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Abais-Battad JM, Mattson DL. Influence of dietary protein on Dahl salt-sensitive hypertension: a potential role for gut microbiota. Am J Physiol Regul Integr Comp Physiol 2018; 315:R907-R914. [PMID: 30133303 PMCID: PMC6295491 DOI: 10.1152/ajpregu.00399.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 07/30/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Abstract
High blood pressure affects 1.39 billion adults across the globe and is the leading preventable cause of death worldwide. Hypertension is a multifaceted disease with known genetic and environmental factors contributing to its progression. Our studies utilizing the Dahl salt-sensitive (SS) rat have demonstrated the remarkable influence of dietary protein and maternal environment on the development of hypertension and renal damage in response to high salt. There is growing interest in the relationship between the microbiome and hypertension, with gut dysbiosis being correlated to a number of pathologies. This review summarizes the current literature regarding the interplay among dietary protein, the gut microbiota, and hypertension. These studies may provide insight into the effects we have observed between diet and hypertension in Dahl SS rats and, we hope, lead to new perspectives where potential dietary interventions or microbiota manipulations could serve as plausible therapies for hypertension.
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Affiliation(s)
| | - David L Mattson
- Department of Physiology, Medical College of Wisconsin , Milwaukee, Wisconsin
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102
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Koppe L, Fouque D. The Role for Protein Restriction in Addition to Renin-Angiotensin-Aldosterone System Inhibitors in the Management of CKD. Am J Kidney Dis 2018; 73:248-257. [PMID: 30149957 DOI: 10.1053/j.ajkd.2018.06.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 06/18/2018] [Indexed: 01/13/2023]
Abstract
In experimental studies a low-protein diet (LPD) and renin-angiotensin-aldosterone system (RAAS) inhibitors are both reported to slow the progression of chronic kidney disease (CKD) and reduce proteinuria. RAAS activity contributes to increased blood pressure, fluid retention, and positive sodium balance, but also to kidney damage by enhancing glomerular capillary filtration pressure and synthesis of profibrotic molecules such as transforming growth factor β. It has been well established that an LPD decreases glomerular hyperfiltration and the generation of uremic toxins, as well as the burden of acid load, phosphorus, and sodium. In different animal CKD models, a significant reduction in proteinuria and glomerulosclerosis has been achieved when an RAAS inhibitor and LPD were combined. To date, high-quality intervention trials investigating this combined strategy are lacking. We summarize the experimental and clinical studies that have examined a potential additive action of these therapies on CKD progression. We outline potential mechanisms of action and additive efficacy of an LPD and RAAS inhibitors in CKD, with a particular emphasis on phosphate levels, uremic toxin production, acid load, and salt intake. Finally, although the evidence is inadequate to recommend combining RAAS inhibitors and an LPD to slow the progression of CKD, we provide a perspective to support a large-scale randomized clinical trial to study this combination.
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Affiliation(s)
- Laetitia Koppe
- University Lyon, CARMEN, Department of Nephrology, Centre Hospitalier Lyon Sud, Pierre-Benite, France
| | - Denis Fouque
- University Lyon, CARMEN, Department of Nephrology, Centre Hospitalier Lyon Sud, Pierre-Benite, France.
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103
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Joshi S, Shah S, Kalantar-Zadeh K. Adequacy of Plant-Based Proteins in Chronic Kidney Disease. J Ren Nutr 2018; 29:112-117. [PMID: 30122652 DOI: 10.1053/j.jrn.2018.06.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/20/2018] [Accepted: 06/25/2018] [Indexed: 11/11/2022] Open
Abstract
Concerns regarding protein and amino acid deficiencies with plant-based proteins have precluded their use in chronic kidney disease (CKD) patients. Many of these concerns were debunked years ago, but recommendations persist regarding the use of "high-biological value" (animal-based) proteins in CKD patients, which may contribute to worsening of other parameters such as blood pressure, metabolic acidosis, and hyperphosphatemia. Plant-based proteins are sufficient in meeting both quantity and quality requirements. Those eating primarily plant-based diets have been observed to consume approximately 1.0 g/kg/day of protein, or more. CKD patients have been seen to consume 0.7-0.9 g/kg/day of mostly plant-based protein without any negative effects. Furthermore, those substituting animal-based proteins for plant-based proteins have shown reductions in severity of hypertension, hyperphosphatemia, and metabolic acidosis. Plant-based proteins, when consumed in a varied diet, are not only nutritionally adequate but have pleiotropic effects which may favor their use in CKD patients.
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Affiliation(s)
- Shivam Joshi
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Sanjeev Shah
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Orange, California
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104
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Kitada M, Ogura Y, Monno I, Koya D. A Low-Protein Diet for Diabetic Kidney Disease: Its Effect and Molecular Mechanism, an Approach from Animal Studies. Nutrients 2018; 10:nu10050544. [PMID: 29702558 PMCID: PMC5986424 DOI: 10.3390/nu10050544] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 12/15/2022] Open
Abstract
A low-protein diet (LPD) can be expected to retard renal function decline in advanced stages of chronic kidney disease (CKD), including diabetic kidney disease (DKD), and is recommended in a clinical setting. Regarding the molecular mechanisms of an LPD against DKD, previous animal studies have shown that an LPD exerts reno-protection through mainly the improvement of glomerular hyperfiltration/hypertension due to the reduction of intraglomerular pressure. On the other hand, we have demonstrated that an LPD, particularly a very-LPD (VLPD), improved tubulo-interstitial damage, inflammation and fibrosis, through the restoration of autophagy via the reduction of a mammalian target of rapamycin complex 1 (mTORC1) activity in type 2 diabetes and obesity animal models. Thus, based on animal studies, a VLPD may show a more beneficial effect against advanced DKD. Previous clinical reports have also shown that a VLPD, not a moderate LPD, slows the progression of renal dysfunction in patients with chronic glomerular nephritis. However, there is insufficient clinical data regarding the beneficial effects of a VLPD against DKD. Additionally, the patients with CKD, including DKD, are a high-risk group for malnutrition, such as protein–energy wasting (PEW), sarcopenia, and frailty. Therefore, an LPD, including a VLPD, should be prescribed to patients when the benefits of an LPD outweigh the risks, upon consideration of adherence, age, and nutritional status. As the future predicts, the development of a VLPD replacement therapy without malnutrition may be expected for reno-protection against the advanced stages of DKD, through the regulation of mTORC1 activity and adequate autophagy induction. However, further studies to elucidate detailed mechanisms by which a VLPD exerts reno-protection are necessary.
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Affiliation(s)
- Munehiro Kitada
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Yoshio Ogura
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Itaru Monno
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
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105
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Crews DC, Banerjee T, Wesson DE, Morgenstern H, Saran R, Burrows NR, Williams DE, Powe NR. Race/Ethnicity, Dietary Acid Load, and Risk of End-Stage Renal Disease among US Adults with Chronic Kidney Disease. Am J Nephrol 2018; 47:174-181. [PMID: 29525790 PMCID: PMC5906156 DOI: 10.1159/000487715] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dietary acid load (DAL) contributes to the risk of CKD and CKD progression. We sought to determine the relation of DAL to racial/ethnic differences in the risk of end-stage renal disease (ESRD) among persons with CKD. METHODS Among 1,123 non-Hispanic black (NHB) and non-Hispanic white (NHW) National Health and Nutrition Examination Survey III participants with estimated glomerular filtration rate 15-59 mL/min/1.73 m2, DAL was estimated using the Remer and Manz net acid excretion (NAEes) formula and 24-h dietary recall. ESRD events were ascertained via linkage with Medicare. A competing risk model (accounting for death) was used to estimate the hazard ratio (HR) for treated ESRD, comparing NHBs with NHWs, adjusting for demographic, clinical and nutritional factors (body surface area, total caloric intake, serum bicarbonate, protein intake), and NAEes. Additionally, whether the relation of NAEes with ESRD risk varied by race/ethnicity was tested. RESULTS At baseline, NHBs had greater NAEes (50.9 vs. 44.2 mEq/day) than NHWs. It was found that 22% developed ESRD over a median of 7.5 years. The unadjusted HR comparing NHBs to NHWs was 3.35 (95% CI 2.51-4.48) and adjusted HR (for factors above) was 1.68 (95% CI 1.18-2.38). A stronger association of NAE with risk of ESRD was observed among NHBs (adjusted HR per mEq/day increase in NAE 1.21, 95% CI 1.12-1.31) than that among NHWs (HR 1.08, 95% CI 0.96-1.20), p interaction for race/ethnicity × NAEes = 0.004. CONCLUSIONS Among US adults with CKD, the association of DAL with progression to ESRD is stronger among NHBs than NHWs. DAL is worthy of further investigation for its contribution to kidney outcomes across race/ethnic groups.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Tanushree Banerjee
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Donald E Wesson
- Diabetes Health and Wellness Institute, Baylor Scott and White Health, Dallas, Texas, USA
| | - Hal Morgenstern
- Departments of Epidemiology and Environmental Health Sciences, School of Public Health, and Department of Urology, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Desmond E Williams
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Neil R Powe
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California, USA
- Department of Medicine, San Francisco General Hospital, San Francisco, California, USA
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106
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Shams-White MM, Chung M, Fu Z, Insogna KL, Karlsen MC, LeBoff MS, Shapses SA, Sackey J, Shi J, Wallace TC, Weaver CM. Animal versus plant protein and adult bone health: A systematic review and meta-analysis from the National Osteoporosis Foundation. PLoS One 2018; 13:e0192459. [PMID: 29474360 PMCID: PMC5825010 DOI: 10.1371/journal.pone.0192459] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/23/2018] [Indexed: 11/22/2022] Open
Abstract
Background Protein may have both beneficial and detrimental effects on bone health depending on a variety of factors, including protein source. Objective The aim was to conduct a systematic review and meta-analysis evaluating the effects of animal versus plant protein intake on bone mineral density (BMD), bone mineral content (BMC) and select bone biomarkers in healthy adults. Methods Searches across five databases were conducted through 10/31/16 for randomized controlled trials (RCTs) and prospective cohort studies in healthy adults that examined the effects of animal versus plant protein intake on 1) total body (TB), total hip (TH), lumbar spine (LS) or femoral neck (FN) BMD or TB BMC for at least one year, or 2) select bone formation and resorption biomarkers for at least six months. Strength of evidence (SOE) was assessed and random effect meta-analyses were performed. Results Seven RCTs examining animal vs. isoflavone-rich soy (Soy+) protein intake in 633 healthy peri-menopausal (n = 1) and post-menopausal (n = 6) women were included. Overall risk of bias was medium. Limited SOE suggests no significant difference between Soy+ vs. animal protein on LS, TH, FN and TB BMD, TB BMC, and bone turnover markers BSAP and NTX. Meta-analysis results showed on average, the differences between Soy+ and animal protein groups were close to zero and not significant for BMD outcomes (LS: n = 4, pooled net % change: 0.24%, 95% CI: -0.80%, 1.28%; TB: n = 3, -0.24%, 95% CI: -0.81%, 0.33%; FN: n = 3, 0.13%, 95% CI: -0.94%, 1.21%). All meta-analyses had no statistical heterogeneity. Conclusions These results do not support soy protein consumption as more advantageous than animal protein, or vice versa. Future studies are needed examining the effects of different protein sources in different populations on BMD, BMC, and fracture.
