Effect of bariatric surgery on microvascular dysfunction associated to metabolic syndrome: a 12-month prospective study.

OBJECTIVE: To prospectively evaluate the effect of weight loss after bariatric surgery on microvascular function in morbidly obese patients with and without metabolic syndrome (MetS). METHODS: A cohort of morbidly obese patients with and without MetS was studied before surgery and after 12 months of surgery. Healthy lean controls were also examined. Microvascular function was assessed by postocclusive reactive hyperemia (PORH) at forearm skin evaluated by laser Doppler flowmetry (LDF). Cutaneous vascular conductance (CVC) was calculated from laser-Doppler skin blood flow and blood pressure. Regression analysis was performed to assess the contribution of different clinical, metabolic and biochemical parameters to microvascular function. RESULTS: Before surgery, 62 obese patients, 39 with MetS and 23 without MetS, and 30 lean control subjects were analyzed. The absolute area under the hyperemic curve (AUC(H)) CVC of PORH was significantly decreased in obese patients compared with lean control subjects. One year after surgery, AUC(H) CVC significantly increased in patients free of MetS, including patients that had MetS before surgery. In contrast, AUC(H) CVC did not significantly change in patients in whom MetS persisted after surgery. Stepwise multivariate regression analysis showed that only changes in HDL cholesterol (HDL-C) and oxidized LDL (oxLDL) independently predicted improvement of AUC(H) after surgery. These two variables together accounted for 40.9% of the variability of change in AUC(H) CVC after surgery. CONCLUSIONS: Bariatric surgery could significantly improve microvascular dysfunction in obese patients, but only in patients free of MetS after surgery. Improvement of microvascular dysfunction is strictly associated to postoperative increase in HDL-C levels and decrease in oxLDL levels.

[Management models in clinical nutrition: weaknesses and strengths]. / Modelos de gestión en nutrición clínica: Puntos débiles y puntos fuertes.

At the 6th Abbott-SENPE Debate Forum a multidisciplinary and multiprofessional discussion was established in order to seek for the model or the models of clinical management most appropriate for Clinical Nutrition and Dietetics Units (CNAD) in Spain. The weaknesses and strengths as well as opportunities for the current systems were assessed concluding that a certain degree of disparity was observed not only due to regional differences but also to different hospital types. It was proposed, from SENPE, the creation of a working group helping to standardize the models and promote the culture of Integral Control and Change Management.

[National registry of home enteral nutrition in Spain 2007]. / Registro de Nutrición Enteral Domiciliaria en España en el año 2007.

OBJECTIVE: To communicate the results from the registry of Home-Based Enteral Nutrition of the NADYASENPE group in 2007. MATERIAL AND METHODS: We included every patient in the registry with home enteral nutrition any time from January 1st to December 31st of 2007. RESULTS: The number of patients with home enteral nutrition in 2007 was 5,107 (52% male) from 28 different hospitals. 95.4% of them were 15 yr or older, with a mean age of 67.96 +/- 18.12, and 4.2 +/- 3.38 among patients aged 14 yr or less. The most common underlying diseases were neurological (37.8%) and neoplastic diseases (29.3%). Enteral nutrition was administered p.o. in most patients (63.5%), followed by nasogastric tube (25.9%), while gastrostomy was only used in 9.2%. The mean time in enteral nutrition support was 9.4 months and the most common reasons for withdrawal were death (58.7%) and switching to oral intake (32%). Activity was limited in 31.4% of patients and 36.01% were house-bound. Most patients needed partial (26.51%) or total (37.68%) care assistance. Enteral formula was provided by hospitals to 69.14% of patients and by pharmacies to 30.17% of them, while disposable material was provided by hospitals to 81.63% and by Primary Care to the remaining patients. CONCLUSIONS: In 2007, there has been an increase of more than 30% of patients registered with home enteral nutrition comparing with 2006, without any big difference in other data, but a higher proportion of patients with enteral nutrition p.o.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity.

