Clodoveo Ferri, MD¹; Rodolfo Puccini, MD²

¹ Istituto Patologia Medica I, University of Pisa; ² Nephrology Unit, "S.CHIARA" Hospital -Pisa - ITALY

Acknowledgments: We thank Ms. Leda Imolesi and Ms. Valentina Batini for their help in the preparation of this booklet.

Various dietary regimens have been proposed to influence the immune system in some immunological diseases. A diet supplemented of certain polyunsaturated fatty acids, precursors of arachidonic acid and pro-inflammatory prostaglandins, can affect organ involvement of systemic lupus in experimental animals or rheumatoid arthritis in humans. On the other hand, the exclusion of certain aliments can positively affect disease manifestations, i.e. elimination of dairy products in the diet of isolated rheumatoid arthritis patients.

The aim low antigen content diet (LAC-diet) is the reduction of the high-molecular-weight exogenous substances crossing the mucosal barrier of the gut. These substances having a potential antigenic activity can be involved in the pathogenesis of some diseases in humans. The reduction of such substances may be useful in some disorders possibly triggered by exogeneous antigens such as the IgA nephropathy. Alternatively, the reduction of the alimentary input of macromolecules directed to mononuclear phagocytic system may improve its function in those conditions characterised by abnormal endogenous production of immune-complexes responsible for organ damage, i. e. mixed cryoglobulinemia and other immune-complex mediated diseases. An impaired function of mononuclear phagocytic system has been also demonstrated in patients with IgA nephropathy.

Given the above pathogenetic considerations, LAC-diet has been usefully employed in short-term treatment of patients with mixed cryoglobulinemia (improved purpura, liver enzymes, cryoglobulin levels) and IgA nephropathy (reduction of 24-hour proteinuria).

REFERENCES

1. Gorevic PD, Kassab HJ, Levo Y, Kohn R, Meltzer M, Prose P, Franklin E: Mixed Cryoglobulinemia: clinical aspects and long-term follow-up of 40 patients. Am J Med 1980; 69: 287-308.
2. Emancipator SN, Lamm ME: Biology of disease. IgA nephropathy: pathogenesis of the most common form of glomerulonephritis. Lab Invest 1989; 60: 168-183.
3. Ferri C, Pietrogrande M, Cecchetti R, et al: Low-antigen-content diet in the treatment of patients with mixed cryoglobulinemia. Am J Med 1989; 87: 519-524.
4. Ferri C, Puccini R, Longombardo G, Paleologo G, Migliorini P, Moriconi L, Pasero G, Cioni L: Low-antigen-content diet in the treatment of patients with IgA nephropathy. Nephrol Dial Transpl 1993; 8: 1193-1198.

Mixed Cryoglobulinemia

The rationale of the use of LAC-diet in the treatment of patients with mixed cryoglobulinemia is to reduce the input of food antigens to the mononuclear phagocytic system which is satured by large amounts of endogenous immune-complexes (chiefly the cryoglobulins).

The administration of the restricted diet (LAC-diet) for 10-15 days every month should maintein the efficiency of mononuclear phagocytic system in the clearance of cryoglobulins.

LAC-diet treatment modality:

at the beginning of the treatment restricted diet should be administered for a month; then for 10-15 days every month; while during the remaining 15-20 days the diet should be totally free.

IgA nephropathy.

The rationale of LAC-diet in this disease is to restore the mononuclear phagocytic system overloaded by immune-complexes and/or to reduce the formation of circulating immune-complexes induced by food antigens crossing the barrier of the gut.

LAC-diet treatment modality:

at the beginning of the treatment restricted diet should be administered for 3-4 months; then for 5 days per week, or 20 days every month.

During no treatment days the diet should be totally free.

These therapeutical approach, similarly to the pharmacological treatments, is suitable only in subjects with normal or moderate reduction of renal function (serum creatinine < 2 mg/dl).

In patients with moderate renal failure may indicated a reduction of daily protein intake (see Table).