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Affiliation(s)
- Marissa M. Shams-White
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA United States of America
| | - Mei Chung
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA United States of America
| | - Zhuxuan Fu
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA United States of America
| | - Karl L. Insogna
- Yale Bone Center at the Yale School of Medicine, Yale University, New Haven, CT United States of America
| | - Micaela C. Karlsen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA United States of America
| | - Meryl S. LeBoff
- Skeletal Health and Osteoporosis Center and Bone Density Unit; Harvard Medical School, Boston, MA United States of America
- Endocrine, Diabetes and Hypertension Division, Brigham and Women's Hospital, Boston, MA United States of America
| | - Sue A. Shapses
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ United States of America
| | - Joachim Sackey
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA United States of America
- Department of Nutritional Sciences, Rutgers School of Health Professions, Newark, NJ United States of America
| | - Jian Shi
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA United States of America
| | - Taylor C. Wallace
- Department of Nutrition and Food Studies, George Mason University, Fairfax, VA United States of America
- Think Healthy Group, Inc, Washington DC United States of America
- * E-mail:
| | - Connie M. Weaver
- Department of Nutrition Science, Women’s Global Health Institute, Purdue University, Nutrition Science, West Lafayette, IN United States of America
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107
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Anderson CAM, Nguyen HA. Nutrition education in the care of patients with chronic kidney disease and end-stage renal disease. Semin Dial 2018; 31:115-121. [PMID: 29455475 DOI: 10.1111/sdi.12681] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Diet counseling and nutrition education are recommended in the prevention and management of chronic kidney disease (CKD) and end-stage renal disease (ESRD). The importance of effectively addressing nutrition with patients has grown given the increasing prevalence of obesity, hypertension, and diabetes; conditions which influence CKD/ESRD. Dietary advice for individuals with CKD/ESRD can be seen as complex; and successful dietary management requires careful planning, periodic assessment of nutritional status, as well as monitoring of dietary compliance. In spite of recommendations and pressing need, formal training in nutrition and adequate preparation for providers is limited; and for physicians the lack of nutrition education has been acknowledged, repeatedly, as an area for improvement in medical training curricula. It has also been suggested that dietitians have an essential role in management of CKD in the primary care setting; however, dietitians who do not practice renal education daily may need training on the specific challenges in CKD/ESRD. The objectives of this chapter were to: characterize select nutrition education resources for providers who care for patients with CKD/ESRD; summarize key dietary components emphasized in the care of patients with CKD/ESRD; and address practical considerations in educational efforts focused on nutrition and CKD/ESRD.
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Affiliation(s)
- Cheryl A M Anderson
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA, USA.,Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Hoang Anh Nguyen
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
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108
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Bushinsky DA, Hostetter T, Klaerner G, Stasiv Y, Lockey C, McNulty S, Lee A, Parsell D, Mathur V, Li E, Buysse J, Alpern R. Randomized, Controlled Trial of TRC101 to Increase Serum Bicarbonate in Patients with CKD. Clin J Am Soc Nephrol 2018; 13:26-35. [PMID: 29102959 PMCID: PMC5753317 DOI: 10.2215/cjn.07300717] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/10/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Metabolic acidosis is common in patients with CKD and has significant adverse effects on kidney, muscle, and bone. We tested the efficacy and safety of TRC101, a novel, sodium-free, nonabsorbed hydrochloric acid binder, to increase serum bicarbonate in patients with CKD and metabolic acidosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS One hundred thirty-five patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter, in-unit study (designated the TRCA-101 Study). Patients had a mean baseline eGFR of 35 ml/min per 1.73 m2, a mean baseline serum bicarbonate of 17.7 mEq/L, and comorbidities, including hypertension (93%), diabetes (70%), and heart failure (21%). Patients ate a controlled diet and were treated for 14 days with placebo or one of four TRC101 dosing regimens (1.5, 3, or 4.5 g twice daily or 6 g once daily). After treatment, patients were discharged and followed for 7-14 days. RESULTS All TRC101 treatment groups had a mean within-group increase in serum bicarbonate of ≥1.3 mEq/L (P<0.001) within 72 hours of the first dose and a mean increase in serum bicarbonate of 3.2-3.9 mEq/L (P<0.001) at the end of treatment compared with placebo, in which serum bicarbonate did not change. In the combined TRC101 treatment group, serum bicarbonate was normalized (22-29 mEq/L) at the end of treatment in 35% of patients and increased by ≥4 mEq/L in 39% of patients. After discontinuation of TRC101, serum bicarbonate decreased nearly to baseline levels within 2 weeks. All adverse events were mild or moderate, with gastrointestinal events most common. All patients completed the study. CONCLUSIONS TRC101 safely and significantly increased the level of serum bicarbonate in patients with metabolic acidosis and CKD.
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Affiliation(s)
- David A. Bushinsky
- Department of Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Thomas Hostetter
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Yuri Stasiv
- Tricida Inc., South San Francisco, California
| | | | | | - Angela Lee
- Tricida Inc., South San Francisco, California
| | | | | | | | | | - Robert Alpern
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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109
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Abstract
Objective Previous studies have reported that a vegetarian diet may lower blood pressure (BP), but the effect of diet on BP in asymptomatic participants with proteinuria is unknown. We examined the association of diet and BP in individuals with or without proteinuria. Materials and Methods This cross-sectional study analyzed data from participants who were more than 40 years old and received physical checkups at Taipei Tzu Chi Hospital from September 5, 2005, to December 31, 2016. Diets were assessed at baseline by a self-reported questionnaire and categorized as vegan, lacto-ovo vegetarian, or omnivore. There were 2818 (7.7%) vegans, 5616 (15.3%) lacto-ovo vegetarians, and 28,183 (77.0%) omnivores. The effect of different parameters on BP was determined using a multivariate multiple linear regression model with no intercept, with control for important characteristics and lifestyle confounders. Results The vegan group had a lower mean systolic BP (-3.87 mmHg, P < 0.001) and diastolic BP (-2.48 mmHg, P < 0.001) than the omnivore group. Participants with proteinuria had a higher systolic BP (4.26 mmHg, P < 0.001) and diastolic BP (2.15 mmHg, P < 0.001) than those without proteinuria. Interaction analysis indicated that vegan participants with proteinuria had a lower systolic BP (-2.73 mmHg, P = 0.046) and diastolic BP (-2.54 mmHg, P = 0.013) than other participants with proteinuria. However, individuals in the lacto-ovo group with proteinuria had a BP similar to other participants with proteinuria. Conclusions A vegan diet was associated with lower BP in asymptomatic participants with proteinuria. This diet could be a nonpharmacologic method to reduce BP.
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Affiliation(s)
- Hao-Wen Liu
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Jia-Sin Liu
- Department of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Ko-Lin Kuo
- Department of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Chauveau P, Lasseur C, Nodimar C, Prezelin-Reydit M, Trolonge S, Combe C, Aparicio M. [Dietary acid load: A novel target for the nephrologist?]. Nephrol Ther 2018; 14:240-246. [PMID: 29289517 DOI: 10.1016/j.nephro.2017.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
The acid production of endogenous origin depends mainly on the metabolism of the food and varies with the nature of these. Of the order of 1mEq/kg/day for contemporary food in industrialized countries, it is reduced by more than one third among vegetarians and close to neutrality among vegans. The dietary acid load is eliminated by the normal kidneys, thus maintaining the acid-base equilibrium. In the setting of CKD, it will overflow the capacities of the nephrons, generating a retention of H+ ions, promoting subclinical acidosis. This tissue retention of H+ ions was confirmed by direct techniques in animal models and indirect techniques in humans. The systemic retention of H+ ions and the accompanying compensatory mechanisms have negative consequences on bone tissue, skeletal muscle, cardiovascular risk and renal function. In the animal, the substitution of casein (acid) by soy (alkaline) prevents metabolic acidosis and slows the progression of renal insufficiency. In man, various prospective studies have confirmed that the risk of renal insufficiency was positively correlated with the dietary acid load. Conversely, bicarbonate supplementation and/or a diet enriched with fruits and vegetables, have a favorable effect on renal insufficiency, including in subjects with normal bicarbonate. These results lead to reconsider the K/DOQI recommendations to correct acidosis when the bicarbonate level falls below 22mEq/L, since tissue retention of H+ ions and its negative consequences appear at higher or even normal levels of bicarbonates.
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Affiliation(s)
- Philippe Chauveau
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France.
| | - Catherine Lasseur
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | - Céline Nodimar
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | - Mathilde Prezelin-Reydit
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Aurad-Aquitaine, 2, allée des Demoiselles, 33170 Gradignan, France
| | | | - Christian Combe
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Unité Inserm 1026, université Bordeaux, 33076 Bordeaux, France
| | - Michel Aparicio
- Service de néphrologie transplantation dialyse, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
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Sanchez-Salazar L, Gonzales GF. Aqueous extract of yellow maca (Lepidium meyenii
) improves sperm count in experimental animals but response depends on hypocotyl size, pH and routes of administration. Andrologia 2017; 50. [DOI: 10.1111/and.12929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- L. Sanchez-Salazar
- Faculty of Sciences and Philosophy; Department of Biological and Physiological Sciences; Universidad Peruana Cayetano Heredia; Lima Peru
- Research Circle on Plants with effects on Health; Universidad Peruana Cayetano Heredia; Lima Peru
| | - G. F. Gonzales
- Faculty of Sciences and Philosophy; Department of Biological and Physiological Sciences; Universidad Peruana Cayetano Heredia; Lima Peru
- Research Circle on Plants with effects on Health; Universidad Peruana Cayetano Heredia; Lima Peru
- Instituto de Investigaciones de la Altura; Universidad Peruana Cayetano Heredia; Lima Peru
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Abstract
Metabolic acidosis is not uncommon in CKD and is linked with bone demineralization, muscle catabolism, and higher risks of CKD progression and mortality. Clinical practice guidelines recommend maintaining serum total CO2 at ≥22 mEq/L to help prevent these complications. Although a definitive trial testing whether correcting metabolic acidosis improves clinical outcomes has not been conducted, results from small, single-center studies support this notion. Furthermore, biologic plausibility supports the notion that a subset of patients with CKD have acid-mediated organ injury despite having a normal serum total CO2 and might benefit from oral alkali before overt acidosis develops. Identifying these individuals with subclinical metabolic acidosis is challenging, but recent results suggest that urinary acid excretion measurements may be helpful. The dose of alkali to provide in this setting is unknown as well. The review discusses these topics and the prevalence and risk factors of metabolic acidosis, mechanisms of acid-mediated organ injury, results from interventional studies, and potential harms of alkali therapy in CKD.
