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Passey C. Reducing the Dietary Acid Load: How a More Alkaline Diet Benefits Patients With Chronic Kidney Disease. J Ren Nutr 2017; 27:151-160. [PMID: 28117137 DOI: 10.1053/j.jrn.2016.11.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 02/02/2023] Open
Abstract
It has been proposed that a low-protein diet will slow progression of chronic kidney disease although studies have not always supported this belief. The accepted practice is that 60% to 70% of protein comes from high biological value (HBV) protein, but this limits patient choice and patients struggle to follow the diet. When a diet with only 30% HBV protein was trialed, there was a significant increase in serum bicarbonate, and patients preferred the diet. The dietary advice given in predialysis clinics was changed. HBV protein was restricted to approximately 50% of total protein, bread and cereal foods were allowed freely, and fruits and vegetables (F&V) were encouraged. Patients who followed the diet have seen a slowing of progression and occasionally regression of their renal function. Both observations and scientific literature indicate that this is because of a reduction in the acid content of the diet. When foods are metabolized, most proteins produce acid, and most F&V produce alkali. A typical 21st-century diet produces 50 to 100 mEq H+ per day which the kidney is challenged to excrete. Acid is excreted with phosphate and is limited to about 45 mEq H+ per day. With chronic kidney disease, this falls progressively to below 20 mEq H+ per day. Historically, ammonium excretion was believed to be excretion of acid (NH3+ + H+ → NH4+), but it is now understood to be a by-product in the neutralization of acid by glutamine. The remaining acid is neutralized or stored within the body. Bone and muscle are lost in order to neutralize the acid. Acid also accumulates within cells, and serum bicarbonate falls. The author postulates that reducing the acid load through a low-protein diet with greater use of vegetable proteins and increased F&V intake will slow progression or occasionally improve renal function while maintaining the nutritional status of the individual.
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Affiliation(s)
- Caroline Passey
- Nutrition and Dietetic Department, Wessex Kidney Centre, Portsmouth Hospitals NHS Trust, Portsmouth, Hampshire, United Kingdom.
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202
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Di Iorio BR, Di Micco L, Marzocco S, De Simone E, De Blasio A, Sirico ML, Nardone L. Very Low-Protein Diet (VLPD) Reduces Metabolic Acidosis in Subjects with Chronic Kidney Disease: The "Nutritional Light Signal" of the Renal Acid Load. Nutrients 2017; 9:nu9010069. [PMID: 28106712 PMCID: PMC5295113 DOI: 10.3390/nu9010069] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/04/2017] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background: Metabolic acidosis is a common complication of chronic kidney disease; current guidelines recommend treatment with alkali if bicarbonate levels are lower than 22 mMol/L. In fact, recent studies have shown that an early administration of alkali reduces progression of CKD. The aim of the study is to evaluate the effect of fruit and vegetables to reduce the acid load in CKD. Methods: We conducted a case-control study in 146 patients who received sodium bicarbonate. Of these, 54 patients assumed very low-protein diet (VLPD) and 92 were controls (ratio 1:2). We calculated every three months the potential renal acid load (PRAL) and the net endogenous acid production (NEAP), inversely correlated with serum bicarbonate levels and representing the non-volatile acid load derived from nutrition. Un-paired T-test and Chi-square test were used to assess differences between study groups at baseline and study completion. Two-tailed probability values ≤0.05 were considered statistically significant. Results: At baseline, there were no statistical differences between the two groups regarding systolic blood pressure (SBP), diastolic blood pressure (DBP), protein and phosphate intake, urinary sodium, potassium, phosphate and urea nitrogen, NEAP, and PRAL. VLPD patients showed at 6 and 12 months a significant reduction of SBP (p < 0.0001), DBP (p < 0.001), plasma urea (p < 0.0001) protein intake (p < 0.0001), calcemia (p < 0.0001), phosphatemia (p < 0.0001), phosphate intake (p < 0.0001), urinary sodium (p < 0.0001), urinary potassium (p < 0.002), and urinary phosphate (p < 0.0001). NEAP and PRAL were significantly reduced in VLPD during follow-up. Conclusion: VLPD reduces intake of acids; nutritional therapy of CKD, that has always taken into consideration a lower protein, salt, and phosphate intake, should be adopted to correct metabolic acidosis, an important target in the treatment of CKD patients. We provide useful indications regarding acid load of food and drinks—the “acid load dietary traffic light”.
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Affiliation(s)
| | - Lucia Di Micco
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Stefania Marzocco
- Department of Pharmacy, School of Pharmacy, University of Salerno, Via Giovanni Paolo II 132, I-84084 Fisciano, Salerno, Italy.
| | | | - Antonietta De Blasio
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Maria Luisa Sirico
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
| | - Luca Nardone
- UOC di Nefrologia, A. Landolfi Hospital, Via Melito SNC, I-83029 Solofra, Avellino, Italy.
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203
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Dietary potential renal acid load and net acid excretion in rural and urban pre-menopausal Gambian women. Proc Nutr Soc 2017. [DOI: 10.1017/s0029665117003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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204
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Wai SN, Kelly JT, Johnson DW, Campbell KL. Dietary Patterns and Clinical Outcomes in Chronic Kidney Disease: The CKD.QLD Nutrition Study. J Ren Nutr 2016; 27:175-182. [PMID: 27939593 DOI: 10.1053/j.jrn.2016.10.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/09/2016] [Accepted: 10/19/2016] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Emerging evidence suggests that dietary patterns are associated with survival in people with chronic kidney disease (CKD). This study evaluated the relationship between dietary habits and renal-related clinical outcomes in an established CKD cohort. DESIGN Prospective cohort study. SETTING Three outpatient nephrology clinics in Queensland, Australia. SUBJECTS A total of 145 adult patients with Stage 3 or 4 CKD (estimated glomerular filtration rate 15-59 mL/minute/1.73 m2). INTERVENTION Dietary intake was measured using 24-hour recall and the HeartWise Dietary Habits Questionnaire (DHQ), which evaluates 10 components of dietary patterns in relation to cooking habits and intake of food groups. MAIN OUTCOME MEASURE The primary outcome was a composite end point of all-cause mortality, commencement of dialysis, and doubling of serum creatinine. Secondary outcome was all-cause mortality alone. Multivariate cox regression analyses calculated hazard ratios (HRs) for associations between DHQ domains and occurrence of composite outcome and adjusted for confounders, including comorbidities and renal function. RESULTS Over a median follow-up of 36 months, 32% (n = 47) reached the composite end point, of which 21% died (n = 30). Increasing DHQ score was associated with a lower risk of the composite end point with increasing intake of fruits and vegetables (HR: 0.61; 95% CI, 0.39-0.94) and limiting alcohol consumption (HR, 0.79; 95% CI: 0.65-0.96). For the secondary outcome of all-cause mortality, there was a significant association with adequate intake of fruits and vegetables (HR: 0.35; 95% CI, 0.15-0.83). CONCLUSION Healthy dietary patterns consisting of adequate fruits and vegetables and limited alcohol consumption are associated with a delay in CKD progression and improved survival in patients with Stage 3 or 4 CKD.
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Affiliation(s)
- Shu Ning Wai
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jaimon T Kelly
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Katrina L Campbell
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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205
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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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206
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Food groups associated with measured net acid excretion in community-dwelling older adults. Eur J Clin Nutr 2016; 71:420-424. [PMID: 27759073 PMCID: PMC5332290 DOI: 10.1038/ejcn.2016.195] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/11/2016] [Accepted: 08/28/2016] [Indexed: 01/22/2023]
Abstract
Background Acid-producing diets have been associated with adverse health conditions. Dietary acid load can be estimated from dietary intake data, but the available methods require a full dietary assessment. We sought to identify a simpler means to estimate 24-hour urinary net acid excretion (NAE), a robust measure of net endogenous acid production, using self-reported intakes of fruits, vegetables (acid-neutralizing foods), grain and/or protein (acid-producing foods)acquired by two different methods in community-dwelling older adults. Identifying food groups associated with NAE using a method not requiring a full diet assessment could have a broad clinical application. Methods Fruit, vegetable, protein, and grain servings/day were estimated with a widely-used food frequency questionnaire (study A, n=162, 63±8 years). Differences in their intakes across NAE categories (<5, ≥5to <15, ≥15to <50, ≥50 milliequivalents (mEq)/day) were analyzed using analysis of variance. The findings were verified in a second study which estimated dietary intakes using a more detailed record-assisted 24- hour recall (study B, n=232, 67±6 years). Results Fruit intake was significantly associated with NAE in both studies. In study A, fruit intake was 9% lower with each categorical NAE increase (unstandardized beta=-0.21,p=0.01) and 7% lower with each categorical NAE increase in study B (unstandardized beta=-0.18;p=0.02). Grain intake was positively associated with NAE in study B only (unstandardized beta=+0.14;p=0.01). Vegetable and protein intake were not associated with NAE in either study. Conclusion The inverse association between fruit intake and NAE suggests low self-reported fruit intake may be an indicator of acid-producing diets in older adults.
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207
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Parmenter BH, Slater GJ, Frassetto LA. Accuracy and precision of estimation equations to predict net endogenous acid excretion using the Australian food database. Nutr Diet 2016; 74:308-312. [DOI: 10.1111/1747-0080.12324] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/09/2016] [Accepted: 08/19/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Benjamin H. Parmenter
- Faculty of Health, Science and Engineering; University of the Sunshine Coast; Queensland Australia
| | - Gary J. Slater
- Faculty of Health, Science and Engineering; University of the Sunshine Coast; Queensland Australia
| | - Lynda A. Frassetto
- School of Medicine; University of California San Francisco (UCSF); California USA
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208
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Ferraro PM, Mandel EI, Curhan GC, Gambaro G, Taylor EN. Dietary Protein and Potassium, Diet-Dependent Net Acid Load, and Risk of Incident Kidney Stones. Clin J Am Soc Nephrol 2016; 11:1834-1844. [PMID: 27445166 PMCID: PMC5053786 DOI: 10.2215/cjn.01520216] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/20/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Protein and potassium intake and the resulting diet-dependent net acid load may affect kidney stone formation. It is not known whether protein type or net acid load is associated with risk of kidney stones. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We prospectively examined intakes of protein (dairy, nondairy animal, and vegetable), potassium, and animal protein-to-potassium ratio (an estimate of net acid load) and risk of incident kidney stones in the Health Professionals Follow-Up Study (n=42,919), the Nurses' Health Study I (n=60,128), and the Nurses' Health Study II (n=90,629). Multivariable models were adjusted for age, body mass index, diet, and other factors. We also analyzed cross-sectional associations with 24-hour urine (n=6129). RESULTS During 3,108,264 person-years of follow-up, there were 6308 incident kidney stones. Dairy protein was associated with lower risk in the Nurses' Health Study II (hazard ratio for highest versus lowest quintile, 0.84; 95% confidence interval, 0.73 to 0.96; P value for trend <0.01). The hazard ratios for nondairy animal protein were 1.15 (95% confidence interval, 0.97 to 1.36; P value for trend =0.04) in the Health Professionals Follow-Up Study and 1.20 (95% confidence interval, 0.99 to 1.46; P value for trend =0.06) in the Nurses' Health Study I. Potassium intake was associated with lower risk in all three cohorts (hazard ratios from 0.44 [95% confidence interval, 0.36 to 0.53] to 0.67 [95% confidence interval, 0.57 to 0.78]; P values for trend <0.001). Animal protein-to-potassium ratio was associated with higher risk (P value for trend =0.004), even after adjustment for animal protein and potassium. Higher dietary potassium was associated with higher urine citrate, pH, and volume (P values for trend <0.002). CONCLUSIONS Kidney stone risk may vary by protein type. Diets high in potassium or with a relative abundance of potassium compared with animal protein could represent a means of stone prevention.
