The low-protein diet for chronic kidney disease: 8 years of clinical experience in a nephrology ward.

BACKGROUND: Guidelines indicate that a low-protein diet (LPD) delays dialysis in severe chronic kidney disease (CKD). We assessed the value of these guidelines by performing a retrospective analysis in our renal clinical practice. METHODS: The analysis was performed from 1 January 2010 to 31 March 2018 in 299 CKD Stage 4 patients followed for 70 months in collaboration with a skilled nutritionist. The patients included 43 patients on a controlled protein diet (CPD) of 0.8 g/kg/day [estimated glomerular filtration rate (eGFR) 20-30 mL/min/1.73 m2 body surface (b.s.)], 171 patients on an LPD of 0.6 g/kg/day and 85 patients on an unrestricted protein diet (UPD) who were not followed by our nutritionist (LPD and UPD, eGFR <20 mL/min/1.73 m2 b.s.). RESULTS: eGFR was higher in CPD patients than in UPD and LPD patients (21.9 ± 7.4 mL/min/1.73 m2 versus 17.6 ± 8.00 mL/min/1.73 m2 and 17.1 ± 7.5 mL/min/1.73 m2; P = 0.008). The real daily protein intake was higher in UPD patients than in LPD and CDP patients (0.80 ± 0.1 g/kg/day versus 0.6 ± 0.2 and 0.63 ± 0.2 g/kg/day; P = 0.01). Body mass index (BMI) was stable in the LPD and CPD groups but decreased from 28.5 ± 4.52 to 25.4 ± 3.94 kg/m2 in the UPD group (P < 0.001). The renal survival of UPD, LPD and CPD patients was 47.1, 84.3 and 90.7%, respectively, at 30 months (P < 0.001), 42.4, 72.0 and 79.1%, respectively, at 50 months (P < 0.001) and 42.4, 64.1 and 74.4%, respectively, at 70 months (P < 0.001). The LPD patients started dialysis nearly 24 months later than the UPD patients. Diet was an independent predictor of dialysis [-67% of RR reduction (hazard ratio = 0.33; confidence interval 0.22-0.48)] together with a reduction in BMI. CONCLUSIONS: An LPD recommended by nephrologists in conjunction with skilled dietitians delays dialysis and preserves nutritional status in severe CKD.

Driving and working with syncope.

Syncope is usually addressed in the Emergency Department (ED) by the doctor in charge of the clinical picture, i.e. the patient's risk is stratified, a diagnostic work-up is done and a prognosis is set. Patients are ultimately admitted to hospital or discharged. However, other aspects related to syncope may deeply affect their daily lives. These include how and when to return to work and to driving, the feelings about a recent loss of consciousness, and the potential relapse of syncope. This is particularly significant if the work setting is intrinsically hazardous. These patients need adequate clinical and psychological support. For patients with syncope, two main parameters should be considered regarding returning to work and to driving. The first is to evaluate the risk of syncope recurrence and the second is to consider the expected harm if syncope does indeed occur during these activities. In the present paper we detail the problem of driving (including professional driving) and work after syncope. We propose a new quantitative model that will guide the physician in stratifying the risk for patients who have had a previous syncope event. The new model considers the syncope recurrence risk, the job task duration, and features that facilitate a syncope during work. On the basis of these variables, the global risk index for a worker is calculated. Following appropriate validation, this method might help ED and occupational physicians in their decision-making process with the goal of safely readmitting syncope patients to the workplace.

Syncope risk stratification in the ED.

Syncope may be the final common presentation of a number of clinical conditions spanning benign (i.e. neurally-mediated syncope) to life-threatening diseases (i.e. cardiac syncope). Hospitalization rate after a syncopal episode is high. An effective risk stratification is crucial to identify patients at risk of poor prognosis in the short term period to avoid unnecessary hospital admissions. The decision to admit or discharge a syncope patient from the ED is often based on the physician's clinical judgment. In recent years, several prognostic tools (i.e. clinical prediction rules and risk scores) have been developed to provide emergency physicians with accurate guidelines for hospital admission. At present, there are no compelling evidence that prognostic tools perform better than physician's clinical judgment in assessing the short-term outcome of syncope. However, the risk factors characterizing clinical prediction rules and risk scores may be profitably used by emergency doctors in their decision making, specifically whenever a syncope patient has to be discharged from ED or admitted to hospital. Patients with syncope of undetermined etiology, who are characterized by an intermediate-high risk profile after the initial evaluation, should be monitored in the ED. Indeed, data suggest that the 48h following syncope are at the highest risk for major adverse events. A new tool for syncope management is represented by the Syncope Unit in the ED or in an outpatient setting. Syncope Unit may reduce hospitalization and length of hospital stay. However, further studies are needed to clarify whether syncope patients' prognosis can be also improved.