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Affiliation(s)
- Kalani L Raphael
- Veterans Affairs Salt Lake City Health Care System and Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Ko BJ, Chang Y, Ryu S, Kim EM, Lee MY, Hyun YY, Lee KB. Dietary acid load and chronic kidney disease in elderly adults: Protein and potassium intake. PLoS One 2017; 12:e0185069. [PMID: 28953915 PMCID: PMC5617182 DOI: 10.1371/journal.pone.0185069] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/06/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Dietary net endogenous acid production (NEAP), which represents total dietary load of nonvolatile acid, may affect kidney function. Estimated NEAP (eNEAP) is calculated indirectly by the ratio of protein and potassium intake. A few studies are available assessing the association between eNEAP and chronic kidney disease (CKD), and its relation to dietary protein and potassium intake in the elderly. METHODS A total 1,369 community-dwelling elderly Koreans in the Kangbuk Samsung Cohort Study (KSCS) were evaluated using a food frequency questionnaire (FFQ) and comprehensive health examination. We evaluated the association between eNEAP and the CKD. We also examined their relation to protein and potassium intake. RESULTS eNEAP was correlated with potassium intake (r = -0.410, P < 0.001), but was not correlated with protein intake (r = -0.004, P = 0.879). In a full multivariate adjustment for sociodemographic factors, dietary factors, and comorbidities, the participants with higher eNEAP quartiles (Q2, Q3, Q4) had higher odds of CKD compared to the lowest eNEAP quartile (Q1); OR (95% CI) were 1.47 (0.78-2.72), 1.66 (0.85-3.23), and 2.30 (1.16-4.60) respectively (P for trend = 0.019). The odds of CKD decreased for participants with higher potassium intake quartiles (Q2, Q3, Q4) compared to the lowest potassium intake quartile (Q1); OR (95% CI) were 0.52 (0.28-0.95), 0.50 (0.26-0.96), and 0.50 (0.21-0.99) respectively (P for trend = 0.050). Protein intake was not associated with CKD. The association between eNEAP and CKD was similar in subgroup analysis. CONCLUSION Dietary acid load was associated with CKD. Among the nutrients related to dietary acid load, potassium intake was negatively associated with CKD, but protein intake was not associated with CKD in elderly adults.
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Affiliation(s)
- Byung-Joon Ko
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoosoo Chang
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seungho Ryu
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Mi Kim
- Department of Dietetics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Yeon Lee
- Department of Biostatistics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Youl Hyun
- Division of Nephrology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Beck Lee
- Division of Nephrology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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114
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Mafra D, Borges NA, Cardozo LFMDF, Anjos JS, Black AP, Moraes C, Bergman P, Lindholm B, Stenvinkel P. Red meat intake in chronic kidney disease patients: Two sides of the coin. Nutrition 2017; 46:26-32. [PMID: 29290351 DOI: 10.1016/j.nut.2017.08.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/01/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
Red meat is an important dietary source of high biological value protein and micronutrients such as vitamins, iron, and zinc that exert many beneficial functions. However, high consumption of animal protein sources, especially red meat, results in an increased intake of saturated fat, cholesterol, iron, and salt, as well as an excessive acid load. Red meat intake may lead to an elevated production of uremic toxins by the gut microbiota, such as trimethylamine n-oxide (TMAO), indoxyl sulfate, and p-cresyl sulfate. These uremic toxins are associated with increased risk for cardiovascular (CV) mortality. Limiting the intake of red meat in patients with chronic kidney disease (CKD) thus may be a good strategy to reduce CV risk, and may slow the progression of kidney disease. In the present review, we discuss the role of red meat in the diet of patients with CKD. Additionally, we report on a pilot study that focused on the effect of a low-protein diet on TMAO plasma levels in nondialysis CKD patients.
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Affiliation(s)
- Denise Mafra
- Post Graduation Program in Medical Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil; Post Graduation Program in Cardiovascular Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil.
| | - Natalia A Borges
- Post Graduation Program in Cardiovascular Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil
| | | | - Juliana S Anjos
- Post Graduation Program in Cardiovascular Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil
| | - Ana Paula Black
- Post Graduation Program in Medical Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil
| | - Cristiane Moraes
- Post Graduation Program in Cardiovascular Sciences, Federal Fluminense University, Niterói, Rio de Janeiro, Brazil
| | - Peter Bergman
- Department of Laboratory Medicine, Clinical Microbiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
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Cosgrove K, Johnston CS. Examining the Impact of Adherence to a Vegan Diet on Acid-Base Balance in Healthy Adults. PLANT FOODS FOR HUMAN NUTRITION (DORDRECHT, NETHERLANDS) 2017; 72:308-313. [PMID: 28677099 DOI: 10.1007/s11130-017-0620-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Acidogenic diets, commonly measured by the potential renal acid load (PRAL), have been linked with metabolic diseases including insulin resistance, hepatic dysfunction, and cardiometabolic risk. Vegan diets are linked to low dietary acid loads, but the degree of adherence to a vegan diet to demonstrate this benefit is unknown. This study compared the change in PRAL and urine pH of omnivores who followed a vegan diet for either 2, 3, or 7 days over one week. Healthy adults were recruited from a campus population and randomly assigned to one of the three groups: VEG7 (vegan diet followed for seven consecutive days); VEG3 (vegan diet followed for three evenly spaced days over one week); or VEG2 (vegan diet followed for two evenly spaced days over one week). Gender, age, and body mass index did not differ between groups (overall: 21.8 ± 2.4 y and 24.4 ± 5.6 kg/m2). Following the one week intervention, outcome measures did not vary between the VEG2 and VEG3 groups, and these groups were collapsed for the final analyses. The 24-h urine pH was raised after seven consistent days of vegan diet adherence and was unchanged after 2-3 days of vegan diet adherence over the course of a week (+0.52 ± 0.69 and -0.02 ± 0.56 respectively, p = 0.048). However, dietary PRAL scores fell significantly in both dietary groups during the 7-day trial. Since low dietary PRAL scores have been related to improve metabolic parameters, adoption of a vegan diets for several days per week should be explored as a diet strategy to lower disease risk.
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Affiliation(s)
- Kelly Cosgrove
- School of Nutrition and Health Promotion, Arizona State University, 500 N. 3rd Street, Phoenix, AZ, 85004, USA
| | - Carol S Johnston
- School of Nutrition and Health Promotion, Arizona State University, 500 N. 3rd Street, Phoenix, AZ, 85004, USA.
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Nagami GT, Hamm LL. Regulation of Acid-Base Balance in Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:274-279. [PMID: 29031353 DOI: 10.1053/j.ackd.2017.07.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/28/2017] [Indexed: 11/11/2022]
Abstract
The kidneys play a major role in the regulation of acid-base balance by reabsorbing bicarbonate filtered by the glomeruli and excreting titratable acids and ammonia into the urine. In CKD, with declining kidney function, acid retention and metabolic acidosis occur, but the extent of acid retention depends not only on the degree of kidney impairment but also on the dietary acid load. Acid retention can occur even when the serum bicarbonate level is apparently normal. With reduced kidney function, acid transport processes in the surviving nephrons are augmented but as disease progresses ammonia excretion and, in some individuals, the ability to reabsorb bicarbonate falls, whereas titratable acid excretion is preserved until kidney function is severely impaired. Urinary ammonia levels are used to gauge the renal response to acid loads and are best assessed by direct measurement of urinary ammonia levels rather than by indirect assessments. In individuals with acidosis from CKD, an inappropriately low degree of ammonia excretion points to the pathogenic role of impaired urinary acid excretion. The presence of a normal bicarbonate level in CKD complicates the interpretation of the urinary ammonia excretion as such individuals could be in acid-base balance or could be retaining acid without manifesting a low bicarbonate level. At this time, the decision to give bicarbonate supplementation in CKD is reserved for those with a bicarbonate level of 22 mEq/L, but because of potential harm of overtreatment, supplementation should be adjusted to maintain a bicarbonate level of <26 mEq/L.
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117
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Kraut JA. Disturbances in Acid-Base, Potassium, and Sodium Balance in Patients With CKD: New Insights and Novel Therapies. Adv Chronic Kidney Dis 2017; 24:272-273. [PMID: 29031352 DOI: 10.1053/j.ackd.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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118
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Long-term intake of a high-protein diet increases liver triacylglycerol deposition pathways and hepatic signs of injury in rats. J Nutr Biochem 2017; 46:39-48. [DOI: 10.1016/j.jnutbio.2017.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/07/2017] [Accepted: 04/11/2017] [Indexed: 12/24/2022]
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119
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Kramer H. Kidney Disease and the Westernization and Industrialization of Food. Am J Kidney Dis 2017; 70:111-121. [DOI: 10.1053/j.ajkd.2016.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/01/2016] [Indexed: 01/12/2023]
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120
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Banerjee T, Crews DC, Wesson DE, Dharmarajan S, Saran R, Ríos Burrows N, Saydah S, Powe NR. Food Insecurity, CKD, and Subsequent ESRD in US Adults. Am J Kidney Dis 2017; 70:38-47. [PMID: 28215947 PMCID: PMC5765854 DOI: 10.1053/j.ajkd.2016.10.035] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 10/22/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD. STUDY DESIGN Longitudinal cohort study. SETTING & PARTICIPANTS 2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years. PREDICTOR Food insecurity, defined as an affirmative response to the food-insecurity screening question. OUTCOME Development of ESRD. MEASUREMENTS Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates. RESULTS 4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts (P<0.05). Median dietary acid load in the food-secure versus food-insecure group was 51.2 mEq/d versus 55.6 mEq/d, respectively (P=0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49). LIMITATIONS Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago. CONCLUSIONS Among adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.
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Affiliation(s)
- Tanushree Banerjee
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA.