PURPOSE: Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO). METHOD: The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies. RESULTS: Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76). CONCLUSION: In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

[V debate forum of the SENPE. Current issues on home-based and ambulatory artificial nutrition]. / V Foro de Debate SENPE: Problemática actual de la nutrición artificial domiciliaria y ambulatoria.

A multidisciplinary and multiprofessional debate is established trying to detect and find plausible solutions regarding Home-based and Ambulatory Enteral Nutrition (HBAEN) in Spain, due to the little attention paid by the Administration to the global problem of hyponutrition, the little interest showed by the collectivity of health care professionals, and the lack of a regulation differentiating the patient at his/her home and the patient at a nursing home. It was concluded that the current legislation on Home Based Enteral Nutrition (HBEN) has been variedly applied and does not contemplate the real clinical health care, with some pathologies subsidiary of this kind of therapy being excluded. Proposals to improve both financing and pathologies irrespective of the kind of nutritional therapy are made.

[Registry of home-based enteral nutrition in Spain for the year 2006 (NADYA-SENPE Group)]. / Registro de la Nutrición Enteral Domiciliaria en España en el año 2006 (Grupo NADYA-SENPE).

OBJECTIVE: To communicate the results obtained from the registry of Home-Based Enteral Nutrition (HBEN) of the NADYA-SENPE group for the year 2006. MATERIAL AND METHODS: Recompilation of the data from the HBEN registry of the NADYA-SENPE group from January 1st to December 31st of 2006. RESULTS: During the year 2006, 3,921 patients (51% men) from 27 hospital centers were registered. Ninety-seven percent were older than 14 years. The mean age for those < 14 years was 4.9 +/- 3.9 (m +/- SD) and in those > or = 14 years, it was 68.5 +/- 18.2 years. The most common underlying disease was neurological pathology (42%), followed by cancer (28%). Enteral nutrition was administered p.o. in 44% of the patients, through nasogastric tube in 40%, gastrostomy in 14%, and jejunostomy in 1%. The average time of nutritional support was 8.8 months. The most common reasons for ending the therapy were patient's death (54%) and switching to oral feeding (32%). Thirty-one percent of the patients presented a limited activity and 40% were confined to bed/coach. Most of the patients required partial (25%) or total (43%) care assistance. The nutritional formula was provided by the hospital in 62% of the cases and from the reference pharmacy in 27%. The fungible material was provided by the hospital in 80% of the cases and by primary care in the remaining patients. CONCLUSIONS: Although the number of registered patients is slightly higher than that from the last years, there are no important changes in the patients characteristics, or way of administration and duration of enteral nutrition.

Integral nutritional approach to the care of cancer patients: results from a Delphi panel.

INTRODUCTION: Malnutrition is a common complication in cancer patients and can negatively affect the outcome of treatments. This study aimed to reach a consensus on nutritional needs and optimize nutritional care in the management of cancer patients at a national level. METHODS: A qualitative, multicenter, two-round Delphi study involving 52 specialists with experience in nutritional support in cancer patients was conducted. RESULTS: Regarding the presence of malnutrition, 57.7% of the participants stated that < 30% of the patients had malnutrition at the time of diagnosis, 40.4% considered that 31-50% had malnutrition during cancer treatment, and 26.9% that > 50% at the end of the treatment. Forty percent of participants believed that the main objective of nutritional treatment was to improve quality of life and 34.6% to improve tolerability and adherence to chemotherapy. The quality nutritional care provided at their centers was rated as medium-low by 67.3%. Enteral and parenteral nutrition was administered to less than 10% and less than 5% of patients in 40.4 and 76.9% of cases, respectively. In relation to nutritional screening at the time of diagnosis, 62.9% of participants considered than screening to assess the risk of malnutrition was performed in < 30% of patients. CONCLUSIONS: There is an important variability in the management of cancer patient nutrition, which is associated with the absence of a national consensus on nutritional support in this field. Given the incidence of nutritional disorders in cancer patients, a specialist in clinical nutrition (regardless of his/her specialty) should be integrated into the strategic cancer plan.

[Study on intestinal absorption, metabolism, and adaptation]. / Evaluación de la absorción y metabolismo intestinal.

