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Qin Y, Huang J, Ping X, Zheng H, Zhang K, Xu X, Yu J. No benefit of higher protein dosing in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. PeerJ 2024; 12:e17433. [PMID: 38799065 PMCID: PMC11122048 DOI: 10.7717/peerj.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose The optimal range of protein dosage and effect of high-dose protein on critically ill patients remain controversial. We conducted a meta-analysis to compare higher and lower doses of protein supplementation for nutritional support in critically ill patients. Methods We searched the PubMed, Embase, Scopus, and Cochrane Library databases for randomized controlled trials that compared higher (≥1.2 g/kg per day) versus lower (<1.2 g/kg per day) doses of protein supplementation among critically ill adult patients. This search spanned from the inception of relevant databases to November 20, 2023. Our primary endpoint of interest was overall mortality, while secondary endpoints included length of stay in the intensive care unit, length of hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury. Results Seventeen studies including 2,965 critically ill patients were included in our meta-analysis. The pooled analyses showed no significant difference in overall mortality (RR 1.03, 95%CI [0.92-1.15], P = 0.65, I2 = 0%), length of intensive care unit stay (MD 0.19, 95%CI [-0.67 to 1.04], P = 0.66, I2 = 25%), length of hospital stay (MD 0.73, 95%CI [-1.59 to 3.04], P = 0.54, I2 = 27%), duration of mechanical ventilation (MD -0.14, 95%CI [-0.83 to 0.54], P = 0.68, I2 = 8%), and incidence of acute kidney injury (RR 1.11, 95%CI [0.87-1.41], P = 0.38, I2 = 0%) between critically ill patients receiving higher or lower doses of protein supplementation. Conclusions For critically ill patients, the protein supplementation dose had no significant effect on clinical outcomes, including overall mortality, length of intensive care unit and hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury.
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Affiliation(s)
- Yonggen Qin
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Jiuqing Yu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Cai L, Huang Y, Li X, Cao D, Liu F. Effects of dietary intervention on diabetic nephropathy: an umbrella review of systematic reviews and meta-analyses of randomized controlled trials. Front Endocrinol (Lausanne) 2024; 15:1385872. [PMID: 38742202 PMCID: PMC11089238 DOI: 10.3389/fendo.2024.1385872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
Objective To evaluate the quality of evidence, potential biases, and validity of all available studies on dietary intervention and diabetic nephropathy (DN). Methods We conducted an umbrella review of existing meta-analyses of randomized controlled trials (RCTs) that focused on the effects of dietary intervention on DN incidence. The literature was searched via PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews. According to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE), evidence of each outcome was evaluated and graded as "high", "moderate", "low" or "very low" quality to draw conclusions. Additionally, we classified evidence of outcomes into 4 categories. Results We identified 36 meta-analyses of RCTs and 55 clinical outcomes of DN from 395 unique articles. Moderate-quality evidence suggested that probiotic supplementation could significantly improve blood urea nitrogen (BUN), total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels in DN patients. Low-quality evidence indicated that probiotic supplementation significantly improved the serum creatinine concentration, urinary albumin-creatinine ratio (UACR), fasting blood glucose (FBG), HbA1c and high-density lipoprotein cholesterol (HDL-C) in DN patients. In addition, low-quality evidence suggested that a salt restriction diet could significantly improve the creatinine clearance rate (CrCl) in patients with DN. Low-quality evidence suggested that vitamin D supplementation could significantly improve the UACR in patients with DN. In addition, low-quality evidence has indicated that soy isoflavone supplementation could significantly improve BUN, FBG, total cholesterol (TC), triglyceride (TG) and LDL-C levels in patients with DN. Furthermore, low-quality evidence suggested that coenzyme Q10 supplementation could significantly improve HbA1c, TC and HDL-C in patients with DN, and dietary polyphenols also significantly improved HbA1c in patients with DN. Finally, low-quality evidence suggested that supplementation with antioxidant vitamins could significantly improve the serum creatinine concentration, systolic blood pressure, and HbA1c level in patients with DN. Given the small sample size, all significantly associated outcomes were evaluated as class IV evidence. Conclusion Moderate to low amounts of evidence suggest that supplementation with probiotics, vitamin D, soy isoflavones, coenzyme Q10, dietary polyphenols, antioxidant vitamins, or salt-restricted diets may significantly improve clinical outcomes in patients with DN. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024512670.
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Affiliation(s)
- Linli Cai
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yin Huang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Xingyuan Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Dehong Cao
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
- Department of Urology, Karamay People’s Hospital of Xinjiang Uygur Autonomous Region, Karamay, China
| | - Fang Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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Vettoretti S, Molinari P, Armelloni S, Castellano G, Caldiroli L. Spontaneous low-protein intake in older CKD patients: one diet may not fit all. Front Nutr 2024; 11:1328939. [PMID: 38419850 PMCID: PMC10899392 DOI: 10.3389/fnut.2024.1328939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
BackgroundProtein restriction has been extended to stage 3 chronic kidney disease (CKD) regardless of age in the latest K-DOQI guidelines for the dietary management of patients with CKD. However, in elderly CKD patients there is a tendency to a spontaneous reduction in protein and energy intake that may impair the overall nutritional status. The aim of our study is to assess whether there are differences in malnutrition, exercise capacity and inflammatory status in elderly CKD patients with spontaneously low protein intake (sLPI) compared with patients with normal protein intake (NPI).MethodsWe performed a cross-sectional analysis of 123 incident patients. Malnutrition was assessed using Malnutrition Inflammation Score (MIS) and serum markers; As for physical performance, we used Short Physical Performance Battery (SPPB) and handgrip strength.ResultsWe found that in older patients with advanced CKD, as many as 68% had low spontaneous protein intake, and they were more malnourished evaluated with MIS (25% vs. 10%, p = 0.033), protein-energy wasting (PEW) (43% vs. 14%, p = 0.002) and nPCR (0.63[0.51–0.69] vs. 0.95[0.87–1.1], p < 0.0001). They also had worse body composition, in terms of lower mid-arm muscular circumference (MAMC), fat tissue index (FTI) and higher overhydration (OH). sLPI patients also had higher levels of IL6 (4.6[2.9–8.9] vs. 2.8[0.8–5.1], p = 0.002). Moreover, sLPI patients were frailer (33% vs. 24%, p = 0.037) and had poorer physical performance especially when assessed with (SPPB) (7[5–9] vs. 9[7–10], p = 0.004) and gait test time (6.08 + 2 vs. 7.22 + 2.7, p = 0.04). sLPI was associated with lower physical performance [SPPB OR, 0.79 (0.46–0.97), p = 0.046] and malnutrition [MIS 1.6 (1.05–3.5), p = 0.041] independently from patients’ age and eGFR.ConclusionWe found that in older patients with advanced CKD, up to 68% had low spontaneous protein intake and were frailer, more malnourished and with lower physical performance. These findings emphasize the importance of assessing patients’ needs, and personalized approaches with individual risk–benefit assessments should be sought. To achieve the best possible outcomes, targeted interventions should use all available tools.
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Affiliation(s)
- Simone Vettoretti
- Unit of Nephrology, Dialysis and Renal Transplantation - Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Paolo Molinari
- Unit of Nephrology, Dialysis and Renal Transplantation - Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Silvia Armelloni
- Unit of Nephrology, Dialysis and Renal Transplantation - Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Giuseppe Castellano
- Unit of Nephrology, Dialysis and Renal Transplantation - Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Lara Caldiroli
- Unit of Nephrology, Dialysis and Renal Transplantation - Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
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Nawawi FA, Wan Md Adnan WAH, Ismail M, Jalaludin MY, Majid HA. Changes in Kidney Function Among Malaysian Adolescents and Its Determinants. Kidney Int Rep 2023; 8:1965-1977. [PMID: 37850001 PMCID: PMC10577368 DOI: 10.1016/j.ekir.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/18/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction The health and wellbeing of adolescents are often neglected, including the knowledge of chronic kidney disease (CKD), especially in its early stages. Methods A total of 607 adolescents were recruited from the Malaysian Health and Adolescents Longitudinal Research Team (MyHeART) study, a prospective cohort study conducted from March 2012 to May 2016 that explored the noncommunicable diseases (NCDs) risk factors among 13 to 17 years old students in 3 states of Peninsular Malaysia. Students who participated in all 3 data collection periods in 2012, 2014, and 2016 with kidney function assessment across all 3-time points were included in the current study. The students' estimated glomerular filtration rate (eGFR) was calculated from isotope-dilution mass spectrometry-traceable Schwartz's equation and categorized based on Kidney Disease: Improving Global Outcomes (KDIGO) classification. Changes in kidney function were examined, and the longitudinal relationship between eGFR and multiple NCD risk factors was analyzed using the generalized estimating equation (GEE). Results The prevalence of decreased eGFR (60-89 ml/min per 1.73 m2) among the students increased from 6.1% (2012) to 30.0% (2014) and 40.2% (2016). Based on the GEE, the student's eGFR decreased over time, with a steeper decline during early to midadolescence. Males and rural students had lower eGFR compared to their counterparts. Students who are morbidly obese had lower eGFR than those with normal body mass index (BMI). Protein consumption also has a potential moderating effect on eGFR in adolescents. Conclusion Kidney function changes can be detected as early as adolescence and are likely attributable to multiple NCD risk factors. Therefore, more comprehensive prevention efforts from various stakeholders are needed to identify health issues like CKD.
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Affiliation(s)
- Fathhullah Azmie Nawawi
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Centre for Population Health, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Maslinor Ismail
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Hazreen Abdul Majid
- Centre for Population Health, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- School of Health and Rehabilitation Sciences, AECC University College, Parkwood Campus, Bournemouth, UK
- Department of Nutrition, Faculty of Public Health, Universitas of Airlangga, Surabaya, Indonesia
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Bettiga A, Fiorio F, Liguori F, Marco FD, Quattrini G, Vago R, Giannese D, Salonia A, Montorsi F, Trevisani F. The Impact of a Mediterranean-like Diet with Controlled Protein Intake on the Onco-Nephrological Scenario: Time for a New Perspective. Nutrients 2022; 14:nu14235193. [PMID: 36501223 PMCID: PMC9740301 DOI: 10.3390/nu14235193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) represents a frequent comorbidity in cancer patients, especially for patients affected by urological cancers. Unfortunately, impaired kidney function may limit the choice of adequate oncological treatments for their potential nephrotoxicity or due to contraindications in case of a low glomerular filtration rate. For these patients, tailored nephrological and nutritional management is mandatory. The K-DIGO guidelines do not define whether the nutritional management of CKD could be useful also in CKD patients affected by urological cancer. In fact, in clinical practice, oncological patients often receive high-protein diets to avoid malnutrition. In our study, we investigated the nutritional and nephrological impact of a Mediterranean-like diet with a controlled protein intake (MCPD) on a cohort of 82 stage III-IV CKD patients. We compared two cohorts: one of 31 non-oncological CKD patients and the other of 51 oncological patients with CKD. The use of an MCPD had a favorable impact on both the oncological and non-oncological CKD patients with an amelioration in all the investigated parameters and with a better quality of life, with no cases of malnutrition or AKI.
