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Moon JS, Kang S, Choi JH, Lee KA, Moon JH, Chon S, Kim DJ, Kim HJ, Seo JA, Kim MK, Lim JH, Song YJ, Yang YS, Kim JH, Lee YB, Noh J, Hur KY, Park JS, Rhee SY, Kim HJ, Kim HM, Ko JH, Kim NH, Kim CH, Ahn J, Oh TJ, Kim SK, Kim J, Han E, Jin SM, Bae J, Jeon E, Kim JM, Kang SM, Park JH, Yun JS, Cha BS, Moon MK, Lee BW. 2023 Clinical Practice Guidelines for Diabetes Management in Korea: Full Version Recommendation of the Korean Diabetes Association. Diabetes Metab J 2024; 48:546-708. [PMID: 39091005 PMCID: PMC11307112 DOI: 10.4093/dmj.2024.0249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/20/2024] [Indexed: 08/04/2024] Open
Affiliation(s)
- Jun Sung Moon
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Shinae Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Han Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Kyung Ae Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Suk Chon
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Dae Jung Kim
- Department of Endocrinology and Metabolism, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ji A Seo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Mee Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Hyun Lim
- Department of Food Service and Nutrition Care, Seoul National University Hospital, Seoul, Korea
| | - Yoon Ju Song
- Department of Food Science and Nutrition, The Catholic University of Korea, Bucheon, Korea
| | - Ye Seul Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - You-Bin Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junghyun Noh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Suk Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hae Jin Kim
- Department of Endocrinology and Metabolism, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jung Hae Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Nam Hoon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chong Hwa Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Jeeyun Ahn
- Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Soo-Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jaehyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eugene Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Sang-Man Jin
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaehyun Bae
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Eonju Jeon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Ji Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seon Mee Kang
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jung Hwan Park
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jae-Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Bong-Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Kyong Moon
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Chinese Guidelines for Medical Nutrition Therapy for Patients with Diabetes (2022 Edition). Asia Pac J Clin Nutr 2024; 33:118-152. [PMID: 38794974 PMCID: PMC11170023 DOI: 10.6133/apjcn.202406_33(2).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/27/2024]
Abstract
Medical nutrition therapy (MNT) is the foundation of the comprehensive treatment of patients with diabetes. In 2010, the Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association developed the first Chinese guideline on MNT for patients with diabetes, and it was updated in 2015. Since then, new evidence has emerged in the field of MNT and metabolic therapy in patients with diabetes. The Nutrition and Metabolic Management Branch of the China International Exchange and Promotive Association for Medical and Health Care organized a team of experts from related institutions, including the Clinical Nutrition Branch of the Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutri-tion, and Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association. Their task was to develop the Chinese Guidelines of Medical Nutrition Therapy in Diabetes (2022 Edition) in accordance with the requirements of the Guidelines for the Formulation/Revision of Clinical Guidelines in China (2022 Edition) by combining the questions raised and evidence gathered in clinical practices in China, to guide and standardize the clinical MNT.
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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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Spahia N, Rroji M, Barbullushi M, Spasovski G. The Role of Protein Restriction in the Progression of Chronic Kidney Disease. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:53-63. [PMID: 37453111 DOI: 10.2478/prilozi-2023-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Even though nephrology has made much progress, reducing the progression of the chronic kidney disease remains, in fact, one of the biggest challenges. Long before the renal replacement therapy (RRT), it was known that limiting the protein could help almost all uremia symptoms. Although it was proposed as early as the 1960s, it only became widely used in the 1980s. By lowering the urea and other nitrogen wastes and lowering the metabolic acidosis, oxidative stress, and insulin resistance, limiting the amount of protein in your diet can help improve uremic symptoms. Also, limiting the protein in the diet positively controls the cardiovascular complications, including the arterial blood pressure and proteinuria reduction, which are risk factors for CKD progression. This mini-review examines the impact of protein restriction on the possibility of slowing CKD progression in depth.
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Affiliation(s)
- Nereida Spahia
- 1Department of Nephrology, University of Medicine, Tirana, Albania
| | - Merita Rroji
- 1Department of Nephrology, University of Medicine, Tirana, Albania
| | | | - Goce Spasovski
- 2University Clinic for Nephrology, Medical Faculty, University St. Cyril and Methodius, Skopje, RN Macedonia
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Jiang S, Fang J, Li W. Protein restriction for diabetic kidney disease. Cochrane Database Syst Rev 2023; 1:CD014906. [PMID: 36594428 PMCID: PMC9809923 DOI: 10.1002/14651858.cd014906.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Diabetic kidney disease (DKD) continues to be the leading cause of kidney failure across the world. For decades dietary protein restriction has been proposed for patients with DKD with the aim to retard the progression of chronic kidney disease (CKD) towards kidney failure. However, the relative benefits and harms of dietary protein restriction for slowing the progression of DKD have not been addressed. OBJECTIVES To determine the efficacy and safety of low protein diets (LPD) (0.6 to 0.8 g/kg/day) in preventing the progression of CKD towards kidney failure and in reducing the incidence of kidney failure and death (any cause) in adult patients with DKD. Moreover, the effect of LPD on adverse events (e.g. malnutrition, hyperglycaemic events, or health-related quality of life (HRQoL)) and compliance were also evaluated. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, 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 DKD not on dialysis were randomised to receive either a LPD (0.6 to 0.8 g/kg/day) or a usual or unrestricted protein diet (UPD) (≥ 1.0 g/kg/day) for at least 12 months. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data. Summary estimates of effect were obtained using a random-effects model. Results were summarised as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised MD (SMD) with 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified eight studies involving 486 participants with DKD. The prescribed protein intake in the intervention groups ranged from 0.6 to 0.8 g/kg/day. The prescribed protein intake in the control groups was ≥ 1.0 g/kg/day, or a calculated protein intake ≥ 1.0 g/kg/day if data on prescribed protein intake were not provided. The mean duration of the interventions was two years (ranging from one to five years). Risks of bias in most of the included studies were high or unclear, most notably for allocation concealment, performance and detection bias. All studies were considered to be at high risk for performance bias due to the nature of the interventions. Most studies were not designed to examine death or kidney failure. In low certainty evidence, a LPD may have little or no effect on death (5 studies, 358 participants: RR 0.38, 95% CI 0.10 to 1.44; I² = 0%), and the number of participants who reached kidney failure (4 studies, 287 participants: RR 1.16, 95% CI 0.38 to 3.59; I² = 0%). Compared to a usual or unrestricted protein intake, it remains uncertain whether a LPD slows the decline of glomerular filtration rate over time (7 studies, 367 participants: MD -0.73 mL/min/1.73 m²/year, 95% CI -2.3 to 0.83; I² = 53%; very low certainty evidence). It is also uncertain whether the restriction of dietary protein intake impacts on the annual decline in creatinine clearance (3 studies, 203 participants: MD -2.39 mL/min/year, 95% CI -5.87 to 1.08; I² = 53%). There was only one study reporting 24-hour urinary protein excretion. In very low certainty evidence, a LPD had uncertain effects on the annual change in proteinuria (1 study, 80 participants: MD 0.90 g/24 hours, 95% CI 0.49 to 1.31). There was no evidence of malnutrition in seven studies, while one study noted this condition in the LPD group. Participant compliance with a LPD was unsatisfactory in nearly half of the studies. One study reported LPD had no effect on HRQoL. No studies reported hyperglycaemic events. AUTHORS' CONCLUSIONS Dietary protein restriction has uncertain effects on changes in kidney function over time. However, it may make little difference to the risk of death and kidney failure. Questions remain about protein intake levels and compliance with protein-restricted diets. There are limited data on HRQoL and adverse effects such as nutritional measures and hyperglycaemic events. Large-scale pragmatic RCTs with sufficient follow-up are required for different stages of CKD.