In patients with increased arterial blood pressure a reduction of salt daily intake is necessary.

Table

LAC diet composition: foods rice pasta, bread, and pastries made with gluten free wheat flour sugar olive oil turkey, rabbit, lamb greens, potatoes pears, apples salt water The following foods must be avoided during the LAC-diet treatment: dairy products eggs fish meats (except turkey, rabbit, lamb) legumes alcohol additives, preservatives tomatoes Protein content of the three meats (turkey, rabbit, lamb) meats (grams) 80 100 110 120 140 proteins (grams) 17 21 23 25 30

Diet schemes with four different caloric contents according to patient's body weight (from 50 to 80 kg).

LAC-diet: person of 50 Kg of body weight
Total Kcalories: 1600 (32 Kcal/Kg bw)
proteins 51 gr/day (1 gr/kg bw)		13% of caloric supply
lipids 50 gr/day		29% of caloric supply
glucides 235 gr/day		58% of caloric supply
daily foods:
barley coffee
jam	20 gr
gluten free slices biscuits	20 gr
gluten free pasta	100 gr
gluten free bread	100 gr
turkey or rabbit or lamb	200 gr
vegetables in season	no limits
fruit	400 gr
olive oil	20 gr
sugar	14 gr
salt (NaCl)	free
breakfast
barley coffee with sugar
gluten free slices biscuits	20 gr	or gluten free bread or gluten free biscuit
apple, pear, orange jam	20 gr
apple, or pear, or orange	100 gr
lunch
gluten free pasta with tomato sauce	70 gr	or with butter or olive oil or vegetable soup
turkey or rabbit or lamb	100 gr
vegetables in season°	no limits	or potatoes*
fruit	150 gr	apples or pears or orange
gluten free bread	40 gr
supper
gluten free pasta	30 gr	see lunch
rabbit or turkey or lamb	100 gr
vegatables in season°	no limits
fruit	150 gr	see lunch
gluten free bread	60 gr
° either row or cooked
* if you prefer potatoes reduce the quantities of pasta and/or bread

LAC-diet: person of 60 Kg of body weight
Total Kcalories: 1868 (31 Kcal/Kg bw)
proteins 60 gr/day (1 gr/kg bw)		13% of caloric supply
lipids 58 gr/day		28% of caloric supply
glucides 295 gr/day		60% of caloric supply
daily foods:
barley coffee
jam	30 gr
gluten free slices biscuits	30 gr
gluten free pasta	120 gr
gluten free bread	130 gr
turkey or rabbit or lamb	240 gr
vegetables in season	no limits
fruit	400 gr
olive oil	20 gr
sugar	10 gr
salt (NaCl)	free
breakfast
barley coffee with sugar
gluten free slices biscuits	30 gr	or gluten free bread or gluten free biscuit
apple, pear, orange jam	30 gr
apple, or pear, or orange	100 gr
lunch
gluten free pasta with tomato sauce	90 gr	or with butter or olive oil or vegetable soup
turkey or rabbit or lamb	120 gr
vegetables in season°	no limits	or potatoes*
fruit	150 gr	apples or pears or orange
gluten free bread	50 gr
supper
gluten free pasta	30 gr	see lunch
rabbit or turkey or lamb	120 gr
vegatables in season°	no limits
fruit	150 gr	see lunch
gluten free bread	80 gr
° either row or cooked
* if you prefer potatoes reduce the quantities of pasta and/or bread