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Donald E Wesson
- Texas A&M College of Medicine and Scott and White Healthcare, Temple, TX
| | - Sai Dharmarajan
- Kidney Epidemiology & Cost Center, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology & Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease and Control and Prevention, Atlanta, GA
| | - Sharon Saydah
- Division of Diabetes Translation, Centers for Disease and Control and Prevention, Atlanta, GA
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA
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Miki A, Hashimoto Y, Tanaka M, Kobayashi Y, Wada S, Kuwahata M, Kido Y, Yamazaki M, Fukui M. Urinary pH reflects dietary acid load in patients with type 2 diabetes. J Clin Biochem Nutr 2017; 61:74-77. [PMID: 28751813 PMCID: PMC5525012 DOI: 10.3164/jcbn.16-118] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 12/19/2016] [Indexed: 11/22/2022] Open
Abstract
Dietary acid load is important information, however, survey of food intake needs time and skill. Therefore, it is difficult to survey food intake from all patients. It remains to be elucidated the association between dietary acid load and urinary pH in patients with type 2 diabetes. In this cross-sectional study of 173 patients, we investigated the relationship between urinary pH and dietary acid load, assessed with potential renal acid load. Habitual food and nutrient intake was assessed by a self-administered diet history questionnaire. Urinary pH was negatively correlated with potential renal acid load (r = –0.24, p = 0.002). Multivariate regression analysis revealed that potential renal acid load (standardized regression coefficient = –0.21, p = 0.036) was associated with urinary pH after adjusting for covariates. In addition, according to the receiver operator characteristic analysis, the optimal cut-off point of urinary pH for high dietary acid load, defined as potential renal acid load over 7.0 mEq/day was 5.7 (area under the receiver operator characteristic curve 0.63 (95% CI 0.54–0.71), sensitivity = 0.56, specificity = 0.70, p = 0.004). Urinary pH was associated with dietary acid load in patients with type 2 diabetes. We suggest that urinary pH can be a practical screening marker for dietary acid load in patients with type 2 diabetes.
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Affiliation(s)
- Akane Miki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yoshitaka Hashimoto
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Muhei Tanaka
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yukiko Kobayashi
- Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo Hangicho, Sakyo-ku Kyoto-shi, Kyoto 606-0823, Japan
| | - Sayori Wada
- Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo Hangicho, Sakyo-ku Kyoto-shi, Kyoto 606-0823, Japan
| | - Masashi Kuwahata
- Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo Hangicho, Sakyo-ku Kyoto-shi, Kyoto 606-0823, Japan
| | - Yasuhiro Kido
- Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo Hangicho, Sakyo-ku Kyoto-shi, Kyoto 606-0823, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Khairallah P, Isakova T, Asplin J, Hamm L, Dobre M, Rahman M, Sharma K, Leonard M, Miller E, Jaar B, Brecklin C, Yang W, Wang X, Feldman H, Wolf M, Scialla JJ. Acid Load and Phosphorus Homeostasis in CKD. Am J Kidney Dis 2017. [PMID: 28645705 DOI: 10.1053/j.ajkd.2017.04.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The kidneys maintain acid-base homeostasis through excretion of acid as either ammonium or as titratable acids that primarily use phosphate as a buffer. In chronic kidney disease (CKD), ammoniagenesis is impaired, promoting metabolic acidosis. Metabolic acidosis stimulates phosphaturic hormones, parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF-23) in vitro, possibly to increase urine titratable acid buffers, but this has not been confirmed in humans. We hypothesized that higher acid load and acidosis would associate with altered phosphorus homeostasis, including higher urinary phosphorus excretion and serum PTH and FGF-23. STUDY DESIGN Cross-sectional. SETTING & PARTICIPANTS 980 participants with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. PREDICTORS Net acid excretion as measured in 24-hour urine, potential renal acid load (PRAL) estimated from food frequency questionnaire responses, and serum bicarbonate concentration < 22 mEq/L. OUTCOME & MEASUREMENTS 24-hour urine phosphorus and calcium excretion and serum phosphorus, FGF-23, and PTH concentrations. RESULTS Using linear and log-linear regression adjusted for demographics, kidney function, comorbid conditions, body mass index, diuretic use, and 24-hour urine creatinine excretion, we found that 24-hour urine phosphorus excretion was higher at higher net acid excretion, higher PRAL, and lower serum bicarbonate concentration (each P<0.05). Serum phosphorus concentration was also higher with higher net acid excretion and lower serum bicarbonate concentration (each P=0.001). Only higher net acid excretion associated with higher 24-hour urine calcium excretion (P<0.001). Neither net acid excretion nor PRAL was associated with FGF-23 or PTH concentrations. PTH, but not FGF-23, concentration (P=0.2) was 26% (95% CI, 13%-40%) higher in participants with a serum bicarbonate concentration <22 versus ≥22 mEq/L (P<0.001). Primary results were similar if stratified by estimated glomerular filtration rate categories or adjusted for iothalamate glomerular filtration rate (n=359), total energy intake, dietary phosphorus, or urine urea nitrogen excretion, when available. LIMITATIONS Possible residual confounding by kidney function or nutrition; urine phosphorus excretion was included in calculation of the titratable acid component of net acid excretion. CONCLUSIONS In CKD, higher acid load and acidosis associate independently with increased circulating phosphorus concentration and augmented phosphaturia, but not consistently with FGF-23 or PTH concentrations. This may be an adaptation that increases titratable acid excretion and thus helps maintain acid-base homeostasis in CKD. Understanding whether administration of base can lower phosphorus concentrations requires testing in interventional trials.
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Affiliation(s)
| | - Tamara Isakova
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John Asplin
- Litholink Corp, Laboratory Corporation of America Holdings, Chicago, IL
| | - Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Mirela Dobre
- Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Mahboob Rahman
- Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Kumar Sharma
- Department of Medicine, University of San Diego, San Diego, CA
| | - Mary Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Edgar Miller
- Department of Medicine, Prevention and Clinical Research, Johns Hopkins University, Baltimore, MD; Welch Center for Epidemiology, Prevention and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Bernard Jaar
- Department of Medicine, Prevention and Clinical Research, Johns Hopkins University, Baltimore, MD; Welch Center for Epidemiology, Prevention and Clinical Research, Johns Hopkins University, Baltimore, MD; Nephrology Center of Maryland, Baltimore, MD
| | - Carolyn Brecklin
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Xue Wang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Harold Feldman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Myles Wolf
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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Chazot C, Jean G, Joly D. Complications métaboliques de l’insuffisance rénale chronique. Nephrol Ther 2017; 13:6S30-6S36. [DOI: 10.1016/s1769-7255(18)30038-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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124
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Carnauba RA, Baptistella AB, Paschoal V, Hübscher GH. Diet-Induced Low-Grade Metabolic Acidosis and Clinical Outcomes: A Review. Nutrients 2017; 9:E538. [PMID: 28587067 PMCID: PMC5490517 DOI: 10.3390/nu9060538] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/05/2017] [Accepted: 05/17/2017] [Indexed: 01/04/2023] Open
Abstract
Low-grade metabolic acidosis is a condition characterized by a slight decrease in blood pH, within the range considered normal, and feeding is one of the main factors that may influence the occurrence of such a condition. The excessive consumption of acid precursor foods (sources of phosphorus and proteins), to the detriment of those precursors of bases (sources of potassium, calcium, and magnesium), leads to acid-base balance volubility. If this condition occurs in a prolonged, chronic way, low-grade metabolic acidosis can become significant and predispose to metabolic imbalances such as kidney stone formation, increased bone resorption, reduced bone mineral density, and the loss of muscle mass, as well as the increased risk of chronic diseases such as type 2 diabetes mellitus, hypertension, and non-alcoholic hepatic steatosis. Considering the increase in the number of studies investigating the influence of diet-induced metabolic acidosis on clinical outcomes, this review gathers the available evidence evaluating the association of this disturbance and metabolic imbalances, as well as related mechanisms. It is necessary to look at the western dietary pattern of most countries and the increasing incidence of non-comunicable diseases for the balance between fruit and vegetable intake and the appropriate supply of protein, mainly from animal sources, so that it does not exceed the daily recommendations.
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Affiliation(s)
| | | | - Valéria Paschoal
- VP Research Institute, 287, Carlos Petit St, São Paulo 04110-000, Brazil.
| | - Gilberti Helena Hübscher
- Departament of Food Science and Technology, Federal University of Santa Maria, Rio Grande do Sul 97105-900, Brazil.
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125
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Patel S. Stressor-driven extracellular acidosis as tumor inducer via aberrant enzyme activation: A review on the mechanisms and possible prophylaxis. Gene 2017; 626:209-214. [PMID: 28546124 DOI: 10.1016/j.gene.2017.05.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/09/2017] [Accepted: 05/21/2017] [Indexed: 02/08/2023]
Abstract
When the extracellular pH of human body vacillates in either direction, tissue homeostasis is compromised. Fluctuations in acidity have been linked to a wide variety of pathological conditions, including bone loss, cancer, allergies, and auto-immune diseases. Stress conditions affect oxygen tension, and the resultant hypoxia modulates the expression and/or activity of membrane-tethered transporters/pumps, transcription factors, enzymes and intercellular junctions. These modifications provoke erratic gene expression, aberrant tissue remodeling and oncogenesis. While the physiological optimization of pH in tissues is practically challenging, it is at least theoretically achievable and can be considered as a possible therapy to resolve a broad array of diseases.
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Affiliation(s)
- Seema Patel
- Bioinformatics and Medical Informatics Research Center, San Diego State University, 92182 San Diego, CA, USA; Bioinformatics and Medical Informatics Research Center, San Diego State University, 5500 Campanile Dr San Diego, CA 92182, USA..
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126
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Sadjadi SA, Pi A. Hyperphosphatemia, a Cause of High Anion Gap Metabolic Acidosis: Report of a Case and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:463-466. [PMID: 28450695 PMCID: PMC5417588 DOI: 10.12659/ajcr.902862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Patient: Male, 74 Final Diagnosis: Metabolic acidosis due to hyperphosphatemia Symptoms: Abdominal pain Medication:— Clinical Procedure: — Specialty: Nephrology
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Affiliation(s)
- Seyed Ali Sadjadi
- Department of Nephrology, Jerry L Pettis VA Medical Center, Loma Linda, CA, USA
| | - Alexander Pi
- Department of Nephrology, Jerry L Pettis VA Medical Center, Loma Linda, CA, USA
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Vegetarian Diet in Chronic Kidney Disease-A Friend or Foe. Nutrients 2017; 9:nu9040374. [PMID: 28394274 PMCID: PMC5409713 DOI: 10.3390/nu9040374] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/10/2017] [Accepted: 04/05/2017] [Indexed: 12/17/2022] Open
Abstract
Healthy diet is highly important, especially in patients with chronic kidney disease (CKD). Proper nutrition provides the energy to perform everyday activities, prevents infection, builds muscle, and helps to prevent kidney disease from getting worse. However, what does a proper diet mean for a CKD patient? Nutrition requirements differ depending on the level of kidney function and the presence of co-morbid conditions, including hypertension, diabetes, and cardiovascular disease. The diet of CKD patients should help to slow the rate of progression of kidney failure, reduce uremic toxicity, decrease proteinuria, maintain good nutritional status, and lower the risk of kidney disease-related secondary complications (cardiovascular disease, bone disease, and hypertension). It has been suggested that plant proteins may exert beneficial effects on blood pressure, proteinuria, and glomerular filtration rate, as well as results in milder renal tissue damage when compared to animal proteins. The National Kidney Foundation recommends vegetarianism, or part-time vegetarian diet as being beneficial to CKD patients. Their recommendations are supported by the results of studies demonstrating that a plant-based diet may hamper the development or progression of some complications of chronic kidney disease, such as heart disease, protein loss in urine, and the progression of kidney damage. However, there are sparse reports suggesting that a vegan diet is not appropriate for CKD patients and those undergoing dialysis due to the difficulty in consuming enough protein and in maintaining proper potassium and phosphorus levels. Therefore, this review will focus on the problem as to whether vegetarian diet and its modifications are suitable for chronic kidney disease patients.