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Affiliation(s)
- Pietro Manuel Ferraro
- Division of Nephrology, Fondazione Policlinico Universitario “A. Gemelli”, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Gary C. Curhan
- Renal Division, Department of Medicine and
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Giovanni Gambaro
- Division of Nephrology, Fondazione Policlinico Universitario “A. Gemelli”, Catholic University of the Sacred Heart, Rome, Italy
| | - Eric N. Taylor
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
- Division of Nephrology and Transplantation, Maine Medical Center, Portland, Maine
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209
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Williams RS, Heilbronn LK, Chen DL, Coster AC, Greenfield JR, Samocha-Bonet D. Dietary acid load, metabolic acidosis and insulin resistance – Lessons from cross-sectional and overfeeding studies in humans. Clin Nutr 2016; 35:1084-90. [DOI: 10.1016/j.clnu.2015.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 06/26/2015] [Accepted: 08/05/2015] [Indexed: 12/31/2022]
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210
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Sun X, Tommasi E, Molina D, Sah R, Brosnihan KB, Diz D, Petrovic S. Deletion of proton-sensing receptor GPR4 associates with lower blood pressure and lower binding of angiotensin II receptor in SFO. Am J Physiol Renal Physiol 2016; 311:F1260-F1266. [PMID: 27681561 DOI: 10.1152/ajprenal.00410.2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/22/2016] [Indexed: 11/22/2022] Open
Abstract
Diets rich in grains and meat and low in fruits and vegetables (acid-producing diets) associate with incident hypertension, whereas vegetarian diets associate with lower blood pressure (BP). However, the pathways that sense and mediate the effects of acid-producing diets on BP are unknown. Here, we examined the impact of the deletion of an acid sensor GPR4 on BP. GPR4 is a proton-sensing G protein-coupled receptor and an acid sensor in brain, kidney, and blood vessels. We found that GPR4 mRNA was higher in subfornical organ (SFO) than other brain regions. GPR4 protein was abundant in SFO and present in capillaries throughout the brain. Since SFO partakes in BP regulation through the renin-angiotensin system (RAS), we measured BP in GPR4-/- and GPR4+/+ mice and found that GPR4 deletion associated with lower systolic BP: 87 ± 1 mmHg in GPR4-/- (n = 35) vs. 99 ± 2 mmHg (n = 29) in GPR4+/+; P < 0.0001, irrespective of age and sex. Angiotensin II receptors detected by 125I-Sarthran binding were lower in GPR4-/- than GPR4+/+ mice in SFO and in paraventricular nucleus of hypothalamus. Circulating angiotensin peptides were comparable in GPR4-/- and GPR4+/+ mice, as were water intake and excretion, serum and urine osmolality, and fractional excretion of sodium, potassium, or chloride. A mild metabolic acidosis present in GPR4-/- mice did not associate with elevated BP, implying that deficiency of GPR4 may preclude the effect of chronic acidosis on BP. Collectively, these results posit the acid sensor GPR4 as a novel component of central BP control through interactions with the RAS.
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Affiliation(s)
- Xuming Sun
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Ellen Tommasi
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Doris Molina
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Renu Sah
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - K Bridget Brosnihan
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Debra Diz
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Snezana Petrovic
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina; .,Department of Internal Medicine, Section on Gerontology and Geriatric and Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
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211
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Han E, Kim G, Hong N, Lee YH, Kim DW, Shin HJ, Lee BW, Kang ES, Lee IK, Cha BS. Association between dietary acid load and the risk of cardiovascular disease: nationwide surveys (KNHANES 2008-2011). Cardiovasc Diabetol 2016; 15:122. [PMID: 27565571 PMCID: PMC5002186 DOI: 10.1186/s12933-016-0436-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/10/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Acid-base imbalance has been reported to increase incidence of hypertension and diabetes. However, the association between diet-induced acid load and cardiovascular disease (CVD) risk in the general population has not been fully investigated. METHODS This was a population-based, retrospectively registered cross-sectional study using nationally representative samples of 11,601 subjects from the Korea National Health and Nutrition Examination Survey 2008-2011. Individual CVD risk was evaluated using atherosclerotic cardiovascular disease (ASCVD) risk equations according to 2013 ACC/AHA guideline assessment in subjects aged 40-79 without prior CVD. Acid-base status was assessed with both the potential renal acid load (PRAL) and the dietary acid load (DAL) scores derived from nutrient intake. RESULTS Individuals in the highest PRAL tertile had a significant increase in 10 year ASCVD risks (9.6 vs. 8.5 %, P < 0.01) and tended to belong to the high-risk (10 year risk >10 %) group compared to those in the lowest PRAL tertile (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.22-1.35). The association between higher PRAL score and high CVD risk was stronger in the middle-aged group. Furthermore, a multiple logistic regression analysis also demonstrated this association (OR 1.20 95 % CI 1.01-1.43). Subgroup analysis stratified obesity or exercise status; individuals in unhealthy condition with lower PRAL scores had comparable ASCVD risk to people in the higher PRAL group that were in favorable physical condition. In addition, elevated PRAL scores were associated with high ASCVD risk independent of obesity, exercise, and insulin resistance, but not sarcopenia. Similar trends were observed with DAL scores. CONCLUSION Diet-induced acid load was associated with increased risk of CVD, independent of obesity and insulin resistance.
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Affiliation(s)
- Eugene Han
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Gyuri Kim
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-ho Lee
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Woo Kim
- Department of Home Economics, Food and Nutrition, Korea National Open University, Seoul, Korea
| | - Hyun Joon Shin
- Department of Nutrition, Harvard School of Public Health, Boston, MA USA
- Department of Medicine, Baylor University Medical Center and Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX USA
| | - Byung-Wan Lee
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Seok Kang
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - In-Kyu Lee
- Division of Endocrinology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Bong-Soo Cha
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
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212
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Abstract
PURPOSE OF REVIEW Although the overall mortality rate of patients with end-stage renal disease in the United States continues to decline, cardiac complications remain a leading cause of death in this population. The purpose of this review is to identify principles that can be used to optimize the dialysate concentration of electrolytes in order to reduce the incidence of sudden cardiac deaths (SCDs). RECENT FINDINGS The ratio of observed to expected SCD is 1.71 in the 12 h following the onset of a hemodialysis session. A dialysate potassium concentration of less than 2 mEq/l has been associated with an increased risk of SCD as has a dialysate calcium less than 2.5 mEq/l and an elevated serum to dialysate calcium gradient. Midweek predialysis serum bicarbonate concentrations that are less than 22 or more than 27 mEq/l have been associated with increased mortality. An elevated predialysis serum bicarbonate may be a sign of the malnutrition inflammation complex syndrome. Magnesium has not been well studied in hemodialysis patients. SUMMARY Dialysate content plays an important role in the risk of SCD in hemodialysis patients on hemodialysis. There is a need for further studies designed to identify patients at risk and to determine what strategies can be used to lower this risk.
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213
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Xu H, Åkesson A, Orsini N, Håkansson N, Wolk A, Carrero JJ. Modest U-Shaped Association between Dietary Acid Load and Risk of All-Cause and Cardiovascular Mortality in Adults. J Nutr 2016; 146:1580-5. [PMID: 27385761 DOI: 10.3945/jn.116.231019] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/31/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Conflicting evidence associates diet acidity with the incidence of chronic diseases such as hypertension, diabetes, kidney disease, and bone-mineral disorders. It is currently unknown whether dietary acidity is associated with death. OBJECTIVE We investigated the association of dietary acid load with the risk of all-cause and cardiovascular disease (CVD) mortality. METHODS We used data from 2 prospective cohorts, the Swedish Mammography Cohort and the Cohort of Swedish Men, which included 36,740 women and 44,957 men aged 45-84 y at the start of a 15-y follow-up period (1998-2012). Acid load was estimated from food-frequency questionnaires by use of the validated potential renal acid load (PRAL) algorithm. Deaths were ascertained via record linkage. Associations of PRAL with mortality were modeled by use of restricted cubic splines. RESULTS The median PRAL was 0.65 mEq/d (range: -109 to 81.5 mEq/d) in women and 12.3 mEq/d (-111 to 121 mEq/d) in men. During a mean of 13.5 ± 3.3 y of follow-up, there were 8576 and 13,332 deaths, of which 3203 and 5427 were attributed to cardiovascular causes in woman and men, respectively. In both sexes, a nonlinear U-shaped relation was observed, with higher mortality rates for both dietary acid and alkali excess. Compared with neutral PRAL (0 mEq/d), the HRs for all-cause mortality for the 10th and 90th percentiles of PRAL were 1.05 (95% CI: 1.01, 1.10) and 1.03 (95% CI: 0.98, 1.08), respectively, in women. The corresponding results for men were HRs 1.01 (95% CI: 1.00, 1.02) and 1.04 (95% CI: 1.00, 1.08) respectively. This relation was slightly stronger for CVD mortality. CONCLUSIONS Excess diet alkalinity and acidity both showed weak associations with higher mortality in Swedish adults. An acid-base balanced diet was associated with the lowest mortality, but the magnitude of mortality reduction was modest. The Swedish Mammography Cohort was registered at clinicaltrials.gov as NCT01127698 The Cohort of Swedish Men was registered at clinicaltrials.gov as NCT01127711.