The human intestine is a complex and variable in lenght organ, oscillating between 3 and 8 metres, depending on the individual characteristics and the techniques used to measure it. The main function of the intestine is to get a suitable incorporation of food into the body and this is carried out by menas of the digestion and food absorption processes. When these functions fail, Maldigestion and Malabsorption appear. These have characteristic clinical data and must be studied with the help of specific techniques for every digestive step and every food (fat malabsorption, proteins and carbohydrates tests).

[IV Debate Forum of the SENPE: questions on nutrition research]. / IV Foro de Debate SENPE: problemática de la investigación en nutrición.

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

[Causes and impact of hyponutrition and cachexia in the oncologic patient]. / Causas e impacto clinico de la desnutrición y caquexia en el paciente oncológico.

The maximal expression of hyponutrition in cancer is tumoral cachexia, which will direct or indirectly account for mortality in one third of cancer patients. Causes of hyponutrition in cancer are related with the tumor, the patient, or therapies, and summarily we may differentiate four main mechanisms by which hyponutrition may occur in cancer patients: Poor energy and nutrients intake; Impairments of nutrient digestion and/or absorption; Increased demands; Impairments of nutrient metabolism; Any modality of oncologic therapy induces hyponutrition occurrence, especially in those cases in which several therapies are administered to cure cancer (surgery, radiotherapy, chemotherapy). Hyponutrition in cancer patients produces a decrease in muscle mass, which leads to strength loss, having important consequences on functional status of the individual since it increases dependence on others (relatives, caregivers) and decreases quality of life. Besides, hyponutrition is associated to poorer response to radiotherapy and chemotherapy, or poorer tolerability of such therapies. Hyponutrition also impairs scarring mechanisms and increases the risk for surgical complications such as suture dehiscence or infections. Both infectious complications and surgically derived complications entail longer hospital staying, which contributes to increase management costs. Finally, effects of hyponutrition on mortality should not be neglected, with severe weight loss being associated to lower survival.

[National registry of Home Enteral Nutrition in 2003]. / Registro nacional de la Nutrición Enteral Domiciliaria del año 2003.

GOAL: To communicate the information available by the NADYA-SENPE Working Group from patients on Home Enteral Nutrition (HEN) in our country during the year 2003. MATERIAL AND METHODS: The data were collected through a closed questionnaire included in the web site of the Working Group (www.nadya-senpe.com) available only by the authorized users. Variable included were: epidemiological information, the indication to prescribe this treatment, the access path, the specific nutritional formula used, the treatment duration, the complications and hospital readmission related to the nutritional treatment, the follow-up and the quality of life. RESULTS: We register 3,858 patients that belong to twenty-one hospitals. Mean age from those adults 66.2 +/- 18.9 years, and from those younger than 14, 6.0 +/- 4.3 years. Neurological and neoplasic diseases were the diagnostics more frequents (38.9% and 37.4%, respectively). Oral nutrition was the preferential rout used for the enteral nutrition (54.7%) followed by naso-enteral tube (26.6%), and only in 17.6% we used ostomy tubes. Polymeric was the enteral formula mainly utilized (80.1%). The mean time on HEN was 6.6 +/- 4.3 months; the 28.8% of patients stayed in the treatment for less than 3 months, 21.2 % between 3 and 6 months, and 50.0% more than 6 months. Patients were followed mainly by Nutritional Support Unit from the reference hospital (73.1%). While the reference hospital supplies the material (62.4%), reference hospital pharmacy (46.8%) and public pharmacies (32.0%) provides the enteral formula. Complications related to enteral nutrition included change of enteral tube (44.5%), gastrointestinal complications (30.5%), mechanical complications (21.7%), and the metabolic one (3.3%). These complications were followed by 0.02 hospitalizations/patient. At the end of the year, 54.7% of patients were in the HEN programme, and in 35.2 % HEN was finish due to accept oral conventional alimentation (49.2%) or by deceased of patients (40.9%). While 26.6% of the patients were confined to bed or armchair, 19.7 % no or light discapacity degree was observed. CONCLUSIONS: We found a persistence of these treatment in our country. Neurological and neoplasic diseases were the more frequent diagnosis in patients analysed. The high prevalence of cancer patients could be the main cause of oral access for enteral nutrition. Change of enteral tube was the more frequent complication observed during this treatment.

