has evaluated the effects of 80 mg telmisartan, given as monotherapy, on 24 h BP levels and uP loss in 16 non-diabetic patients affected by proteinuric renal disease. These patients did not meet the recommended values of mean BP, i.e. 114 mmHg, nephrotic syndrome or severe renal failure (creatinine clearance < 20 ml/min) were excluded. After 4.2 +/- 2.7 month therapy, ambulatory BP monitoring showed a significant decrease (P < 0.001) of 24 h BP levels: systolic 135 +/- 11 vs. 122 +/- 13 mmHg, diastolic 84.4 +/- 8.1 vs. 75.9 +/- 8.5 mmHg, mean 101 +/- 8 vs. 91 +/- 9 mmHg. The effect was quite evident during either day-time or night-time. Clinic BP levels also significantly decreased (P < 0.001), and five patients reached the target values. uP excretion lowered by 37% (median) from 1.60 +/- 0.90 to 1.06 +/- 0.63 g/24 h (P < 0.01). No change in creatinine clearance (53.3 +/- 31.1 vs. 51.7 +/- 30.9 ml/min) or serum potassium level (4.3 +/- 0.3 vs. 4.4 +/- 0.4 mEq/l) was observed. Our results show that 80 mg of telmisartan, taken once daily, is effective in reducing uP excretion and BP throughout the 24 h, in normotensive or mild hypertensive renal patients. Since evidence exists that adequate control of BP, including during night-time, and reduction of proteinuria play a crucial role in the protection of renal function, telmisartan can be usefully considered in the conservative treatment of renal patients
Physical activity and exercise training: a relevant aspect of the dialysis patient's care.
No full textSedentary lifestyle is frequent in hemodialysis patients whose physical capabilities are largely reduced when compared with healthy subjects, and evidence exists that sedentary dialysis patients are at higher risk of death as compared to non-sedentary ones. Dialysis patients may suffer from cardiovascular disease, diabetes, malnutrition, depression, which limits their exercise capacity; conversely, regular physical exercise may favor rehabilitation and correction of several cardiovascular, metabolic and nutritional abnormalities. Many observational, population-based studies show that the level of physical activity is related to quality of life and nutritional status, as well as to the survival probability. Intervention studies are instead lacking; a randomized controlled multicenter trial is in progress in Italy to assess the effect of home-based exercise programs on survival and hospitalization rate in stable dialysis patients. Implementation of physical activity should be one of the goals of dialysis care management, but several barriers prevent a widespread implementation of physical exercise programs in the dialysis units. A lack of patients' or care-givers' motivation or willingness, and structural or functional resources are the most frequent obstacles to exercise implementation. Since the hemodialysis population is quite heterogeneous for physical abilities and comorbidities, exercise in not for everyone and individual prescription is required for a correct and safe implementation of physical activity
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