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Affiliation(s)
- Hong Xu
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology
| | - Agneta Åkesson
- Division of Nutritional Epidemiology, Institute of Environmental Medicine, and
| | - Nicola Orsini
- Division of Nutritional Epidemiology, Institute of Environmental Medicine, and
| | - Niclas Håkansson
- Division of Nutritional Epidemiology, Institute of Environmental Medicine, and
| | - Alicja Wolk
- Division of Nutritional Epidemiology, Institute of Environmental Medicine, and
| | - Juan Jesús Carrero
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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214
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Moghadam SK, Bahadoran Z, Mirmiran P, Tohidi M, Azizi F. Association between Dietary Acid Load and Insulin Resistance: Tehran Lipid and Glucose Study. Prev Nutr Food Sci 2016; 21:104-9. [PMID: 27390726 PMCID: PMC4935236 DOI: 10.3746/pnf.2016.21.2.104] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/20/2016] [Indexed: 11/28/2022] Open
Abstract
In the current study, we investigated the longitudinal association between dietary acid load and the risk of insulin resistance (IR) in the Tehranian adult population. This longitudinal study was conducted on 925 participants, aged 22~80 years old, in the framework of the third (2006~2008) and fourth (2009~2011) phases of the Tehran Lipid and Glucose Study. At baseline, the dietary intake of subjects was assessed using a validated semi-quantitative food frequency questionnaire, and the potential renal acid load (PRAL) and net endogenous acid production (NEAP) scores were calculated at baseline. Fasting serum insulin and glucose were measured at baseline and again after a 3-year of follow-up; IR was defined according to optimal cut-off values. Multiple logistic regression models were used to estimate the risk of IR according to the PRAL and NEAP quartile categories. Mean age and body mass index of the participants were 40.3 years old of 26.4 kg/m2, respectively. Mean PRAL and NEAP scores were −11.2 and 35.6 mEq/d, respectively. After adjustment for potential confounders, compared to the lowest quartile of PRAL and NEAP, the highest quartile was accompanied with increased risk of IR [odds ratio (OR)=2.81, 95% confidence interval (CI)=1.32~5.97 and OR=2.18, 95% CI=1.03 ~4.61, respectively]. Our findings suggest that higher acidic dietary acid-base load, defined by higher PRAL and NEAP scores, may be a risk factor for the development of IR and related metabolic disorders.
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Affiliation(s)
- Sajjad Khalili Moghadam
- Students' Research Committee, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran; Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
| | - Zahra Bahadoran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
| | - Parvin Mirmiran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorder Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
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215
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Toxqui L, Vaquero MP. An Intervention with Mineral Water Decreases Cardiometabolic Risk Biomarkers. A Crossover, Randomised, Controlled Trial with Two Mineral Waters in Moderately Hypercholesterolaemic Adults. Nutrients 2016; 8:nu8070400. [PMID: 27367723 PMCID: PMC4963876 DOI: 10.3390/nu8070400] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/16/2022] Open
Abstract
Water intake is essential for health maintenance and disease prevention. The effects of an intervention with two mineral waters, sodium-bicarbonated mineral water (BW) or control mineral water low in mineral content (CW), on cardiometabolic risk biomarkers were studied. In a randomised-controlled crossover-trial, sixty-four moderately hypercholesterolaemic adults were randomly assigned to consume 1 L/day of either BW (sodium, 1 g/L; bicarbonate, 2 g/L) or CW with the main meals for eight weeks, separated by an eight-week washout period. Blood lipids, lipid oxidation, glucose, insulin, aldosterone, urine pH, urinary electrolytes, blood pressure, body weight, fluid intake, energy, and nutrients from total diet and beverages were determined. Total cholesterol, LDL cholesterol, and glucose decreased (p < 0.01), oxidised LDL tended to decrease (p = 0.073), and apolipoprotein B increased during the intervention, without water type effect. Energy and carbohydrates from beverages decreased since soft drinks and fruit juice consumptions decreased throughout the trial. BW increased urinary pH (p = 0.006) and reduced calcium/creatinine excretion (p = 0.011). Urinary potassium/creatinine decreased with both waters. Consumption of 1 L/day of mineral water with the main meals reduces cardiometabolic risk biomarkers, likely to be attributed to a replacement of soft drinks by water. In addition, BW does not affect blood pressure and exerts a moderate alkalizing effect in the body.
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Affiliation(s)
- Laura Toxqui
- Institute of Food Science, Technology and Nutrition (ICTAN-CSIC), Madrid 28040, Spain.
| | - M Pilar Vaquero
- Institute of Food Science, Technology and Nutrition (ICTAN-CSIC), Madrid 28040, Spain.
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216
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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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217
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Williams RS, Kozan P, Samocha-Bonet D. The role of dietary acid load and mild metabolic acidosis in insulin resistance in humans. Biochimie 2016; 124:171-177. [DOI: 10.1016/j.biochi.2015.09.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 09/07/2015] [Indexed: 01/23/2023]
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218
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Akter S, Kurotani K, Kashino I, Goto A, Mizoue T, Noda M, Sawada N, Tsugane S. High Dietary Acid Load Score Is Associated with Increased Risk of Type 2 Diabetes in Japanese Men: The Japan Public Health Center-based Prospective Study. J Nutr 2016; 146:1076-83. [PMID: 27052540 DOI: 10.3945/jn.115.225177] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/01/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Diet-induced metabolic acidosis has been linked to cardiometabolic abnormalities in Westerners, but the evidence on this issue is scarce in Asians. OBJECTIVE The present study prospectively examined the association between dietary acid load and type 2 diabetes (T2D) in Japanese adults. METHODS Study participants were 27,809 men and 36,851 women, aged 45-75 y, who completed a dietary questionnaire of the second survey of the Japan Public Health Center-based Prospective Study and had no previous history of T2D. Dietary intake was assessed by using a validated 147-item food-frequency questionnaire. Potential renal acid load (PRAL) and net endogenous acid production (NEAP) scores were derived from the nutrient intake. A multilevel logistic regression model was used to estimate ORs and 95% CIs of self-reported, physician-diagnosed T2D over 5 y, with adjustment for potential confounding variables. RESULTS A total of 1191 cases of newly diagnosed T2D were reported. PRAL score was positively associated with T2D in men; the multivariable-adjusted ORs (95% CIs) for the lowest through the highest quartiles of PRAL were 1.00, 1.09 (0.87, 1.36), 1.10 (0.88, 1.37), and 1.25 (1.01, 1.55) (P-trend = 0.047). Further adjustment for dietary intake strengthened the association. NEAP score was not associated with the risk of T2D (P-trend = 0.20). In stratified analyses, the positive association between PRAL and T2D was confined to younger men (age <50 y; P-trend = 0.046). There was no association between dietary acid load score and T2D in women. CONCLUSION A high dietary acid load score is associated with an increased risk of T2D in Japanese men.
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Affiliation(s)
- Shamima Akter
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan;
| | - Kayo Kurotani
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ikuko Kashino
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Atsushi Goto
- Department of Public Health, Tokyo Women's University, Tokyo, Japan; Department of Diabetes Research, National Center for Global Health and Medicine, Tokyo, Japan; and
| | - Tetsuya Mizoue
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsushiko Noda
- Department of Public Health, Tokyo Women's University, Tokyo, Japan
| | - Norie Sawada
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan
| | - Shoichiro Tsugane
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan
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219
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Gore E, Mardon J, Guerinon D, Lebecque A. Exploratory study of acid-forming potential of commercial cheeses: impact of cheese type. Int J Food Sci Nutr 2016; 67:412-21. [DOI: 10.3109/09637486.2016.1166188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Ecaterina Gore
- VetAgro Sup – Campus agronomique de Clermont, CALITYSS, Europe Avenue, BP-35, Lempdes, France
| | - Julie Mardon
- VetAgro Sup – Campus agronomique de Clermont, CALITYSS, Europe Avenue, BP-35, Lempdes, France
| | - Delphine Guerinon
- VetAgro Sup – Campus agronomique de Clermont, CALITYSS, Europe Avenue, BP-35, Lempdes, France
| | - Annick Lebecque
- VetAgro Sup – Campus agronomique de Clermont, CALITYSS, Europe Avenue, BP-35, Lempdes, France
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220
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High dietary acid load is associated with insulin resistance: The Furukawa Nutrition and Health Study. Clin Nutr 2016; 35:453-459. [DOI: 10.1016/j.clnu.2015.03.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 02/27/2015] [Accepted: 03/22/2015] [Indexed: 11/19/2022]
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221
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Granic A, Jagger C, Davies K, Adamson A, Kirkwood T, Hill TR, Siervo M, Mathers JC, Sayer AA. Effect of Dietary Patterns on Muscle Strength and Physical Performance in the Very Old: Findings from the Newcastle 85+ Study. PLoS One 2016; 11:e0149699. [PMID: 26934360 PMCID: PMC4774908 DOI: 10.1371/journal.pone.0149699] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/02/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Healthy diet has been associated with better muscle strength and physical performance in cross-sectional studies of older adults but the effect of dietary patterns (DP) on subsequent decline, particularly in the very old (aged 85+), has not been determined. OBJECTIVE We investigated the association between previously established DP and decline in muscle strength and physical performance in the very old. DESIGN 791 participants (61.8% women) from the Newcastle 85+ Study were followed-up for change in hand grip strength (HGS) and Timed Up-and Go (TUG) test over 5 years (four waves 1.5 years apart). Mixed models were used to determine the effects of DP on muscle strength and physical performance in the entire cohort and separately by sex. RESULTS Previously we have established three DP that varied in intake of red meats, potato, gravy and butter and differed with key health and social factors. HGS declined linearly by 1.59 kgF in men and 1.08 kgF in women (both p<0.001), and TUG slowed by 0.13 log10-transformed seconds (log10-s) in men and 0.11 log10-s in women per wave after adjusting for important covariates (both p<0.001), and also showed a nonlinear change (p<0.001). Men in DP1 ('High Red Meat') had worse overall HGS (β = -1.70, p = 0.05), but men in DP3 ('High Butter') had a steeper decline (β = -0.63, p = 0.05) than men in DP2 ('Low Meat'). Men in DP1 and women in DP3 also had overall slower TUG than those in DP2 (β = 0.08, p = 0.001 and β = 0.06, p = 0.01, respectively), but similar rate of decline after adjusting for sociodemographic, lifestyle, health, and functioning factors. The results for HGS and TUG were not affected by participants' cognitive status. CONCLUSIONS DP high in red meats, potato and gravy (DP1), or butter (DP3) may adversely affect muscle strength and physical performance in later life, independently of important covariates and cognitive status.
