Problema de salud AUGE N° 64
Prevención de la Progresión de la Enfermedad Renal Crónica
Juicio del Panel y Evidencia
En persona adultas con enfermedad renal crónica, el Ministerio de Salud sugiere una dieta normoproteica (0.8 g/Kg de peso ideal) por sobre una dieta hipoproteica
Comentarios del Panel de Expertos:
►Si bien para la mayoría de las personas con enfermedad renal en etapa 1-3 una dieta normoproteica podría resultar apropiada, en personas con insuficiencia renal en etapa 4, la dieta hipoproteica puede ayudar a reducir los síntomas de la uremia y el riesgo de complicaciones metabólicas
El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Triviales: El equipo elaborador de la Guía estimó que los efectos deseables de «usar dieta hipoproteica» en comparación a «usar dieta normoproteica» son triviales o no relevantes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Consideraciones Adicionales
El panel de expertos considera que las personas en etapa 4 con alteraciones metabólica se podrían ver beneficiados respecto al alivio de los síntomas con la dieta hipoproteica.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Dieta hipoproteica comparado con dieta normoproteica en enfermedad renal crónica (etapa 1-4) |
||||||
|
Pacientes |
Persona adultas con enfermedad renal crónica (etapa 1-4). |
|||||
|
Intervención |
Dieta hipoproteica. |
|||||
|
Comparación |
Dieta normoproteica. |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
Dieta normoproteica |
Dieta hipoproteica |
Diferencia (IC 95%) |
||||
|
Mortalidad |
RR 0,77 (0,51 a 1,18) — 5 ensayos / 1680 pacientes [19, 37, 38, 52, 59] |
55 por 1000 |
42 por 1000 |
Diferencia: 13 menos (27 menos a 10 más) |
⊕⊕◯◯1,2 Baja |
La dieta hipoproteica podría disminuir la mortalidad, pero la certeza de la evidencia es baja. |
|
Progresión a enfermedad renal crónica terminal |
RR 1,03 (0,73 a 1,47) — 6 ensayos / 1814 pacientes [19, 25, 37, 38, 52, 59] |
144 por 1000 |
148 por 1000 |
Diferencia: 4 más (39 menos a 68 más) |
⊕◯◯◯1,2,3 Muy baja |
La dieta hipoproteica podría acelerar la progresión a enfermedad renal crónica terminal. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON dieta normoproteica está basado en el riesgo del grupo control en los estudios. El riesgo CON dieta hipoproteica (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en la mayoría de los ensayos no está clara la secuencia de aleatorización ni el ocultamiento de ésta.
2 Se disminuyó un nivel de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente.
3 Se disminuyó un nivel de certeza de evidencia por inconsistencia ya que diferentes ensayos presentan diferentes conclusiones (I2 de 62%).
Fecha de elaboración de la tabla: Octubre, 2018.
Referencias
2. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency: meta-analysis. BMJ (Clinical research ed.). 1992;304(6821):216-20.
3. Fouque D, Wang P, Laville M, Boissel JP. Low protein diets delay end-stage renal disease in non-diabetic adults with chronic renal failure. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2000;15(12):1986-92.
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6. Nezu U, Kamiyama H, Kondo Y, Sakuma M, Morimoto T, Ueda S. Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ open. 2013;3(5).
7. Pan Y, Guo LL, Jin HM. Low-protein diet for diabetic nephropathy: a meta-analysis of randomized controlled trials. The American journal of clinical nutrition. 2008;88(3):660-6.
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. Annals of internal medicine. 1996;124(7):627-32.
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16. Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with type 2 diabetes: one-year follow-up of a randomised trial. Diabetologia. 2004;47(10):1677-86.
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22. Di Iorio BR, Minutolo R, De Nicola L, Bellizzi V, Catapano F, Iodice C, Rubino R, Conte G. Supplemented very low protein diet ameliorates responsiveness to erythropoietin in chronic renal failure. Kidney international. 2003;64(5):1822-8.
23. Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of protein-restricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and hypertension. Diabetes care. 1993;16(2):483-92.
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26. European Study Group for the Conservative Management of Chronic Renal Failure 2. European Study Group for the Conservative Management of Chronic Renal Failure. Dietary compliance in the trial of the European Study Group. An interim analysis. European Study Group for the Conservative Management of Chronic Renal Failure. 1992;98:133-41.
27. Feiten SF, Draibe SA, Watanabe R, Duenhas MR, Baxmann AC, Nerbass FB, Cuppari L. Short-term effects of a very-low-protein diet supplemented with ketoacids in nondialyzed chronic kidney disease patients. European journal of clinical nutrition. 2005;59(1):129-36.
28. Garneata L, Stancu A, Dragomir D, Stefan G, Mircescu G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. Journal of the American Society of Nephrology : JASN. 2016;27(7):2164-76.
