The Role of Nutraceuticals in Statin Intolerant Patients

Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

Biomarkers, myocardial fibrosis and co-morbidities in heart failure with preserved ejection fraction: an overview

The prevalence of heart failure with preserved ejection fraction (HFpEF) is steadily increasing. Its diagnosis remains difficult and controversial and relies mostly on non-invasive echocardiographic detection of left ventricular diastolic dysfunction and elevated filling pressures. The large phenotypic heterogeneity of HFpEF from pathophysiologic al underpinnings to clinical manifestations presents a major obstacle to the development of new therapies targeted towards specific HF phenotypes. Recent studies suggest that natriuretic peptides have the potential to improve the diagnosis of early HFpEF, but they still have significant limitations, and the cut-off points for diagnosis and prognosis in HFpEF remain open to debate. The purpose of this review is to present potential targets of intervention in patients with HFpEF, starting with myocardial fibrosis and methods of its detection. In addition, co-morbidities are discussed as a means to treat HFpEF according to cut-points of biomarkers that are different from usual. Biomarkers and approaches to co-morbidities may be able to tailor therapies according to patients' pathophysiological needs. Recently, soluble source of tumorigenicity 2 (sST2), growth differentiation factor 15 (GDF-15), galectin-3, and other cardiac markers have emerged, but evidence from large cohorts is still lacking. Furthermore, the field of miRNA is a very promising area of research, and further exploration of miRNA may offer diagnostic and prognostic applications and insight into the pathology, pointing to new phenotype-specific therapeutic targets.

Impact of Vitamin D on the Cardiovascular System in Advanced Chronic Kidney Disease (CKD) and Dialysis Patients

In patients suffering from chronic kidney disease (CKD), the prevalence of cardiovascular disease is much more common than in the general population. The role of vitamin D deficiency had been underestimated until a significant association was found between vitamin D therapy and survival benefit in haemodialysis patients. Vitamin D deficiency is present even in the early stages of chronic kidney disease. The results of experimental studies have revealed the relationship between vitamin D deficiency and impairment of cardiac contractile function, higher cardiac mass and increased myocardial collagen content. Experimental models propose that intermediate end points for the relationship between vitamin D deficiency and higher risk of cardiovascular disease comprise diminished left ventricular hypertrophy (LVH), enhanced left ventricular diastolic function, and decreased frequency of heart failure. Multiple observational studies have demonstrated an association between the use of active vitamin D therapy in patients on dialysis and with CKD and improved survival. However, there are also many studies indicating important adverse effects of such treatment. Therefore, large randomized trials are required to analyze whether supplementation of vitamin D may affect outcomes and whether it is safe to be used in CKD patients.

Are Markers of Cardiac Dysfunction Useful in the Assessment of Cardiovascular Risk in Dialysis Patients?

BACKGROUND

Cardiovascular morbidity and mortality of dialysis patients are major problems in this group of patients.

METHODS

The purpose of this study was also to evaluate whether any of the studied markers are better than troponin in early detection of the occurrence of ventricular arrhythmias and prolongation of QT interval. This study included 45 patients undergoing hemodialysis. ECG Holter and echocardiographic examination were performed before and after dialysis. The concentrations of markers: copeptin, GDF-15, HFABP and troponin were measured with the use of ELISA tests.

RESULTS

We observed significantly higher QT (p=0.004), QTc (0.018), right atrium volume (p=0.006) and concentrations of copeptin (p<0.0001) and H-FABP (p<0.0001) as well as smaller left atrium volume (p<0.0001) and width of inferior vena cava (p<0.0001) after dialysis than before it. Significantly longer QT and higher copeptin levels were seen in patients with ventricular arrhythmia. A trend between the increase in copeptin concentration and H-FABP level and the presence of ventricular arrhythmias was also noted.

CONCLUSION

Generally, we failed to find any strong predictor of post-dialysis ventricular arrhythmia or the prolongation of QT, however, it seems that copeptin may have prognostic value, but this has to be analyzed in large studies.