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Affiliation(s)
- Antoneta Granic
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- NIHR Newcastle Biomedical Research Centre in Ageing and Chronic Disease, and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, United Kingdom
- Ageing, Geriatrics & Epidemiology, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail:
| | - Carol Jagger
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Karen Davies
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- NIHR Newcastle Biomedical Research Centre in Ageing and Chronic Disease, and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, United Kingdom
- Ageing, Geriatrics & Epidemiology, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ashley Adamson
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas Kirkwood
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tom R. Hill
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
- School of Agriculture, Food and Rural Development, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Siervo
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John C. Mathers
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Avan Aihie Sayer
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- NIHR Newcastle Biomedical Research Centre in Ageing and Chronic Disease, and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, United Kingdom
- Ageing, Geriatrics & Epidemiology, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- NIHR Collaboration for Leadership in Applied Health Research and Care: Wessex, University of Southampton, Southampton, United Kingdom
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222
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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: 119] [Impact Index Per Article: 14.9] [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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Chen X, Wei G, Jalili T, Metos J, Giri A, Cho ME, Boucher R, Greene T, Beddhu S. The Associations of Plant Protein Intake With All-Cause Mortality in CKD. Am J Kidney Dis 2015; 67:423-30. [PMID: 26687923 DOI: 10.1053/j.ajkd.2015.10.018] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 10/10/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Plant protein intake is associated with lower production of uremic toxins and lower serum phosphorus levels. Therefore, at a given total protein intake, a higher proportion of dietary protein from plant sources might be associated with lower mortality in chronic kidney disease. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS 14,866 NHANES III participants 20 years or older without missing data for plant and animal protein intake and mortality. PREDICTORS Plant protein to total protein ratio and total plant protein intake. Patients were stratified by estimated glomerular filtration rate (eGFR)<60 or ≥60mL/min/1.73m(2). OUTCOMES All-cause mortality. MEASUREMENTS Plant and total protein intakes were estimated from 24-hour dietary recalls. Mortality was ascertained by probabilistic linkage with National Death Index records through December 31, 2000. RESULTS Mean values for plant protein intake and plant protein to total protein ratio were 24.6±13.2 (SD) g/d and 33.0% ± 14.0%, respectively. The prevalence of eGFRs<60mL/min/1.73m(2) was 4.9%. There were 2,163 deaths over an average follow-up of 8.4 years. Adjusted for demographics, smoking, alcohol use, comorbid conditions, body mass index, calorie and total protein intake, and physical inactivity, each 33% increase in plant protein to total protein ratio was not associated with mortality (HR, 0.88; 95% CI, 0.74-1.04) in the eGFR≥60mL/min/1.73m(2) subpopulation, but was associated with lower mortality risk (HR, 0.77; 95% CI, 0.61-0.96) in the eGFR<60mL/min/1.73m(2) subpopulation. In sensitivity analyses, results were similar in those with eGFR<60mL/min/1.73m(2) defined by serum cystatin C level. LIMITATIONS Whether results are related to plant protein itself or to other factors associated with more plant-based diets is difficult to establish. CONCLUSIONS A diet with a higher proportion of protein from plant sources is associated with lower mortality in those with eGFR<60mL/min/1.73m(2). Future studies are warranted to determine the causal role of plant protein intake in reducing mortality in those with eGFR<60mL/min/1.73m(2).
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Affiliation(s)
- Xiaorui Chen
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; Division of Nutrition, University of Utah, Salt Lake City, UT
| | - Guo Wei
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT
| | - Thunder Jalili
- Division of Nutrition, University of Utah, Salt Lake City, UT
| | - Julie Metos
- Division of Nutrition, University of Utah, Salt Lake City, UT
| | - Ajay Giri
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT
| | - Monique E Cho
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; VA Healthcare System, Salt Lake City, UT
| | - Robert Boucher
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT
| | - Tom Greene
- VA Healthcare System, Salt Lake City, UT
| | - Srinivasan Beddhu
- Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; VA Healthcare System, Salt Lake City, UT.
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225
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Garcia AH, Franco OH, Voortman T, de Jonge EAL, Gordillo NG, Jaddoe VWV, Rivadeneira F, van den Hooven EH. Dietary acid load in early life and bone health in childhood: the Generation R Study. Am J Clin Nutr 2015; 102:1595-603. [PMID: 26537942 DOI: 10.3945/ajcn.115.112821] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/05/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dietary contribution to acid-base balance in early life may influence subsequent bone mineralization. Previous studies reported inconsistent results regarding the associations between dietary acid load and bone mass. OBJECTIVE We examined the associations of dietary acid load in early life with bone health in childhood. DESIGN In a prospective, multiethnic, population-based cohort study of 2850 children, we estimated dietary acid load as dietary potential renal acid load (dPRAL), based on dietary intakes of calcium, magnesium, phosphorus, potassium, and protein, and as a protein intake to potassium intake ratio (Pro:K) at 1 y of age and in a subgroup at 2 y of age : Bone mineral density, bone mineral content (BMC), area-adjusted BMC, and bone area were assessed by dual-energy X-ray absorptiometry at the median age of 6 y. Data were analyzed by using multivariable linear regression models. RESULTS After adjusting for relevant maternal and child factors, dietary acid load estimated as either dPRAL or Pro:K ratio was not consistently associated with childhood bone health. Associations did not differ by sex, ethnicity, weight status, or vitamin D supplementation. Only in those children with high protein intake in our population (i.e., >42 g/d), a 1-unit increase in dPRAL (mEq/d) was inversely associated with BMC (difference: -0.32 g; 95% CI: -0.64, -0.01 g). CONCLUSIONS Dietary acid load in early life was not consistently associated with bone health in childhood. Further research is needed to explore the extent to which dietary acid load in later childhood may affect current and future bone health.
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Affiliation(s)
- Audry H Garcia
- Department of Epidemiology, The Generation R Study Group
| | | | - Trudy Voortman
- Department of Epidemiology, The Generation R Study Group
| | - Ester A L de Jonge
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Vincent W V Jaddoe
- Department of Epidemiology, The Generation R Study Group, Department of Pediatrics, and
| | - Fernando Rivadeneira
- Department of Epidemiology, The Generation R Study Group, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Kuo CC, Yeh HC, Chen B, Tsai CW, Lin YS, Huang CC. Prevalence of Metformin Use and the Associated Risk of Metabolic Acidosis in US Diabetic Adults With CKD: A National Cross-Sectional Study. Medicine (Baltimore) 2015; 94:e2175. [PMID: 26705203 PMCID: PMC4697969 DOI: 10.1097/md.0000000000002175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/10/2015] [Accepted: 11/04/2015] [Indexed: 01/18/2023] Open
Abstract
The use of metformin in chronic kidney disease (CKD) population has been intensely debated with conflicting evidence. Large population studies are needed to inform risk assessment and therapeutic decision-making. We evaluated the associations among metformin, metabolic acidosis, and CKD in a 10-year nationally representative noninstitutionalized civilian population in the United States.In this cross-sectional study, a total of 2279 diabetic adults aged 20 years or older in the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2012 were included and had measurements of serum bicarbonate, sodium, potassium, and chloride. The exposure was metformin use. The outcome was subclinical and severe metabolic acidosis defined by serum bicarbonate <23 mEq/L and anion gap > 16mEq/L and by serum bicarbonate < 20 mEq/L, respectively.The prevalence of metformin use decreased from 67.2% among CKD-1 and -2, 40.6% among CKD-3, to 1.3% among advanced CKD-4 and -5. Across CKD stages up to CKD-3b, we observed a tendency of lower levels of serum bicarbonate that was significant in metformin users with CKD-2 and CKD-3a and marginally significant with CKD-3b compared to nonmetformin users. The corresponding tendency of higher anion gap in metformin users with the estimated glomerular filtration rate >60 mL/min/1.73 m was also observed. In multiple linear regression analysis, metformin was significantly associated with decreased serum bicarbonate levels (β = -0.45, 95% CI: -0.73, -0.17) and increased serum anion gap levels (β = 0.40, 95% CI: 0.19, 0.61). The adjusted odds ratio of subclinical high anion gap and severe metabolic acidosis for metformin users was 1.68 (95% CI: 1.11, 2.55) and 1.31 (0.49, 3.47), respectively. The association between metformin and serum bicarbonate was significantly modified by CKD status. No interaction was found between metformin and CKD stages for serum anion gap and acidosis.Metformin is associated with subclinical metabolic acidosis but not with severe metabolic acidosis. The propensity of serum bicarbonate-lowering effect was intensified in advanced CKD; however, such tendency was not associated with the risk of clinically defined acidosis. Our findings highlight a potential of cautious expansion of metformin use among CKD-3b patients with diabetes meriting further investigations.
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Affiliation(s)
- Chin-Chi Kuo
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health (C-CK); Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health (C-CK); Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD (C-CK); Department of Internal Medicine, Kidney Institute and Division of Nephrology, China Medical University Hospital and College of Medicine, China Medical University, Taichung (C-CK, H-CY, C-WT, C-CH); Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (BC); and Department of Environmental and Occupational Health, University of North Texas Health Science Center, Fort Worth, TX (Y-SL)
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Chen TK, Choi MJ, Kao WHL, Astor BC, Scialla JJ, Appel LJ, Li L, Lipkowitz MS, Wolf M, Parekh RS, Winkler CA, Estrella MM, Crews DC. Examination of Potential Modifiers of the Association of APOL1 Alleles with CKD Progression. Clin J Am Soc Nephrol 2015; 10:2128-35. [PMID: 26430087 DOI: 10.2215/cjn.05220515] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/12/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Common apolipoprotein L1 (APOL1) variants are associated with increased risk of progressive CKD; however, not all individuals with high-risk APOL1 variants experience CKD progression. Identification of factors contributing to heterogeneity has important scientific and clinical implications. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using multivariable Cox models, we analyzed data from 693 participants in the African American Study of Kidney Disease and Hypertension to identify factors that modify the association between APOL1 genotypes and CKD progression (doubling of serum creatinine or incident ESRD). RESULTS Participant mean age was 54 years old, median GFR was 49 ml/min per 1.73 m(2), and 23% had the APOL1 high-risk genotype (two copies of the high-risk allele). Over a mean follow-up of 7.8 years, 288 (42%) participants experienced CKD progression. As previously reported, the high-risk genotype was associated with higher risk of CKD progression compared with the low-risk genotype (hazard ratio [HR], 1.88; 95% confidence interval [95% CI], 1.46 to 2.41). Although we found some suggestion that obesity (HR, 1.48; 95% CI, 1.05 to 2.08 and HR, 2.44; 95% CI, 1.66 to 3.57 for body mass index ≥ 30 versus <30 kg/m(2); P interaction =0.04) and increased urinary excretion of urea nitrogen (HR, 1.43; 95% CI, 0.98 to 2.09 versus HR, 2.33; 95% CI, 1.65 to 3.30 for urine urea nitrogen ≥ 8 versus <8 g/d; P interaction =0.04) were associated with lower APOL1-associated risk for CKD progression, these findings were not robust in sensitivity analyses with alternative cut points. No other sociodemographic (e.g., education and income), clinical (e.g., systolic BP and smoking), or laboratory (e.g., net endogenous acid production, urinary sodium and potassium excretions, 25-hydroxy vitamin D, intact parathyroid hormone, or fibroblast growth factor 23) variables modified the association between APOL1 and CKD progression (P interaction >0.05 for each). CONCLUSIONS Sociodemographic factors and common risk factors for CKD progression do not seem to alter APOL1-related CKD progression. Additional investigation is needed to identify nontraditional factors that may affect the association between APOL1 and progressive CKD.