29. Hansen HP, Christensen PK, Tauber-Lassen E, Klausen A, Jensen BR, Parving HH. Low-protein diet and kidney function in insulin-dependent diabetic patients with diabetic nephropathy. Kidney international. 1999;55(2):621-8.
30. Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney international. 2002;62(1):220-8.
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32. Jesudason DR, Pedersen E, Clifton PM. Weight-loss diets in people with type 2 diabetes and renal disease: a randomized controlled trial of the effect of different dietary protein amounts. The American journal of clinical nutrition. 2013;98(2):494-501.
33. 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. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2009;24(8):2551-8.
34. Koya D, Haneda M, Inomata S, Suzuki Y, Suzuki D, Makino H, Shikata K, Murakami Y, Tomino Y, Yamada K, Araki SI, Kashiwagi A, Kikkawa R, Low-Protein Diet Study Group. Long-term effect of modification of dietary protein intake on the progression of diabetic nephropathy: a randomised controlled trial. Diabetologia. 2009;52(10):2037-45.
35. Larsen RN, Mann NJ, Maclean E, Shaw JE. The effect of high-protein, low-carbohydrate diets in the treatment of type 2 diabetes: a 12 month randomised controlled trial. Diabetologia. 2011;54(4):731-40.
36. Lindenau K, Abendroth K, Kokot F, Vetter K, Rehse C, Fröhling PT. Therapeutic effect of keto acids on renal osteodystrophy. A prospective controlled study. Nephron. 1990;55(2):133-5.
37. Locatelli F, Alberti D, Graziani G, Buccianti G, Redaelli B, Giangrande A, Marcelli D, Francucci BM. Factors affecting chronic renal failure progression: results from a multicentre trial. The Northern Italian Cooperative Study Group. Mineral and electrolyte metabolism. 1992;18(2-5):295-302.
38. MDRD 1. Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS. Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney international. 2000;57(4):1688-703.
39. MDRD Feasibility A. Teschan PE, Beck GJ, Dwyer JT, Greene T, Klahr S, Levy AS, Mitch WE, Snetselaar LG, Steinman TI, Walser M. Effect of a ketoacid-aminoacid-supplemented very low protein diet on the progression of advanced renal disease: a reanalysis of the MDRD feasibility study. Clinical nephrology. 1998;50(5):273-83.
40. MDRD Feasibility Study B. Perrone RD, Steinman TI, Beck GJ, Skibinski CI, Royal HD, Lawlor M, Hunsicker LG. Utility of radioisotopic filtration markers in chronic renal insufficiency: simultaneous comparison of 125I-iothalamate, 169Yb-DTPA, 99mTc-DTPA, and inulin. The Modification of Diet in Renal Disease Study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1990;16(3):224-35.
41. MDRD Study 2. 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. Journal of the American Society of Nephrology : JASN. 1999;10(11):2426-39.
42. Malvy D, Maingourd C, Pengloan J, Bagros P, Nivet H. Effects of severe protein restriction with ketoanalogues in advanced renal failure. Journal of the American College of Nutrition. 1999;18(5):481-6.
43. Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone-Gallucci M, Casciani CU. Severe dietary protein restriction in overt diabetic nephropathy: benefits or risks?. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2002;12(2):96-101.
44. Meloni C, Tatangelo P, Cipriani S, Rossi V, Suraci C, Tozzo C, Rossini B, Cecilia A, Di Franco D, Straccialano E, Casciani CU. Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(4):208-13.
45. Milovanov IuS, Lysenko LV, Milovanova LIu, Dobrosmyslov IA. [The role of balanced low-protein diet in inhibition of predialysis chronic kidney disease progression in patients with systemic diseases]. Terapevticheskii arkhiv. 2009;81(8):52-7.
46. Mircescu G, Gârneaţă L, Stancu SH, Căpuşă C. Effects of a supplemented hypoproteic diet in chronic kidney disease. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2007;17(3):179-88.
47. Montes-Delgado R, Guerrero Riscos MA, García-Luna PP, Martín Herrera C, Pereira Cunill JL, Garrido Vázquez M, López Muñoz I, Suárez García MJ, Martín-Espejo JL, Soler Junco ML, Barbosa Martín F. [Treatment with low-protein diet and caloric supplements in patients with chronic kidney failure in predialysis. Comparative study]. Revista clinica espanola. 1998;198(9):580-6.
48. Pijls LT, de Vries H, Donker AJ, van Eijk JT. The effect of protein restriction on albuminuria in patients with type 2 diabetes mellitus: a randomized trial. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 1999;14(6):1445-53.
49. Prakash S, Pande DP, Sharma S, Sharma D, Bal CS, Kulkarni H. Randomized, double-blind, placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(2):89-96.
50. Qiu HY, Liu F, Zhao LJ, Huang SM, Zuo C, Zhong H, Chen F. [Comparison of the effects of alpha-keto/ amino acid supplemented low protein diet and diabetes diet in patients with diabetic nephropathy]. Sichuan da xue xue bao. Yi xue ban = Journal of Sichuan University. Medical science edition. 2012;43(3):425-8.
51. Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L, Panz VR. Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6-mo prospective study. The American journal of clinical nutrition. 1994;60(4):579-85.
52. Rosman Study 1. Rosman JB, ter Wee PM. Relationship between proteinuria and response to low protein diets early in chronic renal failure. Blood purification. 1989;7(1):52-7.
53. Rosman Study 2. Bock HA, Brunner FP. Dietary protein restriction in chronic renal failure. Lancet (London, England). 1985;1(8426):465-6.
54. Teplan V, Schuck O, Bubenicek P, Mengerova O, Tesarova Z, Hajny J, et al.. The effect of long‐term administration of a low‐protein diet on the metabolic status and progression of chronic renal failure: a multicentre study. Nephrology Dialysis Transplantation. 1998;13:820.
55. Teplan V, Schück O, Knotek A, Hajný J, Horácková M, Skibová J, Malý J. Effects of low-protein diet supplemented with ketoacids and erythropoietin in chronic renal failure: a long-term metabolic study. Annals of transplantation. 2001;6(1):47-53.
56. Teplan V, Schück O, Racek J, Mareckova O, Stollova M, Hanzal V, Malý J. Reduction of plasma asymmetric dimethylarginine in obese patients with chronic kidney disease after three years of a low-protein diet supplemented with keto-amino acids: a randomized controlled trial. Wiener klinische Wochenschrift. 2008;120(15-16):478-85.
57. Università degli Studi di Brescia [provisional name]. Brunori G, Viola BF, Parrinello G, De Biase V, Como G, Franco V, Garibotto G, Zubani R, Cancarini GC. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2007;49(5):569-80.
58. Velázquez López L, Sil Acosta MJ, Goycochea Robles MV, Torres Tamayo M, Castañeda Limones R. Effect of protein restriction diet on renal function and metabolic control in patients with type 2 diabetes: a randomized clinical trial. Nutrición hospitalaria. 2008;23(2):141-7.
59. Williams PS, Stevens ME, Fass G, Irons L, Bone JM. Failure of dietary protein and phosphate restriction to retard the rate of progression of chronic renal failure: a prospective, randomized, controlled trial. The Quarterly journal of medicine. 1991;81(294):837-55.
60. Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. The New England journal of medicine. 1991;324(2):78-84.
61. Attman PO, Ewald J, Isaksson B. Body composition during long-term treatment of uremia with amino acid supplemented low-protein diet. The American journal of clinical nutrition. 1980;33(4):801-10.
62. Attman PO. Long-term treatment with low protein diet in uremia. Contributions to nephrology. 1986;53:128-36.
63. Barsotti G, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Nutritional treatment of renal failure in type 1 diabetic nephropathy. Clinical nephrology. 1988;29(6):280-7.
64. Barsotti, G., Cupisti, A., Barsotti, M., Sposini, S., Palmieri, D., Meola, M., Lenti, C., Morelli, E.. Dietary treatment of diabetic nephropathy with chronic renal failure. Nephrology Dialysis Transplantation. 1998;13(suppl 8):49-52.
65. Bellizzi V, Di Iorio BR, De Nicola L, Minutolo R, Zamboli P, Trucillo P, Catapano F, Cristofano C, Scalfi L, Conte G, ERIKA Study-group. Very low protein diet supplemented with ketoanalogs improves blood pressure control in chronic kidney disease. Kidney international. 2007;71(3):245-51.
66. Chauveau P, Barthe N, Rigalleau V, Ozenne S, Castaing F, Delclaux C, de Précigout V, Combe C, Aparicio M. Outcome of nutritional status and body composition of uremic patients on a very low protein diet. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1999;34(3):500-7.
67. Chauveau P, Vendrely B, El Haggan W, Barthe N, Rigalleau V, Combe C, Aparicio M. Body composition of patients on a very low-protein diet: a two-year survey with DEXA. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2003;13(4):282-7.