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Affiliation(s)
- Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Jinying Fang
- China-Japan Friendship Institute of Clinical Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
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Klammer C, Schindler K, Bugl R, Plazek D, Vötter M, Kirchner T, Martino C, Klammer-Martin J, Brix J, Dämon S, Hoppichler F, Kautzky-Willer A, Kruschitz R, Toplak H, Clodi M, Ludvik B. [Nutrition for diabetic patients (Update 2023)]. Wien Klin Wochenschr 2023; 135:62-77. [PMID: 37101026 PMCID: PMC10133079 DOI: 10.1007/s00508-023-02170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
All patients with diabetes require individual and personalized nutritional consultation with professionals. The patient's needs should be the primary focus of the dietary therapy, taking their lifestyle and the type of diabetes into consideration. With the recommendations to the patient's diet, there need to be specific metabolic goals to reduce the disease's progression and to avoid long term health effects. Therefore, practical guidelines such as portion size and meal planning tips should be the main focus.According to the latest national and international standards, patients suffering from diabetes should have access to nutrition consulting and nutritional training. During consultation they can be supported on- how to manage their health condition and choosing food and beverage to improve their health.These practical recommendations sum up the latest literature on nutritional aspects of diabetes treatment.
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Affiliation(s)
- Carmen Klammer
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
- ICMR - Institute of Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Österreich
| | - Karin Schindler
- Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz, Wien, Österreich
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Rita Bugl
- Wiener Gesundheitsverband Klinik Ottakring, Wien, Österreich
| | | | | | - Tanja Kirchner
- Österreichische Gesundheitskasse Mein Peterhof Baden, Baden, Österreich
| | - Claudia Martino
- Österreichische Gesundheitskasse Mein Gesundheitszentrum Floridsdorf, Wien, Österreich
| | | | - Johanna Brix
- Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Sabine Dämon
- Special Institute for Preventive Cardiology and Nutrition, SIPCAN - Initiative für ein gesundes Leben, Elsbethen/Salzburg, Österreich
| | - Friedrich Hoppichler
- Special Institute for Preventive Cardiology and Nutrition, SIPCAN - Initiative für ein gesundes Leben, Elsbethen/Salzburg, Österreich
- Abteilung für Innere Medizin, Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Österreich
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Renate Kruschitz
- Abteilung für Innere Medizin, Krankenhaus der Elisabethinen, Klagenfurt, Österreich
| | - Hermann Toplak
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Martin Clodi
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich.
- ICMR - Institute of Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Österreich.
| | - Bernhard Ludvik
- Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
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Mottl AK, Alicic R, Argyropoulos C, Brosius FC, Mauer M, Molitch M, Nelson RG, Perreault L, Nicholas SB. KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD. Am J Kidney Dis 2022; 79:457-479. [PMID: 35144840 PMCID: PMC9740752 DOI: 10.1053/j.ajkd.2021.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/14/2022]
Abstract
In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.
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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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Apetrii M, Timofte D, Voroneanu L, Covic A. Nutrition in Chronic Kidney Disease-The Role of Proteins and Specific Diets. Nutrients 2021; 13:956. [PMID: 33809492 PMCID: PMC7999704 DOI: 10.3390/nu13030956] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health burden, needing comprehensive management for preventing and delaying the progression to advanced CKD. The role of nutritional therapy as a strategy to slow CKD progression and uremia has been recommended for more than a century. Although a consistent body of evidence suggest a benefit of protein restriction therapy, patients' adherence and compliance have to be considered when prescribing nutritional therapy in advanced CKD patients. Therefore, these prescriptions need to be individualized since some patients may prefer to enjoy their food without restriction, despite knowing the potential importance of dietary therapy in reducing uremic manifestations, maintaining protein-energy status.
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Affiliation(s)
- Mugurel Apetrii
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
| | - Daniel Timofte
- Surgical Department I, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Luminita Voroneanu
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
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Mihalache A, Garneata L, Mocanu CA, Simionescu TP, Mircescu G. Low-salt low-protein diet and blood pressure control in patients with advanced diabetic kidney disease and heavy proteinuria. Int Urol Nephrol 2021; 53:1197-1207. [PMID: 33389459 DOI: 10.1007/s11255-020-02717-2] [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: 08/28/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the associations between effects of low salt, low protein diet supplemented with keto-analogues (sLPD)-on salt intake, blood pressure (BP) and cardiovascular events (CVEs) in patients with advanced diabetic kidney disease (DKD) and heavy proteinuria. METHODS Prospective, single-center study (total duration of 15 months), enrolling 92 patients with advanced DKD (median eGFR 11.7 ml/min) and heavy proteinuria (median 4.8 g/g creatininuria). The intervention consisted in a low salt-low protein (0.6 g/kg-day) diet (sLPD) under intensive nutritional counselling, and adjustment of antihypertensive therapy. The endpoints of this sub-analysis were a salt intake ≤ 5 g/day, a mean blood pressure (MAP) ≤ 97 mmHg, corresponding to KDIGO target of 130/80 mmHg, and the rate of CVEs. RESULTS Salt intake decreased with 2.5 g/day and the proportion of patients reaching the salt intake endpoint increased with 58%. A salt intake ≤ 5 g/day was associated with a reduced MAP, BMI, proteinuria, fractional excretion of sodium, and eGFR, suggesting a salt-related volume contraction but was not related to protein intake. Mean arterial pressure decreased with 13 mmHg. MAP ≤ 97 mmHg was associated with lower proteinuria, salt, and protein intake, but the contribution of salt intake cannot be differentiated from that of protein intake. CVEs occurred in 20% of patients and were independently related to a lower age and MAP, and increased comorbidities. eGFR only minimally declined and no renal adverse events were noted. sLPD was nutritionally safe. CONCLUSIONS The multifactorial personalized intervention allowed a stable MAP reduction to KDIGO recommended levels (≤ 97 mmHg), related to the decrease in salt and protein intake. However, BP lower than 130/80 mmHg increased the cardiovascular but not the renal risk in heavy proteinuric patients with advanced DKD. TRIAL REGISTRATION NUMBER 0341507433: NCT03415074. Registered 02/02/2015 in US National Library of Medicine, ClinicalTrials.gov (NCT).