Short-term safety, tolerability and efficacy of a very low-calorie-ketogenic diet interventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus.

UNLABELLED: Brackground:The safety and tolerability of very low-calorie-ketogenic (VLCK) diets are a current concern in the treatment of obese type 2 diabetes mellitus (T2DM) patients. OBJECTIVE: Evaluating the short-term safety and tolerability of a VLCK diet (<50 g of carbohydrate daily) in an interventional weight loss program including lifestyle and behavioral modification support (Diaprokal Method) in subjects with T2DM. METHODS: Eighty-nine men and women, aged between 30 and 65 years, with T2DM and body mass index between 30 and 35 kg m(-)(2) participated in this prospective, open-label, multi-centric randomized clinical trial with a duration of 4 months. Forty-five subjects were randomly assigned to the interventional weight loss (VLCK diet), and 44 to the standard low-calorie diet. RESULTS: No significant differences in the laboratory safety parameters were found between the two study groups. Changes in the urine albumin-to-creatinine ratio in VLCK diet were not significant and were comparable to control group. Creatinine and blood urea nitrogen did not change significantly relative to baseline nor between groups. Weight loss and reduction in waist circumference in the VLCK diet group were significantly larger than in control subjects (both P<0.001). The decline in HbA1c and glycemic control was larger in the VLCK diet group (P<0.05). No serious adverse events were reported and mild AE in the VLCK diet group declined at last follow-up. CONCLUSIONS: The interventional weight loss program based on a VLCK diet is most effective in reducing body weight and improvement of glycemic control than a standard hypocaloric diet with safety and good tolerance for T2DM patients.

[The year 2002 national register on home-based parenteral nutrition]. / Registro nacional de la nutrición parenteral domiciliaria del año 2002.

AIM: To report on the results of the Registry on Home-based Parenteral Nutrition (HPN) of the NADYA-SENPE working group, corresponding to the year 2002. MATERIALS AND METHOD: Compilation of the registry data loaded by the Units in charge of HPN patients care. It consists of an on-line registry available to the registered users of the group's web page (www.nadya-senpe.com). Epidemiological, diagnostic, access route, complications, hospital admissions, degree of disability, and course until December 31st of 2002. RESULTS: Data from 74 patients were gathered (56.8% women and 43.2% men), from 18 hospital centers. Mean age of adult patients was 49.4 +/- 15.5 years and 2.3-1.1 years for patients younger than 14 years (n=3 patients). Diseases that prompted the use of HPN were mesenteric ischemia (29.7%), followed by neoplasms (16.2%), radiation enteritis (12.2%), motility impairments (8.1%), and Crohn's disease (5.4%). Tunneled catheters were used in 52.7% of cases, as compared to 36.5% of subcutaneous reservoirs. Mean treatment duration was 8.7 +/- 4.4 months; 68.9% of patients remained on HPN for a duration longer than 6 months, and in 41.9% longer than one year. Patients' follow-up was mainly done from the reference hospital (87.8%), and the remaining patients (12.5%) by the home care team. In no case patients were followed by the primary care team or other specialists than the ones that prescribed nutritional support. In 94 cases there were complications related to nutritional therapy. The more frequent complications presented were infectious. These complications represented 1.84 admissions per patient. The mean number of visits was 12.9 per patient (10.2 routinary visits and 2.7 emergency visits). At the end of the year, we observed that 74.3% patients stayed in the program, whereas in the remaining 23.6% HPN had been discontinued. The main causes for discontinuation were death (52.9%), and switch to oral diet (23.5%) or enteral nutrition (11.8%). With regards to disability degree, 16.1% were confined to a wheelchair or bed, and 17.6% had no disability at all or only a mild social disability. CONCLUSIONS: We observed a sustained HPN prevalence rate in Spain (1.8 patient pmp). The main cause for its use was short bowel syndrome secondary to vascular disease, followed by cancer. Complications associated to nutritional therapy were common, especially of infectious origin.