68. Cupisti A, D’Alessandro C, Morelli E, Rizza GM, Galetta F, Franzoni F, Barsotti G. Nutritional status and dietary manipulation in predialysis chronic renal failure patients. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(3):127-33.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
Triviales: El equipo elaborador de la Guía estimó que los efectos indeseables de «usar dieta hipoproteica» en comparación a «usar dieta normoproteica» son triviales o no relevantes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Dieta hipoproteica comparado con dieta normoproteica en enfermedad renal crónica (etapa 1-4) |
||||||
|
Pacientes |
Persona adultas con enfermedad renal crónica (etapa 1-4). |
|||||
|
Intervención |
Dieta hipoproteica. |
|||||
|
Comparación |
Dieta normoproteica. |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
Dieta normoproteica |
Dieta hipoproteica |
Diferencia (IC 95%) |
||||
|
Mortalidad |
RR 0,77 (0,51 a 1,18) — 5 ensayos / 1680 pacientes [19, 37, 38, 52, 59] |
55 por 1000 |
42 por 1000 |
Diferencia: 13 menos (27 menos a 10 más) |
⊕⊕◯◯1,2 Baja |
La dieta hipoproteica podría disminuir la mortalidad, pero la certeza de la evidencia es baja. |
|
Progresión a enfermedad renal crónica terminal |
RR 1,03 (0,73 a 1,47) — 6 ensayos / 1814 pacientes [19, 25, 37, 38, 52, 59] |
144 por 1000 |
148 por 1000 |
Diferencia: 4 más (39 menos a 68 más) |
⊕◯◯◯1,2,3 Muy baja |
La dieta hipoproteica podría acelerar la progresión a enfermedad renal crónica terminal. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON dieta normoproteica está basado en el riesgo del grupo control en los estudios. El riesgo CON dieta hipoproteica (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en la mayoría de los ensayos no está clara la secuencia de aleatorización ni el ocultamiento de ésta.
2 Se disminuyó un nivel de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente.
3 Se disminuyó un nivel de certeza de evidencia por inconsistencia ya que diferentes ensayos presentan diferentes conclusiones (I2 de 62%).
Fecha de elaboración de la tabla: Octubre, 2018.
Referencias
2. Fouque D, Laville M, Boissel JP, Chifflet R, Labeeuw M, Zech PY. Controlled low protein diets in chronic renal insufficiency: meta-analysis. BMJ (Clinical research ed.). 1992;304(6821):216-20.
3. Fouque D, Wang P, Laville M, Boissel JP. Low protein diets delay end-stage renal disease in non-diabetic adults with chronic renal failure. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2000;15(12):1986-92.
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6. Nezu U, Kamiyama H, Kondo Y, Sakuma M, Morimoto T, Ueda S. Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ open. 2013;3(5).
7. Pan Y, Guo LL, Jin HM. Low-protein diet for diabetic nephropathy: a meta-analysis of randomized controlled trials. The American journal of clinical nutrition. 2008;88(3):660-6.
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. Annals of internal medicine. 1996;124(7):627-32.
9. Rhee CM, Ahmadi SF, Kovesdy CP, Kalantar-Zadeh K. Low-protein diet for conservative management of chronic kidney disease: a systematic review and meta-analysis of controlled trials. Journal of cachexia, sarcopenia and muscle. 2018;9(2):235-245.
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11. Rughooputh MS, Zeng R, Yao Y. Protein Diet Restriction Slows Chronic Kidney Disease Progression in Non-Diabetic and in Type 1 Diabetic Patients, but Not in Type 2 Diabetic Patients: A Meta-Analysis of Randomized Controlled Trials Using Glomerular Filtration Rate as a Surrogate. PloS one. 2015;10(12):e0145505.
12. Zhu HG, Jiang ZS, Gong PY, Zhang DM, Zou ZW, Qian-Zhang None, Ma HM, Guo ZG, Zhao JY, Dong JJ, Lin-Liao None. Efficacy of low-protein diet for diabetic nephropathy: a systematic review of randomized controlled trials. Lipids in health and disease. 2018;17(1):141.
13. Woodrow G, Oldroyd B, Turney JH, Tompkins L, Brownjohn AM, Smith MA. Whole body and regional body composition in patients with chronic renal failure. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 1996;11(8):1613-8.
14. Bergström J, Alvestrand A, Bucht H, Gutierrez A. Progression of chronic renal failure in man is retarded with more frequent clinical follow-ups and better blood pressure control. Clinical nephrology. 1986;25(1):1-6.
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16. Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with type 2 diabetes: one-year follow-up of a randomised trial. Diabetologia. 2004;47(10):1677-86.
17. Brouhard BH, LaGrone L. Effect of dietary protein restriction on functional renal reserve in diabetic nephropathy. The American journal of medicine. 1990;89(4):427-31.
18. Chauveau P, Lebkiri B, Ployard F, Ciancioni C, Man NK, Jungers P. [Effect of keto analogs of essential amino acids on the progress of advanced chronic renal insufficiency: controlled prospective study]. Nephrologie. 1986;7(4):137-42.
19. Cianciaruso B, Pota A, Pisani A, Torraca S, Annecchini R, Lombardi P, Capuano A, Nazzaro P, Bellizzi V, Sabbatini M. Metabolic effects of two low protein diets in chronic kidney disease stage 4-5–a randomized controlled trial. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2008;23(2):636-44.
20. Ciavarella A, Di Mizio G, Stefoni S, Borgnino LC, Vannini P. Reduced albuminuria after dietary protein restriction in insulin-dependent diabetic patients with clinical nephropathy. Diabetes care. 1987;10(4):407-13.