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Affiliation(s)
- Andreea Mihalache
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Liliana Garneata
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, 4 Calea Grivitei, Sector 1, 010731, Bucharest, Romania.
| | - Carmen Antonia Mocanu
- Department of Nephrology, Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Tudor-Petrisor Simionescu
- Department of Nephrology, Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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11
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Zhang PN, Zhou MQ, Guo J, Zheng HJ, Tang J, Zhang C, Liu YN, Liu WJ, Wang YX. Mitochondrial Dysfunction and Diabetic Nephropathy: Nontraditional Therapeutic Opportunities. J Diabetes Res 2021; 2021:1010268. [PMID: 34926696 PMCID: PMC8677373 DOI: 10.1155/2021/1010268] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022] Open
Abstract
Diabetic nephropathy (DN) is a progressive microvascular diabetic complication. Growing evidence shows that persistent mitochondrial dysfunction contributes to the progression of renal diseases, including DN, as it alters mitochondrial homeostasis and, in turn, affects normal kidney function. Pharmacological regulation of mitochondrial networking is a promising therapeutic strategy for preventing and restoring renal function in DN. In this review, we have surveyed recent advances in elucidating the mitochondrial networking and signaling pathways in physiological and pathological contexts. Additionally, we have considered the contributions of nontraditional therapy that ameliorate mitochondrial dysfunction and discussed their molecular mechanism, highlighting the potential value of nontraditional therapies, such as herbal medicine and lifestyle interventions, in therapeutic interventions for DN. The generation of new insights using mitochondrial networking will facilitate further investigations on nontraditional therapies for DN.
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Affiliation(s)
- Ping Na Zhang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Meng Qi Zhou
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Jing Guo
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Hui Juan Zheng
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Jingyi Tang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Chao Zhang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Yu Ning Liu
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
| | - Wei Jing Liu
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
- Institute of Nephrology and Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, China
| | - Yao Xian Wang
- Renal Research Institution of Beijing University of Chinese Medicine and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Shipping Warehouse No. 5, Beijing 100700, China
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12
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Li Q, Wen F, Wang Y, Li S, Lin S, Qi C, Chen Z, Qiu X, Zhang Y, Zhang S, Tao Y, Feng Z, Li Z, Li R, Ye Z, Liang X, Liu S, Xie J, Wang W. Diabetic Kidney Disease Benefits from Intensive Low-Protein Diet: Updated Systematic Review and Meta-analysis. Diabetes Ther 2021; 12:21-36. [PMID: 33150563 PMCID: PMC7843835 DOI: 10.1007/s13300-020-00952-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023] Open
Abstract
A dietary protein intake (DPI) of between 0.6 and 0.8 g protein per kilogram body weight per day (g/kg/day) is frequently recommended for adults with moderate-to-advanced chronic kidney disease (CKD). However, evidence on whether patients with diabetic kidney disease (DKD) actually benefit from a DPI of ≤ 0.8 g/kg/day and from a low-protein diet (LPD) at CKD stages 1-3 has not been consistent. We systematically searched MEDLINE, EMBASE, Cochrane Library, Web of Knowledge, as well as the bibliographies of articles identified in the search, for eligible randomized controlled trials that had investigated the effects of LPD (prescribed DPI < 0.8 g/kg/day) versus control diet on the progression of DKD. Nine trials that included 506 participants and follow-up periods varying from 4.5 to 60 months were included in the subsequent systematic review and meta-analysis. The data showed that patients with DKD who consumed < 0.8 g protein/kg/day had a significantly reduced decline in glomerular filtration rate (GFR) (mean difference [MD] 22.31 mL/min/1.73 m2, 95% confidence interval [CI] 17.19, 27.42; P < 0.01) and a significant decrease in proteinuria (standard mean difference [SMD] - 2.26 units, 95% CI - 2.99, - 1.52; P < 0.001) versus those on the control diet. The benefits of LPD to patients with DKD at CKD stages 1-3 were a markedly decreased proteinuria (SMD - 0.96 units, 95% CI - 1.81, - 0.11; P = 0.03) and slight but significant decreases in glycated hemoglobin (- 0.42%) and cholesterol levels (- 0.22 mmol/L). Our meta-analysis indicated that a DPI of < 0.8 g/kg/day was strongly associated with a slow decline in GFR and decreased proteinuria in the patients with DKD. Patients with CKD stages CKD 1-3 benefited from LPD in terms of a marked decrease of proteinuria and slight but significant improvements in lipid and glucose control.
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Affiliation(s)
- Qiuling Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, 515041, China
| | - Feng Wen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yanhui Wang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Sheng Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Shaochun Lin
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, 515041, China
| | - Chunfang Qi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Zujiao Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Xueqian Qiu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Yifan Zhang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Shaogui Zhang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Yiming Tao
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhonglin Feng
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhilian Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Ruizhao Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhiming Ye
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Xinling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Shuangxin Liu
- Division of Nephrology, 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, 510080, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Wenjian Wang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China.
- Shantou University Medical College, Shantou, 515041, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- School of Medicine, South China University of Technology, Guangzhou, 510006, China.
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13
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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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14
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Medical nutrition therapy and dietary counseling for patients with diabetes-energy, carbohydrates, protein intake and dietary counseling. Diabetol Int 2020; 11:224-239. [PMID: 32802703 DOI: 10.1007/s13340-020-00437-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 12/11/2022]
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15
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Kadowaki M, Kubota M, Watanabe R. Physiological Multifunctions of Rice Proteins of Endosperm and Bran. J Nutr Sci Vitaminol (Tokyo) 2020; 65:S42-S47. [PMID: 31619644 DOI: 10.3177/jnsv.65.s42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although it is considered a staple food, rice intake is under serious debate for its physiological usefulness, especially for diabetic patients, because of starch content. However, rice protein, the second major component of rice, has gained attention recently for its newly-discovered functions, which were previously unknown. Rice protein, a plant protein, shows multiple beneficial functions on lipid metabolism and diabetes and its complications, nephropathy, fatty liver and osteoporosis. Rice proteins of endosperm and bran, an ingredient of white rice and an unused product of brown rice, respectively, are valuable components for human health.
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Affiliation(s)
- Motoni Kadowaki
- Faculty of Agriculture, Niigata University.,Fuculty of Engineering, Niigata Institute of Technology
| | | | - Reiko Watanabe
- Department of Health and Nutrition, University of Niigata Prefecture
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16
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The Effects of Different Quantities and Qualities of Protein Intake in People with Diabetes Mellitus. Nutrients 2020; 12:nu12020365. [PMID: 32019211 PMCID: PMC7071151 DOI: 10.3390/nu12020365] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
The recommended amount and quality of protein in diets of diabetic patients are highly controversial. In order to provide evidence-based information, the Diabetes Nutrition Study Group (DNSG) used a grading procedure used for quality of evidence and strength of recommendations (GRADE). A protein intake of 10% to 20% of energy intake (E%) or about 0.8 to 1.3 g/kg body weight in people below 65 years of age, and 15% to 20% of E% in people above 65 years of age appeared safe in weight-stable conditions. There were no intervention studies addressing metabolic effects, mortality, or cardiovascular events over prolonged periods. Body weight is closely linked to metabolic control and high protein diets are often recommended. Weight-loss diets that include 23% to 32% of E% as protein for up to one year reduced blood pressure and body weight slightly but significantly more than lower protein diets, whereas blood lipids, fasting blood glucose, and HbA1c improved similarly with higher or lower protein intakes in participants with a glomerular filtration rate (GFR) >60 mL/min/1.73 m2. Patients with a GFR <60 mL/min/1.73 m2 did not show a faster decline of GFR or kidney function with protein intakes around 0.8 g/kg body weight as compared with lower intakes, thereby arguing against a restriction. The effects of protein intake on diabetic eye or nerve disease have not been reported. There are a number of studies that have compared different types of animal proteins (milk, chicken, beef, pork, and fish) or compared animal with plant protein in diabetic patients and have reported a greater reduction of serum cholesterol with plant protein. In summary, the suggested range of protein intake appears to be safe and can be adapted according to personal dietary preferences.