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Affiliation(s)
- Arianna Bettiga
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Francesco Fiorio
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Francesca Liguori
- IRCCS San Raffaele Hospital, Direzione Sanitaria, 20132 Milano, Italy
| | - Federico Di Marco
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Giulia Quattrini
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Riccardo Vago
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy
| | - Andrea Salonia
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Francesco Montorsi
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Francesco Trevisani
- Division of Experimental Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
- Correspondence: ; Tel.: +39-3497052906
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Utility of muscle ultrasound in nutritional assessment of children with nephrotic syndrome. Pediatr Nephrol 2022; 38:1821-1829. [PMID: 36357636 PMCID: PMC10154282 DOI: 10.1007/s00467-022-05776-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/09/2022] [Accepted: 09/25/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Nutritional status assessment in children with nephrotic syndrome (NS) is critical for identifying patients who are at risk of protein-energy wasting (PEW) and for determining their nutritional needs and monitoring nutritional intervention outcomes. METHODS In a case-control study, we enrolled 40 children (age range: 2-16 years) with NS and 40 apparently healthy children (age and sex-matched) as a control group. Anthropometric data, as well as demographic, clinical, and laboratory data, were collected. A dietary intake assessment using a 3-day food intake record was done, and the quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) were assessed using B-mode ultrasound and compared between both groups. RESULTS Children with NS had lower QRFT and QVIT measurements than control groups (p < 0.001). Inadequacy in protein intake occurred in 62.5% and 27.5% of the NS and control groups, respectively (p = 0.002). The thickness of the rectus and vastus muscles by ultrasound was significantly associated with the percentage of protein intake (p < 0.001). The ROC curve revealed that the best cutoff value of QRFT for the prediction of the patient at risk of malnutrition was ≤ 1.195 with an area under curve of 0.907, with p < 0.001. CONCLUSION In children with NS, skeletal muscle ultrasound is a simple and easy-to-use bedside technique for the identification of patients at risk of malnutrition. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Caldiroli L, Molinari P, Abinti M, Rusconi C, Castellano G, Vettoretti S. Can Mediterranean Diet Have a Positive Impact on Kidney Health? A Pending Answer to a Long-Time Question. Nutrients 2022; 14:nu14204366. [PMID: 36297050 PMCID: PMC9608621 DOI: 10.3390/nu14204366] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Dietary studies conducted in chronic kidney disease (CKD) patients were focused on the quantities of single nutrients, however it is possible that the excessive attention put on the restriction of proteins, sodium, potassium and phosphorus may compromise the overall quality of the diet in terms of micronutrients and palatability. Instead, concentrating on the nutritional quality healthy dietary patterns, may provide a better approach to improve nutritional prescriptions in CKD patients. All these dietary regimens share common features as reduced content of red meat, salt and saturated fatty acids, and higher fiber content, but may differ in terms of single nutrients consumption. In particular, Mediterranean Diet (Med Diet) has been associated with reduced incidence of diabetes, cardiovascular diseases and obesity, all conditions that are also strictly related to CKD. Given its low content of animal proteins and high contents of fiber it is possible that Med Diet may exert also positive effects on CKD as well as on its metabolic complications. In this review we summarize the role of Med Diet in primary prevention of CKD and on its progression.
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Affiliation(s)
- Lara Caldiroli
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Paolo Molinari
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Matteo Abinti
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Chiara Rusconi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Giuseppe Castellano
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Simone Vettoretti
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-02-55-03-45-52; Fax: +39-02-55-03-45-50
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Sohouli MH, Mirmiran P, Seraj SS, Kutbi E, Alkahmous HAM, Almuqayyid F, Arafah OA, Barakeh ARR, Abu-Zaid A. Impact of low-protein diet on cardiovascular risk factors and kidney function in diabetic nephropathy: A systematic review and meta-analysis of randomized-controlled trials. Diabetes Res Clin Pract 2022; 191:110068. [PMID: 36084854 DOI: 10.1016/j.diabres.2022.110068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/09/2022] [Accepted: 08/31/2022] [Indexed: 12/13/2022]
Abstract
AIM To assess the efficacy of low-protein diets (LPD) on cardiovascular risk factors and kidney function in diabetic nephropathy (DN) based on randomized controlled trials (RCTs). METHODS A comprehensive systematic search was undertaken in PubMed/MEDLINE, Web of Science, SCOPUS and Embase databases from inception until January 2022 without using time or language restrictions. RCTs which reported the effects of LPD on cardiovascular risk factors and kidney function in DN were considered. RESULTS The results of the present study showed that a LPD significantly reduces urinary urea (WMD: -244.49 g/day, 95 % CI: -418.83, -70.16, P = 0.006) and HbA1c (WMD: -0.20, 95 % CI: -0.39, -0.01, P = 0.036) levels. However, the results did not show neither significant nor beneficial effect on other renal function and cardiovascular risk factors. Furthermore, the results of subgroup analysis showed LPD caused a further decrease in HbA1c during the follow-up period of ≤ 24 weeks, protein intake less than 0.8 g/kg/d and in individuals younger than 50 years. Albuminuria also showed a greater reduction in people under the age of 50 with type 1 diabetes (DMT1) following a LPD. CONCLUSION The results of the present study showed that LPD significantly reduces urinary urea and HbA1c.
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Affiliation(s)
- Mohammad Hassan Sohouli
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parvin Mirmiran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P.O. Box 19395-4741, Tehran, Iran.
| | - Shaikh Sanjid Seraj
- Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall, West Midlands WS2 9PS, United Kingdom
| | - Emad Kutbi
- Department of Biorepository, Biomedical Research Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | | | | | | | - Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
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Wang Y, Chen Z, Li J, Li Z, Xie J, Wang D, Li S, Zhang Y, Liang T, Yau H, Qi C, Li Q, Lin S, Zhang S, Wang W. Development and validation of a simple equation to evaluate dietary protein intake using the blood urea nitrogen/serum creatinine ratio in patients with stage 3 chronic kidney disease. Int Urol Nephrol 2022; 54:1279-1286. [PMID: 34562197 DOI: 10.1007/s11255-021-02993-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/21/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this research was to develop a simple equation to evaluate dietary protein intake (DPI) in patients with stage 3 chronic kidney disease (CKD) using the blood urea nitrogen (BUN)/serum creatinine (SCr) ratio (BUN/SCr). METHODS In a prospective cohort of 136 inpatients with stage 3 CKD from 2 centres, the estimated dietary protein intake (DPI) was calculated using Maroni's formula after the patients implemented a 7 day protein-restricted diet. We developed estimation equations based on BUN/SCr and the spot urinary urea nitrogen (UUN)/urinary creatinine (UCr) ratio (UUN/UCr) in combination with sex and body mass index (BMI). These equations were then internally and externally validated. RESULTS The following candidate parameters were derived from univariate regression analysis for 5 established models: sex, BMI, BUN/SCr, UUN and UUN/UCr. Sex and BMI were included in all models after variable evaluation using multiple regression analysis. UUN, UUN/UCr and BUN/SCr were included in model 3, model 4 and model 5, respectively. Both internal and external validation indicated that model 5 resulted in the lowest values for bias and root mean square error and the highest P30 compared with model 3 and model 4. Therefore, the model 5 equation, DPI = - 5.18 (- 14.49 if the patient is female) + 1.89 × BMI + 1.38 × BUN/SCr, was selected because of the higher correlation (r = 0.498) between the estimated DPI and predicted DPI. CONCLUSION The DPI equation developed using BUN/SCr, sex and BMI may be used to estimate protein intake for patients with stage 3 CKD. TRIAL REGISTRATION Chinese Clinical Trial Registry Center (ChiCTR-ROC-17011363). Registered on 11 May 2017, Retrospectively registered, http://www.chictr.org.cn/index.aspx .
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Affiliation(s)
- Yanhui Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
- Division of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Zujiao Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Jing Li
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Zhen Li
- Division of Clinical Nutrition, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Jianteng Xie
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Duan Wang
- Division of Clinical Nutrition, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Sheng Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Yifan Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Tiantian Liang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Hokhim Yau
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Chunfang Qi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Qiuling Li
- Shantou University Medical College, Shantou, 515041, China
| | - Shaochun Lin
- Shantou University Medical College, Shantou, 515041, China
| | - Shaogui Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China
| | - Wenjian Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 106 Zhongshan Er Road, Main Building, Room 1436, 510080, GD, China.
- School of Medicine, South China University of Technology, Guangzhou, 510006, China.
- Shantou University Medical College, Shantou, 515041, China.
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10
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Schrauben SJ, Apple BJ, Chang AR. Modifiable Lifestyle Behaviors and CKD Progression: A Narrative Review. KIDNEY360 2022; 3:752-778. [PMID: 35721622 PMCID: PMC9136893 DOI: 10.34067/kid.0003122021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 01/07/2022] [Indexed: 12/19/2022]
Abstract
Living a healthy lifestyle is one of the safest and most cost-effective ways to improve one's quality of life and prevent and/or manage chronic disease. As such, current CKD management guidelines recommend that patients adhere to a healthy diet, perform ≥150 minutes per week of physical activity, manage their body weight, abstain from tobacco use, and limit alcohol. However, there are limited studies that investigate the relationship between these lifestyle factors and the progression of CKD among people with established CKD. In this narrative review, we examine the reported frequencies of health lifestyle behavior engagement among individuals with non-dialysis-dependent CKD and the existing literature that examines the influences of diet, physical activity, weight management, alcohol consumption, and tobacco use on the progression of CKD, as measured by decline in GFR, incident ESKD, or elevated proteinuria or albuminuria in individuals with CKD. Many of the available studies are limited by length of follow-up and small sample sizes, and meta-analyses were limited because the studies were sparse and had heterogeneous classifications of behaviors and/or referent groups and of CKD progression. Further research should be done to determine optimal methods to assess behaviors to better understand the levels at which healthy lifestyle behaviors are needed to slow CKD progression, to investigate the effect of combining multiple lifestyle behaviors on important clinical outcomes in CKD, and to develop effective techniques for behavior change. Despite the lack of evidence of efficacy from large trials on the ability of lifestyle behaviors to slow CKD progression, maintaining a healthy lifestyle remains a cornerstone of CKD management given the undisputed benefits of healthy lifestyle behaviors on cardiovascular health, BP control, and survival.
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Affiliation(s)
- Sarah J. Schrauben
- Renal, Electrolyte-Hypertension Division, Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Alex R. Chang
- Kidney Health Research Institute, Department of Population Health Sciences, Geisinger Health, Danville, Pennsylvania
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11
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Kwon YJ, Lee HS, Park GE, Kim HM, Lee JJ, Kim WJ, Lee JW. The Association Between Total Protein Intake and All-Cause Mortality in Middle Aged and Older Korean Adults With Chronic Kidney Disease. Front Nutr 2022; 9:850109. [PMID: 35445069 PMCID: PMC9014017 DOI: 10.3389/fnut.2022.850109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background and Aims Over the past decades, the optimum protein intake for patients with chronic kidney disease (CKD) has been an important, controversial issue. Dietary protein restriction has been commonly recommended for patients with CKD for preserving kidney function. However, evidence of the associations between long-term protein intake and mortality is not consistent in patients with CKD. Therefore, we aimed to examine the associations between total protein intake and all-cause mortality in Korean adults with CKD. Methods From three sub-cohorts of the Korean Genome and Epidemiology Study (KoGES) starting from 2001, total 3,892 participants with eGFR < 60 mL/min/1.73 m2 (CKD stage 3–5) were included in this study. Dietary data were collected using food-frequency questionnaires at baseline. Deaths were followed from 2001 to 2019. Cox proportional hazards regression model was used to evaluate the association between protein intake and all-cause mortality. Results During a median follow-up (min-max) of 11.1 years (0.3–15.1), 602 deaths due to all causes of mortality were documented. After adjustment for covariates, higher total protein intake was not associated with all-cause mortality [highest vs. lowest quintile of total protein intake (g/kg/day) and proportion (%) (Q5 vs. Q1), HR = 1.14 (0.75–1.72), and HR = 0.87 (0.67–1.13)] in CKD stage 3–5 patients. Conclusion Dietary protein intake was not associated with mortality from all causes in patients with CKD. Further research is needed to establish optimal protein intake levels and examine the impact of the dietary source of protein on various health outcomes and mortality in CKD.