LAC-diet: person of 70 Kg of body weight
Total Kcalories: 2110 (30 Kcal/Kg bw)
proteins 69 gr/day (1 gr/kg bw)		13% of caloric supply
lipids 68 gr/day		29% of caloric supply
glucides 326 gr/day		58% of caloric supply
daily foods:
barley coffee
jam	30 gr
gluten free slices biscuits	30 gr
gluten free pasta	140 gr
gluten free bread	150 gr
turkey or rabbit or lamb	280 gr
vegetables in season	no limits
fruit	400 gr
olive oil	25 gr
sugar	10 gr
salt	free
breakfast
barley coffee with sugar
gluten free sliced biscuits	30 gr	or gluten free bread or gluten free biscuit
apple, pear, orange jam	30 gr
apple, or pear, or orange	100 gr
lunch
gluten free pasta with tomato sauce	100 gr	or with butter or olive oil or vegetable soup
turkey or rabbit or lamb	140 gr
vegetables in season	no limits	or potatoes*
fruit	150 gr	apples or pears or orange
gluten free bread	70 gr
supper
gluten free pasta	40 gr	see lunch
rabbit or turkey or lamb	140 gr
vegatables in season	no limits
fruit	150 gr	see lunch
gluten free bread	80 gr
° either row or cooked
* if you prefer potatoes reduce the quantities of pasta and/or bread

LAC-diet: person of 80 Kg of body weight
Total Kcalories: 2472 (31 Kcal/Kg bw)
proteins 78 gr/day (1 gr/kg bw)		13% of caloric supply
lipids 78 gr/day		28% of caloric supply
glucides 389 gr/day		59% of caloric supply
daily foods:
barley coffee
jam	30 gr
gluten free slices biscuits	40 gr
gluten free pasta	160 gr
gluten free bread	160 gr
turkey or rabbit or lamb	300 gr
vegetables in season	no limits
fruit	400 gr
olive oil	30 gr
sugar	10 gr
salt (NaCl)	free
breakfast
barley coffee with sugar
gluten free slices biscuits	40 gr	or gluten free bread or gluten free biscuit
apple, pear, orange jam	30 gr
apple, or pear, or orange	100 gr
lunch
gluten free pasta with tomato sauce	80 gr	or with butter or olive oil or vegetable soup
turkey or rabbit or lamb	150 gr
vegetables in season°	no limits	or potatoes*
fruit	150 gr	apples or pears or orange
gluten free bread	80 gr
supper
gluten free pasta	80 gr	see lunch
rabbit or turkey or lamb	150 gr
vegatables in season°	no limits
fruit	150 gr	see lunch
gluten free bread	70 gr
° either row or cooked
* if you prefer potatoes reduce the quantities of pasta and/or bread

These recipes lead to the preparation of delicately flavoured dishes which share an Italian taste. It is therefore recommendable to start the diet with less tasty dishes, such as rice seasoned with oil and lemon/grilled turkey with oil and lemon/ rice in vegetable broth etc.. This will allow You to appreciate the richness of flavours of the combinations hereafter suggested.

DIETETIC SAUCE

Ideally suited to flavour grilled turkey breast or as a dressing for boiled rice.

Ingredients:

1 tablespoonful of olive oil

1 tablespoonful of oregano

4 leaves of chopped fresh basil

1/2 tablespoonful of warm water

juice of 1/2 a lemon

salt

Procedure:

Place all the ingredients in an electric mixer and mix until the sauce becomes smooth.

RISOTTO WITH COURGETTES

Ingredients:

100 gr. rice

2 courgettes

1 tablespoonful of olive oil

1 lemon

vinegar

basil

salt

Procedure:

Slice the courgettes thick and grill them. Place them in a bowl, add a pinch of salt and a few drops of vinegar and let them soak for a few hours. Boil the rice in salted water , strain it and add the courgettes. Sprinkle the oil, the lemon juice and the chopped basil on top.

POT-AU-FEU

This dish substitutes for a meal if You add to it 70 gr. of boiled rice.

Ingredients:

100 gr. of turkey breast

1 rabbit tight

1 onion

1 leek

1 celery

1 carrot

1 turnip

1 potato

1 clove of garlic

1 clove

1/2 a lemon peel

salt

Procedure:

Boil the potato. In another pot pour a litre of water, bring to boil and then add the meat. After 1/2 an hour, add the vegetables finely sliced but the onion and the clove, chich should be added intact. After another 1/2 an hour, remove the meat from the pot, dice them, take away the bones and put them back in the pot for another 2-3 minutes. Finally, remove the pot from heat, add the potato finely sliced and eat the broth together with the boiled meat and vegetables.