The Use of Plant Sterols and Stanols as Lipid-Lowering Agents in Cardiovascular Disease

BACKGROUND

The prevalence of premature atherosclerosis and cardiovascular disease (CVD) is constantly increasing worldwide. It has been proved that LDL-cholesterol (LDL-C) plays causal role in the development of coronary atherosclerosis. The fact that atherosclerosis is a chronic and progressive disease which onsets during the first three decades of life bores questions what to do to maintain LDL-C at low levels throughout life and thus to delay and/or prevent the progress this disease. Currently, most of public health expenses are spared on treatment, but not on prophylaxis.

METHODS

This is a review article summarizing novel reports concerning the efficacy of sterols/stanols as lipidlowering agents, assessing their influence on cardiovascular risk and safety.

RESULTS

It has been suggested that sterols and stanols are effective in the lowering of low-density cholesterol levels and diminishing cardiovascular risk. However, the results of other studies suggest that phytosterols may not exert positive effects during atherogenesis. Firstly, patients with phytosterolaemia (genetic disease in which high plant sterol plasma concentrations are observed) develop malignant premature atherosclerosis. Moreover, several epidemiological studies demonstrated the association between upper normal plasma concentrations of plant sterols and increased risk of cardiovascular events. Finally, the supplementation with plant stanols and plant sterols may be not beneficial due to their incorporation in various tissues and potentially resulting in adverse effects.

CONCLUSION

Despite the worldwide promotion of sterols as health improving supplements, it seems that in some people responding with relatively high phytosterol serum levels after its consumption such additives may turn out to be as good as it has been believed.

Hypertension - Current Natural Strategies to Lower Blood Pressure

The prevalence of hypertension (HTN) worldwide is high and is constantly rising. HTN is considered to be a silent killer since often there are no obvious symptoms but long-term, HTN significantly increases the risk of coronary heart disease and cerebrovascular diseases. Those with diagnosed HTN or at high risk of its development, should start blood pressure (BP) lowering therapy based on natural methods including: lifestyle, regular physical activity, respiratory training, reducing body mass, lowering sodium intake with food, potassium supplementation, balanced diet enriched with herbs, reducing caffeine and alcohol intake, smoking cessation, stress avoidance and regular monitoring of the BP. This review focuses on several most common methods of natural BP lowering since it is not possible to consider all of them.

Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke

Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present treatment guidelines and gaps in evidence. There remains a need for further studies assessing the meaning of potential cardiac sources of embolism and establishment of rules for optimal medical prevention (antiplatelet therapy [APT] vs. oral anticoagulation [OAC]) and interventional procedures to reduce the incidence of ischemic strokes. Currently available data does not provide definitive evidence on the comparative benefits of OAC vs. APT in patients with cryptogenic stroke or embolic stroke of undetermined source. There is a lack of antithrombotic treatment scheme in the time between stroke and the completed diagnosis of potential sources of thromboembolism.

Clinical and prognostic usefulness of soluble urokinase plasminogen activator receptor in hemodialysis patients

PURPOSE

Considering its prognostic usefulness and the relationship with chronic kidney disease, we analyzed the clinical utility of soluble urokinase plasminogen activator receptor (suPAR) in end-stage renal disease patients undergoing hemodialysis treatment. We focused on the association between suPAR levels and clinical outcomes, especially those related to cardiovascular events and mortality as well as the effect of hemodialysis on the protein levels.

METHODS

We enrolled 64 patients. Blood samples for laboratory tests were collected before and after the midweek hemodialysis. The concentration of suPAR was assessed using suPARNostic ELISA, ViroGates.

RESULTS

Spearman rank analyses showed a positive association between suPAR and creatinine, cystatin C, galectin 3, N-terminal prohormone of brain natriuretic peptide and troponin T (p < 0.05). In ROC analysis, the suPAR concentration equal to 11.5 ng/mL was established to be the cutoff value for the prediction of mortality in the analyzed patients. Simultaneous analysis of creatinine and suPAR increased the predictive value of the latter-the area under curve increased to 0.84 (95% CI 0.70-0.94, p < 0.0001). Logistic regression analysis revealed that increase in the suPAR level was associated with the increase in odds ratio for death by 1.3 (95% CI 1.1-1.6, χ2 = 8.2, p = 0.004). In multivariable analysis, the prediction power of suPAR appeared to be stronger after including creatinine (p = 0.0005).