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Affiliation(s)
- Yu-Jin Kwon
- Department of Family Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Go Eun Park
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung-Mi Kim
- Department of Food and Nutrition, Dongduck Women's University, Seoul, South Korea
| | - Jung Joo Lee
- Nutrition Team, Yongin Severance Hospital, Yongin, South Korea
| | - Woo Jeong Kim
- Department of Nutrition Service, Gangnam Severance Hospital, Seoul, South Korea
| | - Ji-Won Lee
- Department of Family Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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12
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Use of low-protein staple foods in the dietary management of patients with stage 3-4 chronic kidney disease: a prospective case-crossover study. BMC Nephrol 2022; 23:114. [PMID: 35313803 PMCID: PMC8939078 DOI: 10.1186/s12882-022-02734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Maintaining a low-protein diet (LPD) is important for patients with chronic kidney disease (CKD) to delay renal degradation and alleviate clinical symptoms. For most patients with CKD, it is difficult to maintain the necessary low level of dietary protein intake (DPI). To improve the current dietary management of CKD, we conducted an intervention study by administering low-protein staple foods (LPSF). DESIGN AND METHODS We conducted a prospective case-crossover study among 25 patients with stage 3-4 CKD. During the initial 12 weeks of the study, we instructed the patients regarding a standard LPD according to the recommendations of a renal dietitian. In the second stage of the study, we requested the patients taking low-protein rice or low-protein flour (250 g/d) as an LPSF diet instead of regular staple food daily, and followed these patients up for 12 weeks. We compared the DPI, dietary energy intake (DEI), normalized protein equivalent of total nitrogen appearance (nPNA), serum creatinine levels, and nutritional index between baseline and the end of the study. RESULTS We found no change in dietary variables among the patients during the first 12 weeks of the LPD. After subjecting them to an LPSF diet, the corresponding variables showed a pronounced change. The patients' DPI decreased from 0.88 ± 0.20 to 0.68 ± 0.14 g/kg/d (P < 0.01) and the nPNA value decreased from 0.99 ± 0.18 to 0.87 ± 0.19 g/kg/d (P < 0.01). The high biological value protein intake proportion increased from 42% (baseline) to 57% (P < 0.01) during the 24 weeks. No variation was found in the measured DEI (28.0 ± 5.8 vs 28.6 ± 5.4 kcal/kg/d), nutrition assessment, or renal function and serum creatinine levels. CONCLUSION Our prospective case-crossover study demonstrated that an LPSF diet can help patients with stage 3-4 CKD reduce DPI and nPNA values, improve the proportion of highly bioavailable proteins, ensure adequate calorie intake, and avoid malnutrition. An LPSF diet is an effective and simple therapy for patients with stage 3-4 CKD.
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13
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Ketoanalogue Supplementation in Patients with Non-Dialysis Diabetic Kidney Disease: A Systematic Review and Meta-Analyses. Nutrients 2022; 14:nu14030441. [PMID: 35276799 PMCID: PMC8838123 DOI: 10.3390/nu14030441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 01/17/2023] Open
Abstract
The effects of supplemental ketoanalogues (KA) in patients with diabetic kidney disease (DKD) are not well characterized. Several databases for peer-reviewed articles were systematically searched to identify studies reporting outcomes associated with the effects of a low-protein diet (LPD) or very-low protein diet (VLPD) in combination with supplemental KA in adults with DKD. Meta-analyses were conducted when feasible. Of 213 identified articles, 11 could be included in the systematic review. Meta-analyses for renal outcomes (4 studies examining glomerular filtration rate; 5 studies examining 24-h urinary protein excretion), metabolic outcomes (5 studies examining serum urea; 7 studies examining blood glucose), clinical outcomes (6 studies examining blood pressure; 4 studies examining hemoglobin), and nutritional outcomes (3 studies examining serum albumin; 4 studies examining body weight) were all in favor of KA use in DKD patients. Data from individual studies that examined other related parameters also tended to show favorable effects from KA-supplemented LPD/VLPD. The regimens were safe and well tolerated, with no evidence of adverse effects on nutritional status. In conclusion, LPD/VLPD supplemented with KA could be considered effective and safe for patients with non-dialysis dependent DKD. Larger studies are warranted to confirm these observations.
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14
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A low aromatic amino-acid diet improves renal function and prevent kidney fibrosis in mice with chronic kidney disease. Sci Rep 2021; 11:19184. [PMID: 34584168 PMCID: PMC8479128 DOI: 10.1038/s41598-021-98718-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/06/2021] [Indexed: 01/18/2023] Open
Abstract
Despite decades of use of low protein diets (LPD) in the management of chronic kidney disease (CKD), their mechanisms of action are unclear. A reduced production of uremic toxins could contribute to the benefits of LPDs. Aromatic amino-acids (AA) are precursors of major uremic toxins such as p-cresyl sulfate (PCS) and indoxyl sulfate (IS). We hypothesize that a low aromatic amino acid diet (LA-AAD, namely a low intake of tyrosine, tryptophan and phenylalanine) while being normoproteic, could be as effective as a LPD, through the decreased production of uremic toxins. Kidney failure was chemically induced in mice with a diet containing 0.25% (w/w) of adenine. Mice received three different diets for six weeks: normoproteic diet (NPD: 14.7% proteins, aromatic AAs 0.019%), LPD (5% proteins, aromatic AAs 0.007%) and LA-AAD (14% proteins, aromatic AAs 0.007%). Both LPD and LA-AAD significantly reduced proteinuria, kidney fibrosis and inflammation. While LPD only slightly decreased plasma free PCS and free IS compared to NPD; free fractions of both compounds were significantly decreased by LA-AAD. These results suggest that a LA-AAD confers similar benefits of a LPD in delaying the progression of CKD through a reduction in some key uremic toxins production (such as PCS and IS), with a lower risk of malnutrition.
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15
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Low-Protein Diet: History and Use of Processed Low-Protein Rice for the Treatment of Chronic Kidney Disease. Foods 2021; 10:foods10102255. [PMID: 34681304 PMCID: PMC8534812 DOI: 10.3390/foods10102255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022] Open
Abstract
The epidemiology of chronic kidney disease (CKD) shows increasing trends in prevalence and mortality and has become the leading health problem worldwide. Reducing the amount of proteins ingested from rice is an easy way to control the total intake of proteins, saving energy sources, particularly in rice-eating countries. In Japan, low-protein white rice had been developed, but the taste and function were not satisfactory for CKD patients. We reviewed the brief history of low-protein dietary therapy for renal diseases and the recent development of low-protein processed brown rice (LPBR). The new LPBR is characterized by a low-protein content, the same energy content as white rice, low potassium and phosphorus contents, and high amounts of dietary fibers, γ-oryzanol, and antioxidant activity. Dietary fibers and γ-oryzanol would stabilize intestinal microbiota and improve uremic dysbiosis and leaky gut syndrome. All these features suggest that the health benefits of LPBR extend to preventing CKD progression and enhancing the quality of life (QOL) of patients with CKD.
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16
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Yan MT, Chao CT, Lin SH. Chronic Kidney Disease: Strategies to Retard Progression. Int J Mol Sci 2021; 22:ijms221810084. [PMID: 34576247 PMCID: PMC8470895 DOI: 10.3390/ijms221810084] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD), defined as the presence of irreversible structural or functional kidney damages, increases the risk of poor outcomes due to its association with multiple complications, including altered mineral metabolism, anemia, metabolic acidosis, and increased cardiovascular events. The mainstay of treatments for CKD lies in the prevention of the development and progression of CKD as well as its complications. Due to the heterogeneous origins and the uncertainty in the pathogenesis of CKD, efficacious therapies for CKD remain challenging. In this review, we focus on the following four themes: first, a summary of the known factors that contribute to CKD development and progression, with an emphasis on avoiding acute kidney injury (AKI); second, an etiology-based treatment strategy for retarding CKD, including the approaches for the common and under-recognized ones; and third, the recommended approaches for ameliorating CKD complications, and the final section discusses the novel agents for counteracting CKD progression.
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Affiliation(s)
- Ming-Tso Yan
- Department of Medicine, Division of Nephrology, Cathay General Hospital, School of Medicine, Fu-Jen Catholic University, Taipei 106, Taiwan;
- National Defense Medical Center, Graduate Institute of Medical Sciences, Taipei 114, Taiwan
| | - Chia-Ter Chao
- Department of Internal Medicine, Nephrology Division, National Taiwan University Hospital, Taipei 104, Taiwan;
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei 104, Taiwan
- Department of Internal Medicine, Nephrology Division, National Taiwan University College of Medicine, Taipei 104, Taiwan
| | - Shih-Hua Lin
- National Defense Medical Center, Graduate Institute of Medical Sciences, Taipei 114, Taiwan
- Department of Internal Medicine, Nephrology Division, National Defense Medical Center, Taipei 104, Taiwan
- Correspondence: or
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17
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Noce A, Marrone G, Wilson Jones G, Di Lauro M, Pietroboni Zaitseva A, Ramadori L, Celotto R, Mitterhofer AP, Di Daniele N. Nutritional Approaches for the Management of Metabolic Acidosis in Chronic Kidney Disease. Nutrients 2021; 13:2534. [PMID: 34444694 PMCID: PMC8401674 DOI: 10.3390/nu13082534] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/11/2022] Open
Abstract
Metabolic acidosis is a severe complication of chronic kidney disease (CKD) which is associated with nefarious impairments such as bone demineralization, muscle wasting, and hormonal alterations, for example, insulin resistance. Whilst it is possible to control this condition with alkali treatment, consisting in the oral administration of sodium citrate or sodium bicarbonate, this type of intervention is not free from side effects. On the contrary, opting for the implementation of a targeted dietetic-nutritional treatment for the control of CKD metabolic acidosis also comes with a range of additional benefits such as lipid profile control, increased vitamins, and antioxidants intake. In our review, we evaluated the main dietary-nutritional regimens useful to counteract metabolic acidosis, such as the Mediterranean diet, the alkaline diet, the low-protein diet, and the vegan low-protein diet, analyzing the potentialities and limits of every dietary-nutritional treatment. Literature data suggest that the Mediterranean and alkaline diets represent a valid nutritional approach in the prevention and correction of metabolic acidosis in CKD early stages, while the low-protein diet and the vegan low-protein diet are more effective in CKD advanced stages. In conclusion, we propose that tailored nutritional approaches should represent a valid therapeutic alternative to counteract metabolic acidosis.