RICE SALAD

Ingredients:

100 gr. of rice

1 carrot

2 celery

3 radishes

1/2 cucumber

1 tomato

4-5 basil leaves

1 tablespoonful of olive oil

1 tablespoonful of lemon juice

1/2 a skinned pepper

Procedure:

Cut finely the cucumber and soak it in salt and vinegar. At the same time, boil the rice in salted water, drain it and wash it under running water. Cut finely all the remaining vegetables and mix them, together with the cucumber to the boiled rice.

Separately, whisk the oil, the lemon juice, a pinch of salt and the basil, finely chopped until You get a creamy sauce to dress the rice salad. Refrigerate for at least 1 hour before serving.

RICE WITH POTATOES AND GREEN BEANS

Ingredients:

100 gr. of rice

100 gr. of green beans

1 potato

1 small onion

1 tablespoonful of olive oil

finely chopped basil

salt

Procedure:

Cook the onion (intact), the beans and the sliced potato in salted water; when the vegetables are half ready add the rice. When the rice is ready, drain everything, remove the onion and season with oil and basil.

TOMATOES RICE SALAD

Ingredients:

80 gr. of rice already boiled in salted water

1 tablespoonful of chopped basil and mint leaves

1 tablespoonful of olive oil

1 tomato

vinegar

salt

Procedure:

Let the rice cool in a bowl. Meanwhile, wash the tomato, cut it finely and remove the seeds. Mix separately the oil, the vinegar, the salt and the chopped herbs until You get a sauce, which will serve to dress the salad. Refrigerate for at least 1 hour before serving. Decorate with mint leaves.

TOMATOES RICE TIMBALE

Ingredients:

130 gr of rice already boiled in salted water

2 tomatoes (almost ripe)

1 onion

2 tablespoonful of vinegar

basil

oil

salt

Procedure:

Wash and slice the tomatoes finely, then cover them in salt and leave them aside until they have lost most of their water content. Scald the onion in water and vinegar. Take a Pyrex dish, wrap it in aluminium foil, and fill it with layers of rice and layers of basil and tomatoes, ending with a layer of basil and tomatoes. Cook in a pre-heated oven at 180° C for approximately 20 minutes. As an alternative, add as a third layer some grilled aubergines.

RICE AND AUBERGINE PIE

Ingredients:

100 gr of rice

200 gr of tomatoes S.Marzano (long ones)

1 aubergine

1 white onion

1 tablespoonful of olive oil

basil

salt

Procedure:

Cut the aubergines and cover them in salt. After 1 hour dry them with a cloth and place them on a heated grill (a few minutes each side). Skin the tomatoes, chop them thickly and cook them with the finely sliced onion and the salt; after 10 minutes add the rice and cook it stirring frequently, adding some water if necessary, until You get a risotto texture.

Wrap a pyrex dish with cooking foil and fill it with the rice, season with a small quantity of oil and cover with the aubergines, basil leaves and oil again. Cover the Pyrex with aluminium foil and cook in the oven at 200° C for approximately 15 minutes.

ROW COURGETTES SALAD

Ingredients:

3 thin courgettes

1 tablespoonful of olive oil

the juice of 1/2 a lemon

basil

salt

Procedure:

Wash the courgettes and slice them finely, then put them in a bowl and dress them with oil, lemon juice and salt. Stir occasionally while You wait 1 hour before serving. Decorate with basil leaves.