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17
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Lin CW, Chen IW, Lin YT, Chen HY, Hung SY. Association of unhealthy dietary behaviors with renal function decline in patients with diabetes. BMJ Open Diabetes Res Care 2020; 8:8/1/e000743. [PMID: 31958295 PMCID: PMC6954781 DOI: 10.1136/bmjdrc-2019-000743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/19/2019] [Accepted: 12/10/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Balanced nutrition is important for patients with diabetes, and nutrition might well influence diabetes-related complications, although there is limited evidence for this supposition at present. Consequently, we investigate the association between dietary behaviors and renal function decline among patients with diabetes. RESEARCH DESIGN AND METHODS From 2011 to 2013, a total of 2797 patients with type 2 diabetes participated in the Diabetes Shared Care Program at Chang Gung Memorial Hospital. All received nutritional consulting by dieticians and an eight-item list of unhealthy dietary behaviors, which included the excessive intake of carbohydrates, fats, protein, fruit, pickled foods, dessert and alcohol, as well as inadequate dietary vegetable. Estimated glomerular filtration rate (eGFR) decline ≥40% was defined as a surrogate end point for kidney damage. Independent dietary risk factors predicting poor renal outcomes were assessed. RESULTS Stable mean glycated hemoglobin (A1c) (7.78% to 7.75%, p=0.151), improved cholesterol (174.04 to 170.13 mg/dL, p<0.001) and low-density lipoprotein (104.19 to 98.07 mg/dL, p<0.001) were found in patients throughout 2 years of therapy. However, significant eGFR decline was noted (94.20 to 88.08 mL/min/1.73 m2, p<0.001). A total of 125 subjects had eGFR decline ≥40% and 2672 had stable renal progression.In regression analysis, 625 stable renal patients (selected via propensity score matching) and 125 subjects with eGFR decline ≥40% demonstrated excessive pickled foods to be predictive of poor renal outcomes (OR 1.861, 95% CI 1.230 to 2.814, p=0.003). CONCLUSIONS Our study suggests that excessive pickled foods deteriorate renal function more than other unhealthy dietary behaviors in patients with diabetes.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - I-Wen Chen
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Ying-Tzu Lin
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Hsin-Yun Chen
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
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18
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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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19
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Ookawara S, Kaku Y, Ito K, Kizukuri K, Namikawa A, Nakahara S, Horiuchi Y, Inose N, Miyahara M, Shiina M, Minato S, Shindo M, Miyazawa H, Hirai K, Hoshino T, Murakoshi M, Tabei K, Morishita Y. Effects of dietary intake and nutritional status on cerebral oxygenation in patients with chronic kidney disease not undergoing dialysis: A cross-sectional study. PLoS One 2019; 14:e0223605. [PMID: 31600287 PMCID: PMC6786594 DOI: 10.1371/journal.pone.0223605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/24/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Dietary management is highly important for the maintenance of renal function in patients with chronic kidney disease (CKD). Cerebral oxygen saturation (rSO2) was reportedly associated with the estimated glomerular filtration rate (eGFR) and cognitive function. However, data concerning the association between cerebral rSO2 and dietary intake of CKD patients is limited. METHODS This was a single-center observational study. We recruited 67 CKD patients not undergoing dialysis. Cerebral rSO2 was monitored using the INVOS 5100c oxygen saturation monitor. Energy intake was evaluated by dietitians based on 3-day meal records. Daily protein and salt intakes were calculated from 24-h urine collection. RESULTS Multivariable regression analysis showed that cerebral rSO2 was independently associated with energy intake (standardized coefficient: 0.370) and serum albumin concentration (standardized coefficient: 0.236) in Model 1 using parameters with p < 0.10 in simple linear regression analysis (body mass index, Hb level, serum albumin concentration, salt and energy intake) and confounding factors (eGFR, serum sodium concentration, protein intake), and the energy/salt index (standardized coefficient: 0.343) and Hb level (standardized coefficient: 0.284) in Model 2 using energy/protein index as indicated by energy intake/protein intake and energy/salt index by energy intake/salt intake in place of salt, protein and energy intake. CONCLUSIONS Cerebral rSO2 is affected by energy intake, energy/salt index, serum albumin concentration and Hb level. Sufficient energy intake and adequate salt restriction is important to prevent deterioration of cerebral oxygenation, which might contribute to the maintenance of cognitive function in addition to the prevention of renal dysfunction in CKD patients.
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Affiliation(s)
- Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshio Kaku
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kanako Kizukuri
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Aiko Namikawa
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shinobu Nakahara
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Horiuchi
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Nagisa Inose
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mayako Miyahara
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Michiko Shiina
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Miho Murakoshi
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Department of Internal Medicine, Minami-uonuma City Hospital, Niigata, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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20
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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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Abstract
Importance Chronic kidney disease (CKD) is the 16th leading cause of years of life lost worldwide. Appropriate screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse CKD-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. Observations Defined as a persistent abnormality in kidney structure or function (eg, glomerular filtration rate [GFR] <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 hours) for more than 3 months, CKD affects 8% to 16% of the population worldwide. In developed countries, CKD is most commonly attributed to diabetes and hypertension. However, less than 5% of patients with early CKD report awareness of their disease. Among individuals diagnosed as having CKD, staging and new risk assessment tools that incorporate GFR and albuminuria can help guide treatment, monitoring, and referral strategies. Optimal management of CKD includes cardiovascular risk reduction (eg, statins and blood pressure management), treatment of albuminuria (eg, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers), avoidance of potential nephrotoxins (eg, nonsteroidal anti-inflammatory drugs), and adjustments to drug dosing (eg, many antibiotics and oral hypoglycemic agents). Patients also require monitoring for complications of CKD, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia. Those at high risk of CKD progression (eg, estimated GFR <30 mL/min/1.73 m2, albuminuria ≥300 mg per 24 hours, or rapid decline in estimated GFR) should be promptly referred to a nephrologist. Conclusions and Relevance Diagnosis, staging, and appropriate referral of CKD by primary care clinicians are important in reducing the burden of CKD worldwide.