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Affiliation(s)
- Teresa K Chen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Michael J Choi
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - W H Linda Kao
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Brad C Astor
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Julia J Scialla
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Lawrence J Appel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Liang Li
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michael S Lipkowitz
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Myles Wolf
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Rulan S Parekh
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Cheryl A Winkler
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michelle M Estrella
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Deidra C Crews
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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228
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Bahadoran Z, Mirmiran P, Khosravi H, Azizi F. Associations between Dietary Acid-Base Load and Cardiometabolic Risk Factors in Adults: The Tehran Lipid and Glucose Study. Endocrinol Metab (Seoul) 2015; 30:201-7. [PMID: 25433661 PMCID: PMC4508265 DOI: 10.3803/enm.2015.30.2.201] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/09/2014] [Accepted: 08/19/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In this study we investigated the associations of dietary acid-base load, identified by potential renal acid load (PRAL) and protein to potassium (Pro:K) ratio, with cardiometabolic risk factors in Tehranian adults. METHODS A cross-sectional study was conducted within the framework of the fourth phase of the Tehran Lipid and Glucose Study (2009 to 2011) on 5,620 men and women aged 19 to 70 years. Dietary data were collected by a trained dietitian using a validated, 147-food item, semi-quantitative food frequency questionnaire, and dietary PRAL and Pro:K ratio were calculated. Multiple linear regression models with adjustment for potential confounding variables were used to evaluate the associations of dietary acid-base load with anthropometric measures, blood pressure, serum triglycerides, high density lipoprotein cholesterol (HDL-C), serum creatinine, and fasting blood glucose. RESULTS The mean±SD age of the participants was 39.8±12.8 years and 54% of participants were women. Mean±SD PRAL was -22.0±29.1; mean PRAL was -15.6 in men and -26.8 in women. Dietary PRAL was associated with weight (β=0.098, P<0.001), waist circumference (β=0.062, P<0.01), serum triglycerides (β=0.143, P<0.01), HDL-C (β=-0.11, P<0.01), diastolic blood pressure (β=0.062, P<0.01), and serum creatinine (β=0.142, P<0.001). Pro:K ratio was associated with weight (β=0.055, P<0.001), waist circumference (β=0.04, P<0.01), serum HDL-C (β=-0.06, P<0.01), serum triglycerides (β=0.03, P<0.05), diastolic blood pressure (β=0.026, P<0.05), and serum creatinine (β=0.07, P<0.01). CONCLUSION A more acidic dietary acid-base load may be a risk factor for the development of metabolic disorders.
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Affiliation(s)
- Zahra Bahadoran
- Nutrition and Endocrine Research Center and Obesity Research Center, Research Institute for Endocrine Sciences, Tehran, Iran
| | - Parvin Mirmiran
- Department of Nutrition and Clinical Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Tehran, Iran.
| | - Hadise Khosravi
- Nutrition and Endocrine Research Center and Obesity Research Center, Research Institute for Endocrine Sciences, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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229
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Byberg L, Bellavia A, Orsini N, Wolk A, Michaëlsson K. Fruit and vegetable intake and risk of hip fracture: a cohort study of Swedish men and women. J Bone Miner Res 2015; 30:976-84. [PMID: 25294687 DOI: 10.1002/jbmr.2384] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/25/2014] [Accepted: 10/03/2014] [Indexed: 01/11/2023]
Abstract
Dietary guidelines recommend a daily intake of 5 servings of fruits and vegetables. Whether such intakes are associated with a lower risk of hip fracture is at present unclear. The aim of the present study was to investigate the dose-response association between habitual fruit and vegetable intake and hip fracture in a cohort study based on 40,644 men from the Cohort of Swedish Men (COSM) and 34,947 women from the Swedish Mammography Cohort (SMC) (total n = 75,591), free from cardiovascular disease and cancer, who answered lifestyle questionnaires in 1997 (age 45 to 83 years). Intake of fruits and vegetables (servings/day) was assessed by food frequency questionnaire and incident hip fractures were retrieved from the Swedish Patient Register (1998 to 2010). The mean follow-up time was 14.2 years. One-third of the participants reported an intake of fruits and vegetables of >5 servings/day, one-third reported >3 to ≤5 servings/day, 28% reported >1 to ≤3 servings/day, and 6% reported ≤1 serving/day. During 1,037,645 person-years we observed 3644 hip fractures (2266 or 62% in women). The dose-response association was found to be strongly nonlinear (p < 0.001). Men and women with zero consumption had 88% higher rate of hip fracture compared with those consuming 5 servings/day; adjusted hazard ratio (HR) was 1.88 (95% CI, 1.53 to 2.32). The rate was gradually lower with higher intakes; adjusted HR for 1 versus 5 servings/day was 1.35 (95% CI, 1.21 to 1.58). However, more than 5 servings/day did not confer additionally lower HRs (adjusted HR for 8 versus 5 servings/day was 0.96; 95% CI, 0.90 to 1.03). Similar results were observed when men and women were analyzed separately. We conclude that there is a dose-response association between fruit and vegetable intake and hip fracture such that an intake below the recommended five servings/day confers higher rates of hip fracture. Intakes above this recommendation do not seem to further lower the risk.
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Affiliation(s)
- Liisa Byberg
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
| | - Andrea Bellavia
- Institute of Environmental Medicine, Unit of Nutritional Epidemiology, Karolinska Institutet, Solna, Sweden
| | - Nicola Orsini
- Institute of Environmental Medicine, Unit of Nutritional Epidemiology, Karolinska Institutet, Solna, Sweden
| | - Alicja Wolk
- Institute of Environmental Medicine, Unit of Nutritional Epidemiology, Karolinska Institutet, Solna, Sweden
| | - Karl Michaëlsson
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
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230
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Lee HW, Osis G, Handlogten ME, Guo H, Verlander JW, Weiner ID. Effect of dietary protein restriction on renal ammonia metabolism. Am J Physiol Renal Physiol 2015; 308:F1463-73. [PMID: 25925252 DOI: 10.1152/ajprenal.00077.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/20/2015] [Indexed: 11/22/2022] Open
Abstract
Dietary protein restriction has multiple benefits in kidney disease. Because protein intake is a major determinant of endogenous acid production, it is important that net acid excretion change in parallel during protein restriction. Ammonia is the primary component of net acid excretion, and inappropriate ammonia excretion can lead to negative nitrogen balance. Accordingly, we examined ammonia excretion in response to protein restriction and then we determined the molecular mechanism of the changes observed. Wild-type C57Bl/6 mice fed a 20% protein diet and then changed to 6% protein developed an 85% reduction in ammonia excretion within 2 days, which persisted during a 10-day study. The expression of multiple proteins involved in renal ammonia metabolism was altered, including the ammonia-generating enzymes phosphate-dependent glutaminase (PDG) and phosphoenolpyruvate carboxykinase (PEPCK) and the ammonia-metabolizing enzyme glutamine synthetase. Rhbg, an ammonia transporter, increased in expression in the inner stripe of outer medullary collecting duct intercalated cell (OMCDis-IC). However, collecting duct-specific Rhbg deletion did not alter the response to protein restriction. Rhcg deletion did not alter ammonia excretion in response to dietary protein restriction. These results indicate 1) dietary protein restriction decreases renal ammonia excretion through coordinated regulation of multiple components of ammonia metabolism; 2) increased Rhbg expression in the OMCDis-IC may indicate a biological role in addition to ammonia transport; and 3) Rhcg expression is not necessary to decrease ammonia excretion during dietary protein restriction.
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Affiliation(s)
- Hyun-Wook Lee
- Division of Nephrology, Hypertension and Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Gunars Osis
- Division of Nephrology, Hypertension and Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Mary E Handlogten
- Division of Nephrology, Hypertension and Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Hui Guo
- Division of Nephrology, Second Hospital of Shanxi Medical University, Yaiyuan, Shanxi, Peoples Republic of China; and
| | - Jill W Verlander
- Division of Nephrology, Hypertension and Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - I David Weiner
- Division of Nephrology, Hypertension and Transplantation, University of Florida College of Medicine, Gainesville, Florida, Nephrology and Hypertension Section, Medical Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida
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231
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Chan R, Wong VWS, Chu WCW, Wong GLH, Li LS, Leung J, Chim AML, Yeung DKW, Sea MMM, Woo J, Chan FKL, Chan HLY. Higher estimated net endogenous Acid production may be associated with increased prevalence of nonalcoholic Fatty liver disease in chinese adults in Hong Kong. PLoS One 2015; 10:e0122406. [PMID: 25905490 PMCID: PMC4407987 DOI: 10.1371/journal.pone.0122406] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/20/2015] [Indexed: 12/28/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) has been associated with reduced growth hormone levels and signaling. Such hormonal changes also occur in metabolic acidosis. Since mild metabolic acidosis can be diet induced, diet-induced acid load may constitute a nutritional factor with possible influence on NAFLD development. This study explored whether a higher diet-induced acid load is associated with an increased likelihood of NAFLD. Apparently healthy Chinese adults (330 male, 463 female) aged 19-72 years were recruited through population screening between 2008 and 2010 in a cross-sectional population-based study in Hong Kong. Estimated net endogenous acid production (NEAP) was calculated using Frassetto’s method and potential renal acid load (PRAL) was calculated using Remer’s method based on dietary data from a food frequency questionnaire. NAFLD was defined as intrahepatic triglyceride content at >5% by proton-magnetic resonance spectroscopy. Possible advanced fibrosis was defined as liver stiffness at >7.9 kPa by transient elastography. Multivariate logistic regression models were used to examine the association between each measure of dietary acid load and prevalent NAFLD or possible advanced fibrosis with adjustment for potential anthropometric and lifestyle factors. 220 subjects (27.7%) were diagnosed with NAFLD. Estimated NEAP was positively associated with the likelihood of having NAFLD after adjustment for age, sex, body mass index, current drinker status and the presence of metabolic syndrome [OR (95% CI) = 1.25 (1.02-1.52), p = 0.022]. The association was slightly attenuated but remained significant when the model was further adjusted for other dietary variables. No association between PRAL and NAFLD prevalence was observed. Both estimated NEAP and PRAL were not associated with the presence of possible advance fibrosis. Our findings suggest that there may be a modest association between diet-induced acid load and NAFLD. More studies are needed to ascertain the link between diet-induced acid load and NAFLD and to investigate the underlying mechanisms.