CONCLUSIONS

Elevated suPAR levels provide independent information on mortality risk in patients undergoing hemodialysis. The protein appears not to cross the dialysis membrane; thus, blood collection before the second hemodialysis session seems to give reliable information on the suPAR level for clinical interpretation.

Increased Exhaled H2O2 and Impaired Lung Function in Patients Undergoing Bioincompatible Hemodialysis

Background

Chronic renal failure (CRF) and hemodialysis (HD) accumulate an inflammatory milieu, contributing to increased systemic and airway oxidative stress that may lead to lung damage.

Objectives

This study was designed to assess exhaled hydrogen peroxide (H2O2), lung function and whole blood chemiluminescence in HD and CRF patients and healthy controls.

Methods

The study included 59 patients (Polyamide S™ or Hemophan® membranes-19, cuprophane-16, hemodiafiltration-14, continuous ambulatory peritoneal dialysis-10), 16 CRF and 16 healthy controls. The assessment of lung function included FVC (forced vital capacity), FEV1 (forced expiratory volume in the first second) and DLCOc (single breath CO diffusing capacity). Exhaled H2O2 was determined fluorometrically and resting and n-formyl-methionyl-leucyl-phenylalanine (fMLP) luminol-dependent whole blood chemiluminescence (LBCL) were measured simultaneously.

Results

Only cuprophane HD patients presented decreased lung function (FVC 63.8±17.4%, FEV1 55.9±20.3 and DLCOc 72.1± 9.3 % of predicted; p<0.05 vs. controls). These patients exhaled the highest H2O2 levels in comparison to CRF (p<0.01): median 0.36 μM (range R: 0.09–0.56 μM) and controls (p<0.05): 0.17 μM (0.2–17.8 μM). These levels were not decreased during the HD session: preHD 1.25 μM (0.2–16.5μM) and postHD 1.3 μM (0.2–17.8 μM). As a marker of systemic oxidative stress, fMLP-induced LBCL (total light emission) was increased in these patients (1570.6 aUxs /10phagocytes; R: 274.2–8598.9) and in the CRF group (2389.4 aUxs /10phagocytes; R: 491.5–6184; p<0.05 vs. controls). Other patient groups did not express elevated LBCL and revealed decreased exhaled H2O2 after a session.

Conclusions

An increased oxidative burden in the lungs may contribute to functional lung impairment in patients dialyzed with a cellulose membrane. Biocompatible dialysis with other modalities might reduce airway-borne oxidative stress and is not related with lung damage.

[Complications of endoscopic retrograde cholangiopancreatography]

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure of the diagnosis and treatment of biliary and pancreatic diseases. ERCP combines both endoscopic and radiologic imaging. Despite the fact that it is widely considered as relatively safe and useful procedure when performed by an experienced endoscopist, ERCP may potentially result in complications due to its invasive nature. These complications vary in severity and include post-ERCP pancreatitis, cholangitis, hemorrhage and perforations of the gastrointestinal tract. Therefore, the selection of patients and their appropriate preparation before the procedure as well as the careful consideration of indications are highly required.

Lipoprotein Subfractions, Uric Acid and Cardiovascular Risk in End-Stage Renal Disease (ESRD) Patients

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem and an independent risk factor for cardiovascular disease (CVD).

OBJECTIVE

We assessed cardiovascular risk in end-stage renal disease (ESRD) patients and evaluated the relationship between serum uric acid (SUA) and lipoprotein subfractions.

METHODS

The study group consisted of 66 patients on dialysis and a control group of 25 healthy volunteers. Concentration of high-density lipoproteins (HDL) and low-density lipoproteins (LDL) subfractions were analysed using a Lipoprint™. Lipid profiles and SUA were measured.