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Affiliation(s)
- Teresa K Chen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daphne H Knicely
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan E Grams
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
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22
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Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, Mitri J, Pereira RF, Rawlings K, Robinson S, Saslow L, Uelmen S, Urbanski PB, Yancy WS. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care 2019; 42:731-754. [PMID: 31000505 PMCID: PMC7011201 DOI: 10.2337/dci19-0014] [Citation(s) in RCA: 612] [Impact Index Per Article: 122.4] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Alison B Evert
- UW Neighborhood Clinics, UW Medicine, University of Washington, Seattle, WA
| | | | - Christopher D Gardner
- Stanford Diabetes Research Center and Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA
| | - W Timothy Garvey
- Diabetes Research Center, Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL
- Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | | | | | - Joanna Mitri
- Section on Clinical, Behavioral and Outcomes Research Lipid Clinic, Adult Diabetes Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | | | | | | | - Laura Saslow
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI
| | | | | | - William S Yancy
- Duke Diet and Fitness Center, Department of Medicine, Duke University Health System, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
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23
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Seki M, Nakayama M, Sakoh T, Yoshitomi R, Fukui A, Katafuchi E, Tsuda S, Nakano T, Tsuruya K, Kitazono T. Blood urea nitrogen is independently associated with renal outcomes in Japanese patients with stage 3-5 chronic kidney disease: a prospective observational study. BMC Nephrol 2019; 20:115. [PMID: 30940101 PMCID: PMC6444850 DOI: 10.1186/s12882-019-1306-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
Background Blood urea nitrogen (BUN) is one of the substances that affects the calculated serum osmolality (cSosm). A previous study demonstrated that BUN and cSosm were independently associated with the development of chronic kidney disease (CKD) in patients with preserved kidney function. In advanced CKD stages, there is a concomitant increase in cSosm and BUN levels. However, it remains unclear whether BUN or cSosm levels are related to renal outcomes in patients with moderate to severe kidney dysfunction. The aim of this study was to clarify whether the BUN or cSosm level is associated with kidney disease progression in patients with advanced CKD. Methods In this prospective study, we enrolled 459 patients with CKD (stages 3–5). The composite renal endpoint was end-stage renal disease (ESRD) or death, and ESRD alone was added as an alternative outcome. A Cox proportional hazards model was utilized to determine the risk factors for a poor renal outcome. We adjusted for covariates including estimated glomerular filtration rate (eGFR). The cSosm (mOsm/kg) was calculated using the following formula: (2 × sodium) + (BUN/2.8) + (glucose/18). Results During a median follow-up of 25.8 months, the renal endpoint was observed in 210 patients. Multivariable Cox analysis determined the hazard ratio (HR) [95% confidence interval (CI)] for the composite renal outcome in the second, third, and fourth BUN quartiles were 1.36 (0.72–2.58), 1.87 (0.95–3.66), and 2.66 (1.23–5.76) (P for trend < 0.01), respectively compared with the first BUN quartile. Conversely, by multivariable Cox analysis, the HRs (95% CIs) for poor outcomes in the second, third, and fourth cSosm quartiles, compared with the first cSosm quartile, were 1.13 (0.69–1.87), 0.95 (0.58–1.55), and 1.26 (0.78–2.03), respectively (P for trend = 0.39). In addition, with regard to the renal outcome of ESRD alone, higher BUN quartiles had a significantly increased risk for the outcome, but cSosm levels were not associated with the outcome. Conclusions Higher BUN levels, but not cSosm levels, were associated with adverse renal outcomes independent of the eGFR, suggesting that BUN may be a useful marker for predicting kidney disease progression. Electronic supplementary material The online version of this article (10.1186/s12882-019-1306-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Makiko Seki
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Masaru Nakayama
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Teppei Sakoh
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Ryota Yoshitomi
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Akiko Fukui
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Eisuke Katafuchi
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Susumu Tsuda
- Division of Nephrology and Clinical Research Institute, Department of Internal Medicine, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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24
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Mitchell NS, Scialla JJ, Yancy WS. Are low-carbohydrate diets safe in diabetic and nondiabetic chronic kidney disease? Ann N Y Acad Sci 2019; 1461:25-36. [PMID: 30644556 DOI: 10.1111/nyas.13997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/04/2018] [Accepted: 12/12/2018] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus and obesity both contribute to chronic kidney disease (CKD) and diabetic kidney disease (DKD), and they can accelerate the loss of kidney function. Dietary intake can potentially have wide-reaching effects on the risk of CKD/DKD and their progression by reducing weight and blood pressure, improving glycemic control, reducing hyperfiltration, and modulating inflammation. Low-carbohydrate (LC) diets can reduce weight and improve glycemic control, but the relatively higher protein content also raises concern in CKD/DKD. Empiric evidence supporting the kidney-related benefits or risks of LC diets is needed to understand the balance of these potential harms and benefits for patients with DKD and is the subject of our review.
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Affiliation(s)
- Nia S Mitchell
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Duke Diet and Fitness Center, Duke University Health System, Durham, North Carolina
| | - Julia J Scialla
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - William S Yancy
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Duke Diet and Fitness Center, Duke University Health System, Durham, North Carolina.,Department of Veterans Affairs, Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina
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25
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Postprandial Glycaemic, Hormonal and Satiety Responses to Rice and Kiwifruit Preloads in Chinese Adults: A Randomised Controlled Crossover Trial. Nutrients 2018; 10:nu10081110. [PMID: 30126094 PMCID: PMC6116117 DOI: 10.3390/nu10081110] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 11/22/2022] Open
Abstract
Controlling postprandial glycaemia helps to prevent and manage non-communicable diseases. One strategy in controlling glycaemia may be to consume meals in two parts; a preload, followed by the remainder of the meal. Our aim was to test preloading a rice meal given for breakfast and lunch on different days, either by splitting the meal (rice preload followed by rice meal) or by using kiwifruit as a preload compared with consuming the rice meal in one sitting. Primary outcomes were glycaemic and insulinaemic responses with secondary outcomes of other hormonal responses, subjective satiety, and subsequent energy intake. Following breakfast, postprandial glycaemic peak concentration was 0.9 (95% CI: 0.2, 1.6) mmol/L lower for the kiwifruit preload compared with the rice meal eaten in one sitting. Following lunch, glycaemic peak concentrations were 1.0 (0.7, 1.4) and 1.1 (0.5, 1.7) mmol/L lower for the rice-split and kiwifruit preload compared with the rice meal alone, respectively. Postprandial insulinaemia area-under-the-curve was 1385 (87, 2684) mU/L·min less for the kiwifruit preload compared with the rice-split. There were no differences among treatments for subsequent energy intake. Meal splitting is useful for lowering postprandial glycaemia, and replacing part of a meal with kiwifruit may help with insulin efficiency without detriment to subsequent energy intake.