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Affiliation(s)
- Annalisa Noce
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
| | - Giulia Marrone
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
| | - Georgia Wilson Jones
- Center of Research of Immunopathology and Rare Diseases—Nephrology and Dialysis Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy;
| | - Manuela Di Lauro
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
| | - Anna Pietroboni Zaitseva
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
| | - Linda Ramadori
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
- School of Specialization in Geriatrics, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Roberto Celotto
- Department of Cardiovascular Disease, Tor Vergata University of Rome, 00133 Rome, Italy;
| | - Anna Paola Mitterhofer
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
| | - Nicola Di Daniele
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (M.D.L.); (A.P.Z.); (L.R.); (A.P.M.); (N.D.D.)
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18
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Cyrino LG, Galpern J, Moore L, Borgi L, Riella LV. A Narrative Review of Dietary Approaches for Kidney Transplant Patients. Kidney Int Rep 2021; 6:1764-1774. [PMID: 34307973 PMCID: PMC8258457 DOI: 10.1016/j.ekir.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/16/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
A healthy eating pattern has proven to lower the risk of metabolic and cardiovascular diseases. However, there are sparse dietary recommendations for kidney transplant recipients, and the ones available focus only on single nutrients intake, such as sodium, potassium, and proteins, and not on the overall eating pattern. Considering that individuals do not typically consume nutrients in isolation, but as part of a complete dietary pattern, it is challenging for the average transplanted patient to understand and implement specific dietary recommendations. Also, single-nutrient interventions demonstrate largely inconclusive effects, and it seems improbable that they could have a strong enough impact on transplant outcomes. Dietary trends such as plant-based diets, intermittent fasting, low-carb diet/keto-diet, and juicing, have gained major attention from the media. Herein, we review the potential risks and benefits of these diets in kidney transplant recipients and provide an updated dietary recommendation for this population with consideration of current nutritional trends. Overall, the Mediterranean and DASH diets have demonstrated to be the most beneficial dietary patterns to the post kidney transplant population by focusing on less meat and processed foods, while increasing the intake of fresh foods and plant-based choices. We believe that to maintain a healthy lifestyle posttransplant, patients should be educated about the scientific evidence of different diets and choose a dietary pattern that is sustainable long-term.
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Affiliation(s)
- LG Cyrino
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennie Galpern
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lori Moore
- Division of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lea Borgi
- Division of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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19
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Molina P, Gavela E, Vizcaíno B, Huarte E, Carrero JJ. Optimizing Diet to Slow CKD Progression. Front Med (Lausanne) 2021; 8:654250. [PMID: 34249961 PMCID: PMC8267004 DOI: 10.3389/fmed.2021.654250] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
Due to the unique role of the kidney in the metabolism of nutrients, patients with chronic kidney disease (CKD) lose the ability to excrete solutes and maintain homeostasis. Nutrient intake modifications and monitoring of nutritional status in this population becomes critical, since it can affect important health outcomes, including progression to kidney failure, quality of life, morbidity, and mortality. Although there are multiple hemodynamic and metabolic factors involved in the progression and prognosis of CKD, nutritional interventions are a central component of the care of patients with non-dialysis CKD (ND-CKD) and of the prevention of overweight and possible protein energy-wasting. Here, we review the reno-protective effects of diet in adults with ND-CKD stages 3-5, including transplant patients.
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Affiliation(s)
- Pablo Molina
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Eva Gavela
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Belén Vizcaíno
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Emma Huarte
- Department of Nephrology, Hospital San Pedro, Logroño, Spain
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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20
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Tsuchiya K, Akihisa T. The Importance of Phosphate Control in Chronic Kidney Disease. Nutrients 2021; 13:nu13051670. [PMID: 34069053 PMCID: PMC8156430 DOI: 10.3390/nu13051670] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
A series of problems including osteopathy, abnormal serum data, and vascular calcification associated with chronic kidney disease (CKD) are now collectively called CKD-mineral bone disease (CKD-MBD). The pathophysiology of CKD-MBD is becoming clear with the emerging of αKlotho, originally identified as a progeria-causing protein, and bone-derived phosphaturic fibroblast growth factor 23 (FGF23) as associated factors. Meanwhile, compared with calcium and parathyroid hormone, which have long been linked with CKD-MBD, phosphate is now attracting more attention because of its association with complications and outcomes. Incidentally, as the pivotal roles of FGF23 and αKlotho in phosphate metabolism have been unveiled, how phosphate metabolism and hyperphosphatemia are involved in CKD-MBD and how they can be clinically treated have become of great interest. Thus, the aim of this review is reconsider CKD-MBD from the viewpoint of phosphorus, its involvement in the pathophysiology, causing complications, therapeutic approach based on the clinical evidence, and clarifying the importance of phosphorus management.
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Affiliation(s)
- Ken Tsuchiya
- Department of Blood Purification, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
- Correspondence:
| | - Taro Akihisa
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo 162-8666, Japan;
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21
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Aycart DF, Acevedo S, Eguiguren-Jimenez L, Andrade JM. Influence of Plant and Animal Proteins on Inflammation Markers among Adults with Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Nutrients 2021; 13:1660. [PMID: 34068841 PMCID: PMC8153567 DOI: 10.3390/nu13051660] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
Proteins, especially plant proteins, may reduce inflammation among adults with chronic kidney disease (CKD). This systematic review and meta-analysis were conducted to evaluate the effect protein types (animal or plant) have on inflammation markers (CRP, IL-6, TNF-α) among adults with varying stages of CKD. The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) was conducted to identify articles from inception until January 2021, utilizing six databases. Controlled trials that compared the effects of different protein types were analyzed using random-effects meta-analysis. Quality assessment and risk of bias of the included articles were assessed by using Cochrane risk of bias instrument and ROBINS-I. Out of the 10 studies that met the criteria, there was a decreasing trend in CRP levels when consuming plant proteins compared to animal proteins among non-dialysis participants. There was a statistically significant decrease when comparing animal proteins to unspecified proteins in CRP levels among dialysis participants [Hedges' g = 2.11; 95% CI 1.12, 3.11; p ≤ 0.001], favoring unspecified proteins. Furthermore, animal proteins (eggs, red meat) showed increasing trends in CRP levels compared to whey protein isolate. Caution must be considered regarding these results as controlled, non-randomized, trials were included in the analysis, which may have contributed to high risk of bias. Future research should focus on protein types and the impact they have on kidney disease progression and inflammation markers.
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Affiliation(s)
| | | | | | - Jeanette Mary Andrade
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL 32611, USA; (D.F.A.); (S.A.); (L.E.-J.)
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22
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Fois A, Torreggiani M, Trabace T, Chatrenet A, Longhitano E, Mazé B, Lippi F, Vigreux J, Beaumont C, Moio MR, Piccoli GB. Quality of Life in CKD Patients on Low-Protein Diets in a Multiple-Choice Diet System. Comparison between a French and an Italian Experience. Nutrients 2021; 13:nu13041354. [PMID: 33919635 PMCID: PMC8073895 DOI: 10.3390/nu13041354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022] Open
Abstract
Prescribing a low-protein diet (LPD) is part of the standard management of patients in advanced stages of chronic kidney disease (CKD). However, studies on the quality of life (QoL) of patients on LPDs are lacking, and the impact these diets have on their QoL is often given as a reason for not prescribing one. We, therefore, decided to assess the QoL in a cohort of CKD stage 3–5 patients followed up by a multiple-choice diet approach in an outpatient nephrology clinic in France. To do so, we used the short version of the World Health Organization’s quality of life questionnaire and compared the results with a historical cohort of Italian patients. We enrolled 153 patients, managed with tailored protein restriction in Le Mans, and compared them with 128 patients on similar diets who had been followed in Turin (Italy). We found there were no significant differences in terms of age (median 73 vs. 74 years, respectively), gender, CKD stage, and comorbidities (Charlson’s Comorbidity Index 7 vs. 6). French patients displayed a greater body mass index (29.0 vs. 25.4, p < 0.001) and prevalence of obesity (41.2 vs. 15.0%, p < 0.001). Baseline protein intake was over the target in France (1.2 g/kg of real body weight/day). In both cohorts, the burden of comorbidities was associated with poorer physical health perception while kidney function was inversely correlated to satisfaction with social life, independently of the type of diet. Our study suggests that the type of LPD they follow does not influence QoL in CKD patients and that a personalized approach towards protein restriction is feasible, even in elderly patients.
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Affiliation(s)
- Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Massimo Torreggiani
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Tiziana Trabace
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.O.U. “G. Martino”, University of Messina, 98124 Messina, Italy;
| | - Béatrice Mazé
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Francoise Lippi
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Jerome Vigreux
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Coralie Beaumont
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Maria Rita Moio
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
| | - Giorgina Barbara Piccoli
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; (A.F.); (M.T.); (T.T.); (A.C.); (B.M.); (F.L.); (J.V.); (C.B.); (M.R.M.)
- Correspondence: ; Tel.: +33-66-973-3371
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23
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Narasaki Y, Okuda Y, Moore LW, You AS, Tantisattamo E, Inrig JK, Miyagi T, Nakata T, Kovesdy CP, Nguyen DV, Kalantar-Zadeh K, Rhee CM. Dietary protein intake, kidney function, and survival in a nationally representative cohort. Am J Clin Nutr 2021; 114:303-313. [PMID: 33742197 PMCID: PMC8246621 DOI: 10.1093/ajcn/nqab011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND High-protein diets (e.g., Paleo, Atkins, South Beach, ketogenic) have gained popularity as a means to promote weight loss and avoid excess carbohydrate consumption. Yet in chronic kidney disease (CKD) patients, evidence suggests low dietary protein intake (DPI) leads to attenuation of kidney function decline, although concerns remain for risk of protein-energy wasting. OBJECTIVES To examine associations of DPI with mortality in a nationally representative cohort of US adults, stratified by kidney function. METHODS We examined the association between daily DPI scaled to actual body weight (ABW), ascertained by 24-h dietary recall, with all-cause mortality among 27,604 continuous NHANES adult participants (1999-2010), stratified according to impaired versus normal kidney function (estimated glomerular filtration rates <60 compared with ≥60 ml/min/1.72 m2, respectively), using multivariable Cox models. We also examined the relation between high biological value (HBV) protein consumption with mortality. RESULTS In participants with impaired kidney function, a high DPI of ≥1.4 g/kg ABW/day was associated with higher mortality, while lower DPI levels were not associated with mortality (reference, 0.6 to <1.0 g/kg ABW/day): the adjusted HRs (aHRs) were 1.09 (95% CI: 0.90, 1.32), 1.03 (95% CI: 0.82, 1.29), and 1.37 (95% CI: 1.02, 1.85) for DPI <0.6, 1.0 to <1.4, and ≥1.4 g/kg ABW/day, respectively. Yet in participants with normal kidney function, a low DPI of <0.6 g/kg ABW/day was associated with higher mortality, whereas higher DPI levels were not associated with death: the aHRs were 1.18 (95% CI: 1.04, 1.34), 0.92 (95% CI: 0.81, 1.04), and 0.99 (95% CI: 0.85, 1.16) for DPI <0.6, 1.0 to <1.4, and ≥1.4 g/kg ABW/day, respectively. The highest 2 tertiles of HBV consumption were associated with higher mortality in participants with impaired kidney function. CONCLUSIONS Among participants with impaired kidney function, a higher DPI and greater HBV consumption were associated with higher mortality, whereas a lower DPI was associated with higher mortality in those with normal kidney function. Further studies are needed to elucidate the specific pathways between higher DPI and mortality in CKD.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,Department of Clinical Nutrition and Food Management, Tokushima University Graduate School of Nutrition and Biosciences, Tokushima, Japan,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Yusuke Okuda
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Jula K Inrig
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,IQVIA, Therapeutic Science and Strategy Unit, San Diego, CA, USA
| | - Tsuyoshi Miyagi
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus School of Medicine, Okinawa, Japan
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, VA, USA
| | - Danh V Nguyen
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
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24
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Brown TJ, Williams H, Mafrici B, Jackson HS, Johansson L, Willingham F, McIntosh A, MacLaughlin HL. Dietary interventions with dietitian involvement in adults with chronic kidney disease: A systematic review. J Hum Nutr Diet 2021; 34:747-757. [PMID: 33682964 DOI: 10.1111/jhn.12870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND A comprehensive evidence base is needed to support recommendations for the dietetic management of adults with chronic kidney disease (CKD). The present study aimed to determine the effect of dietary interventions with dietitian involvement on nutritional status, well-being, kidney risk factors and clinical outcomes in adults with CKD. METHODS Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO and EMBASE.com were searched from January 2000 to November 2019. Intentional weight loss and single nutrient studies were excluded. Risk of bias was assessed using the Cochrane risk-of-bias tool. Effectiveness was summarised using the mean difference between groups for each outcome per study. RESULTS Twelve controlled trials (1906 participants) were included. High fruit and vegetable intake, as well as a multidisciplinary hospital and community care programme, slowed the decline in glomerular filtration rate in adults with stage 3-4 CKD. Interventions addressing nutrition-related barriers increased protein and energy intake in haemodialysis patients. A Mediterranean diet and a diet with high n-3 polyunsaturated fatty acids improved the lipid profile in kidney transplant recipients. CONCLUSIONS A limited number of studies suggest benefits as a result of dietary interventions that are delivered by dietitians and focus on diet quality. We did not identify any studies that focussed on our primary outcome of nutritional status or studies that examined the timing or frequency of the nutritional assessment. This review emphasises the need for a wider body of high-quality evidence to support recommendations on what and how dietetic interventions are delivered by dietitians for adults with CKD.