RESULTS

There were significant differences in the distribution of HDL1-HDL5 subfractions levels, which were significantly higher in patients with impaired renal function than in the control group (p≤0.013 for all comparisons). HDL7-HDL10 subfractions were significantly more prevalent in healthy volunteers compared with CKD patients (p≤0.001 for all comparisons). The analysis of LDL subfractions revealed significant differences only in IDL-B (p<0.05), IDL-A (p<0.05) and LDL2 (p<0.001) between patients with CKD stage 5 and controls.

CONCLUSION

Our study demonstrated that higher SUA level might be associated with lower prevalence of CVD among haemodialysis patients. An elevated SUA concentration in haemodialysis population may be a marker of better nutritional status and also represent the antioxidant properties SUA.

Association between statin use and plasma D-dimer levels

D-dimers, specific breakdown fragments of cross-linked fibrin, are generally used as circulating markers of activated coagulation. Statins influence haemostatic factors, but their effect on plasma D-dimer levels is controversial. Therefore, the aim of this meta-analysis was to evaluate the association between statin therapy and plasma D-dimer levels. We searched PubMed, Web of Science, Cochrane Library, Scopus and EMBASE (up to September 25, 2014) to identify randomised controlled trials (RCTs) investigating the impact of statin therapy on plasma D-dimer levels. Two independent reviewers extracted data on study characteristics, methods and outcomes. Meta-analysis of data from nine RCTs with 1,165 participants showed a significant effect of statin therapy in reducing plasma D-dimer levels (standardised mean difference [SMD]: –0.988 µg/ml, 95 % confidence interval [CI]: –1.590 – –0.385, p=0.001). The effect size was robust in sensitivity analysis and omission of no single study significantly changed the overall estimated effect size. In the subgroup analysis, the effect of statins on plasma D-dimer levels was significant only in the subsets of studies with treatment duration ≥ 12 weeks (SMD: –0.761 µg/ml, 95 %CI: –1.163– –0.360; p< 0.001), and for lipophilic statins (atorvastatin and simvastatin) (SMD: –1.364 µg/ml, 95 % CI: –2.202– –0.526; p=0.001). Hydrophilic statins (pravastatin and rosuvastatin) did not significantly reduce plasma D-dimer levels (SMD: –0.237 µg/ml, 95 %CI: –1.140–0.665, p=0.606). This meta-analysis of RCTs suggests a decrease of plasma D-dimer levels after three months of statin therapy, and especially after treatment with lipophilic statins. Well-designed trials are required to validate these results.

Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

Lipid-modifying effects of krill oil in humans: systematic review and meta-analysis of randomized controlled trials

Context

Some experimental and clinical trials have shown that krill oil, extracted from small red crustaceans, might be an effective lipid-modifying agent, but the evidence is not conclusive.

Objective

The effect of krill oil supplements on plasma lipid concentrations was assessed through a systematic review of the literature and a meta-analysis of available randomized controlled trials.

Data sources

PubMed and Scopus were searched up to March 25, 2016, to identify RCTs investigating the effect of krill oil supplements on plasma lipids.

Study selection

Randomized controlled trials that investigated the impact of at least 2 weeks of supplementation with krill oil on plasma/serum concentrations of at least one of the main lipid parameters (ie, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or triglycerides) and that reported sufficient information on plasma/serum lipid levels at baseline and at the end of study in both krill oil and control groups were eligible for inclusion.

Data extraction

Two reviewers independently extracted the following data: first author's name, year of publication, study location, study design, number of participants in the krill oil and control groups, dosage of krill oil, type of control allocation, treatment duration, demographic characteristics of study participants, and baseline and follow-up plasma concentrations of lipids. Effect size was expressed as the weighted mean difference (WMD) and 95% confidence interval (95%CI).

Results

Meta-analysis of data from 7 eligible trials (14 treatment arms) with 662 participants showed a significant reduction in plasma concentrations of low-density lipoprotein cholesterol (WMD, -15.52 mg/dL; 95%CI, -28.43 to -2.61; P = 0.018) and triglycerides (WMD, -14.03 mg/dL; 95%CI, -21.38 to -6.67; P < 0.001) following supplementation with krill oil. A significant elevation in plasma concentrations of high-density lipoprotein cholesterol was also observed (WMD, 6.65 mg/dL; 95%CI, 2.30 to 10.99; P = 0.003), while a reduction in plasma concentrations of total cholesterol did not reach statistical significance (WMD, -7.50 mg/dL; 95%CI, -17.94 to 2.93; P = 0.159).