21. DCCT 1 and 2. Levey AS, Greene T, Schluchter MD, Cleary PA, Teschan PE, Lorenz RA, Molitch ME, Mitch WE, Siebert C, Hall PM. Glomerular filtration rate measurements in clinical trials. Modification of Diet in Renal Disease Study Group and the Diabetes Control and Complications Trial Research Group. Journal of the American Society of Nephrology : JASN. 1993;4(5):1159-71.
22. Di Iorio BR, Minutolo R, De Nicola L, Bellizzi V, Catapano F, Iodice C, Rubino R, Conte G. Supplemented very low protein diet ameliorates responsiveness to erythropoietin in chronic renal failure. Kidney international. 2003;64(5):1822-8.
23. Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of protein-restricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and hypertension. Diabetes care. 1993;16(2):483-92.
24. Dussol B, Iovanna C, Raccah D, Darmon P, Morange S, Vague P, Vialettes B, Oliver C, Loundoun A, Berland Y. A randomized trial of low-protein diet in type 1 and in type 2 diabetes mellitus patients with incipient and overt nephropathy. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2005;15(4):398-406.
25. European Study Group for the Conservative Management of Chronic Renal Failure 1. European Study Group for the Conservative Management of Chronic Renal Failure. Dietary compliance in the trial of the European Study Group. An interim analysis. European Study Group for the Conservative Management of Chronic Renal Failure. 1992;98:133-41.
26. European Study Group for the Conservative Management of Chronic Renal Failure 2. European Study Group for the Conservative Management of Chronic Renal Failure. Dietary compliance in the trial of the European Study Group. An interim analysis. European Study Group for the Conservative Management of Chronic Renal Failure. 1992;98:133-41.
27. Feiten SF, Draibe SA, Watanabe R, Duenhas MR, Baxmann AC, Nerbass FB, Cuppari L. Short-term effects of a very-low-protein diet supplemented with ketoacids in nondialyzed chronic kidney disease patients. European journal of clinical nutrition. 2005;59(1):129-36.
28. Garneata L, Stancu A, Dragomir D, Stefan G, Mircescu G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. Journal of the American Society of Nephrology : JASN. 2016;27(7):2164-76.
29. Hansen HP, Christensen PK, Tauber-Lassen E, Klausen A, Jensen BR, Parving HH. Low-protein diet and kidney function in insulin-dependent diabetic patients with diabetic nephropathy. Kidney international. 1999;55(2):621-8.
30. Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney international. 2002;62(1):220-8.
31. Ihle BU, Becker GJ, Whitworth JA, Charlwood RA, Kincaid-Smith PS. The effect of protein restriction on the progression of renal insufficiency. The New England journal of medicine. 1989;321(26):1773-7.
32. Jesudason DR, Pedersen E, Clifton PM. Weight-loss diets in people with type 2 diabetes and renal disease: a randomized controlled trial of the effect of different dietary protein amounts. The American journal of clinical nutrition. 2013;98(2):494-501.
33. 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. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2009;24(8):2551-8.
34. Koya D, Haneda M, Inomata S, Suzuki Y, Suzuki D, Makino H, Shikata K, Murakami Y, Tomino Y, Yamada K, Araki SI, Kashiwagi A, Kikkawa R, Low-Protein Diet Study Group. Long-term effect of modification of dietary protein intake on the progression of diabetic nephropathy: a randomised controlled trial. Diabetologia. 2009;52(10):2037-45.
35. Larsen RN, Mann NJ, Maclean E, Shaw JE. The effect of high-protein, low-carbohydrate diets in the treatment of type 2 diabetes: a 12 month randomised controlled trial. Diabetologia. 2011;54(4):731-40.
36. Lindenau K, Abendroth K, Kokot F, Vetter K, Rehse C, Fröhling PT. Therapeutic effect of keto acids on renal osteodystrophy. A prospective controlled study. Nephron. 1990;55(2):133-5.
37. Locatelli F, Alberti D, Graziani G, Buccianti G, Redaelli B, Giangrande A, Marcelli D, Francucci BM. Factors affecting chronic renal failure progression: results from a multicentre trial. The Northern Italian Cooperative Study Group. Mineral and electrolyte metabolism. 1992;18(2-5):295-302.
38. MDRD 1. Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS. Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney international. 2000;57(4):1688-703.
39. MDRD Feasibility A. Teschan PE, Beck GJ, Dwyer JT, Greene T, Klahr S, Levy AS, Mitch WE, Snetselaar LG, Steinman TI, Walser M. Effect of a ketoacid-aminoacid-supplemented very low protein diet on the progression of advanced renal disease: a reanalysis of the MDRD feasibility study. Clinical nephrology. 1998;50(5):273-83.
40. MDRD Feasibility Study B. Perrone RD, Steinman TI, Beck GJ, Skibinski CI, Royal HD, Lawlor M, Hunsicker LG. Utility of radioisotopic filtration markers in chronic renal insufficiency: simultaneous comparison of 125I-iothalamate, 169Yb-DTPA, 99mTc-DTPA, and inulin. The Modification of Diet in Renal Disease Study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1990;16(3):224-35.