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128
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Abstract
PURPOSE OF REVIEW Acid-base homeostasis is impaired in chronic kidney disease (CKD) and may contribute to disease progression. Diabetes, a major cause of CKD worldwide, may exacerbate acidosis further due to differences in acid production and excretion. Here, we review the role of abnormal acid-base homeostasis in the pathogenesis and progression of diabetes and diabetic kidney disease. RECENT FINDINGS Acidosis and dietary acid loading may contribute to the development and worsening of insulin resistance and hypertension, thereby promoting diabetes and diabetic CKD. However, although metabolic acidosis associates with progression of CKD generally, the results in diabetic CKD are mixed. Data suggests that metabolic acid production in diabetes may be higher than would be predicted based on dietary intake alone, and new observational data suggests that this higher diet-independent acid production could potentially be protective. The role of acid-base homeostasis in diabetic CKD progression is complex and must consider differences in endogenous acid production and excretion in diabetes. Ongoing observational and interventional studies in this field should consider the unique physiology of diabetes.
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Affiliation(s)
- Pascale Khairallah
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Julia J Scialla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA.
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129
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Abstract
The optimal approach to managing acid-base balance is less well defined for patients receiving hemodialysis than for those receiving peritoneal dialysis. Interventional studies in hemodialysis have been limited and inconsistent in their findings, whereas more compelling data are available from interventional studies in peritoneal dialysis. Both high and low serum bicarbonate levels associate with an increased risk of mortality in patients receiving hemodialysis, but high values are a marker for poor nutrition and comorbidity and are often highly variable from month to month. Measurement of pH would likely provide useful additional data. Concern has arisen regarding high-bicarbonate dialysate and dialysis-induced alkalemia, but whether these truly cause harm remains to be determined. The available evidence is insufficient for determining the optimal target for therapy at this time.
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Affiliation(s)
- Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, and
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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130
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Kiefte-de Jong JC, Li Y, Chen M, Curhan GC, Mattei J, Malik VS, Forman JP, Franco OH, Hu FB. Diet-dependent acid load and type 2 diabetes: pooled results from three prospective cohort studies. Diabetologia 2017; 60:270-279. [PMID: 27858141 PMCID: PMC5831375 DOI: 10.1007/s00125-016-4153-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 10/17/2016] [Indexed: 02/08/2023]
Abstract
AIMS/HYPOTHESIS Studies suggest a potential link between low-grade metabolic acidosis and type 2 diabetes. A western dietary pattern increases daily acid load but the association between diet-dependent acid load and type 2 diabetes is still unclear. This study aimed to assess whether diet-dependent acid load is associated with the risk of type 2 diabetes. METHODS We examined the association between energy-adjusted net endogenous acid production (NEAP), potential renal acid load (PRAL) and animal protein-to-potassium ratio (A:P) on incident type 2 diabetes in 67,433 women from the Nurses' Health Study, 84,310 women from the Nurses' Health Study II and 35,743 men from the Health Professionals' Follow-up Study who were free from type 2 diabetes, cardiovascular disease and cancer at baseline. Study-specific HRs were estimated using Cox proportional hazards models with time-varying covariates and were pooled using a random effects meta-analysis. RESULTS We documented 15,305 cases of type 2 diabetes during 4,025,131 person-years of follow-up. After adjustment for diabetes risk factors, dietary NEAP, PRAL and A:P were positively associated with type 2 diabetes (pooled HR [95% CI] for highest (Q5) vs lowest quintile (Q1): 1.29 [1.22, 1.37], p trend <0.0001; 1.29 [1.22, 1.36], p trend <0.0001 and 1.32 [1.24, 1.40], p trend <0.0001 for NEAP, PRAL and A:P, respectively). These results were not fully explained by other dietary factors including glycaemic load and dietary quality (HR [95% CI] for Q5 vs Q1: 1.21 [1.09, 1.33], p trend <0.0001; 1.19 [1.08, 1.30] and 1.26 [1.17, 1.36], p trend <0.0001 for NEAP, PRAL and A:P, respectively). CONCLUSIONS/INTERPRETATION This study suggests that higher diet-dependent acid load is associated with an increased risk of type 2 diabetes. This association is not fully explained by diabetes risk factors and overall diet quality.
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Affiliation(s)
- Jessica C Kiefte-de Jong
- Department of Epidemiology, Erasmus MC, Room NA2903, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.
- Department of Global Public Health, Leiden University College, The Hague, the Netherlands.
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Yanping Li
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Mu Chen
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Gary C Curhan
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Josiemer Mattei
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Vasanti S Malik
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - John P Forman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, Room NA2903, PO Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Frank B Hu
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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131
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Scialla JJ, Asplin J, Dobre M, Chang AR, Lash J, Hsu CY, Kallem RR, Hamm LL, Feldman HI, Chen J, Appel LJ, Anderson CAM, Wolf M. Higher net acid excretion is associated with a lower risk of kidney disease progression in patients with diabetes. Kidney Int 2017; 91:204-215. [PMID: 27914710 PMCID: PMC5518613 DOI: 10.1016/j.kint.2016.09.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 09/01/2016] [Accepted: 09/08/2016] [Indexed: 01/14/2023]
Abstract
Higher diet-dependent nonvolatile acid load is associated with faster chronic kidney disease (CKD) progression, but most studies have used estimated acid load or measured only components of the gold standard, net acid excretion (NAE). Here we measured NAE as the sum of urine ammonium and titratable acidity in 24-hour urines from a random subset of 980 participants in the Chronic Renal Insufficiency Cohort (CRIC) Study. In multivariable models accounting for demographics, comorbidity and kidney function, higher NAE was significantly associated with lower serum bicarbonate (0.17 mEq/l lower serum bicarbonate per 10 mEq/day higher NAE), consistent with a larger acid load. Over a median of 6 years of follow-up, higher NAE was independently associated with a significantly lower risk of the composite of end-stage renal disease or halving of estimated glomerular filtration rate among diabetics (hazard ratio 0.88 per 10 mEq/day higher NAE), but not those without diabetes (hazard ratio 1.04 per 10 mEq/day higher NAE). For comparison, we estimated the nonvolatile acid load as net endogenous acid production using self-reported food frequency questionnaires from 2848 patients and dietary urine biomarkers from 3385 patients. Higher net endogenous acid production based on biomarkers (urea nitrogen and potassium) was modestly associated with faster CKD progression consistent with prior reports, but only among those without diabetes. Results from the food frequency questionnaires were not associated with CKD progression in any group. Thus, disparate results obtained from analyses of nonvolatile acid load directly measured as NAE and estimated from diet suggest a novel hypothesis that the risk of CKD progression related to low NAE or acid load may be due to diet-independent changes in acid production in diabetes.
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Affiliation(s)
- Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.
| | - John Asplin
- Litholink Corp, Laboratory Corporation of America Holdings, Chicago, Illinois, USA
| | - Mirela Dobre
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania, USA
| | - James Lash
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Radhakrishna R Kallem
- Department of Biostatistics and Epidemiology and the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - L Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology and the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University School of Medicine and The Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, Maryland, USA
| | - Cheryl A M Anderson
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
| | - Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Abstract
PURPOSE OF REVIEW High-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. This can cause damage to glomerular structure leading to or aggravating chronic kidney disease (CKD). Hence, a low-protein diet (LPD) of 0.6-0.8 g/kg/day is often recommended for the management of CKD. We reviewed the effect of protein intake on incidence and progression of CKD and the role of LPD in the CKD management. RECENT FINDINGS Actual dietary protein consumption in CKD patients remains substantially higher than the recommendations for LPD. Notwithstanding the inconclusive results of the 'Modification of Diet in Renal Disease' (MDRD) study, the largest randomized controlled trial to examine protein restriction in CKD, several prior and subsequent studies and meta-analyses appear to support the role of LPD on retarding progression of CKD and delaying initiation of maintenance dialysis therapy. LPD can also be used to control metabolic derangements in CKD. Supplemented LPD with essential amino acids or their ketoanalogs may be used for incremental transition to dialysis especially on nondialysis days. The LPD management in lieu of dialysis therapy can reduce costs, enhance psychological adaptation, and preserve residual renal function upon transition to dialysis. Adherence and adequate protein and energy intake should be ensured to avoid protein-energy wasting. SUMMARY A balanced and individualized dietary approach based on LPD should be elaborated with periodic dietitian counseling and surveillance to optimize management of CKD, to assure adequate protein and energy intake, and to avoid or correct protein-energy wasting.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Amanda R. Tortoricci
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
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Melchart D, Doerfler W, Weidenhammer W, Eustachi A. Acid-base status in healthy volunteers: Reliability of the venous blood titration method according to Joergensen and van Limburg Stirum. Eur J Integr Med 2016. [DOI: 10.1016/j.eujim.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rebholz CM, Crews DC, Grams ME, Steffen LM, Levey AS, Miller ER, Appel LJ, Coresh J. DASH (Dietary Approaches to Stop Hypertension) Diet and Risk of Subsequent Kidney Disease. Am J Kidney Dis 2016; 68:853-861. [PMID: 27519166 PMCID: PMC5123940 DOI: 10.1053/j.ajkd.2016.05.019] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are established guidelines for recommended dietary intake for hypertension treatment and cardiovascular disease prevention. Evidence is lacking for effective dietary patterns for kidney disease prevention. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Atherosclerosis Risk in Communities (ARIC) Study participants with baseline estimated glomerular filtration rate (eGFR) ≥ 60mL/min/1.73m2 (N=14,882). PREDICTOR The Dietary Approaches to Stop Hypertension (DASH) diet score was calculated based on self-reported dietary intake of red and processed meat, sweetened beverages, sodium, fruits, vegetables, whole grains, nuts and legumes, and low-fat dairy products, averaged over 2 visits. OUTCOMES Cases were ascertained based on the development of eGFRs<60mL/min/1.73m2 accompanied by ≥25% eGFR decline from baseline, an International Classification of Diseases, Ninth/Tenth Revision code for a kidney disease-related hospitalization or death, or end-stage renal disease from baseline through 2012. RESULTS 3,720 participants developed kidney disease during a median follow-up of 23 years. Participants with a DASH diet score in the lowest tertile were 16% more likely to develop kidney disease than those with the highest score tertile (HR, 1.16; 95% CI, 1.07-1.26; P for trend < 0.001), after adjusting for sociodemographics, smoking status, physical activity, total caloric intake, baseline eGFR, overweight/obese status, diabetes status, hypertension status, systolic blood pressure, and antihypertensive medication use. Of the individual components of the DASH diet score, high red and processed meat intake was adversely associated with kidney disease and high nuts, legumes, and low-fat dairy products intake was associated with reduced risk for kidney disease. LIMITATIONS Potential measurement error due to self-reported dietary intake and lack of data for albuminuria. CONCLUSIONS Consuming a DASH-style diet was associated with lower risk for kidney disease independent of demographic characteristics, established kidney risk factors, and baseline kidney function. Healthful dietary patterns such as the DASH diet may be beneficial for kidney disease prevention.