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Affiliation(s)
- Tamara J Brown
- Usher Institute, Old Medical School, University of Edinburgh, Edinburgh, UK
| | - Harriet Williams
- Department of Nutrition and Dietetics, Betsi Cadwaladr University Health Board, Bangor, UK
| | - Bruno Mafrici
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helena S Jackson
- Renal and Transplantation Unit (Nutrition & Dietetics), St George's University Hospitals NHS Trust, London, UK
| | - Lina Johansson
- Department of Metabolism, Digestion and Reproduction, Imperial Healthcare NHS Trust, London, UK
| | - Fiona Willingham
- Dietetic department, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Ashleigh McIntosh
- Faculty of Health Sciences and Medicine, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Helen L MacLaughlin
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
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25
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Gallieni M, Buskermolen M, Boggio A, De Salvo C, Camerotto C. Plant-based kidney diets prescribed in nutrition clinics: clinical advantages with low risks of hyperkalemia. Intern Emerg Med 2021; 16:23-24. [PMID: 32399955 DOI: 10.1007/s11739-020-02363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Maurizio Gallieni
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Di Milano, Via G.B. Grassi, 74, 20157, Milan, Italy.
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy.
| | | | - Anna Boggio
- Nutritional Service, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Cristina De Salvo
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Carla Camerotto
- Nutritional Service, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
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26
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Hsu CK, Su SC, Chang LC, Shao SC, Yang KJ, Chen CY, Chen YT, Wu IW. Effects of Low Protein Diet on Modulating Gut Microbiota in Patients with Chronic Kidney Disease: A Systematic Review and Meta-analysis of International Studies. Int J Med Sci 2021; 18:3839-3850. [PMID: 34790060 PMCID: PMC8579282 DOI: 10.7150/ijms.66451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/09/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Although associations between low protein diet (LPD) and changes of gut microbiota have been reported; however, systematic discernment of the effects of LPD on diet-microbiome-host interaction in patients with chronic kidney disease (CKD) is lacking. Methods: We searched PUBMED and EMBASE for articles published on changes of gut microbiota associated with implementation of LPD in CKD patients until July 2021. Independent researchers extracted data and assessed risks of bias. We conducted meta-analyses of combine p-value, mean differences and random effects for gut microbiota and related metabolites. Study heterogeneity was measured by Tau2 and I2 statistic. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Five articles met inclusion criteria. The meta-analyses of gut microbiota exhibited enrichments of Lactobacillaceae (meta-p= 0.010), Bacteroidaceae (meta-p= 0.048) and Streptococcus anginosus (meta-p< 0.001), but revealed depletion of Bacteroides eggerthii (p=0.017) and Roseburia faecis (meta-p=0.019) in LPD patients compared to patients undergoing normal protein diet. The serum IS levels (mean difference: 0.68 ug/mL, 95% CI: -8.38-9.68, p= 0.89) and pCS levels (mean difference: -3.85 ug/mL, 95% CI: -15.49-7.78, p < 0.52) did not change between groups. We did not find significant differences on renal function associated with change of microbiota between groups (eGFR, mean difference: -7.21 mL/min/1.73 m2, 95% CI: -33.2-18.79, p= 0.59; blood urea nitrogen, mean difference: -6.8 mg/dL, 95% CI: -46.42-32.82, p= 0.74). Other clinical (sodium, potassium, phosphate, albumin, fasting sugar, uric acid, total cholesterol, triglycerides, C-reactive protein and hemoglobin) and anthropometric estimates (body mass index, systolic blood pressure and diastolic blood pressure) did not differ between the two groups. Conclusions: This systematic review and meta-analysis suggested that the effects of LPD on the microbiota were observed predominantly at the families and species levels but minimal on microbial diversity or richness. In the absence of global compositional microbiota shifts, the species-level changes appear insufficient to alter metabolic or clinical outputs.
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Affiliation(s)
- Cheng-Kai Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Chi Su
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Lun-Ching Chang
- Department of Mathematical Sciences, Florida Atlantic University, Florida, US
| | - Shih-Chieh Shao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kai-Jie Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chun-Yu Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yih-Ting Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - I-Wen Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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27
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Verzola D, Picciotto D, Saio M, Aimasso F, Bruzzone F, Sukkar SG, Massarino F, Esposito P, Viazzi F, Garibotto G. Low Protein Diets and Plant-Based Low Protein Diets: Do They Meet Protein Requirements of Patients with Chronic Kidney Disease? Nutrients 2020; 13:E83. [PMID: 33383799 PMCID: PMC7824653 DOI: 10.3390/nu13010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023] Open
Abstract
A low protein diet (LPD) has historically been used to delay uremic symptoms and decrease nitrogen (N)-derived catabolic products in patients with chronic kidney disease (CKD). In recent years it has become evident that nutritional intervention is a necessary approach to prevent wasting and reduce CKD complications and disease progression. While a 0.6 g/kg, high biological value protein-based LPD has been used for years, recent observational studies suggest that plant-derived LPDs are a better approach to nutritional treatment of CKD. However, plant proteins are less anabolic than animal proteins and amino acids contained in plant proteins may be in part oxidized; thus, they may not completely be used for protein synthesis. In this review, we evaluate the role of LPDs and plant-based LPDs on maintaining skeletal muscle mass in patients with CKD and examine different nutritional approaches for improving the anabolic properties of plant proteins when used in protein-restricted diets.
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Affiliation(s)
- Daniela Verzola
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
| | - Daniela Picciotto
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Michela Saio
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Francesca Aimasso
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Francesca Bruzzone
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Samir Giuseppe Sukkar
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Fabio Massarino
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Pasquale Esposito
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Giacomo Garibotto
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
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28
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Letourneau P, Bataille S, Chauveau P, Fouque D, Koppe L. Source and Composition in Amino Acid of Dietary Proteins in the Primary Prevention and Treatment of CKD. Nutrients 2020; 12:E3892. [PMID: 33352729 PMCID: PMC7766732 DOI: 10.3390/nu12123892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/13/2022] Open
Abstract
Nutrition is a cornerstone in the management of chronic kidney disease (CKD). To limit urea generation and accumulation, a global reduction in protein intake is routinely proposed. However, recent evidence has accumulated on the benefits of plant-based diets and plant-derived proteins without a clear understanding of underlying mechanisms. Particularly the roles of some amino acids (AAs) appear to be either deleterious or beneficial on the progression of CKD and its complications. This review outlines recent data on the role of a low protein intake, the plant nature of proteins, and some specific AAs actions on kidney function and metabolic disorders. We will focus on renal hemodynamics, intestinal microbiota, and the production of uremic toxins. Overall, these mechanistic effects are still poorly understood but deserve special attention to understand why low-protein diets provide clinical benefits and to find potential new therapeutic targets in CKD.
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Affiliation(s)
- Pierre Letourneau
- Departement of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69495 Pierre Bénite, France; (P.L.); (D.F.)
| | - Stanislas Bataille
- Phocean Nephrology Institute, Clinique Bouchard, ELSAN, 13000 Marseille, France;
- INSERM, INRA, C2VN, Aix Marseille University, 13000 Marseille, France
| | - Philippe Chauveau
- Association Pour l’Utilisation Du Rein Artificiel A Domicile, 33110 Gradignan, France;
| | - Denis Fouque
- Departement of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69495 Pierre Bénite, France; (P.L.); (D.F.)
- University Lyon, CarMeN Laboratory, INSA-Lyon, INSERM U1060, INRA, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
| | - Laetitia Koppe
- Departement of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69495 Pierre Bénite, France; (P.L.); (D.F.)
- University Lyon, CarMeN Laboratory, INSA-Lyon, INSERM U1060, INRA, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
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29
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Ready to Change: Attitudes of an Elderly CKD Stage 3-5 Population towards Testing Protein-Free Food. Nutrients 2020; 12:nu12113519. [PMID: 33207579 PMCID: PMC7696537 DOI: 10.3390/nu12113519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 01/21/2023] Open
Abstract
The recent Kidney Disease Outcomes Quality Initiative (K-DOQI) guidelines suggest an early start of protein restriction, raising issues on willingness to change dietary habits. The aim of this exploratory real-life study was to report on a test of dietary products (protein-free, not previously available in France) in a large, mainly elderly, chronic kidney disease (CKD) population (220 patients, median age: 77.5 years, Charlson comorbidity index (CCI): seven, malnutrition inflammation score (MIS): five, estimated glomerular filtration rate (eGFR): 26 mL/min), also as a means to tailor further implementation strategies. Forty-nine patients (22.28%) were considered to be poor candidates for the trial (metabolically unstable or with psychological, psychiatric or logistic barriers); of the remaining 171, 80.70% agreed to participate. Patients to whom the diet was not proposed had lower eGFR and higher comorbidity (eGFR 21 vs. 27 p = 0.021; MIS six vs. four p: <0.001). Patients who refused were 10 years older than those who accepted (83 vs. 73 years p < 0.001), with a higher CCI (eight vs. seven p = 0.008) and MIS (five vs. four p = 0.01). In the logistic regression, only age was significantly associated with refusal to participate (Odds ratio (OR): 5.408; 95% CI: 1.894 to 15.447). No difference was found according to low/intermediate/high frequency of weekly use of protein-free food. Our study suggests that most of the patients are ready to test new diet approaches. Only old age correlated with refusal, but frequency of implementation depended on individual preferences, underlying the importance of tailored approaches to improve adherence.