[The year 2002 national registry on home-based enteral nutrition]. / Registro nacional de la nutrición enteral domiciliaria del año 2002.

GOAL: To communicate the information available by the NADYA-SENPE Working Group from patients on Home Enteral Nutrition (HEN) in our country during the year 2002. MATERIAL AND METHODS: The data were collected through a closed questionnaire included in the web site of the Working Group (www.nadya-senpe.com) available only by the authorized users. Variable included were: epidemiological information, the indication to prescribe this treatment, the access path, the specific nutritional formula used, the treatment duration, the complications and hospital readmission related to the nutritional treatment, the follow-up and the quality of life. RESULTS: We register 3967 patients that belong to twenty-one hospitals. Mean age from those adults 69.2 +/- 19.2 years, and from those younger than 14, 5.6 +/- 4.1 years. Neurological and neoplasic diseases were the diagnostics more frequents (39.2% and 34.6%, respectively). Oral nutrition was the preferential rout used for the enteral nutrition (53.6%) followed by naso-enteral tube (30.6%), and only in 15.8% we used ostomy tubes. Polymeric was the enteral formula mainly utilized (81.5%). The mean time on HEN was 5.8 +/- 4.4 months; the 35.7% of patients stayed in the treatment for less than 3 months, 22.4% between 3 and 6 months, and 41.6% more than 6 months. Patients were followed mainly by Nutritional Support Unit from the reference hospital (75.3%). While the reference hospital supplies the material (65.7%), reference hospital pharmacy (43%) and public pharmacies (37.3%) provides the enteral formula. Complications related to enteral nutrition included change of enteral tube (29.7%), mechanical complications (22.9%), gastrointestinal complications (22.9%), and the metabolic one (9.2%). These complications were followed by 0.02 hospitalizations/patient. At the end of the year, 49.3% of patients were in the HEN programme, and in 41.5% HEN was finish due to accept oral conventional alimentation (47.3%) or by deceased of patients. While 31.8% of the patients were confined to bed o armchair, 17.8% no o light discapacity degree was observed. CONCLUSIONS: We found a persistence of these treatment in our country (96.5 patients/million inhabitants. Neurological and neoplasic diseases were the more frequent diagnosis in patients analysed. The high prevalence of cancer patients could be the main cause of oral access for enteral nutrition. Change of enteral tube was the more frequent complication observed during this treatment.

Serum leptin levels in male marathon athletes before and after the marathon run.

Leptin is a hormone produced by the adipocytes to regulate food intake and energy expenditure at the hypothalamic level. It is commonly accepted that the main determinants of leptin secretion are the net amount of body fat and the mean size of adipocytes. On the contrary, important vectors of energy flux in the organism, such as food intake and energy expended on exercise, are not thought to be regulators of that secretion. To understand whether leptin is regulated by an acute energy expenditure such as strenuous exercise, 29 male athletes who had trained for marathon running were studied before and after a marathon run and compared with 22 nonobese, age-, sex-, and body mass index (BMI)-matched sedentary controls. Controls and marathon athletes showed no differences in BMI or fat-free mass. Marathon runners showed a strong reduction in total fat mass (6.2 +/- 0.4 kg; 9.1 +/- 0.5% of body fat) compared with controls (12.3 +/- 0.5 kg; 16.1 +/- 0.5% of body fat; P < 0.05). This difference in body composition was paralleled by a mean serum leptin level that in marathonians (2.9 +/- 0.2 micrograms/L) was significantly (P < 0.05) reduced compared with that in controls (5.1 +/- 0.6 micrograms/L). It is remarkable that the ratio of leptin per kg body fat, showed a very good agreement between the two groups, 0.40 +/- 0.04 microgram/L.kg for controls and 0.46 +/- 0.03 microgram/L.kg for marathonians. In the two groups, leptin was correlated with both body weight, BMI, and fat mass (P < 0.001). The marathon trajectory was the standard 42.195 km accomplished in an average time of 3 h, 17 min, 7 s, with a calculated energy expenditure of over 2800 Cal. After the marathon run, a water imbalance occurred, with a significant decrease in body weight and an increase in serum albumin. A significant (P < 0.05) reduction in leptin values was observed after the run (2.6 +/- 0.2 micrograms/L) compared with before (2.9 +/- 0.2 micrograms/L), which was more relevant considering the relative hemoconcentration. In conclusion, 1) compared with sedentary subjects, leptin levels are reduced in male marathon runners in parallel with the relevant reduction in total body fat; 2) expressed as a ratio of leptin per kg body fat, no differences were observed between marathonians and controls; and 3) after an energy expenditure of 2800 Cal in the marathon run, a reduction in leptin levels occurred. Strong changes in energy expenditure may regulate serum leptin levels in man.