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Affiliation(s)
- Casey M Rebholz
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Morgan E Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lyn M Steffen
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Andrew S Levey
- William B. Schwartz Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Edgar R Miller
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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Rebholz CM, Tin A, Liu Y, Fanelli-Kuczmarski MT, Evans MK, Zonderman AB, Crews DC. Dietary Magnesium and Kidney Function Decline: The Healthy Aging in Neighborhoods of Diversity across the Life Span Study. Am J Nephrol 2016; 44:381-387. [PMID: 27771720 PMCID: PMC5130225 DOI: 10.1159/000450861] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/25/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Prior studies suggest that certain aspects of the diet related to magnesium intake, such as dietary acid load, protein intake and dietary patterns rich in fruits and vegetables, may impact kidney disease risk. We hypothesized that lower dietary magnesium intake would be prospectively associated with more rapid kidney function decline. METHODS Among participants in the Healthy Aging in Neighborhoods of Diversity across the Life Span study with estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 at baseline (2004-2009), dietary magnesium intake was calculated from two 24-hour dietary recalls. Rapid decline was defined as ≥3% eGFR decline per year. RESULTS Median (25th-75th percentile) dietary magnesium intake was 116 (96-356) mg/1,000 kcal. Among 1,252 participants, those with lower dietary magnesium intake were younger, and were more likely to be African-American men. A total of 177 participants (14.1%) experienced rapid eGFR decline over a median follow-up of 5 years. Lower dietary magnesium intake was significantly associated with a greater odds of rapid eGFR decline (OR for tertile 1 vs. 3: 2.02, 95% CI 1.05-3.86, p value for trend across tertiles = 0.02) in analyses adjusted for sociodemographics (age, sex, race, education level, health insurance status, poverty status), kidney disease risk factors (smoking status, diabetes, hemoglobin A1c, hypertension, body mass index), baseline eGFR and dietary factors (total energy intake; diet quality; dietary intake of fiber, sodium, calcium, potassium and phosphorus). CONCLUSIONS In this urban population, lower dietary magnesium intake was independently associated with greater odds of rapid kidney function decline.
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Affiliation(s)
- Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Adrienne Tin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Yang Liu
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marie T. Fanelli-Kuczmarski
- Department of Behavioral Health & Nutrition, College of Health Sciences, University of Delaware, Newark, Delaware
| | - Michele K. Evans
- Laboratory of Epidemiology and Population Sciences, National Institute of Aging, National Institutes of Health, Baltimore, Maryland
| | - Alan B. Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute of Aging, National Institutes of Health, Baltimore, Maryland
| | - Deidra C. Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bellasi A, Di Micco L, Santoro D, Marzocco S, De Simone E, Cozzolino M, Di Lullo L, Guastaferro P, Di Iorio B. Correction of metabolic acidosis improves insulin resistance in chronic kidney disease. BMC Nephrol 2016; 17:158. [PMID: 27770799 PMCID: PMC5075179 DOI: 10.1186/s12882-016-0372-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/12/2016] [Indexed: 01/12/2023] Open
Abstract
Background Correction of metabolic acidosis (MA) with nutritional therapy or bicarbonate administration is widely used in chronic kidney disease (CKD) patients. However, it is unknown whether these interventions reduce insulin resistance (IR) in diabetic patients with CKD. We sought to evaluate the effect of MA correction on endogenous insulin action in diabetic type 2 (DM2) CKD patients. Methods A total of 145 CKD subjects (83 men e 62 women) with DM2 treated with oral antidiabetic drugs were included in the study and followed up to 1 year. All patients were randomly assigned 1:1 to either open-label (A) oral bicarbonate to achieve serum bicarbonate levels of 24–28 mmol/L (treatment group) or (B) no treatment (control group). The Homeostatic model assessment (HOMA) index was used to evaluate IR at study inception and conclusion. Parametric and non-parametric tests as well as linear regression were used. Results At baseline no differences in demographic and clinical characteristics between the two groups was observed. Average dose of bicarbonate in the treatment group was 0.7 ± 0.2 mmol/kg. Treated patients showed a better metabolic control as confirmed by lower insulin levels (13.4 ± 5.2 vs 19.9 ± 6.3; for treated and control subjects respectively; p < 0.001), Homa-IR (5.9[5.0-7.0] vs 6.3[5.3–8.2]; p = 0.01) and need for oral antidiabetic drugs. The serum bicarbonate and HOMA-IR relationship was non-linear and the largest HOMA-IR reduction was noted for serum bicarbonate levels between 24 and 28 mmol/l. Adjustment for confounders, suggests that serum bicarbonate rather than treatment drives the effect on HOMA-IR. Conclusions Serum bicarbonate is related to IR and the largest HOMA-IR reduction is noted for serum bicarbonate between 24 and 28 mmol/l. Treatment with bicarbonate influences IR. However, changes in serum bicarbonate explains the effect of treatment on HOMA index. Future efforts are required to validate these results in diabetic and non-diabetic CKD patients. Trial registration The trial was registered at www.clinicaltrial.gov (Use of Bicarbonate in Chronic Renal Insufficiency (UBI) study - NCT01640119)
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Affiliation(s)
- Antonio Bellasi
- Department of Nephrology and Dialysis, ASST-Lariana, Ospedale Sant' Anna, Como, (CO), Italy
| | - Lucia Di Micco
- Department of Nephrology and Dialysis, UOC Nefrologia, PO "A Landolfi", Via Melito, snc, I-83029, Solofra, (AV), Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Messina, Italy
| | - Stefania Marzocco
- Department of Pharmacy, School of Pharmacy, University of Salerno, Fisciano, (SA), Italy
| | - Emanuele De Simone
- Department of Nephrology and Dialysis, UOC Nefrologia, PO "A Landolfi", Via Melito, snc, I-83029, Solofra, (AV), Italy
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Ospedale Parodi, Delfino, Colleferro, (Rome), Italy
| | | | - Biagio Di Iorio
- Department of Nephrology and Dialysis, UOC Nefrologia, PO "A Landolfi", Via Melito, snc, I-83029, Solofra, (AV), Italy.
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Liu Y, Kuczmarski MF, Miller ER, Nava MB, Zonderman AB, Evans MK, Powe NR, Crews DC. Dietary Habits and Risk of Kidney Function Decline in an Urban Population. J Ren Nutr 2016; 27:16-25. [PMID: 27771303 DOI: 10.1053/j.jrn.2016.08.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/30/2016] [Accepted: 08/15/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Explore the association between following a Dietary Approaches to Stop Hypertension (DASH)-accordant diet and kidney end points among urban adults. DESIGN Prospective cohort study. SETTING Healthy Aging in Neighborhoods of Diversity across the Life Span study. SUBJECTS A total of 1,534 urban dwelling participants of the Healthy Aging in Neighborhoods of Diversity across the Life Span study with a baseline estimated glomerular filtration rate (eGFR) ≥60 mL/minute/1.73 m2. INTERVENTION DASH diet accordance determined via a score based on nine target nutrients. MAIN OUTCOME MEASURE Rapid kidney function decline (eGFR decline >3 mL/minute/1.73 m2 per year), incident chronic kidney disease (CKD) (follow-up eGFR <60 mL/minute/1.73 m2), and eGFR decline >25%. RESULTS Participants' mean age was 48 years, and 59% were African-American. Median DASH score was 1.5 (range, 0-8). Over a median of 5 years, 13.4% experienced rapid eGFR decline, including 15.2% among participants not following a DASH-accordant diet (score ≤1) and 12.0% with higher accordance (score >1) (P = .08). Outcomes varied by hypertension status. In multinomial logistic regression models, following adjustment for sociodemographic and clinical factors, including total energy intake, low DASH diet accordance was associated with rapid eGFR decline among participants with hypertension (risk ratio, 1.68; 95% confidence interval: 1.17-2.42) but not among those without hypertension (risk ratio, 0.83; 95% confidence interval: 0.56-1.24; P interaction .001). There was no statistically significant association between DASH diet accordance and incident CKD or eGFR decline >25%. Results were similar when DASH diet accordance was analyzed in tertiles. CONCLUSIONS Among urban adults, low accordance to a DASH-type diet was not associated with incident CKD, but was associated with higher risk of rapid eGFR decline among those with hypertension, yet not among those without hypertension. Further study of dietary patterns as a potential target for improving kidney outcomes among high-risk populations is warranted.
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Affiliation(s)
- Yang Liu
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Edgar R Miller
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - M Berenice Nava
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Alan B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Michele K Evans
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Neil R Powe
- Department of Medicine, San Francisco General Hospital and University of California at San Francisco, San Francisco, California
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Lew QLJ, Jafar TH, Koh HWL, Jin A, Chow KY, Yuan JM, Koh WP. Red Meat Intake and Risk of ESRD. J Am Soc Nephrol 2016; 28:304-312. [PMID: 27416946 DOI: 10.1681/asn.2016030248] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/19/2016] [Indexed: 11/03/2022] Open
Abstract
Randomized controlled trials suggest that protein restriction may retard the progression of CKD toward ESRD. However, the effects of dietary protein intake level and the food sources of dietary protein on the risk of ESRD in the general population remain unclear. We investigated these effects in the Singapore Chinese Health Study, a prospective population-based cohort that recruited 63,257 Chinese adults aged 45-74 years from 1993 to 1998. We collected habitual diet information via a validated semiquantitative food frequency questionnaire and identified ESRD via record linkage with a nationwide registry. In all, 951 cases of ESRD occurred over a mean follow-up of 15.5 years. Regarding total protein intake, compared with the lowest quartile, the three higher quartiles combined had a hazard ratio for ESRD of 1.24 (95% confidence interval [95% CI], 1.05 to 1.46), but the dose-dependent association across the quartiles was not statistically significant (Ptrend=0.16). Red meat intake strongly associated with ESRD risk in a dose-dependent manner (hazard ratio for highest quartile versus lowest quartile,1.40 [95% CI, 1.15 to 1.71; Ptrend<0.001]). Intake of poultry, fish, eggs, or dairy products did not associate with risk of ESRD. In substitution analysis, replacing one serving of red meat with other food sources of protein associated with a maximum relative risk reduction of 62.4% (95% CI, 33.1 to 78.9; P<0.01). Our study shows that red meat intake may increase the risk of ESRD in the general population and substituting alternative sources of protein may reduce the incidence of ESRD.