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26
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Zhu HG, Jiang ZS, Gong PY, Zhang DM, Zou ZW, Qian-Zhang, Ma HM, Guo ZG, Zhao JY, Dong JJ, Lin-Liao. Efficacy of low-protein diet for diabetic nephropathy: a systematic review of randomized controlled trials. Lipids Health Dis 2018; 17:141. [PMID: 29914534 PMCID: PMC6006775 DOI: 10.1186/s12944-018-0791-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 05/28/2018] [Indexed: 11/29/2022] Open
Abstract
Background A low-protein diet (LPD) is believed to be beneficial in slowing the progression of kidney disease. It is reported that low protein diet can improve protein, sugar and lipid metabolism, and reduce the symptoms and complications of renal insufficiency. However, there has been controversial regarding the effects of protein restriction on diabetic nephropathy (DN). Objective To investigate the efficacy of LPD on renal function in patients with type 1 or 2 DN by meta-analysis of randomized controlled trials (RCTs). Design PubMed, MEDLINE, EMBASE and China National Knowledge Infrastructure databases were searched. Eleven randomized controlled trials met the inclusion criteria, of which 10 were English and 1 was Chinese. The primary outcome was a change in glomerular filtration rate (GFR). The secondary outcome was a change in proteinuria. Random-effects models were used to calculate the standardized mean difference (SMD) and the corresponding 95% confidence intervals (CI). Subgroup analyses were also performed. Results Our research indicated that LPD was not associated with a significant improvement in GFR (1.59 ml · min−1 · 1.73 m−2, 95% CI -0.57, 3.75, I2 = 76%; p = 0.15). This effect was consistent across the subgroups regardless of type of diabetes, course of diabetes and intervention period. Our results also showed that there was no significant difference on improvement of proteinuria in patients of LPD and those in normal-protein diet groups (− 0.48, 95%CI-1.70, 0.74, I2 = 94%, p = 0.44). Subgroup analysis revealed that LPD resulted in increased excretion of proteinuria in patients with type 2 diabetes (1.32, 95% CI 0.17, 2.47, I2 = 86%, p = 0.02). Conclusion The present research showed that LPD was not significantly associated with improvement of renal function in patients with either type 1 or 2 diabetic nephropathy. Although these results do not completely eliminate the possibility that LPD is beneficial for patients with diabetic nephropathy, it does not seem to be significant benefit to renal function.
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Affiliation(s)
- Huan-Gao Zhu
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhao-Shun Jiang
- Division of Endocrinology, The General Hospital of Jinan Military Command, 25 Shifan Road, Jinan, 250031, Shandong, China
| | - Pi-Yun Gong
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Dong-Mei Zhang
- Division of Endocrinology, The Ninth Hospital of Xi An, Shan xi, China
| | - Zhi-Wei Zou
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Qian-Zhang
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Hui-Mei Ma
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhen-Gang Guo
- Internal medicine department, Guanxian hospital of traditional Chinese medicine, Liaocheng, Shandong, China
| | - Jun-Yu Zhao
- Division of Endocrinology, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Jian-Jun Dong
- Division of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Lin-Liao
- Division of Endocrinology, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China.
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27
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Kitada M, Ogura Y, Monno I, Koya D. A Low-Protein Diet for Diabetic Kidney Disease: Its Effect and Molecular Mechanism, an Approach from Animal Studies. Nutrients 2018; 10:nu10050544. [PMID: 29702558 PMCID: PMC5986424 DOI: 10.3390/nu10050544] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 12/15/2022] Open
Abstract
A low-protein diet (LPD) can be expected to retard renal function decline in advanced stages of chronic kidney disease (CKD), including diabetic kidney disease (DKD), and is recommended in a clinical setting. Regarding the molecular mechanisms of an LPD against DKD, previous animal studies have shown that an LPD exerts reno-protection through mainly the improvement of glomerular hyperfiltration/hypertension due to the reduction of intraglomerular pressure. On the other hand, we have demonstrated that an LPD, particularly a very-LPD (VLPD), improved tubulo-interstitial damage, inflammation and fibrosis, through the restoration of autophagy via the reduction of a mammalian target of rapamycin complex 1 (mTORC1) activity in type 2 diabetes and obesity animal models. Thus, based on animal studies, a VLPD may show a more beneficial effect against advanced DKD. Previous clinical reports have also shown that a VLPD, not a moderate LPD, slows the progression of renal dysfunction in patients with chronic glomerular nephritis. However, there is insufficient clinical data regarding the beneficial effects of a VLPD against DKD. Additionally, the patients with CKD, including DKD, are a high-risk group for malnutrition, such as protein–energy wasting (PEW), sarcopenia, and frailty. Therefore, an LPD, including a VLPD, should be prescribed to patients when the benefits of an LPD outweigh the risks, upon consideration of adherence, age, and nutritional status. As the future predicts, the development of a VLPD replacement therapy without malnutrition may be expected for reno-protection against the advanced stages of DKD, through the regulation of mTORC1 activity and adequate autophagy induction. However, further studies to elucidate detailed mechanisms by which a VLPD exerts reno-protection are necessary.
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Affiliation(s)
- Munehiro Kitada
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Yoshio Ogura
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Itaru Monno
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan.
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28
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A low-protein diet exerts a beneficial effect on diabetic status and prevents diabetic nephropathy in Wistar fatty rats, an animal model of type 2 diabetes and obesity. Nutr Metab (Lond) 2018; 15:20. [PMID: 29507597 PMCID: PMC5833106 DOI: 10.1186/s12986-018-0255-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 02/26/2018] [Indexed: 12/15/2022] Open
Abstract
Background The objective of this study is to investigate the effects of a low-protein diet (LPD) starting from a young age on diabetic status and renal injury in a rat model of type 2 diabetes and obesity. Methods Diabetic male Wistar fatty (fa/fa) rats (WFRs) were fed a standard diet (23.84% protein) or an LPD (5.77% protein) for 24 weeks beginning at 6 weeks of age. We investigated the effects of the LPD on total body weight (BW); fat weight (FW); lower-limb muscle weight (MW); several measures of diabetic status, including fasting/random glucose levels, HOMA-IR and the IPITT; and renal injuries, including renal hypertrophy, albuminuria and histological changes. Additionally, autophagy and activation of mTORC1 were evaluated in the diabetic renal cortex. Furthermore, plasma FGF21 and high-molecular-weight (HMW) adiponectin levels, as well as UCP1 expression levels in brown adipose tissue (BAT), were evaluated. Results Increases in BW and FW in WFRs were significantly reduced by the LPD, and the LPD resulted in a significant reduction of lower-limb MW in WFRs. The LPD suppressed the elevation of glucose levels in WFRs through improvement of insulin resistance. The LPD also elevated the plasma FGF21 and HMW adiponectin of WFRs, as well as UCP1 expression in the BAT of the animals. Renal hypertrophy, albuminuria, renal histological changes, and increased expression of p62 and phospho-S6 ribosomal protein (p-S6RP) were observed in WFRs compared with the values from WLRs. The LPD clearly prevented the diabetic kidneys from sustaining any damage. Conclusions The LPD prevented the progression of diabetic status; this effect may have been associated with the reduction of FW and the elevation of plasma FGF21 and HMW adiponectin, as well as UCP1 expression in BAT, resulting in suppression of diabetic nephropathy. However, MW was decreased in rats by the consumption of an LPD from a young age; therefore, further research is needed to resolve the nutritional issue of LPD on decreasing in MW.