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Affiliation(s)
- Ruth Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Nutritional Studies, The Chinese University of Hong Kong, Hong Kong, China
- * E-mail:
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Winnie Chiu-Wing Chu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Liz Sin Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jason Leung
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong, China
| | - Angel Mei-Ling Chim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - David Ka-Wai Yeung
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, China
| | - Mandy Man-Mei Sea
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Nutritional Studies, The Chinese University of Hong Kong, Hong Kong, China
| | - Jean Woo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Centre for Nutritional Studies, The Chinese University of Hong Kong, Hong Kong, China
| | - Francis Ka-Leung Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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232
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Performance Enhancing Diets and the PRISE Protocol to Optimize Athletic Performance. J Nutr Metab 2015; 2015:715859. [PMID: 25949823 PMCID: PMC4408745 DOI: 10.1155/2015/715859] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 03/03/2015] [Indexed: 12/14/2022] Open
Abstract
The training regimens of modern-day athletes have evolved from the sole emphasis on a single fitness component (e.g., endurance athlete or resistance/strength athlete) to an integrative, multimode approach encompassing all four of the major fitness components: resistance (R), interval sprints (I), stretching (S), and endurance (E) training. Athletes rarely, if ever, focus their training on only one mode of exercise but instead routinely engage in a multimode training program. In addition, timed-daily protein (P) intake has become a hallmark for all athletes. Recent studies, including from our laboratory, have validated the effectiveness of this multimode paradigm (RISE) and protein-feeding regimen, which we have collectively termed PRISE. Unfortunately, sports nutrition recommendations and guidelines have lagged behind the PRISE integrative nutrition and training model and therefore limit an athletes' ability to succeed. Thus, it is the purpose of this review to provide a clearly defined roadmap linking specific performance enhancing diets (PEDs) with each PRISE component to facilitate optimal nourishment and ultimately optimal athletic performance.
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233
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Tabatabai LS, Cummings SR, Tylavsky FA, Bauer DC, Cauley JA, Kritchevsky SB, Newman A, Simonsick EM, Harris TB, Sebastian A, Sellmeyer DE. Arterialized venous bicarbonate is associated with lower bone mineral density and an increased rate of bone loss in older men and women. J Clin Endocrinol Metab 2015; 100:1343-9. [PMID: 25642590 PMCID: PMC4399281 DOI: 10.1210/jc.2014-4166] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Higher dietary net acid loads have been associated with increased bone resorption, reduced bone mineral density (BMD), and increased fracture risk. OBJECTIVE The objective was to compare bicarbonate (HCO3) measured in arterialized venous blood samples to skeletal outcomes. DESIGN Arterialized venous samples collected from participants in the Health, Aging and Body Composition (Health ABC) Study were compared to BMD and rate of bone loss. SETTING The setting was a community-based observational cohort. PARTICIPANTS A total of 2287 men and women age 74 ± 3 years participated. INTERVENTION Arterialized venous blood was obtained at the year 3 study visit and analyzed for pH and pCO2. HCO3 was determined using the Henderson-Hasselbalch equation. MAIN OUTCOME MEASURE BMD was measured at the hip by dual-energy x-ray absorptiometry at the year 1 (baseline) and year 3 study visits. RESULTS Plasma HCO3 was positively associated with BMD at both year 1 (P = .001) and year 3 (P = .001) in models adjusted for age, race, sex, clinic site, smoking, weight, and estimated glomerular filtration rate. Plasma HCO3 was inversely associated with rate of bone loss at the total hip over the 2.1 ± 0.3 (mean ± SD) years between the two bone density measurements (P < .001). Across quartiles of plasma HCO3, the rate of change in BMD over the 2.1 years ranged from a loss of 0.72%/y in the lowest quartile to a gain of 0.15%/y in the highest quartile of HCO3. CONCLUSIONS Arterialized plasma HCO3 was associated positively with cross-sectional BMD and inversely with the rate of bone loss, implying that systemic acid-base status is an important determinant of skeletal health during aging. Ongoing bone loss was linearly related to arterialized HCO3, even after adjustment for age and renal function. Further research in this area may have major public health implications because reducing dietary net acid load is possible through dietary intervention or through supplementation with alkaline potassium compounds.
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Affiliation(s)
- L S Tabatabai
- Division of Endocrinology (L.S.T., D.E.S.), Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, Maryland 21224; California Pacific Medical Center Research Institute (S.R.C.), San Francisco, California 94118; Department of Preventive Medicine (F.A.T.), University of Tennessee Health Science Center, Memphis, Tennessee 38163; Department of Medicine (D.C.B., A.S.), School of Medicine, University of California, San Francisco, San Francisco, California 94143; Department of Epidemiology (J.A.C., A.N.), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15260; Department of Internal Medicine (S.B.K.), Wake Forest School of Medicine, Winston-Salem, North Carolina 27157; Translational Gerontology Branch (E.M.S.), National Institute on Aging, Baltimore, Maryland 21224; and Laboratory of Epidemiology and Population Science (T.B.H.), National Institute on Aging, Bethesda, Maryland 20892
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Greater Fruit Intake was Associated With Better Bone Mineral Status Among Chinese Elderly Men and Women: Results of Hong Kong Mr. Os and Ms. Os Studies. J Am Med Dir Assoc 2015; 16:309-15. [DOI: 10.1016/j.jamda.2014.11.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/03/2014] [Indexed: 01/26/2023]
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235
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Huston HK, Abramowitz MK, Zhang Y, Greene T, Raphael KL. Net endogenous acid production and mortality in NHANES III. Nephrology (Carlton) 2015; 20:209-15. [DOI: 10.1111/nep.12365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2014] [Indexed: 01/10/2023]
Affiliation(s)
- Hunter K Huston
- Department of Internal Medicine; University of Utah; Salt Lake City Utah
| | - Matthew K Abramowitz
- Division of Nephrology; Department of Medicine; Albert Einstein College of Medicine; Bronx New York USA
- Department of Epidemiology and Population Health; Albert Einstein College of Medicine; Bronx New York USA
| | - Yingying Zhang
- Department of Internal Medicine; University of Utah; Salt Lake City Utah
| | - Tom Greene
- Department of Internal Medicine; University of Utah; Salt Lake City Utah
| | - Kalani L Raphael
- Department of Internal Medicine; University of Utah; Salt Lake City Utah
- Salt Lake City Veterans Affairs Health Care System; Salt Lake City Utah
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236
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Banerjee T, Crews DC, Wesson DE, Tilea AM, Saran R, Ríos-Burrows N, Williams DE, Powe NR. High Dietary Acid Load Predicts ESRD among Adults with CKD. J Am Soc Nephrol 2015; 26:1693-700. [PMID: 25677388 DOI: 10.1681/asn.2014040332] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 09/12/2014] [Indexed: 12/29/2022] Open
Abstract
Small clinical trials have shown that a reduction in dietary acid load (DAL) improves kidney injury and slows kidney function decline; however, the relationship between DAL and risk of ESRD in a population-based cohort with CKD remains unexamined. We examined the association between DAL, quantified by net acid excretion (NAEes), and progression to ESRD in a nationally representative sample of adults in the United States. Among 1486 adults with CKD age≥20 years enrolled in the National Health and Nutrition Examination Survey III, DAL was determined by 24-h dietary recall questionnaire. The development of ESRD was ascertained over a median 14.2 years of follow-up through linkage with the Medicare ESRD Registry. We used the Fine-Gray competing risks method to estimate the association of high, medium, and low DAL with ESRD after adjusting for demographics, nutritional factors, clinical factors, and kidney function/damage markers and accounting for intervening mortality events. In total, 311 (20.9%) participants developed ESRD. Higher levels of DAL were associated with increased risk of ESRD; relative hazards (95% confidence interval) were 3.04 (1.58 to 5.86) for the highest tertile and 1.81 (0.89 to 3.68) for the middle tertile compared with the lowest tertile in the fully adjusted model. The risk of ESRD associated with DAL tertiles increased as eGFR decreased (P trend=0.001). Among participants with albuminuria, high DAL was strongly associated with ESRD risk (P trend=0.03). In conclusion, high DAL in persons with CKD is independently associated with increased risk of ESRD in a nationally representative population.