STUFFED COURGETTES

Ingredients:

3 courgettes

100 gr. of breast turkey

2-3 tablespoonful of tomatoes pulp

1 tablespoonful of marjoram's and thyme's leaves

1 tablespoonful of oil

salt

Procedure:

Wash the courgettes, cut each one in half lengthways, add salt and leave them to strain onto an inclined plane. Remove the pulp from the courgettes and mix it with marjoram , minced thyme and a pinch of salt. In the meanwhile cook the turkey with 1 glass of water, 2 leaves of sage and salt; when all the water will have evaporated mince the meat and add it to the courgettes pulp. Fill the courgettes left without the pulp with this mixture and set them into a Pyrex dish covered with a baking sheet, sprinkle the tomatoes pulp on top and cover with tin foil. Bake in a moderate oven ( 220° C ) about 30 minutes. Remove the tin foil 10 minutes before taking them out of the oven and cover it with oil.

COURGETTES WITH OREGANO

Ingredients:

300 gr. courgettes

oregano

salt pepper

Procedure:

Wash the courgettes and put them into a small pan with 1/2 a glass of salted water. When the courgettes are cooked, season with oregano and oil. These courgettes can also be added to boiled rice to make a dish.

TURKEY BREAST WITH COURGETTES

Ingredients:

3 slices of turkey breast

200 gr courgettes

parsley

thyme

sage

salt

Procedure:

Cook the turkey breasts in a Pyrex dish with a few leaves of sage, 1/2 a glass of water and a little salt. When the water has evaporated, remove from heat; separately, slice the courgettes finely and cook them with a tablespoonful of water, a little salt, and the chopped parsley and thyme. When they are soft use them to cover the turkey and cook all in the oven at 200° C for 10 minutes.

LAMB CUTLETS IN A MINT SAUCE

Ingredients:

3 lamb cutlets

1 lemon

a pinch of sugar

mint

salt

Procedure:

Chop finely a bunch of mint leaves, place them in a bowl with the sugar, a pinch of salt and 1/2 a glass of lemon juice; cover the cutlets with this sauce and leave for 1 hour. Afterwards, grill the cutlets 5 minutes each and serve with new potatoes.

GRILLED TURKEY TIGHT

Ingredients:

1 turkey tight

herbs (as preferred)

salt

Procedure:

Put the turkey in a pan after having seasoned it with herbs and salt. Switch on the grill and, when its hot, put the pan underneath it and cook for 1/2 an hour turning the tight quite frequently.

TURKEY SATAY

Ingredients:

150 gr of turkey breast

1 courgette

1 aubergine

olive oil

salt

Procedure:

Chop the vegetables and cover them in salt; leave for 1 hour. Chop the turkey, season it with finely cut herbs, and put this and the vegetables on the spits, alternating the former with the latter. Cook as You like.

ROASTED TURKEY

To last for 2 or 3 meals

Ingredients:

1/2 kg of turkey

1 tablespoonful of herbs

salt

Procedure:

Put the herbs and the salt into and on the turkey, hence tie with a thread and add more herbs. Wrap perfectly the turkey in an oil-greased aluminium foil. Lay the meat on a baking-tin and cook in a pre-heated oven at 220° C for 1 hour.

MIXED VEGETABLES 'AL CARTOCCIO'

Ingredients:

1 onion

3 courgettes

1 carrot

1 potato

1 aubergine

1 tablespoonful of olive oil

salt

Procedure:

Grease half of a large aluminium foil with oil, slice the vegetables finely and place them on the greased half of that foil; add salt and close perfectly the pack. Cook in a pre-heated oven at 220° C for approximately 1/2 an hour.

Alternatively mix the vegetables with boiled rice and dress with oil and chopped parsley.

APPLE 'AL CARTOCCIO'

Ingredients:

1 apple

1 tablespoonful of apricot jam

the peel of 1 lemon

1 tablespoonful of sugar

Procedure:

Skin the apple, remove the core, fill it with the jam and the lemon peel previously mixed. Wrap the apple in an aluminium foil and put it into a pre-heated oven at 220° C for 3/4 of an hour. Alternatively cook the apple covering it for half into a pot with boiling water.