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Affiliation(s)
| | - Tazeen Hasan Jafar
- Duke-NUS Medical School, Singapore.,Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Hiromi Wai Ling Koh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Aizhen Jin
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - Khuan Yew Chow
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - Jian-Min Yuan
- Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; and.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Woon-Puay Koh
- Duke-NUS Medical School, Singapore; .,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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139
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Tyson CC, Lin PH, Corsino L, Batch BC, Allen J, Sapp S, Barnhart H, Nwankwo C, Burroughs J, Svetkey LP. Short-term effects of the DASH diet in adults with moderate chronic kidney disease: a pilot feeding study. Clin Kidney J 2016; 9:592-8. [PMID: 27478603 PMCID: PMC4957723 DOI: 10.1093/ckj/sfw046] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/02/2016] [Indexed: 11/21/2022] Open
Abstract
Background Although the Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure (BP) for adults with normal kidney function, evidence is lacking regarding its safety and efficacy in chronic kidney disease (CKD). We aimed to test the effects of the DASH diet on serum electrolytes and BP in adults with moderate CKD. Methods In a prospective before–after feeding study, 11 adults with an estimated glomerular filtration rate of 30–59 mL/min/1.73 m2 and medication-treated hypertension were provided a reduced-sodium, run-in diet for 1 week followed by a reduced-sodium, DASH diet for 2 weeks. Changes in serum electrolytes and BP were compared pre–post DASH. Results Eleven participants underwent feeding; 1 completed 1 week and 10 completed 2 weeks of DASH. Compared with baseline, DASH modestly increased serum potassium at 1 week (mean ± standard deviation, +0.28 ± 0.4 mg/dL; P = 0.043) but had no significant effect on potassium at 2 weeks (+0.15 ± 0.28 mg/dL; P = 0.13). Serum bicarbonate was reduced (−2.5 ± 3.0 mg/dL; P = 0.03) at 2 weeks. Neither incident hyperkalemia nor new onset metabolic acidosis was observed. Clinic BP and mean 24-h ambulatory BP was unchanged. DASH significantly reduced mean nighttime BP (−5.3 ± 5.8 mmHg; P = 0.018), and enhanced percent declines in both nocturnal systolic BP (−2.1% to −5.1%; P = 0.004) and diastolic BP (−3.7% to −10.0%; P = 0.008). Conclusions These pilot data suggest that a reduced-sodium DASH dietary pattern does not cause acute metabolic events in adults with moderate CKD and may improve nocturnal BP. Definitive studies are needed to determine long-term effects of DASH in CKD.
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Affiliation(s)
| | - Pao-Hwa Lin
- Department of Medicine, Duke University, Durham, NC, USA; Sarah W. Stedman Nutrition & Metabolism Center, Duke University Medical Center, Durham, NC, USA
| | - Leonor Corsino
- Department of Medicine , Duke University , Durham, NC , USA
| | - Bryan C Batch
- Department of Medicine , Duke University , Durham, NC , USA
| | - Jenifer Allen
- Sarah W. Stedman Nutrition & Metabolism Center , Duke University Medical Center , Durham, NC , USA
| | - Shelly Sapp
- Duke Clinical Research Institute , Durham, NC , USA
| | | | - Chinazo Nwankwo
- Sarah W. Stedman Nutrition & Metabolism Center , Duke University Medical Center , Durham, NC , USA
| | - Jasmine Burroughs
- Sarah W. Stedman Nutrition & Metabolism Center , Duke University Medical Center , Durham, NC , USA
| | - Laura P Svetkey
- Department of Medicine, Duke University, Durham, NC, USA; Sarah W. Stedman Nutrition & Metabolism Center, Duke University Medical Center, Durham, NC, USA
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140
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Scialla JJ. The balance of the evidence on acid-base homeostasis and progression of chronic kidney disease. Kidney Int 2016; 88:9-11. [PMID: 26126088 PMCID: PMC4487414 DOI: 10.1038/ki.2015.87] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Normalization of acid-base homeostasis in chronic kidney disease (CKD) holds promise for mitigating disease progression, but whether efforts should focus on patients with low serum bicarbonate or high dietary acid load is unknown. Vallet et al. report that low urinary ammonia excretion independently associates with increased progression in moderate CKD. Whether this finding implicates differences in endogenous acid production or the ability to excrete an acid load in the pathogenesis of progression requires further study.
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Affiliation(s)
- Julia J Scialla
- 1] Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA [2] Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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141
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Ikizler HO, Zelnick L, Ruzinski J, Curtin L, Utzschneider KM, Kestenbaum B, Himmelfarb J, de Boer IH. Dietary Acid Load is Associated With Serum Bicarbonate but not Insulin Sensitivity in Chronic Kidney Disease. J Ren Nutr 2016; 26:93-102. [PMID: 26508542 PMCID: PMC4762747 DOI: 10.1053/j.jrn.2015.08.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/05/2015] [Accepted: 08/16/2015] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE In chronic kidney disease (CKD), dietary acid may promote metabolic acidosis and insulin resistance, which in turn may contribute to adverse clinical health outcomes. We examined associations between dietary acid load, serum bicarbonate, and insulin sensitivity in CKD. DESIGN In a cross-sectional study, we collected 3-day prospective food diaries to quantify dietary acid load as net endogenous acid production (NEAP, the nonvolatile acid load produced by the diet's acid balance) and potential renal acid load (PRAL). We measured urine net acid excretion (NAE) in 24-hour urine samples. Insulin sensitivity was measured by hyperinsulinemic euglycemic clamp. SUBJECTS Forty-two patients with CKD Stages 3 to 5 attending nephrology clinics in the Pacific Northwest and 21 control subjects (estimated glomerular filtration rate [eGFR] ≥ 60 mL/minute/1.73 m(2)). MAIN OUTCOME MEASURES Serum bicarbonate and insulin sensitivity (SIclamp). RESULTS Mean age was 60.8 ± 13.6 years, and 54% of participants were men. Mean eGFR and serum bicarbonate concentrations were 34.4 ± 13.1 mL/minute/1.73 m(2) and 24.1 ± 2.9 mEq/L for participants with CKD and 88.6 ± 14.5 mL/minute/1.73 m(2) and 26.3 ± 1.8 mEq/L for control subjects, respectively. Mean NEAP, PRAL, and NAE were 58.2 ± 24.3, 9.7 ± 18.4, and 32.1 ± 19.8 mEq/day, respectively. Considering all participants, dietary acid load was significantly, inversely associated with serum bicarbonate, adjusting for age, gender, race, eGFR, body mass index, and diuretic use: -1.2 mEq/L per standard deviation (SD) NEAP (95% confidence interval [CI] -1.8 to -0.6, P < .0001); -0.9 mEq/L bicarbonate per SD PRAL (95% CI -1.5 to -0.4, P = .0005); -0.7 mEq/L bicarbonate per SD NAE (95% CI -1.2 to -0.1, P = .01). These associations were similar in participants with and without CKD. However, neither NEAP and PRAL nor NAE was significantly associated with SIclamp. Serum bicarbonate was also not significantly associated with SIclamp. CONCLUSIONS In CKD, dietary acid load is associated with serum bicarbonate, suggesting that acidosis may be improved by dietary changes, but not with insulin sensitivity.
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Affiliation(s)
- Halil O Ikizler
- University of Vermont College of Medicine, Burlington, Vermont; Kidney Research Institute, University of Washington, Seattle, Washington
| | - Leila Zelnick
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - John Ruzinski
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Laura Curtin
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Kristina M Utzschneider
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, Washington; Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Jonathan Himmelfarb
- Kidney Research Institute, University of Washington, Seattle, Washington; Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, Washington; Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington.
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Rebholz CM, Coresh J, Grams ME, Steffen LM, Anderson CAM, Appel LJ, Crews DC. Dietary Acid Load and Incident Chronic Kidney Disease: Results from the ARIC Study. Am J Nephrol 2016; 42:427-35. [PMID: 26789417 PMCID: PMC4733508 DOI: 10.1159/000443746] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/10/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Higher dietary acid load can result in metabolic acidosis and is associated with faster kidney disease progression in patients with chronic kidney disease (CKD). However, the relationship between dietary acid load and incident CKD has not been evaluated. METHODS We conducted prospective analyses of the Atherosclerosis Risk in Communities study participants without CKD at baseline (1987-1989, n = 15,055). Dietary acid load was estimated using the equation for potential renal acid load by Remer and Manz, incorporating dietary intake data from a food frequency questionnaire. Incident CKD was assessed from baseline through 2010 and defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 accompanied by 25% eGFR decline, CKD-related hospitalization or death or end-stage renal disease identified by linkage to the US Renal Data System registry. RESULTS In the overall study population, 55% were female, 26% were African-American and mean age at baseline was 54 years. During a median follow-up of 21 years, there were 2,351 (15.6%) incident CKD cases. After adjusting for demographics (age, sex, race-center), established risk factors (diabetes status, hypertension status, overweight/obese status, smoking status, education level, physical activity), caloric intake and baseline eGFR, higher dietary acid load were associated with higher risk of incident CKD (hazard ratio [HR] for quartile 4 vs. 1: 1.13, 95% CI 1.01-1.28, p for trend = 0.02; HR per interquartile range increase: 1.06, 95% CI 1.00-1.11, p = 0.04). CONCLUSION Dietary acid load is associated with incident CKD in a population-based sample. These data suggest a potential avenue for CKD risk reduction through diet.
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Affiliation(s)
- Casey M Rebholz
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Md., USA
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143
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Citarda S, Hanf W, Vrigneaud L, Bataille S, Gosselin M, Beaume J, Dariane C, Madec FX, Larceneux F, Fiard G, Bertocchio JP. [Mineral-based alkaline waters' prescription in France: Patients are the key point for both nephrologists and urologists]. Nephrol Ther 2015; 12:38-47. [PMID: 26563589 DOI: 10.1016/j.nephro.2015.07.471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/17/2015] [Indexed: 11/25/2022]
Abstract
Alkali therapy is frequently used during chronic kidney disease and nephrolithiasis: nephrologists and urologists are the key operators. Very few is known about the underlying conditions of such a prescription: the aim of this study was to delineate those determinants. We conducted a prospective survey where French nephrologists and urologists were involved. Responders were without gender distinction and principally nephrologists. Prescription frequency was associated with gender (women), specialty (nephrologists), indications and perceived efficiency. Urologists prescribe more often during nephrolithiasis and nephrologists during chronic kidney disease. Urologists were more expert (by scoring on mineral-based alkaline waters compositions knowledge). By multivariate analysis, prescription frequency is associated with gender (women), indications and perceived efficiency by prescribers, which is itself influenced by feedback from patients. These results could have been influenced by a huge representation of nephrologists but foster physicians to go on listening to feedback from patients, due to a lack of clinical trials on the efficiency of mineral-based alkaline waters in such a field. Finally, physicians' education (especially young nephrologists) on mineral-based alkaline waters should be intensified.