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30
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Cupisti A, Gallieni M, Avesani CM, D’Alessandro C, Carrero JJ, Piccoli GB. Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication. J Clin Med 2020; 9:E3644. [PMID: 33198365 PMCID: PMC7697617 DOI: 10.3390/jcm9113644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an "option" in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, University of Milan, 20157 Milan, Italy;
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy
| | - Carla Maria Avesani
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institutet, 14186 Stockholm, Sweden;
| | - Claudia D’Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden;
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy;
- Nephrologie, Centre Hospitalier Le Mans, 72100 Le Mans, France
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Abstract
BACKGROUND Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006, 2009 and 2018. OBJECTIVES To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 7 September 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi RCTs in which adults with non-diabetic CKD (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/day) compared with a low protein intake (0.5 to 0.6 g/kg/day) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/day) for 12 months or more. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE. MAIN RESULTS We identified 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months. Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding. Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence). Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence). Final body weight was reported in only three studies. It is uncertain whether the intervention alters final body weight (3 studies, 89 participants: MD -0.40 kg, 95% CI -6.33 to 5.52; very low certainty evidence).Twelve studies reported no evidence of protein energy wasting (malnutrition) in their study participants while three studies reported small numbers of participants in each group with protein energy wasting. Most studies reported that adherence to diet was satisfactory. Quality of life was not formally assessed in any studies. AUTHORS' CONCLUSIONS This review found that very low protein diets probably reduce the number of people with CKD 4 or 5, who progress to ESKD. In contrast low protein diets may make little difference to the number of people who progress to ESKD. Low or very low protein diets probably do not influence death. However there are limited data on adverse effects such as weight differences and protein energy wasting. There are no data on whether quality of life is impacted by difficulties in adhering to protein restriction. Studies evaluating the adverse effects and the impact on quality of life of dietary protein restriction are required before these dietary approaches can be recommended for widespread use.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Denis Fouque
- Department of Nephrology, Nutrition and Dialysis, Université de Lyon, UCBL, CARMEN, Centre Hospitalier Lyon Sud, Pierre Bénite, France
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Coelho-Junior HJ, Marzetti E, Picca A, Cesari M, Uchida MC, Calvani R. Protein Intake and Frailty: A Matter of Quantity, Quality, and Timing. Nutrients 2020; 12:E2915. [PMID: 32977714 PMCID: PMC7598653 DOI: 10.3390/nu12102915] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023] Open
Abstract
Frailty is a geriatric syndrome that refers to a state of reduced resiliency to stressful events that occurs in response to physiological and/or psychosocial detriments. Frailty is a predictor of poor prognosis, given that frail older adults are at higher risk of many adverse health-related events. Hence, the identification of potential strategies to prevent the development and progression of frailty is of extreme importance for avoiding its negative outcomes. An adequate protein consumption is advocated as a possible intervention for the management of frailty in older adults due to its effects on muscle mass and physical function. However, empirical evidence is still needed to support this proposition. On the other hand, substantial evidence from observational studies has provided important information on the association between frailty and dietary protein-related parameters. Here, we provide a narrative review of the current literature regarding the association between protein intake (amount (how much?), quality (what type?), and distribution across meals (when?)) and frailty-related parameters. The ultimate aim of this work is to offer practical, evidence-based indications to healthcare professionals responsible for the care of frail older adults.
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Affiliation(s)
- Hélio J. Coelho-Junior
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Applied Kinesiology Laboratory-LCA, School of Physical Education, University of Campinas, 083-851 Campinas-SP, Brazil;
- Mãe Mariana Nursing Home, Rehabilitation Unit, 08562-460 Poá-SP, Brazil
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (R.C.)
| | - Anna Picca
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (R.C.)
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, Università di Milano, 20133 Milan, Italy;
- Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marco C. Uchida
- Applied Kinesiology Laboratory-LCA, School of Physical Education, University of Campinas, 083-851 Campinas-SP, Brazil;
| | - Riccardo Calvani
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (R.C.)
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Fukuma S, Ikenoue T, Bragg-Gresham J, Norton E, Yamada Y, Kohmoto D, Saran R. Body mass index change and estimated glomerular filtration rate decline in a middle-aged population: health check-based cohort in Japan. BMJ Open 2020; 10:e037247. [PMID: 32895282 PMCID: PMC7476489 DOI: 10.1136/bmjopen-2020-037247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Obesity is a growing public health problem worldwide. We evaluated the mediators and association between changes in obesity metrics and renal outcomes in the general population. METHODS Using the Japanese nationwide health check-based cohort from April 2011 to March 2019, we selected individuals aged 40-74 years, with a baseline estimated glomerular filtration rate (eGFR) ≥45 mL/min/1.73 m2, whose body mass index (BMI) change was assessed. The primary outcome was combined 30% decline in eGFR, eGFR <15 mL/min/1.73 m2 and end-stage renal disease. RESULTS During 245 147 person-years' follow-up among 50 604 participants (mean eGFR, 83.7 mL/min/1.73 m2; mean BMI, 24.1 kg/m2), 645 demonstrated eGFR decline (incidence rate 2.6/1000 person-years, 95% CI: 2.4 to 2.8). We observed continued initial changes in BMI for over 6 years and a U-shaped association between BMI change and eGFR decline. Compared with 0% change in BMI, adjusted HRs for changes of -10%, -4%, 4% and 10% were 1.53 (95% CI: 1.15 to 2.04), 1.14 (95% CI: 1.01 to 1.30), 1.16 (95% CI: 1.02 to 1.32) and 1.87 (95% CI: 1.25 to 2.80), respectively. The percentage of excess risk of BMI increase (>4%) mediated by three risk factors (blood pressure, haemoglobin A1c and total cholesterol), was 13.3%. CONCLUSION In the middle-aged Japanese population, both, increase and decrease in BMI were associated with subsequent eGFR decline. Changes in risk factors mediated a small proportion of the association between BMI increase and eGFR decline. Our findings support the clinical significance of monitoring BMI as a renal risk factor.
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Affiliation(s)
- Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tatsuyoshi Ikenoue
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jennifer Bragg-Gresham
- Internal Medicine and Molecular and Integrative Physiology, Division of Nephrology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Edward Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Daichi Kohmoto
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Rajiv Saran
- Internal Medicine and Molecular and Integrative Physiology, Division of Nephrology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Long-Term Effects of Ketoanalogues on Mortality and Renal Outcomes in Advanced Chronic Kidney Disease Patients Receiving a Low-Protein Diet. Nutrients 2020; 12:nu12092708. [PMID: 32899821 PMCID: PMC7551296 DOI: 10.3390/nu12092708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022] Open
Abstract
The effects of ketoanalogues (KA) supplementation on mortality and progression to dialysis in patients with pre-dialysis stage 5 chronic kidney disease (CKD) receiving a low-protein diet (LPD) remain ambiguous. From Taiwan’s National Health Insurance Research Database during 1996–2011, 165 patients with pre-dialysis CKD on an LPD (0.6 g/kg/day) with KA supplementation were matched with 165 patients with pre-dialysis CKD on an LPD without KA supplementation. Of the 165 patients with advanced CKD receiving KA supplementation, 34 (20.6%) died, and 124 (75.2%) underwent long-term dialysis during the study period. There was no significant difference in mortality between the KA-user group and the KA-nonuser group (adjusted hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.68–2.93; p = 0.355). KA supplementation significantly increased long-term dialysis risk (adjusted HR, 1.41; 95% CI, 1.04–1.90; p = 0.025) and combined outcome risk (defined as long-term dialysis and death; adjusted HR, 1.37; 95% CI, 1.02–1.83; p = 0.034). KA supplementation also increased long-term dialysis risk (adjusted HR, 1.49; 95% CI, 1.00–2.20; p = 0.048) in the subgroup of pre-dialysis patients with diabetes mellitus (DM), but not in those patients without DM. In conclusion, KA supplementation might increase long-term dialysis risk in patients with advanced CKD receiving an LPD, but it did not increase mortality.
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Sabatino A, D'Alessandro C, Regolisti G, di Mario F, Guglielmi G, Bazzocchi A, Fiaccadori E. Muscle mass assessment in renal disease: the role of imaging techniques. Quant Imaging Med Surg 2020; 10:1672-1686. [PMID: 32742960 DOI: 10.21037/qims.2020.03.05] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Muscle wasting is a frequent finding in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on chronic dialysis. Muscle wasting in CKD is a main feature of malnutrition, and results principally from a vast array of metabolic derangements typical of the syndrome, that converge in determining reduced protein synthesis and accelerated protein catabolism. In this clinical setting, muscle wasting is also frequently associated with disability, frailty, infections, depression, worsened quality of life and increased mortality. On these grounds, the evaluation of nutritional status is crucial for an adequate management of renal patients, and consists of a comprehensive assessment allowing for the identification of malnourished patients and patients at nutritional risk. It is based essentially on the assessment of the extent and trend of body weight loss, as well as of spontaneous dietary intake. Another key component of this evaluation is the determination of body composition, which, depending on the selected method among several ones available, can identify accurately patients with decreased muscle mass. The choice will depend on the availability and ease of application of a specific technique in clinical practice based on local experience, staff resources and good repeatability over time. Surrogate methods, such as anthropometry and bioimpedance analysis (BIA), represent the most readily available techniques. Other methods based on imaging modalities [dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI), and whole body computed tomography (CT)] are considered to be the "gold standard" reference methods for muscle mass evaluation, but their use is mainly confined to research purposes. New imaging modalities, such as segmental CT scan and muscle ultrasound have been proposed in recent years. Particularly, ultrasound is a promising technique in this field, as it is commonly available for bedside evaluation of renal patients in nephrology wards. However, more data are needed before a routine use of ultrasound for muscle mass evaluation can be recommended in clinical practice.
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Affiliation(s)
- Alice Sabatino
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Regolisti
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Francesca di Mario
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Piccoli GB, Cupisti A, Aucella F, Regolisti G, Lomonte C, Ferraresi M, Claudia D, Ferraresi C, Russo R, La Milia V, Covella B, Rossi L, Chatrenet A, Cabiddu G, Brunori G. Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology. J Nephrol 2020; 33:681-698. [PMID: 32297293 PMCID: PMC7381479 DOI: 10.1007/s40620-020-00734-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France.
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy.