In vitro short-term effects of SMS 201-995, bromocriptine and TRH on growth hormone cell morphology from human pituitary adenomas.

This study reports, by immunocytochemistry, ultrastructure and morphometry, the in vitro effects of SMS 201-995 (10 nM), bromocriptine (1 microM) and TRH (10 microM) on the morphology of cells from two acromegalic patient adenomas containing immunoreactive growth hormone (GH). By electron microscopy, one tumor presented numerous large secretory granules (densely granulated growth hormone cell adenoma) while they were scarce and small in the other (sparsely granulated growth hormone cell adenoma); fibrous bodies could be seen in the specimen and in vitro. In the sparsely granulated growth hormone cell adenoma, TRH produced an increase in endoplasmic reticulum surface density compared to the other cultures. Bromocriptine increased the number and decreased the secretory granule diameters, while SMS 201-995 produced no significant changes in the same time. In the densely granulated growth hormone cell adenoma, the three substances increased the number of granules. TRH increased the mitochondrial volume density and endoplasmic reticulum surface density (with respect to the other cultures). SMS 201-995 decreased the mitochondrial and lysosome volume densities and endoplasmic reticulum surface density. We conclude that 1) TRH produces in cultured cells of both adenoma types an increase in cellular activity. 2) In cultured sparsely granulated growth hormone adenoma cells, bromocriptine has a stronger inhibitory effect than SMS 201-995. In cultured densely granulated growth hormone cells adenoma, bromocriptine has smaller inhibitory effect than SMS 201-995.

Esophageal obstruction by solidification of the enteral feed: a complication to be prevented.

We report three cases of esophageal obstruction due to solidification of enteral feed refluxed from the stomach in patients being fed through a nasogastric tube. All three patients were administered sucralfate continuously by tube. The few previous descriptions of this rare complication have also implicated sucralfate with its pathogenesis. Given its clinical importance and the growing use of long-term enteral nutrition, this adverse event needs to be considered.

Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases.

We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.

Nutritional support in chronic renal failure: systematic review.

BACKGROUND AND AIMS: The purpose of this systematic review was to locate and assess in patients with chronic renal disease the quality of scientific evidence to establish graded recommendations based on the efficacy and effectiveness of nutritional support. METHODS: Computerized and online versions of MEDLINE (from 1989 through March 1999) and EMBASE (from 1988 through January 1999) were consulted. The Cochrane Library and the online Healthstar (from 1975) databases were also searched for clinical trials. A total of 593 studies were assessed. Following methodological review (primary reviewer), only 45 studies reviewed met criteria for selection and were analyzed by a group of experts (secondary reviewer). A final consensus was reached between the co-ordinators, experts and methodologists. RESULTS AND CONCLUSIONS: Low and very low-protein diets associated with specific enteral supplements are indicated in most patients with chronic renal disease and in patients with incipient diabetic nephropathy to slow progression of disease and to improve their overall status, contributing to improved survival (grade A recommendation). The use of protein-restricted diets in diabetic nephropathy is only indicated in type I diabetes mellitus (grade A recommendation). An improvement in nutritional parameters was found when specific diets were given in chronic renal disease (grade C recommendation).