Conclusion

Krill oil supplementation can reduce low-density lipoprotein cholesterol and triglycerides. Additional clinical studies with more participants are needed to assess the impact of krill oil supplementation on other indices of cardiometabolic risk and on the risk of cardiovascular outcomes.

The role and function of HDL in patients with diabetes mellitus and the related cardiovascular risk

BACKGROUND

Diabetes mellitus (DM) is a major public health problem which prevalence is constantly raising, particularly in low- and middle-income countries. Both diabetes mellitus types (DMT1 and DMT2) are associated with high risk of developing chronic complications, such as retinopathy, nephropathy, neuropathy, endothelial dysfunction, and atherosclerosis.

METHODS

This is a review of available articles concerning HDL subfractions profile in diabetes mellitus and the related cardiovascular risk. In this review, HDL dysfunction in diabetes, the impact of HDL alterations on the risk diabetes development as well as the association between disturbed HDL particle in DM and cardiovascular risk is discussed.

RESULTS

Changes in the amount of circulation lipids, including triglycerides and LDL cholesterol as well as the HDL are frequent also in the course of DMT1 and DMT2. In normal state HDL exerts various antiatherogenic properties, including reverse cholesterol transport, antioxidative and anti-inflammatory capacities. However, it has been suggested that in pathological state HDL becomes "dysfunctional" which means that relative composition of lipids and proteins in HDL, as well as enzymatic activities associated to HDL, such as paraoxonase 1 (PON1) and lipoprotein-associated phospholipase 11 (Lp-PLA2) are altered. HDL properties are compromised in patients with diabetes mellitus (DM), due to oxidative modification and glycation of the HDL protein as well as the transformation of the HDL proteome into a proinflammatory protein. Numerous studies confirm that the ability of HDL to suppress inflammatory signals is significantly reduced in this group of patients. However, the exact underlying mechanisms remains to be unravelled in vivo.

CONCLUSIONS

The understanding of pathological mechanisms underlying HDL dysfunction may enable the development of therapies targeted at specific subpopulations and focusing at the diminishing of cardiovascular risk.

Telomere attrition, kidney function, and prevalent chronic kidney disease in the United States

Background

Telomere length is an emerging novel biomarker of biologic age, cardiovascular risk and chronic medical conditions. Few studies have focused on the association between telomere length (TL) and kidney function.

Objective

We investigated the association between TL and kidney function/prevalent chronic kidney disease (CKD) in US adults.

Methods

The National Health and Nutrition Examination Survey (NHANES) participants with measured data on kidney function and TL from 1999 to 2002 were included. Estimated glomerular filtration rate (eGFR) was based on CKD Epidemiology Collaboration (CKD-EPI) equation. Urinary albumin excretion was assessed using urinary albumin-creatinine ratio (ACR). We used multivariable adjusted linear and logistic regression models, accounting for the survey design and sample weights.

Results

Of the 10568 eligible participants, 48.0% (n=5020) were men. Their mean age was 44.1 years. eGFR significantly decreased and ACR significantly increased across increasing quarters of TL (all p<0.001). The association between TL and kidney function remained robust even after adjusting for potential confounding factors, but the association between TL and ACR was only borderline significant (β-coefficient= -0.012, p=0.056).

Conclusion

The association of kidney function with a marker of cellular senescence suggests an underlying mechanism influencing the progression of nephropathy.