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS "Casa Sollievo Della Sofferenza" Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Giuseppe Regolisti
- Department of Internal Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Martina Ferraresi
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - D'Alessandro Claudia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Carlo Ferraresi
- Department of Mechanical and Aerospace, DIMEAS, Politecnico of Torino, Turin, Italy
| | - Roberto Russo
- Nephology Unit. Azienda Ospedaliera Universitaria Policlinico, Bari, Italy
| | | | - Bianca Covella
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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Plant-based diets, insulin sensitivity and inflammation in elderly men with chronic kidney disease. J Nephrol 2020; 33:1091-1101. [PMID: 32514991 PMCID: PMC7557485 DOI: 10.1007/s40620-020-00765-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In persons with CKD, adherence to plant-based diets is associated with lower risk of CKD progression and death, but underlying mechanisms are poorly characterized. We here explore associations between adherence to plant-based diets and measures of insulin sensitivity and inflammation in men with CKD stages 3-5. METHODS Cross-sectional study including 418 men free from diabetes, aged 70-71 years and with cystatin-C estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2 and not receiving kidney-specific dietetic advice. Information from 7-day food records was used to evaluate the adherence to a plant-based diet index (PBDi), which scores positively the intake of plant-foods and negatively animal-foods. Insulin sensitivity and glucose disposal rate were assessed with the gold-standard hyperinsulinemic euglycemic glucose clamp technique. Inflammation was evaluated by serum concentrations of C-reactive protein (CRP) and interleukin (IL)-6. Associations were explored through linear regression and restricted cubic splines. RESULTS The majority of men had CKD stage 3a. Hypertension and cardiovascular disease were the most common comorbidities. The median PBDi was 38 (range 14-55). Across higher quintiles of PBDi (i.e. higher adherence), participants were less often smokers, consumed less alcohol, had lower BMI and higher eGFR (P for trend <0.05 for all). Across higher PBDi quintiles, patients exhibited higher insulin sensitivity and lower inflammation (P for trend <0.05). After adjustment for eGFR, lifestyle factors, BMI, comorbidities and energy intake, a higher PBDi score remained associated with higher glucose disposal rate and insulin sensitivity as well as with lower levels of IL-6 and CRP. CONCLUSION In elderly men with non-dialysis CKD stages 3-5, adherence to a plant-based diet was associated with higher insulin sensitivity and lower inflammation, supporting a possible role of plant-based diets in the prevention of metabolic complications of CKD.
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Association between Low Protein Intake and Mortality in Patients with Type 2 Diabetes. Nutrients 2020; 12:nu12061629. [PMID: 32492838 PMCID: PMC7352318 DOI: 10.3390/nu12061629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/13/2020] [Accepted: 05/28/2020] [Indexed: 01/13/2023] Open
Abstract
The aim of this study was to investigate the association between protein intake and mortality risk in patients with type 2 diabetes. We analyzed a pooled data of 2494 diabetic patients from two prospective longitudinal studies. Nutritional intake was assessed using a Food Frequency Questionnaire at baseline. Protein intake per body weight (kg) per day was categorized into quartile groups. Adjusted hazard ratios (HRs) and 95% confidence interval (CI) were calculated using Cox regression analysis. During the six-year follow-up, there were 152 incidents of all-cause mortality. The HR for mortality in the lowest quartile of protein intake per body weight compared with the highest quartile was 2.26 (95% CI: 1.34–3.82, p = 0.002) after adjustment for covariates. Subgroup analyses revealed significant associations between low protein intake and mortality in patients aged over 75 years or under 65 years. After further adjustment of the total energy intake, a significant association between protein intake and mortality remained in patients aged ≥ 75 years, whereas the association was attenuated in those aged < 65 years. Our results suggest that adequate protein intake is necessary in older diabetic patients over 75 years, whereas with diabetes, whereas whole optimal total energy intake is required in younger patients with type 2 diabetes.
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Baragetti I, De Simone I, Biazzi C, Buzzi L, Ferrario F, Luise MC, Santagostino G, Furiani S, Alberghini E, Capitanio C, Terraneo V, Milia VL, Pozzi C. The low-protein diet for chronic kidney disease: 8 years of clinical experience in a nephrology ward. Clin Kidney J 2020; 13:253-260. [PMID: 32296529 PMCID: PMC7147315 DOI: 10.1093/ckj/sfz141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Guidelines indicate that a low-protein diet (LPD) delays dialysis in severe chronic kidney disease (CKD). We assessed the value of these guidelines by performing a retrospective analysis in our renal clinical practice. METHODS The analysis was performed from 1 January 2010 to 31 March 2018 in 299 CKD Stage 4 patients followed for 70 months in collaboration with a skilled nutritionist. The patients included 43 patients on a controlled protein diet (CPD) of 0.8 g/kg/day [estimated glomerular filtration rate (eGFR) 20-30 mL/min/1.73 m2 body surface (b.s.)], 171 patients on an LPD of 0.6 g/kg/day and 85 patients on an unrestricted protein diet (UPD) who were not followed by our nutritionist (LPD and UPD, eGFR <20 mL/min/1.73 m2 b.s.). RESULTS eGFR was higher in CPD patients than in UPD and LPD patients (21.9 ± 7.4 mL/min/1.73 m2 versus 17.6 ± 8.00 mL/min/1.73 m2 and 17.1 ± 7.5 mL/min/1.73 m2; P = 0.008). The real daily protein intake was higher in UPD patients than in LPD and CDP patients (0.80 ± 0.1 g/kg/day versus 0.6 ± 0.2 and 0.63 ± 0.2 g/kg/day; P = 0.01). Body mass index (BMI) was stable in the LPD and CPD groups but decreased from 28.5 ± 4.52 to 25.4 ± 3.94 kg/m2 in the UPD group (P < 0.001). The renal survival of UPD, LPD and CPD patients was 47.1, 84.3 and 90.7%, respectively, at 30 months (P < 0.001), 42.4, 72.0 and 79.1%, respectively, at 50 months (P < 0.001) and 42.4, 64.1 and 74.4%, respectively, at 70 months (P < 0.001). The LPD patients started dialysis nearly 24 months later than the UPD patients. Diet was an independent predictor of dialysis [-67% of RR reduction (hazard ratio = 0.33; confidence interval 0.22-0.48)] together with a reduction in BMI. CONCLUSIONS An LPD recommended by nephrologists in conjunction with skilled dietitians delays dialysis and preserves nutritional status in severe CKD.
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Affiliation(s)
- Ivano Baragetti
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Ilaria De Simone
- Division of Nephrology and Dialysis, Legnano Hospital, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Cecilia Biazzi
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Laura Buzzi
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Francesca Ferrario
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Maria Carmen Luise
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Gaia Santagostino
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Silvia Furiani
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Elena Alberghini
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Chiara Capitanio
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Veronica Terraneo
- Division of Nephrology and Dialysis, Bassini Hospital, ASST Nord Milano, Cinisello Balsamo, Milan, Italy
| | - Vicenzo La Milia
- Division of Nephrology and Dialysis, Manzoni Hospital, ASST Lecco, Lecco (Lecco), Italy
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Abstract
People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a better option for preparing these patients for dialysis, transplantation or conservative care. This review focuses on the different aspects of such transition clinics. We discuss which patients should be referred to these units and when referral should take place. Patient involvement in the decision-making process is important and requires unbiased patient education. There are many themes, both patient-centred and within the healthcare structure, that will influence the process of shared decision-making and the modality choice. Aspects of placing an access for haemodialysis and peritoneal dialysis are reviewed. Finally, we discuss the importance of pre-emptive transplantation and a planned dialysis start, all with a focus on multidisciplinary collaboration at the transition clinic.
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Affiliation(s)
- Marie Evans
- Renal Unit, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Kai Lopau
- Department of Internal Medicine , University of Würzburg, Würzburg, Germany
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41
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Taguchi K, Elias BC, Brooks CR, Ueda S, Fukami K. Uremic Toxin-Targeting as a Therapeutic Strategy for Preventing Cardiorenal Syndrome. Circ J 2019; 84:2-8. [PMID: 31827008 DOI: 10.1253/circj.cj-19-0872] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is a global health problem. CKD patients are at high risk of developing cardiovascular disease (CVD), including coronary artery disease, heart failure and stroke. Several factors invoke a vicious cycle of CKD and CVD, which is referred as to "cardiorenal syndrome". Among these factors, the compounds retained through loss of renal excretion play a pathological role in causing atherosclerosis and CVD. These compounds have been broadly classified as uremic toxins because of their accumulation with declining renal function and cytotoxicity. The major uremic toxins contributing to CVD are asymmetric dimethylarginine (ADMA), advanced glycation endproducts (AGE), and trimethyl amine N-oxide (TMAO). ADMA is linked to CVD through regulation of nitric oxide, reactive oxygen species, and renal anemia. AGE not only directly accumulates in the heart and kidney, but interacts with the receptor for AGE (RAGE), leading to cell damage in CVD. TMAO correlates with a high prevalence of CVD and promotes organ fibrosis by itself. The levels of these and other uremic toxins rise with worsening CKD, inducing multiplicative damage in the heart and kidney. Therefore, a better understanding of uremic toxins has great clinical importance for preventing cardiorenal syndrome. This review highlights the molecular mechanism by which these uremic toxins are implicated in CVD and suggests the possible mutual relationship between them.
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Affiliation(s)
- Kensei Taguchi
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine.,Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Bertha C Elias
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Craig R Brooks
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Seiji Ueda
- Division of Nephrology, Department of Internal Medicine, Juntendo University
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine
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Gandolfini I, Regolisti G, Bazzocchi A, Maggiore U, Palmisano A, Piotti G, Fiaccadori E, Sabatino A. Frailty and Sarcopenia in Older Patients Receiving Kidney Transplantation. Front Nutr 2019; 6:169. [PMID: 31781571 PMCID: PMC6861371 DOI: 10.3389/fnut.2019.00169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022] Open
Abstract
Kidney transplantation is the treatment of choice for most of the patients with end-stage renal disease (ESRD). It improves quality of life, life expectancy, and has a lower financial burden to the healthcare system in comparison to dialysis. Every year more and more older patients are included in the kidney transplant waitlist. Within this patient population, transplanted subjects have better survival and quality of life as compared to those on dialysis. It is therefore crucial to select older patients who may benefit from renal transplantation, as well as those particularly at risk for post-transplant complications. Sarcopenia and frailty are frequently neglected in the evaluation of kidney transplant candidates. Both conditions are interrelated complex geriatric syndromes that are linked to disability, aging, comorbidities, increased mortality, and graft failure post-transplantation. Chronic kidney disease (CKD) and more importantly ESRD are characterized by multiple metabolic complications that contribute for the development of sarcopenia and frailty. In particular, anorexia, metabolic acidosis and chronic low-grade inflammation are the main contributors to the development of sarcopenia, a key component in frail transplant candidates and recipients. Both frailty and sarcopenia are considered to be reversible. Frail patients respond well to multiprofessional interventions that focus on the patients' positive frailty criteria, while physical rehabilitation and oral supplementation may improve sarcopenia. Prospective studies are still needed to evaluate the utility of formally measuring frailty and sarcopenia in the older candidates to renal transplantation as part of the transplant evaluation process.
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Affiliation(s)
- Ilaria Gandolfini
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alessandra Palmisano
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giovanni Piotti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alice Sabatino
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
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Kramer H. Diet and Chronic Kidney Disease. Adv Nutr 2019; 10:S367-S379. [PMID: 31728497 PMCID: PMC6855949 DOI: 10.1093/advances/nmz011] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/04/2018] [Accepted: 01/07/2019] [Indexed: 02/07/2023] Open
Abstract
Kidney disease affects almost 15% of the US population, and prevalence is anticipated to grow as the population ages and the obesity epidemic continues due to Western dietary practices. The densely caloric Western diet, characterized by high animal protein and low fruit and vegetable content, has fueled the growth of chronic diseases, including chronic kidney disease. The glomerulus or filtering unit of the kidney is very susceptible to barotrauma, and diets high in animal protein impede the glomerulus' ability to protect itself from hemodynamic injury. High animal protein intake combined with low intake of fruits and vegetables also leads to a high net endogenous acid production requiring augmentation of ammonium excretion in order to prevent acidosis. This higher workload of the kidney to maintain a normal serum bicarbonate level may further exacerbate kidney disease progression. This article reviews the potential mechanisms whereby several key characteristics of the typical Western diet may impact kidney disease incidence and progression. Reducing animal protein intake and egg yolk and increasing intake of fruits and vegetables and fiber may prevent or delay end-stage renal disease, but few clinical trials have examined vegetarian diets for management of chronic kidney disease. More research is needed to determine optimal dietary patterns for the prevention of kidney disease and its progression.