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Affiliation(s)
- Salvatore Citarda
- Centre associatif lyonnais de dialyse (CALYDIAL), 51, rue Yvours, 69540 Irigny, France; Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France
| | - William Hanf
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de néphrologie, centre hospitalier Alpes-Léman, 74130 Contamine-sur-Arve, France
| | - Laurence Vrigneaud
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de médecine interne et néphrologie, centre hospitalier de Valenciennes, avenue Desandrouin, 59300 Valenciennes, France
| | - Stanislas Bataille
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Institut phocéen de néphrologie, clinique Bouchard, 13006 Marseille, France
| | - Morgane Gosselin
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de néphrologie et transplantation rénale, CHRU La Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - Julie Beaume
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de dialyse, HIA Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - Charles Dariane
- Service d'urologie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris, France; Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France
| | - François-Xavier Madec
- Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie infantile, hôpital Mère-Enfant, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - Fabrice Larceneux
- Dauphine recherches en management, UMR CNRS 7088, université Paris Dauphine, place du Maréchal-de-Lattre-de-Tassigny, 75016 Paris, France
| | - Gaëlle Fiard
- Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Grenoble, laboratoire TIMC-IMAG, CNRS, université Grenoble-Alpes, 38000 Grenoble, France
| | - Jean-Philippe Bertocchio
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service d'explorations fonctionnelles rénales et métaboliques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris, France.
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144
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Kraut JA, Madias NE. Metabolic Acidosis of CKD: An Update. Am J Kidney Dis 2015; 67:307-17. [PMID: 26477665 DOI: 10.1053/j.ajkd.2015.08.028] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/01/2015] [Indexed: 01/02/2023]
Abstract
The kidney has the principal role in the maintenance of acid-base balance. Therefore, a decrease in renal ammonium excretion and a positive acid balance often leading to a reduction in serum bicarbonate concentration are observed in the course of chronic kidney disease (CKD). The decrease in serum bicarbonate concentration is usually absent until glomerular filtration rate decreases to <20 to 25mL/min/1.73 m(2), although it can develop with lesser degrees of decreased kidney function. Non-anion gap acidosis, high-anion gap acidosis, or both can be found at all stages of CKD. The acidosis can be associated with muscle wasting, bone disease, hypoalbuminemia, inflammation, progression of CKD, and increased mortality. Administration of base may decrease muscle wasting, improve bone disease, and slow the progression of CKD. Base is suggested when serum bicarbonate concentration is <22 mEq/L, but the target serum bicarbonate concentration is unclear. Evidence that increments in serum bicarbonate concentration > 24 mEq/L might be associated with worsening of cardiovascular disease adds complexity to treatment decisions. Further study of the mechanisms through which metabolic acidosis contributes to the progression of CKD, as well as the pathways involved in mediating the benefits and complications of base therapy, is warranted.
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Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA; Division of Nephrology, VHAGLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA.
| | - Nicolaos E Madias
- Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
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145
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Kaname S. [Kidney diseases and metabolic disorders--Basics and applications required for general physicians. Topics: V. Acid-base disorders and kidney disease]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2015; 104:938-947. [PMID: 26591343 DOI: 10.2169/naika.104.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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146
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Association between the markers of metabolic acid load and higher all-cause and cardiovascular mortality in a general population with preserved renal function. Hypertens Res 2015; 38:433-8. [PMID: 25762414 DOI: 10.1038/hr.2015.23] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/29/2014] [Accepted: 01/25/2015] [Indexed: 12/11/2022]
Abstract
Although metabolic acid load has been associated with many well-known risk factors for mortality, its clinical implications are not yet clear. To evaluate the association between biomarkers of metabolic acid load, such as serum bicarbonate, serum anion gap and urine pH and mortality, we analyzed the health records of 31,590 adults who underwent a health screening between January 2001 and December 2010 and had an estimated glomerular filtration rate ⩾60 ml min(-1) per 1.73 m2. Urine pH was measured by a dipstick test performed on fast morning urine sample and categorized as acidic (urine pH ⩽5.5), neutral and alkaline (urine pH ⩾8.0). Using the Cox proportional hazard model, the adjusted hazard ratio (aHR) of all-cause mortality of the lowest quartile of serum bicarbonate was 1.460 (95% confidence interval (CI) 1.068-1.995) compared with the highest quartile, after a median follow-up of 93 months. The aHRs of cardiovascular and cancer mortality of the lowest quartile of serum bicarbonate were 2.647 (95% CI 1.148-6.103) and 1.604 (95% CI 1.024-2.513), respectively, compared with the highest quartile. Acidic and neutral urine pH were significantly associated with a higher all-cause mortality (aHR 2.550, 95% CI 1.316-4.935; aHR 2.376 95% CI 1.254-4.501, respectively), compared with an alkaline urine pH. In conclusion, higher metabolic acid load was associated with an increased all-cause and cardiovascular mortality in a healthy population. The association between metabolic acid load and mortality and the causality of the relationship need to be confirmed.
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147
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148
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Crews DC, Kuczmarski MF, Miller ER, Zonderman AB, Evans MK, Powe NR. Dietary habits, poverty, and chronic kidney disease in an urban population. J Ren Nutr 2015; 25:103-10. [PMID: 25238697 PMCID: PMC4339637 DOI: 10.1053/j.jrn.2014.07.008] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 07/20/2014] [Accepted: 07/22/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Poverty is associated with chronic kidney disease (CKD) in the United States and worldwide. Poor dietary habits may contribute to this disparity. STUDY DESIGN Cross-sectional study. SETTING AND PARTICIPANTS A total of 2,058 community-dwelling adults aged 30 to 64 years residing in Baltimore City, Maryland. PREDICTORS Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet. DASH scoring based on 9 target nutrients (total fat, saturated fat, protein, fiber, cholesterol, calcium, magnesium, sodium, and potassium); adherence defined as score ≥4.5 of maximum possible score of 9. Poverty (self-reported household income <125% of 2004 Department of Health and Human Services guideline) and nonpoverty (≥125% of guideline). OUTCOMES AND MEASUREMENTS CKD defined as estimated glomerular filtration rate <60 mL/minute/1.73 m(2) (CKD epidemiology collaboration equation). Multivariable logistic regression was used to calculate adjusted odds ratios (AORs) for relation of DASH score tertile and CKD, stratified by poverty status. RESULTS Among 2,058 participants (mean age 48 years; 57% black; 44% male; 42% with poverty), median DASH score was low, 1.5 (interquartile range, 1-2.5). Only 5.4% were adherent. Poverty, male sex, black race, and smoking were more prevalent among the lower DASH score tertiles, whereas higher education and regular health care were more prevalent among the highest DASH score tertile (P < .05 for all). Fiber, calcium, magnesium, and potassium intake were lower, and cholesterol higher, among the poverty compared with nonpoverty group (P < .05 for all), with no difference in sodium intake. A total of 5.6% of the poverty and 3.8% of the nonpoverty group had CKD (P = .05). The lowest DASH tertile (compared with the highest) was associated with more CKD among the poverty (AOR 3.15, 95% confidence interval 1.51-6.56), but not among the nonpoverty group (AOR 0.73, 95% confidence interval 0.37-1.43; P interaction = .001). CONCLUSIONS Poor dietary habits are strongly associated with CKD among the urban poor and may represent a target for interventions aimed at reducing disparities in CKD.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | | | - Edgar R Miller
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alan B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Michele K Evans
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | - Neil R Powe
- Department of Medicine, San Francisco General Hospital, University of California at San Francisco, San Francisco, California
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149
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Gutiérrez OM. Contextual poverty, nutrition, and chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:31-8. [PMID: 25573510 DOI: 10.1053/j.ackd.2014.05.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/07/2014] [Accepted: 05/22/2014] [Indexed: 12/18/2022]
Abstract
Nutrition plays an important role in CKD outcomes. One of the strongest factors that affects nutrition is socioeconomic status as evidenced by the large body of epidemiologic data showing that income and education are directly associated with diet quality. Apart from individual-level markers of socioeconomic status such as income and education, contextual factors such as availability of and transportation to food outlets that provide healthy food options and the density of fast-food restaurants within particular regions markedly affect the ability of individuals to comply with nutrition recommendations. This is particularly true for nutrition guidelines most specific to individuals with CKD such as the consumption of protein, saturated fat, sodium, and phosphorus, all of which have been shown to affect CKD health and are influenced by the availability of healthy food options within individual neighborhood food environments. Because of the strong association of contextual poverty with the diet quality, any serious attempt to improve the diet of CKD patients must include a discussion of the environmental barriers that each individual faces in trying to access healthy foods, and health care providers should take account of these barriers when tailoring specific recommendations.
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150
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Haghighatdoost F, Najafabadi MM, Bellissimo N, Azadbakht L. Association of dietary acid load with cardiovascular disease risk factors in patients with diabetic nephropathy. Nutrition 2014; 31:697-702. [PMID: 25837215 DOI: 10.1016/j.nut.2014.11.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 11/19/2014] [Accepted: 11/21/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE An association between dietary acid load and cardiovascular disease risk has been reported in epidemiologic studies; however, there are no reports to our knowledge of this association in patients with diabetic nephropathy (DN). Therefore, the aim of this study was to examine the association between dietary acid load, based on potential renal acid load (PRAL) and protein:potassium ratio (Pro:K) scores, and cardiovascular disease risk factors in individuals with DN. METHODS In this cross-sectional study, we randomly enrolled 547 patients with DN. Dietary intake was assessed using a validated food frequency questionnaire. Biochemical and anthropometric measures were assessed using standard methods. RESULTS Participants had a mean age of 66.8 y and body mass index of 24 kg/m(2). After controlling for potential confounders, participants in the low PRAL group had lower hemoglobin (Hb)A1c (5.7% ± 0.5% versus 7.8% ± 0.5%; P = 0.01), triacylglycerols (246.9 ± 2.3 mg/dL versus 257.4 ± 2.3 mg/dL; P = 0.006), systolic blood pressure (103.6 ± 0.7 mm Hg versus 106.1 ± 0.7 mm Hg; P = 0.03), and lower creatinine and fasting blood sugar compared with the high PRAL group. Pro:K was positively related to HbA1c (5.8% ± 0.5% versus 7.6% ± 0.5%; P = 0.03), but inversely associated with low-density lipoprotein and waist circumference. CONCLUSIONS We found that both PRAL and Pro:K were positively related to HbA1c in the setting of DN, whereas other biochemical and kidney-related markers varied with PRAL and Pro:K status. Future studies are warranted to clarify the clinical outcomes of dietary acid load in older populations as well as in patients with chronic kidney disease.
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Affiliation(s)
- Fahimeh Haghighatdoost
- Department of Community Nutrition, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Nick Bellissimo
- Faculty of Community Services, School of Nutrition, Ryerson University, Toronto, Canada
| | - Leila Azadbakht
- Department of Community Nutrition, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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