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Affiliation(s)
- Tanushree Banerjee
- Division of General Internal Medicine, Department of Medicine, University of California, 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
| | - Donald E Wesson
- Department of Internal Medicine, Texas A&M College of Medicine and Scott and White Healthcare, Temple, Texas
| | | | - Rajiv Saran
- Kidney Epidemiology and Cost Center and Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Nilka Ríos-Burrows
- Division of Diabetes Translation, Centers of Disease and Control and Prevention, Atlanta, Georgia; and
| | - Desmond E Williams
- Division of Diabetes Translation, Centers of Disease and Control and Prevention, Atlanta, Georgia; and
| | - Neil R Powe
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California; Department of Medicine, San Francisco General Hospital, San Francisco, California
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Jia T, Byberg L, Lindholm B, Larsson TE, Lind L, Michaëlsson K, Carrero JJ. Dietary acid load, kidney function, osteoporosis, and risk of fractures in elderly men and women. Osteoporos Int 2015; 26:563-70. [PMID: 25224295 DOI: 10.1007/s00198-014-2888-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
SUMMARY Because kidney dysfunction reduces the ability to excrete dietary acid excess, we hypothesized that underlying kidney function may have confounded the mixed studies linking dietary acid load with the risk of osteoporosis and fractures in the community. In a relatively large survey of elderly men and women, we report that dietary acid load did neither associate with DEXA-estimated bone mineral density nor with fracture risk. Underlying kidney function did not modify these null findings. Our results do not support the dietary acid-base hypothesis of bone loss. INTRODUCTION Impaired renal function reduces the ability to excrete dietary acid excess. We here investigate the association between dietary acid load and bone mineral density (BMD), osteoporosis, and fracture risk by renal function status. METHODS An observational study was conducted in 861 community-dwelling 70-year-old men and women (49% men) with complete dietary data from the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS). The exposure was dietary acid load as estimated from 7-day food records by the net endogenous acid production (NEAP) and potential renal acid load (PRAL) algorithms. Renal function assessed by cystatin C estimated glomerular filtration rate was reduced in 21% of the individuals. Study outcomes were BMD and osteoporosis state (assessed by DEXA) and time to fracture (median follow-up of 9.2 years). RESULTS In cross-section, dietary acid load had no significant associations with BMD or with the diagnosis of osteoporosis. During follow-up, 131 fractures were validated. Neither NEAP (adjusted hazard ratios (HR) (95% confidence interval (CI)), 1.01 (0.85-1.21), per 1 SD increment) nor PRAL (adjusted HR (95% CI), 1.07 (0.88-1.30), per 1 SD increment) associated with fracture risk. Further multivariate adjustment for kidney function or stratification by the presence of kidney disease did not modify these null associations. CONCLUSIONS The hypothesis that dietary acid load associates with reduced BMD or increased fracture risk was not supported by this study in community-dwelling elderly individuals. Renal function did not influence on this null finding.
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Affiliation(s)
- T Jia
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Luis D, Huang X, Riserus U, Sjögren P, Lindholm B, Arnlöv J, Cederholm T, Carrero JJ. Estimated dietary acid load is not associated with blood pressure or hypertension incidence in men who are approximately 70 years old. J Nutr 2015; 145:315-21. [PMID: 25644353 DOI: 10.3945/jn.114.197020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Dietary acid load affects acid-base homeostasis, which may be associated with blood pressure (BP). Previous research on dietary acid load and BP in the community has provided conflicting results, which may be confounded by underlying kidney function with inability to eliminate acid excess. OBJECTIVE The objective of this study was to determine whether dietary acid load is associated with blood pressure or the incidence of hypertension in older men taking into account each individual's kidney function. METHODS We included 673 men aged 70-71 y and not receiving antihypertensive medication from the Uppsala Longitudinal Study of Adult Men. Of those, 378 men were re-examined after 7 y. Dietary acid load was estimated at baseline by potential renal acid load (PRAL) and net endogenous acid production (NEAP), based on nutrient intake assessed by 7-d food records at baseline. Ambulatory blood pressure monitoring (ABPM) was performed at both visits. Cystatin C-estimated kidney function allowed identification of underlying chronic kidney disease. RESULTS Median estimated PRAL and NEAP were 3.3 and 40.7 mEq/d, respectively. In cross-section, PRAL was in general not associated with ABPM measurements (all P > 0.05, except for the 24-h diastolic BP). During follow-up, PRAL did not predict ABPM changes (all P > 0.05). When individuals with baseline hypertension (ABPM ≥ 130/80 mm Hg) or nondippers (with nighttime-to-daytime systolic BP ratio > 0.9) were excluded, PRAL was not a predictor of incident cases (P > 0.30). Kidney function did not modify these null relations. Similar findings were obtained with the use of NEAP as the exposure. CONCLUSION Our analyses linking estimated dietary acid load with BP outcome measurements both cross-sectionally and after 7 y in community-based older Swedish men of similar age did not reveal an association between dietary acid load and BP.
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Affiliation(s)
- Desiree Luis
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, and
| | - Xiaoyan Huang
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, and Division of Nephrology, Peking University Shenzhen Hospital, Peking University, Shenzhen, China
| | | | | | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, and
| | - Johan Arnlöv
- Geriatrics Section, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; and School of Health and Social Studies, Dalarna University, Falun, Sweden
| | | | - Juan Jesús Carrero
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention, and Technology, and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden;
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Chen W, Melamed ML, Abramowitz MK. Serum bicarbonate and bone mineral density in US adults. Am J Kidney Dis 2015; 65:240-8. [PMID: 25168294 PMCID: PMC4305466 DOI: 10.1053/j.ajkd.2014.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/02/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic metabolic acidosis leads to bone mineral loss and results in lower bone mineral density (BMD), which is a risk factor for osteoporosis-related fractures. The effect of low-level metabolic acidosis on bone density in the general population is unknown. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS 9,724 nationally representative adults 20 years or older in NHANES (National Health and Nutrition Examination Survey) 1999-2004. FACTOR Serum bicarbonate level. OUTCOMES Lumbar and total BMD, as well as low lumbar and total bone mass, defined as 1.0 SD below the sex-specific mean value of young adults. MEASUREMENTS BMD was measured by dual-energy x-ray absorptiometry and serum bicarbonate was measured in all participants. RESULTS Both men and women with lower serum bicarbonate levels were more likely to be current smokers and had higher body mass index and estimated net endogenous acid production. There was a significant linear trend across quartiles of serum bicarbonate with lumbar BMD in the total population, as well as in sex-specific models (P=0.02 for all 3 models, P=0.1 for interaction). For total BMD, a significant association was seen with serum bicarbonate level for women but not men (P=0.02 and P=0.1, respectively; P=0.8 for interaction), and a significant association was seen for postmenopausal women but not premenopausal women (P=0.02 and P=0.2, respectively; P=0.5 for interaction). Compared with women with serum bicarbonate levels <24mEq/L, those with serum bicarbonate levels ≥27mEq/L had 0.018-g/cm(2) higher total BMD (95% CI, 0.004-0.032; P=0.01) and 31% lower odds of having low total bone mass (OR, 0.68; 95% CI, 0.46-0.99; P=0.049). LIMITATIONS Cross-sectional study using a single measurement of serum bicarbonate. Subgroup differences are not definitive. CONCLUSIONS Lower serum bicarbonate levels are associated with lower BMD in US adults. Further studies should examine whether serum bicarbonate levels should be incorporated into the diagnostic assessment and management of osteoporosis.
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Affiliation(s)
- Wei Chen
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Michal L Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
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Bone resorption levels are related to diet in UK dwelling South Asian but not Caucasian women. Proc Nutr Soc 2015. [DOI: 10.1017/s0029665115000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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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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242
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Hietavala EM, Stout JR, Hulmi JJ, Suominen H, Pitkänen H, Puurtinen R, Selänne H, Kainulainen H, Mero AA. Effect of diet composition on acid-base balance in adolescents, young adults and elderly at rest and during exercise. Eur J Clin Nutr 2014; 69:399-404. [PMID: 25491498 DOI: 10.1038/ejcn.2014.245] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/15/2014] [Accepted: 09/07/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Diets rich in animal protein and cereal grains and deficient in vegetables and fruits may cause low-grade metabolic acidosis, which may impact exercise and health. We hypothesized that (1) a normal-protein diet with high amount of vegetables and fruits (HV) induces more alkaline acid-base balance compared with a high-protein diet with no vegetables and fruits (HP) and (2) diet composition has a greater impact on acid-base balance in the elderly (ELD). SUBJECTS/METHODS In all, 12-15 (adolescents (ADO)), 25-35 (young adults (YAD)) and 60-75 (ELD)-year-old male and female subjects (n=88) followed a 7-day HV and a 7-day HP in a randomized order and at the end performed incremental cycle ergometer tests. We investigated the effect of diet composition and age on capillary (c-pH) and urine pH (u-pH), strong ion difference (SID), partial pressure of carbon dioxide (pCO2) and total concentration of weak acids (Atot). Linear regression analysis was used to examine the contribution of SID, pCO2 and Atot to c-pH. RESULTS In YAD and ELD, c-pH (P⩽0.038) and u-pH (P<0.001) were higher at rest after HV compared with HP. During cycling, c-pH was higher (P⩽0.034) after HV compared with HP at submaximal workloads in YAD and at 75% of VO2max (maximal oxygen consumption) in ELD. The contribution of SID, pCO2 and Atot to c-pH varied widely. Gender effects or changes in acid-base balance of ADO were not detected. CONCLUSIONS A high intake of vegetables and fruits increases blood and u-pH in YAD and ELD. ELD compared with younger persons may be more sensitive for the diet-induced acid-base changes.
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Affiliation(s)
- E-M Hietavala
- Department of Biology of Physical Activity, University of Jyväskylä, Jyväskylä, Finland
| | - J R Stout
- Institute of Exercise Physiology and Wellness, University of Central Florida, Orlando, FL, USA
| | - J J Hulmi
- Department of Biology of Physical Activity, University of Jyväskylä, Jyväskylä, Finland
| | - H Suominen
- Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | | | - R Puurtinen
- Department of Biology of Physical Activity, University of Jyväskylä, Jyväskylä, Finland
| | - H Selänne
- LIKES Research Center for Sport and Health Sciences, Jyväskylä, Finland
| | - H Kainulainen
- Department of Biology of Physical Activity, University of Jyväskylä, Jyväskylä, Finland
| | - A A Mero
- Department of Biology of Physical Activity, University of Jyväskylä, Jyväskylä, Finland
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Chan R, Leung J, Woo J. Association Between Estimated Net Endogenous Acid Production and Subsequent Decline in Muscle Mass Over Four Years in Ambulatory Older Chinese People in Hong Kong: A Prospective Cohort Study. ACTA ACUST UNITED AC 2014; 70:905-11. [DOI: 10.1093/gerona/glu215] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 10/23/2014] [Indexed: 01/03/2023]
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244
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Yenchek R, Ix JH, Rifkin DE, Shlipak MG, Sarnak MJ, Garcia M, Patel KV, Satterfield S, Harris TB, Newman AB, Fried LF. Association of serum bicarbonate with incident functional limitation in older adults. Clin J Am Soc Nephrol 2014; 9:2111-6. [PMID: 25381341 DOI: 10.2215/cjn.05480614] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cross-sectional studies have found that low serum bicarbonate is associated with slower gait speed. Whether bicarbonate levels independently predict the development of functional limitation has not been previously studied. Whether bicarbonate was associated with incident persistent lower extremity functional limitation and whether the relationship differed in individuals with and without CKD were assessed in participants in the Health, Aging, and Body Composition study, a prospective study of well functioning older individuals DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Functional limitation was defined as difficulty in walking 0.25 miles or up 10 stairs on two consecutive reports 6 months apart in the same activity (stairs or walking). Kidney function was measured using eGFR by the Chronic Kidney Disease Epidemiology Collaboration creatinine equation, and CKD was defined as an eGFR<60 ml/min per 1.73 m(2). Serum bicarbonate was measured using arterialized venous blood gas. Cox proportional hazards analysis was used to assess the association of bicarbonate (<23, 23-25.9, and ≥26 mEq/L) with functional limitation. Mixed model linear regression was performed to assess the association of serum bicarbonate on change in gait speed over time. RESULTS Of 1544 participants, 412 participants developed incident persistent functional limitation events over a median 4.4 years (interquartile range, 3.1 to 4.5). Compared with ≥26 mEq/L, lower serum bicarbonate was associated with functional limitation. After adjustment for demographics, CKD, diabetes, body mass index, smoking, diuretic use, and gait speed, lower serum bicarbonate was significantly associated with functional limitation (hazard ratio, 1.35; 95% confidence interval, 1.08 to 1.68 and hazard ratio, 1.58; 95% confidence interval, 1.12 to 2.22 for bicarbonate levels from 23 to 25.9 and <23, respectively). There was not a significant interaction of bicarbonate with CKD. In addition, bicarbonate was not significantly associated with change in gait speed. CONCLUSIONS Lower serum bicarbonate was associated with greater risk of incident, persistent functional limitation. This association was present in individuals with and without CKD.