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29
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Sabatino A, Regolisti G, Gandolfini I, Delsante M, Fani F, Gregorini MC, Fiaccadori E. Diet and enteral nutrition in patients with chronic kidney disease not on dialysis: a review focusing on fat, fiber and protein intake. J Nephrol 2017; 30:743-754. [PMID: 28884267 DOI: 10.1007/s40620-017-0435-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
The clinical data available on dietary requirements of patients with chronic kidney disease (CKD) not on dialysis are limited and largely inconclusive in terms of the renal, cardiovascular and nutritional outcomes achievable through dietary modifications. Restriction of protein intake during the early stages of CKD may in fact slow its progression, but at the same time this approach may also lead to protein-energy wasting, if energy intake is not adequate and properly monitored. Unfortunately, compliance to dietary recommendations is traditionally low in this patient population. A switch from saturated to mono- and polyunsaturated fats is generally recognized as advantageous for cardiac health; however, the benefits in term of renal function are largely unknown. Similarly, the association between dietary fiber intake and kidney disease is largely unknown. In fact, while there is evidence on the positive health effects of dietary fibers in the general population, nutritional guidelines for CKD lack formal recommendations concerning fiber intake. This paper reviews data and evidence from clinical trials and meta-analyses on renal and cardiovascular outcomes related to modifications in protein, fat and fiber intake. Suggestions for maintaining nutritional status through patient-oriented dietary patterns and enteral supplementation in CKD patients on conservative therapy are also presented.
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Affiliation(s)
- Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Giuseppe Regolisti
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Ilaria Gandolfini
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Marco Delsante
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Filippo Fani
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy. .,Postgraduate School of Nephrology, University of Parma, Parma, Italy.
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30
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Metzger M, Yuan WL, Haymann JP, Flamant M, Houillier P, Thervet E, Boffa JJ, Vrtovsnik F, Froissart M, Bankir L, Fouque D, Stengel B. Association of a Low-Protein Diet With Slower Progression of CKD. Kidney Int Rep 2017; 3:105-114. [PMID: 29340320 PMCID: PMC5762958 DOI: 10.1016/j.ekir.2017.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 06/21/2017] [Accepted: 08/07/2017] [Indexed: 01/17/2023] Open
Abstract
Introduction Reducing protein intake is recommended for slowing chronic kidney disease (CKD) progression, but assessment of its true effectiveness is sparse. Methods Using the Maroni formula, we assessed dietary protein intake (DPI) from 24-hour urinary urea excretion in 1594 patients (67% men and 33% women) with CKD, 784 of whom also had 7-day food records. Cause-specific hazard ratios (HRs) and 95% confidence intervals for the competing risks of DPI-associated end-stage renal disease (ESRD) or death were estimated in 1412 patients with baseline glomerular filtration rate ≥15 ml/min per 1.73 m2, measured by 51Cr-EDTA renal clearance (mGFR). Results Overall, mean DPI estimated from urea excretion was 1.09 ± 0.30 g/kg of body weight per day (range = 0.34-2.76); 20% of patients had values > 1.3 g/kg per day, and 1.9% had values < 0.6 g/kg per day. Urea excretion and food records produced similar estimates of mean DPI. The lower the mGFR, the lower the mean DPI. Over a median follow-up of 5.6 years, there were 319 ESRD events and 189 pre-ESRD deaths. After adjusting for relevant covariates, each 0.1 g/kg daily higher baseline urea excretion-based DPI or food record-based DPI was associated with an HR for ESRD of 1.05 (95% confidence interval 1.01-1.10) or 1.09 (95% confidence interval 1.04-1.14), respectively. HRs were stronger in patients with baseline mGFR < 30 ml/min per 1.73 m2. There was no association with mortality. The mean age of the patients was 59 ± 15 years, and mean body mass index was 26.6 ± 5.2 kg/m2. Conclusion In this prospective observational study, the lower the baseline DPI, the slower the progression toward ESRD. Most importantly, the absence of threshold for the relation between DPI and ESRD risk indicates that there is no optimal DPI in the range observed in this cohort.
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Affiliation(s)
- Marie Metzger
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
| | - Wen Lun Yuan
- Centre des Sciences du Goût et de l’Alimentation, Centre National de la Recherche Scientifique, Institut National de la Recherche Agronomique, University of Bourgogne Franche-Comté, Dijon, France
- Centre de Recherche Épidémiologie et Statistique Sorbonne, Inserm, University of Paris-Descartes, Villejuif, France
| | - Jean-Philippe Haymann
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
- Inserm Unité mixte de recherche scientifique, 1155, University Pierre et Marie-Curie, Paris, France
| | - Martin Flamant
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Centre de Recherche sur l’Inflammation, Inserm, Université Paris-Diderot, Paris, France
| | - Pascal Houillier
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- Inserm Unité mixte de recherche scientifique, 1138, Centre de Recherche des Cordeliers, Paris, 75006, France
- University Paris Descartes, Paris, France
| | - Eric Thervet
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- Paris Centre de Recherche Cardiovasculaire, Inserm, University of Paris-Descartes, Paris, France
| | - Jean-Jacques Boffa
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
- Inserm Unité mixte de recherche scientifique, 1155, University Pierre et Marie-Curie, Paris, France
| | - François Vrtovsnik
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Centre de Recherche sur l’Inflammation, Inserm, Université Paris-Diderot, Paris, France
| | - Marc Froissart
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
- Centre hospitalier universitaire vaudois/University of Lausanne, Centre de Recherche Clinique, Lausanne, Switzerland
| | - Lise Bankir
- Inserm Unité mixte de recherche scientifique, 1138, Centre de Recherche des Cordeliers, Paris, 75006, France
| | - Denis Fouque
- Centre Hospitalier Lyon Sud, Pierre-Bénite, France
- Laboratoire Cardiovasculaire, Métabolisme, Diabétologie et Nutrition, Unité mixte de recherche scientifique, 1060, Inserm, University Lyon-Sud, Oullins, France
| | - Bénédicte Stengel
- Centre de recherches en Epidémiologie et Santé des Populations, Inserm, University of Paris-Sud, University of Versailles Saint-Quentin, University of Paris-Saclay, Villejuif, France
- Correspondence: Bénédicte Stengel, Inserm U1018, CESP, Team 5, 16, avenue P. Vaillant Couturier, F-94807, Villejuif, France.Inserm U1018CESPTeam 5, 16, avenue P. Vaillant Couturier, F-94807VillejuifFrance
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Ko GJ, Kalantar-Zadeh K, Goldstein-Fuchs J, Rhee CM. Dietary Approaches in the Management of Diabetic Patients with Kidney Disease. Nutrients 2017; 9:E824. [PMID: 28758978 PMCID: PMC5579617 DOI: 10.3390/nu9080824] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is one of the most prevalent complications of diabetes, and patients with diabetic kidney disease (DKD) have a substantially higher risk of cardiovascular disease and death compared to their non-diabetic CKD counterparts. In addition to pharmacologic management strategies, nutritional and dietary interventions in DKD are an essential aspect of management with the potential for ameliorating kidney function decline and preventing the development of other end-organ complications. Among DKD patients with non-dialysis dependent CKD, expert panels recommend lower dietary protein intake of 0.8 g/kg of body weight/day, while higher dietary protein intake (>1.2 g/kg of body weight/day) is advised among diabetic end-stage renal disease patients receiving maintenance dialysis to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Carbohydrates from sugars should be limited to less than 10% of energy intake, and it is also suggested that higher polyunsaturated and monounsaturated fat consumption in lieu of saturated fatty acids, trans-fat, and cholesterol are associated with more favorable outcomes. While guidelines recommend dietary sodium restriction to less than 1.5-2.3 g/day, excessively low sodium intake may be associated with hyponatremia as well as impaired glucose metabolism and insulin sensitivity. As patients with advanced DKD progressing to end-stage renal disease may be prone to the "burnt-out diabetes" phenomenon (i.e., spontaneous resolution of hypoglycemia and frequent hypoglycemic episodes), further studies in this population are particularly needed to determine the safety and efficacy of dietary restrictions in this population.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
- Department of Internal Medicine, Korea University, School of Medicine, Seoul 08308, Korea.