41. MDRD Study 2. 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. Journal of the American Society of Nephrology : JASN. 1999;10(11):2426-39.
42. Malvy D, Maingourd C, Pengloan J, Bagros P, Nivet H. Effects of severe protein restriction with ketoanalogues in advanced renal failure. Journal of the American College of Nutrition. 1999;18(5):481-6.
43. Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone-Gallucci M, Casciani CU. Severe dietary protein restriction in overt diabetic nephropathy: benefits or risks?. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2002;12(2):96-101.
44. Meloni C, Tatangelo P, Cipriani S, Rossi V, Suraci C, Tozzo C, Rossini B, Cecilia A, Di Franco D, Straccialano E, Casciani CU. Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(4):208-13.
45. Milovanov IuS, Lysenko LV, Milovanova LIu, Dobrosmyslov IA. [The role of balanced low-protein diet in inhibition of predialysis chronic kidney disease progression in patients with systemic diseases]. Terapevticheskii arkhiv. 2009;81(8):52-7.
46. Mircescu G, Gârneaţă L, Stancu SH, Căpuşă C. Effects of a supplemented hypoproteic diet in chronic kidney disease. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2007;17(3):179-88.
47. Montes-Delgado R, Guerrero Riscos MA, García-Luna PP, Martín Herrera C, Pereira Cunill JL, Garrido Vázquez M, López Muñoz I, Suárez García MJ, Martín-Espejo JL, Soler Junco ML, Barbosa Martín F. [Treatment with low-protein diet and caloric supplements in patients with chronic kidney failure in predialysis. Comparative study]. Revista clinica espanola. 1998;198(9):580-6.
48. Pijls LT, de Vries H, Donker AJ, van Eijk JT. The effect of protein restriction on albuminuria in patients with type 2 diabetes mellitus: a randomized trial. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 1999;14(6):1445-53.
49. Prakash S, Pande DP, Sharma S, Sharma D, Bal CS, Kulkarni H. Randomized, double-blind, placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(2):89-96.
50. Qiu HY, Liu F, Zhao LJ, Huang SM, Zuo C, Zhong H, Chen F. [Comparison of the effects of alpha-keto/ amino acid supplemented low protein diet and diabetes diet in patients with diabetic nephropathy]. Sichuan da xue xue bao. Yi xue ban = Journal of Sichuan University. Medical science edition. 2012;43(3):425-8.
51. Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L, Panz VR. Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6-mo prospective study. The American journal of clinical nutrition. 1994;60(4):579-85.
52. Rosman Study 1. Rosman JB, ter Wee PM. Relationship between proteinuria and response to low protein diets early in chronic renal failure. Blood purification. 1989;7(1):52-7.
53. Rosman Study 2. Bock HA, Brunner FP. Dietary protein restriction in chronic renal failure. Lancet (London, England). 1985;1(8426):465-6.
54. Teplan V, Schuck O, Bubenicek P, Mengerova O, Tesarova Z, Hajny J, et al.. The effect of long‐term administration of a low‐protein diet on the metabolic status and progression of chronic renal failure: a multicentre study. Nephrology Dialysis Transplantation. 1998;13:820.
55. Teplan V, Schück O, Knotek A, Hajný J, Horácková M, Skibová J, Malý J. Effects of low-protein diet supplemented with ketoacids and erythropoietin in chronic renal failure: a long-term metabolic study. Annals of transplantation. 2001;6(1):47-53.
56. Teplan V, Schück O, Racek J, Mareckova O, Stollova M, Hanzal V, Malý J. Reduction of plasma asymmetric dimethylarginine in obese patients with chronic kidney disease after three years of a low-protein diet supplemented with keto-amino acids: a randomized controlled trial. Wiener klinische Wochenschrift. 2008;120(15-16):478-85.
57. Università degli Studi di Brescia [provisional name]. Brunori G, Viola BF, Parrinello G, De Biase V, Como G, Franco V, Garibotto G, Zubani R, Cancarini GC. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2007;49(5):569-80.
58. Velázquez López L, Sil Acosta MJ, Goycochea Robles MV, Torres Tamayo M, Castañeda Limones R. Effect of protein restriction diet on renal function and metabolic control in patients with type 2 diabetes: a randomized clinical trial. Nutrición hospitalaria. 2008;23(2):141-7.
59. Williams PS, Stevens ME, Fass G, Irons L, Bone JM. Failure of dietary protein and phosphate restriction to retard the rate of progression of chronic renal failure: a prospective, randomized, controlled trial. The Quarterly journal of medicine. 1991;81(294):837-55.
60. Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. The New England journal of medicine. 1991;324(2):78-84.