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Affiliation(s)
- Holly Kramer
- Department of Public Health Sciences and Medicine
- Division of Nephrology and Hypertension, Loyola University, Chicago, IL
- Address correspondence to HK (e-mail: )
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Wright M, Southcott E, MacLaughlin H, Wineberg S. Clinical practice guideline on undernutrition in chronic kidney disease. BMC Nephrol 2019; 20:370. [PMID: 31619185 PMCID: PMC6796390 DOI: 10.1186/s12882-019-1530-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 01/12/2023] Open
Affiliation(s)
| | | | | | - Stuart Wineberg
- Patient Representative, c/o The Renal Association, Bristol, UK
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45
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Effects of dietary protein intake on renal outcome and mortality in patients with advanced diabetic nephropathy. Clin Exp Nephrol 2019; 24:119-125. [PMID: 31587125 DOI: 10.1007/s10157-019-01796-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/24/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The difficulty of adhering to a low-protein diet is a serious limitation of randomized controlled trials aimed at validating the efficacy of this therapy. In this observational study of patients with diabetic nephropathy, we examined the association of dietary protein intake (DPI) with renal outcome and mortality, taking into account the nutritional status. METHODS We conducted a single-center historical cohort study of 449 adult Japanese patients with type 2 diabetes and the urinary albumin-to-creatinine ratio of ≥ 300 mg/g or estimated glomerular filtration rate of < 30 mL/min/1.73 m2. DPI was estimated with a formula using nitrogen levels in spot urine and body mass index. Malnutrition was defined as the Geriatric Nutritional Risk Index of ≤ 98. The primary and secondary endpoints were renal replacement therapy (RRT) initiation and mortality before RRT initiation, respectively. The Fine and Gray subdistribution hazard model was used to determine the relative effects of DPI on the respective endpoint. RESULTS Decreased DPI was associated with lower incidence of RRT with an adjusted hazard ratio of 0.81 (95% confidence interval: 0.72-0.92, p < 0.001). The interaction between DPI and nutritional status with respect to mortality was significant (p interaction = 0.047). Decreased DPI was a risk factor for mortality in patients with malnutrition (p = 0.009) but not in those without malnutrition (p = 0.559). CONCLUSIONS In patients with type 2 diabetic nephropathy, lower DPI was associated with lower incidence of RRT initiation, suggesting beneficial effects of a low-protein diet on kidneys. Conversely, lower DPI might lead to increased mortality in patients with malnutrition.
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46
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Ketoacid Analogues Supplementation in Chronic Kidney Disease and Future Perspectives. Nutrients 2019; 11:nu11092071. [PMID: 31484354 PMCID: PMC6770434 DOI: 10.3390/nu11092071] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/14/2022] Open
Abstract
Diet is a key component of care during chronic kidney disease (CKD). Nutritional interventions, and, specifically, a restricted protein diet has been under debate for decades. In order to reduce the risk of nutritional disorders in very-low protein diets (VLDP), supplementation by nitrogen-free ketoacid analogues (KAs) have been proposed. The aim of this review is to summarize the potential effects of this dietary therapy on renal function, uremic toxins levels, and nutritional and metabolic parameters and propose future directions. The purpose of this paper is also to select all experimental and randomized clinical studies (RCTs) that have compared VLDP + KA to normal diet or/and low protein diet (LPD). We reviewed the SCOPUS, WEB of SCIENCES, CENTRAL, and PUBMED databases from their inception to 1 January, 2019. Following duplicate removal and application of exclusion criteria, 23 RCTs and 12 experimental studies were included. LPD/VLPD + KAs appear nutritionally safe even if how muscle protein metabolism adapts to an LPD/VLPD + KAs is still largely unknown. VLPD + KAs seem to reduce uremic toxins production but the impact on intestinal microbiota remains unexplored. All studies observed a reduction of acidosis, phosphorus, and possibly sodium intake, while still providing adequate calcium intake. The impact of this diet on carbohydrate and bone parameters are only preliminary and need to be confirmed with RCTs. The Modification of Diet in Renal Disease study, the largest RCTs, failed to demonstrate a benefit in the primary outcome of the decline rate for the glomerular filtration rate. However, the design of this study was challenged and data were subsequently reanalyzed. However, when adherent patients were selected, with a rapid rate of progression and a long-term follow up, more recent meta-analysis and RCTs suggest that these diets can reduce the loss of the glomerular filtration rate in addition to the beneficial effects of renin-angiotensin-aldosterone system (RAAS) inhibitors. The current evidence suggests that KAs supplemented LPD diets should be included as part of the clinical recommendations for both the nutritional prevention and metabolic management of CKD. More research is needed to examine the effectiveness of KAs especially on uremic toxins. A reflection about the dose and composition of the KAs supplement, the cost-effective features, and their indication to reduce the frequency of dialysis needs to be completed.
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47
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Di Micco L, Di Lullo L, Bellasi A, Di Iorio BR. Very Low Protein Diet for Patients with Chronic Kidney Disease: Recent Insights. J Clin Med 2019; 8:jcm8050718. [PMID: 31137545 PMCID: PMC6572310 DOI: 10.3390/jcm8050718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/30/2022] Open
Abstract
Use of nutritional therapy (NT) in chronic kidney disease (CKD) patients is still debated among nephrologists, but it represents a fundamental point in the conservative treatment of CKD. It has been used for years and it has new goals today, such as (1) the reduction of edema, diuretics, and blood pressure values with a low sodium-content diet; (2) the dose reduction of phosphate levels and phosphate binders; (3) the administration of bicarbonate with vegetables in order to correct metabolic acidosis and delay CKD progression; (4) the reduction of the number and the doses of drugs and chemical substances; and (5) the lowering of urea levels, the cure of intestinal microbioma, and the reduction of cyanates levels (such as indoxyl-sulphate and p-cresol sulphate), which are the most recent known advantages achievable with NT. In conclusion, NT and especially very low protein diet (VLPD) have several beneficial effects in CKD patients and slows the progression of CKD.
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Affiliation(s)
- Lucia Di Micco
- Nefrology and Dialysis, AORN "San Giuseppe Moscati, 83100 Avellino AV, Italy.
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Rome, Italy.
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, 24127 Bergamo BG, Italy.
| | - Biagio R Di Iorio
- Nephrology and Dialysis, AORN "Antonio Cardarelli", 80131 Napoli, Italy.
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48
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Methionine Restriction Partly Recapitulates the Sympathetically Mediated Enhanced Energy Expenditure Induced by Total Amino Acid Restriction in Rats. Nutrients 2019; 11:nu11030707. [PMID: 30917593 PMCID: PMC6470753 DOI: 10.3390/nu11030707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022] Open
Abstract
Total amino acid (AA) restriction promotes hyperphagia and energy expenditure. We determined whether (i) methionine restriction mimics the effects of total AA restriction, (ii) methionine supplementation attenuates these responses, and iii) sympathetic signaling mediates such effects. Rats were injected with either vehicle (V) or 6-hydroxydopamine (S) to induce chemical sympathectomy, and then randomized to four diets: 16% AA (16AA), 5% AA (5AA), 16% AA-methionine (16AA-Met), and 5% AA+methionine (5AA+Met). Propranolol or ondansetron were injected to examine the role of sympathetic and serotonergic signaling, respectively. 5AA, 5AA+Met, and 16AA-Met increased the food conversion rate for 1–3 weeks in the V and S groups, and increased mean energy expenditure in V group,; the magnitude of these changes was attenuated in the S group. Propranolol decreased the energy expenditure of V16AA, V5AA, and V5AA+Met and of S5AA, S5AA+Met, and S16AA-Met, whereas ondansetron decreased the energy expenditure in only the S groups. Compared to 16AA, the other V groups had reduced body weights from days 7–11 onwards and decreased lean masses throughout the study and the other S groups had decreased body weights and lean masses from day 14 onwards. Total AA restriction enhanced the energy expenditure and reduced the weight and lean mass; these effects were partly recapitulated by methionine restriction and were sympathetically mediated.
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49
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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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50
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Attini R, Montersino B, Leone F, Minelli F, Fassio F, Rossetti MM, Colla L, Masturzo B, Barreca A, Menato G, Piccoli GB. Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature. J Clin Med 2019; 8:jcm8010123. [PMID: 30669543 PMCID: PMC6352283 DOI: 10.3390/jcm8010123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is increasingly reported in chronic kidney disease (CKD), reflecting higher awareness, improvements in materno-foetal care, and a more flexible attitude towards “allowing” pregnancy in the advanced stages of CKD. Success is not devoid of problems and an important grey area regards the indications for starting dialysis (by urea level, clinical picture, and residual glomerular filtration rate) and for dietary management. The present case may highlight the role of plant-based diets in dietary management in pregnant CKD women, aimed at retarding dialysis needs. The case. A 28-year-old woman, affected by glomerulocystic disease and unilateral renal agenesis, in stage-4 CKD, was referred at the 6th week of amenorrhea: she weighed 40 kg (BMI 16.3), was normotensive, had no sign of oedema, her serum creatinine was 2.73 mg/dL, blood urea nitrogen (BUN) 35 mg/dL, and proteinuria 200 mg/24 h. She had been on a moderately protein-restricted diet (about 0.8 g/kg/real body weight, 0.6 per ideal body weight) since childhood. Low-dose acetylsalicylate was added, and a first attempt to switch to a protein-restricted supplemented plant-based diet was made and soon stopped, as she did not tolerate ketoacid and aminoacid supplementation. At 22 weeks of pregnancy, creatinine was increased (3.17 mg/dL, BUN 42 mg/dL), dietary management was re-discussed and a plant-based non-supplemented diet was started. The diet was associated with a rapid decrease in serum urea and creatinine; this favourable effect was maintained up to the 33rd gestational week when a new rise in urea and creatinine was observed, together with signs of cholestasis. After induction, at 33 weeks + 6 days, she delivered a healthy female baby, adequate for gestational age (39th centile). Urea levels decreased after delivery, but increased again when the mother resumed her usual mixed-protein diet. At the child’s most recent follow-up visit (age 4 months), development was normal, with normal weight and height (50th–75th centile). In summary, the present case confirms that a moderate protein-restricted diet can be prescribed in pregnancies in advanced CKD without negatively influencing foetal growth, supporting the importance of choosing a plant-based protein source, and suggests focusing on the diet’s effects on microcirculation to explain these favourable results.
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Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Benedetta Montersino
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Filomena Leone
- Department of Surgery, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Fosca Minelli
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Federica Fassio
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Maura Maria Rossetti
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Loredana Colla
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Antonella Barreca
- Department of Medical Sciences, University of Torino, 10100 Torino, Italy.
| | - Guido Menato
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Giorgina Barbara Piccoli
- Department of Biological and Clinical Sciences, University of Torino, 10100 Torino, Italy.
- Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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