Novel Biomarkers in the Diagnosis of Chronic Kidney Disease and the Prediction of Its Outcome

In its early stages, symptoms of chronic kidney disease (CKD) are usually not apparent. Significant reduction of the kidney function is the first obvious sign of disease. If diagnosed early (stages 1 to 3), the progression of CKD can be altered and complications reduced. In stages 4 and 5 extensive kidney damage is observed, which usually results in end-stage renal failure. Currently, the diagnosis of CKD is made usually on the levels of blood urea and serum creatinine (sCr), however, sCr has been shown to be lacking high predictive value. Due to the development of genomics, epigenetics, transcriptomics, proteomics, and metabolomics, the introduction of novel techniques will allow for the identification of novel biomarkers in renal diseases. This review presents some new possible biomarkers in the diagnosis of CKD and in the prediction of outcome, including asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), uromodulin, kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), miRNA, ncRNA, and lincRNA biomarkers and proteomic and metabolomic biomarkers. Complicated pathomechanisms of CKD development and progression require not a single marker but their combination in order to mirror all types of alterations occurring in the course of this disease. It seems that in the not so distant future, conventional markers may be exchanged for new ones, however, confirmation of their efficacy, sensitivity and specificity as well as the reduction of analysis costs are required.

The effect of statins on cardiovascular outcomes by smoking status: A systematic review and meta-analysis of randomized controlled trials

Smoking is an important risk factor for cardiovascular disease (CVD) morbidity and mortality. The impact of statin therapy on CVD risk by smoking status has not been fully investigated. Therefore we assessed the impact of statin therapy on CVD outcomes by smoking status through a systematic review of the literature and meta-analysis of available randomized controlled trials (RCTs). The literature search included EMBASE, ProQuest, CINAHL and PUBMED databases to 30 January 2016 to identify RCTs that investigated the effect of statin therapy on cumulative incidence of major CVD endpoints (e.g. non-fatal myocardial infarction, revascularization, unstable angina, and stroke). Relative risks (RR) ratios were calculated from the number of events in different treatment groups for both smokers and non-smokers. Finally 11 trials with 89,604 individuals were included. The number of smokers and non-smokers in the statin groups of the analyzed studies was 8826 and 36,090, respectively. The RR for major CV events was 0.73 (95% confidence interval [CI]: 0.67-0.81; p<0.001) in nonsmokers and 0.72 (95%CI: 0.64-0.81; p<0.001) in smokers. Moderate to high heterogeneity was observed both in non-smokers (I²=77.1%, p<0.001) and in smokers (I²=51.6%, p=0.024) groups. Smokers seemed to benefit slightly more from statins than non-smokers according to the number needed to treat (NNT) analysis (23.5 vs 26.8) based on RRs applied to the control event rates. The number of avoided events per 1000 individuals was 42.5 (95%CI: 28.9-54.6) in smokers and 37.3 (95%CI: 27.2-46.4) in non-smokers. In conclusion, this meta-analysis suggests that the effect of statins on CVD is similar for smokers and non-smokers, but in terms of NNTs and number of avoided events, smokers seem to benefit more although non-significantly.

The Effect of Diet on the Survival of Patients with Chronic Kidney Disease

The prevalence of chronic kidney disease (CKD) is high and it is gradually increasing. Individuals with CKD should introduce appropriate measures to hamper the progression of kidney function deterioration as well as prevent the development or progression of CKD-related diseases. A kidney-friendly diet may help to protect kidneys from further damage. Patients with kidney damage should limit the intake of certain foods to reduce the accumulation of unexcreted metabolic products and also to protect against hypertension, proteinuria and other heart and bone health problems. Despite the fact that the influence of certain types of nutrients has been widely studied in relation to kidney function and overall health in CKD patients, there are few studies on the impact of a specific diet on their survival. Animal studies demonstrated prolonged survival of rats with CKD fed with protein-restricted diets. In humans, the results of studies are conflicting. Some of them indicate slowing down of the progression of kidney disease and reduction in proteinuria, but other underline significant worsening of patients' nutritional state, which can be dangerous. A recent systemic study revealed that a healthy diet comprising many fruits and vegetables, fish, legumes, whole grains, and fibers and also the cutting down on red meat, sodium, and refined sugar intake was associated with lower mortality in people with kidney disease. The aim of this paper is to review the results of studies concerning the impact of diet on the survival of CKD patients.