61. Attman PO, Ewald J, Isaksson B. Body composition during long-term treatment of uremia with amino acid supplemented low-protein diet. The American journal of clinical nutrition. 1980;33(4):801-10.
62. Attman PO. Long-term treatment with low protein diet in uremia. Contributions to nephrology. 1986;53:128-36.
63. Barsotti G, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Nutritional treatment of renal failure in type 1 diabetic nephropathy. Clinical nephrology. 1988;29(6):280-7.
64. Barsotti, G., Cupisti, A., Barsotti, M., Sposini, S., Palmieri, D., Meola, M., Lenti, C., Morelli, E.. Dietary treatment of diabetic nephropathy with chronic renal failure. Nephrology Dialysis Transplantation. 1998;13(suppl 8):49-52.
65. Bellizzi V, Di Iorio BR, De Nicola L, Minutolo R, Zamboli P, Trucillo P, Catapano F, Cristofano C, Scalfi L, Conte G, ERIKA Study-group. Very low protein diet supplemented with ketoanalogs improves blood pressure control in chronic kidney disease. Kidney international. 2007;71(3):245-51.
66. Chauveau P, Barthe N, Rigalleau V, Ozenne S, Castaing F, Delclaux C, de Précigout V, Combe C, Aparicio M. Outcome of nutritional status and body composition of uremic patients on a very low protein diet. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1999;34(3):500-7.
67. Chauveau P, Vendrely B, El Haggan W, Barthe N, Rigalleau V, Combe C, Aparicio M. Body composition of patients on a very low-protein diet: a two-year survey with DEXA. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2003;13(4):282-7.
68. Cupisti A, D’Alessandro C, Morelli E, Rizza GM, Galetta F, Franzoni F, Barsotti G. Nutritional status and dietary manipulation in predialysis chronic renal failure patients. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2004;14(3):127-33.
69. Cupisti A, Guidi A, Giovannetti S. Nutritional state of severe chronic renal failure patients on a low-protein supplemented diet. Contributions to nephrology. 1990;81:161-8.
70. Cupisti A, Licitra R, Chisari C, Stampacchia G, D’Alessandro C, Galetta F, Rossi B, Barsotti G. Skeletal muscle and nutritional assessment in chronic renal failure patients on a protein-restricted diet. Journal of internal medicine. 2004;255(1):115-24.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Muy Baja: Existe considerable incertidumbre respecto del efecto de «usar dieta hipoproteica» en comparación a «usar dieta normoproteica».
Evidencia de investigación
|
Desenlaces |
Importancia |
Certainty of the evidence |
|
Mortalidad |
CRÍTICO |
⨁⨁◯◯ |
|
Enfermedad renal crónica terminal |
CRÍTICO |
⨁◯◯◯ |
a. Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que la mayoría no está clara la secuencia de aleatorización u ocultamiento de ésta.
b. Se disminuyó un nivel de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente
c. Se disminuyó un nivel de certeza de evidencia por inconsistencia ya que diferentes ensayos presentan diferentes conclusiones (I2 de 62%)
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Posiblemente hay incertidumbre o variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el equipo elaborador de la Guía consideró que posiblemente existe incertidumbre o variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «usar dieta hipoproteica» y «usar dieta normoproteica».
Evidencia de investigación
Un estudio piloto evaluó el estilo de vida, estado anímico y duración de una dieta baja en proteínas. El estudio se realizó con pacientes con enfermedad renal crónica ambulatorios. La dieta elegida fue un mix de bajas proteínas con 0.4 o 0.6g de proteína y 30 -35 kcal/kg de peso corporal El estudio informa algunos pacientes decidieron comer y beber normalmente en situaciones sociales y «pagar por ello» más tarde con síntomas debido a sobrecarga de líquidos o picazón.
Algunos pacientes piensan que las restricciones de la dieta son contradictorias y desorientadoras ya que consideran que los consejos dietéticos se contradicen con una «dieta saludable». Los pacientes se sienten letárgicos, desnutridos y hambrientos siguiendo la dieta indicada.(1)
Otro estudio tuvo como objetivo conocer las perspectivas sobre su enfermedad de los pacientes con enfermedad renal crónica en estadio 1-4, con un enfoque específico en sus necesidades de información para manejar y vivir con CKD y sus secuelas (2)
Los participantes creían que podían prevenir la progresión de la enfermedad manteniendo una dieta específica y controlando la ingesta de líquidos. Algunos se sentían frustrados, ya que percibían que les hacia la falta de asesoría de un nutricionista, les preocupaba consumir alimentos incorrectos y que las cantidades de líquidos fueran inadecuadas y que por ende agravaran su condición. Querían consejos prácticos sobre la preparación de comidas y que alimentos evitar.
Referencia
1) Haeberle KN. Psychological aspects of low protein diet therapy. Blood Purif. 1989;7(1):39–42.