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Affiliation(s)
- Robert Yenchek
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Joachim H Ix
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Dena E Rifkin
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Michael G Shlipak
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Mark J Sarnak
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Melissa Garcia
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kushang V Patel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Suzanne Satterfield
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Tamara B Harris
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Anne B Newman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Linda F Fried
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
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245
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Jain N, Reilly RF. Effects of dietary interventions on incidence and progression of CKD. Nat Rev Nephrol 2014; 10:712-24. [PMID: 25331786 DOI: 10.1038/nrneph.2014.192] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Traditional strategies for management of patients with chronic kidney disease (CKD) have not resulted in any change in the growing prevalence of CKD worldwide. A historic belief that eating healthily might ameliorate kidney disease still holds credibility in the 21(st) century. Dietary sodium restriction to <2.3 g daily, a diet rich in fruits and vegetables and increased water consumption corresponding to a urine output of 3-4 l daily might slow the progression of early CKD, polycystic kidney disease or recurrent kidney stones. Current evidence suggests that a reduction in dietary net acid load could be beneficial in patients with CKD, but the supremacy of any particular diet has yet to be established. More trials of dietary interventions are needed, especially in diabetic nephropathy, before evidence-based recommendations can be made. In the meantime, nephrologists should discuss healthy dietary habits with their patients and provide individualized care aimed at maximizing the potential benefits of dietary intervention, reducing the incidence of CKD and delaying its progression to end-stage renal disease. Keeping in mind the lack of data on hard outcomes, dietary recommendations should take into account barriers to adherence and be tailored to different cultures, ethnicities and geographical locations.
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Affiliation(s)
- Nishank Jain
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8856, USA
| | - Robert F Reilly
- Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Nephrology Section, MC 111G1, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA
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Guerra A, Folesani G, Mena P, Ticinesi A, Allegri F, Nouvenne A, Pinelli S, Del Rio D, Borghi L, Meschi T. Hippuric acid in 24 h urine collections as a biomarker of fruits and vegetables intake in kidney stone formers. Int J Food Sci Nutr 2014; 65:1033-8. [DOI: 10.3109/09637486.2014.950210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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GCN2 and FGF21 are likely mediators of the protection from cancer, autoimmunity, obesity, and diabetes afforded by vegan diets. Med Hypotheses 2014; 83:365-71. [DOI: 10.1016/j.mehy.2014.06.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/14/2014] [Indexed: 12/20/2022]
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Banerjee T, Crews DC, Wesson DE, Tilea A, Saran R, Rios Burrows N, Williams DE, Powe NR. Dietary acid load and chronic kidney disease among adults in the United States. BMC Nephrol 2014; 15:137. [PMID: 25151260 PMCID: PMC4151375 DOI: 10.1186/1471-2369-15-137] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 08/03/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Diet can markedly affect acid-base status and it significantly influences chronic kidney disease (CKD) and its progression. The relationship of dietary acid load (DAL) and CKD has not been assessed on a population level. We examined the association of estimated net acid excretion (NAE(es)) with CKD; and socio-demographic and clinical correlates of NAE(es). METHODS Among 12,293 U.S. adult participants aged >20 years in the National Health and Nutrition Examination Survey 1999-2004, we assessed dietary acid by estimating NAE(es) from nutrient intake and body surface area; kidney damage by albuminuria; and kidney dysfunction by eGFR < 60 ml/min/1.73 m(2) using the MDRD equation. We tested the association of NAE(es) with participant characteristics using median regression; while for albuminuria, eGFR, and stages of CKD we used logistic regression. RESULTS Median regression results (β per quintile) indicated that adults aged 40-60 years (β [95% CI] = 3.1 [0.3-5.8]), poverty (β [95% CI] = 7.1 [4.01-10.22]), black race (β [95% CI] = 13.8 [10.8-16.8]), and male sex (β [95% CI] = 3.0 [0.7- 5.2]) were significantly associated with an increasing level of NAE(es). Higher levels of NAE(es) compared with lower levels were associated with greater odds of albuminuria (OR [95% CI] = 1.57 [1.20-2.05]). We observed a trend toward greater NAE(es) being associated with higher risk of low eGFR, which persisted after adjustment for confounders. CONCLUSION Higher NAE(es) is associated with albuminuria and low eGFR, and socio-demographic risk factors for CKD are associated with higher levels of NAE(es). DAL may be an important target for future interventions in populations at high risk for CKD.
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Affiliation(s)
- Tanushree Banerjee
- Department of Medicine, University of California, San Francisco, CA, USA.
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Xu H, Jia T, Huang X, Risérus U, Cederholm T, Arnlöv J, Sjögren P, Lindholm B, Carrero JJ. Dietary acid load, insulin sensitivity and risk of type 2 diabetes in community-dwelling older men. Diabetologia 2014; 57:1561-8. [PMID: 24875749 DOI: 10.1007/s00125-014-3275-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
AIMS/HYPOTHESIS We tested the hypothesis that dietary acid load may increase the risk of type 2 diabetes, and studied the association between acid load and insulin sensitivity as a possible mechanism involved. METHODS An observational survey with prospective follow-up including 911 non-diabetic Swedish men aged 70-71 years was carried out. The gold standard euglycaemic-hyperinsulinaemic clamp technique and the OGTT were used to determine insulin sensitivity and beta cell function, respectively. Diabetes incidence was assessed during 18 years of follow-up. Renal function was estimated from serum cystatin C concentrations. Dietary acid load was calculated as potential renal acid load (PRAL) and net endogenous acid production (NEAP) algorithms from 7 day food records. Adequate dietary reporters were identified by Goldberg cut-offs. RESULTS PRAL and NEAP were not associated with insulin sensitivity or beta cell function. Underlying kidney function or consideration of dietary adequate reporters did not modify these null findings. During follow-up, 115 new cases of diabetes were validated. Neither PRAL nor NEAP was associated with diabetes incidence. CONCLUSIONS/INTERPRETATION Our results do not support the hypothesis that dietary acid load influences insulin sensitivity, beta cell function or diabetes risk. Interventional studies modifying acid-base dietary intake are needed to further elucidate a possible role of acid load in the development of type 2 diabetes.
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Affiliation(s)
- Hong Xu
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital K56, Karolinska Institutet, 14186, Stockholm, Sweden
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Akter S, Eguchi M, Kurotani K, Kochi T, Pham NM, Ito R, Kuwahara K, Tsuruoka H, Mizoue T, Kabe I, Nanri A. High dietary acid load is associated with increased prevalence of hypertension: the Furukawa Nutrition and Health Study. Nutrition 2014; 31:298-303. [PMID: 25592007 DOI: 10.1016/j.nut.2014.07.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/11/2014] [Accepted: 07/20/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Acid-base status has been suggested to influence blood pressure, but there is a paucity of epidemiologic evidence linking dietary acid load to hypertension. We examined cross-sectionally the association between dietary acid load and hypertension in a Japanese working population. METHODS Data were derived from health surveys from 2028 employees, ages 18 to 70 y, in two workplaces in Japan. A validated brief diet history questionnaire was used to assess diet. Two measures were used to characterize dietary acid load: potential renal acid load and estimated net endogenous acid production, which were derived from nutrient intakes. Multilevel logistic regression was used to examine the association between dietary acid load and hypertension with adjustment of potential confounding variables. RESULTS High dietary acid load was suggestively associated with increased prevalence of hypertension. The multivariable adjusted odds ratios (95% confidence interval) of hypertension for the lowest through highest tertiles of net endogenous acid production were 1.00 (reference), 1.07 (0.80-1.42), and 1.33 (0.998-1.78), respectively (P for trend = 0.053). This positive association was statistically significant among normal-weight (body mass index <23 kg/m(2); P for trend = 0.03) and non-shift workers (P for trend = 0.04). Similar positive associations were observed between potential renal acid load and hypertension. CONCLUSIONS The present findings suggest that high dietary acid load may be associated with increased prevalence of hypertension among those who were normal weight and non-shift workers.
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Affiliation(s)
- Shamima Akter
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Masafumi Eguchi
- Department of Health Administration, Furukawa Electric Corporation, Tokyo, Japan
| | - Kayo Kurotani
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takeshi Kochi
- Department of Health Administration, Furukawa Electric Corporation, Tokyo, Japan
| | - Ngoc Minh Pham
- Department of Epidemiology, Faculty of Public Health, Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen Province, Vietnam
| | - Rie Ito
- Department of Health Administration, Furukawa Electric Corporation, Tokyo, Japan
| | - Keisuke Kuwahara
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroko Tsuruoka
- Department of Health Administration, Furukawa Electric Corporation, Tokyo, Japan
| | - Tetsuya Mizoue
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Isamu Kabe
- Department of Health Administration, Furukawa Electric Corporation, Tokyo, Japan
| | - Akiko Nanri
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
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