2) Palmer SC, Hanson CS, Craig JC, Strippoli GFM, Ruospo M, Campbell K, et al. Dietary and fluid restrictions in CKD: a thematic synthesis of patient views from qualitative studies. Am J Kidney Dis Off J Natl Kidney Found. 2015 Apr;65(4):559–73.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
No favorece la intervención ni la comparación: Considerando que la intervención es «usar dieta hipoproteica» y la comparación es «usar dieta normoproteica», el equipo elaborador de la Guía opinó que la costo-efectividad no favorece ninguna de las dos alternativas.
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Ahorros extensos: El equipo elaborador de la Guía consideró que al «usar dieta hipoproteica» se generan ahorros grandes si es que se compara con los costos de «usar dieta normoproteica», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
A continuación se muestran los precios referenciales de las prestaciones sanitarias es preciso considerar que éstos fueron recogidos con el único objetivo de constituir un antecedente aproximado de usar dieta hipoproteica y usar dieta normo proteica, de modo que el equipo elaborador de la Guía se pudiese pronunciar al respecto.
|
|
DIETA HIPOPROTEICA |
NO HIPOPROTEICA (NORMOPROTEICA) |
|
1. Dieta hipocalórica Dieta hipoproteica 50 gramos de proteína con 50% alto valor biológico ( 25 grs de proteína animal) e hipercalórica 2200 kcal al día. |
Carne baja en grasa = 50 grs = $ 300 (promedio (carne al vacio y beef) = 1 kilo posta = $6000) Huevo = ½ ud al dia = $ 100 Leche semidescremada = 1 taza al dia = $ 200 Frutas = 4 ud al día = $ 800 (promedio 1 unidad de fruta $200) Verduras = 3 tazas al día = $ 500 Aceite = 15 cditas al día = $ 100 (promedio 1 litro aceite = $1000, 1 cdita = $5) (promedio 1 litro aceite = $1000, 1 cdita = $5) Pan = 2 ud al día = $ 400 Cereales = 2 tazas al día = 400 |
Dieta normoproteica (paciente peso 70 kilos = 1 grs de proteína/ kilo) = 70 gramos de proteína con 70% alto valor biológico (50 grs proteína alto valor biológico) hipercalórica 2500 Kcal (35 calorías por kilo de peso) Carne baja en grasa = 150 grs = $ 900 Lácteos medios en grasa = 2 porciones al dia = $ 400 Frutas = 6 ud al día = $ 1.200 Verduras = 4 tazas al día = $ 600 Aceite = 15 cditas al día = $ 100 Pan = 2 ud al día = $ 400 Cereales = 2 tazas al día = 400 |
|
Total diario $2.800 aprox |
Total diario : $ 4.000 aprox |
|
|
Dieta hipoproteica 50 gramos de proteína con 30% alto valor biológico (15 grs de proteína animal) e hipercalórica 2200 kcal al día |
Carne baja en grasa = 50 grs = $ 300 Huevo = ½ ud al día = $ 100 Frutas = 5 ud al día = $ 1000 Verduras = 3 tazas al día = $ 500 Aceite = 10 cditas al día = $ 80 Pan = 2 ½ ud al día = $ 500 Cereales = 3 tazas al día = 600
|
Dieta normoproteica (paciente peso 70 kilos = 1 grs de proteína/ kilo) = 70 gramos de proteína con 70% alto valor biológico (50 grs proteína alto valor biológico) hipercalórica 2500 Kcal (35 calorías por kilo de peso) Carne baja en grasa = 150 grs = $ 900 Lácteos medios en grasa = 2 porciones al dia = $ 400 Frutas = 6 ud al día = $ 1.200 Verduras = 4 tazas al día = $ 600 Aceite = 15 cditas al día = $ 100 Pan = 2 ud al día = $ 400 Cereales = 2 tazas al día = 400 |
|
TOTAL : $ 3.080 aprox |
Total diario : $ 4.000 aprox |
Fuente. 1. Datos aportados por Jefe Unidad de Nefrología y Diálisis y Equipo de Nutricionistas del Hospital Clínico San José.
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Ningún estudio incluido: No se realizó la búsqueda de estudios que abordaran la costo-efectividad «usar dieta hipoproteica» ya que no es considerada una intervención de alto costo (Anual $2.418.399 y Mensual $201.533).*.
Referencia
*Ministerio de Salud – Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la ley 20.850. Santiago; 2015 Nov
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Aumentada: El equipo elaborador de la Guía consideró que la equidad en salud aumentaría si se recomendase «usar dieta hipoproteica», dado que en la actualidad existe amplio acceso, ya sea en términos económicos, geográficos u otros
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El equipo elaborador de la Guía consideró que «usar dieta hipoproteica» probablemente SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros).
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El equipo elaborador de la Guía consideró que «usar dieta hipoproteica» SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.
Consideraciones Adicionales
El panel de expertos informa que las personas con enfermedad renal crónica son atendidas en atención primaria y secundaria con acceso a nutricionistas.