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
- Department of Medicine, Tibor Rubin Veteran Affairs Health System, Long Beach, CA 90822, USA.
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, USA.
| | - Jordi Goldstein-Fuchs
- Sierra Nevada Nephrology Consultants, Reno, NV 89511, USA.
- Department of Internal Medicine, University of Nevada Reno, School of Medicine, Reno, NV 89557, USA.
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA 92868, USA.
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Hanafusa N, Lodebo BT, Kopple JD. Current Uses of Dietary Therapy for Patients with Far-Advanced CKD. Clin J Am Soc Nephrol 2017; 12:1190-1195. [PMID: 28228464 PMCID: PMC5498353 DOI: 10.2215/cjn.09340916] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
For several decades, inquiry concerning dietary therapy for nondialyzed patients with CKD has focused mainly on its capability to retard progression of CKD. However, several studies published in recent years indicate that, independent of whether diet can delay progression of CKD, well designed low-protein diets may provide a number of benefits for people with advanced CKD who are close to requiring or actually in need of RRT. Dietary therapy may both maintain good nutritional status and safely delay the need for chronic dialysis in such patients, offering the possibility of improving quality of life and reducing health care costs. With the growing interest in incremental dialysis, dietary therapy may enable lower doses of dialysis to be safely and effectively used, even as GFR continues to decrease. Such combinations of dietary and incremental dialysis therapy might slow the rate of loss of residual GFR, possibly reduce mortality in patients with advanced CKD, improve quality of life, and also, reduce health care costs. The amount of evidence that supports these possibilities is limited, and more well designed, randomized clinical trials are clearly indicated.
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Affiliation(s)
- Norio Hanafusa
- Department of Blood Purification, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
| | - Bereket Tessema Lodebo
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Joel D. Kopple
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance, California
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; and
- UCLA Fielding School of Public Health, Los Angeles, California
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33
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Palmer SC, Maggo JK, Campbell KL, Craig JC, Johnson DW, Sutanto B, Ruospo M, Tong A, Strippoli GFM. Dietary interventions for adults with chronic kidney disease. Cochrane Database Syst Rev 2017; 4:CD011998. [PMID: 28434208 PMCID: PMC6478277 DOI: 10.1002/14651858.cd011998.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dietary changes are routinely recommended in people with chronic kidney disease (CKD) on the basis of randomised evidence in the general population and non-randomised studies in CKD that suggest certain healthy eating patterns may prevent cardiovascular events and lower mortality. People who have kidney disease have prioritised dietary modifications as an important treatment uncertainty. OBJECTIVES This review evaluated the benefits and harms of dietary interventions among adults with CKD including people with end-stage kidney disease (ESKD) treated with dialysis or kidney transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register (up to 31 January 2017) through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-randomised RCTs of dietary interventions versus other dietary interventions, lifestyle advice, or standard care assessing mortality, cardiovascular events, health-related quality of life, and biochemical, anthropomorphic, and nutritional outcomes among people with CKD. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion and extracted data. Results were summarised as risk ratios (RR) for dichotomous outcomes or mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI) or in descriptive format when meta-analysis was not possible. Confidence in the evidence was assessed using GRADE. MAIN RESULTS We included 17 studies involving 1639 people with CKD. Three studies enrolled 341 people treated with dialysis, four studies enrolled 168 kidney transplant recipients, and 10 studies enrolled 1130 people with CKD stages 1 to 5. Eleven studies (900 people) evaluated dietary counselling with or without lifestyle advice and six evaluated dietary patterns (739 people), including one study (191 people) of a carbohydrate-restricted low-iron, polyphenol enriched diet, two studies (181 people) of increased fruit and vegetable intake, two studies (355 people) of a Mediterranean diet and one study (12 people) of a high protein/low carbohydrate diet. Risks of bias in the included studies were generally high or unclear, lowering confidence in the results. Participants were followed up for a median of 12 months (range 1 to 46.8 months).Studies were not designed to examine all-cause mortality or cardiovascular events. In very-low quality evidence, dietary interventions had uncertain effects on all-cause mortality or ESKD. In absolute terms, dietary interventions may prevent one person in every 3000 treated for one year avoiding ESKD, although the certainty in this effect was very low. Across all 17 studies, outcome data for cardiovascular events were sparse. Dietary interventions in low quality evidence were associated with a higher health-related quality of life (2 studies, 119 people: MD in SF-36 score 11.46, 95% CI 7.73 to 15.18; I2 = 0%). Adverse events were generally not reported.Dietary interventions lowered systolic blood pressure (3 studies, 167 people: MD -9.26 mm Hg, 95% CI -13.48 to -5.04; I2 = 80%) and diastolic blood pressure (2 studies, 95 people: MD -8.95, 95% CI -10.69 to -7.21; I2 = 0%) compared to a control diet. Dietary interventions were associated with a higher estimated glomerular filtration rate (eGFR) (5 studies, 219 people: SMD 1.08; 95% CI 0.26 to 1.97; I2 = 88%) and serum albumin levels (6 studies, 541 people: MD 0.16 g/dL, 95% CI 0.07 to 0.24; I2 = 26%). A Mediterranean diet lowered serum LDL cholesterol levels (1 study, 40 people: MD -1.00 mmol/L, 95% CI -1.56 to -0.44). AUTHORS' CONCLUSIONS Dietary interventions have uncertain effects on mortality, cardiovascular events and ESKD among people with CKD as these outcomes were rarely measured or reported. Dietary interventions may increase health-related quality of life, eGFR, and serum albumin, and lower blood pressure and serum cholesterol levels.Based on stakeholder prioritisation of dietary research in the setting of CKD and preliminary evidence of beneficial effects on risks factors for clinical outcomes, large-scale pragmatic RCTs to test the effects of dietary interventions on patient outcomes are required.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Jasjot K Maggo
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Katrina L Campbell
- Bond UniversityFaculty of Health Science and Medicine2 Promenthean WayRobinaQueenslandAustralia4226
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of Nephrology199 Ipswich RdWoolloongabbaQueenslandAustralia4102
| | - Bernadet Sutanto
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadNSWAustralia2145
| | - Marinella Ruospo
- DiaverumMedical Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineVia Solaroli 17NovaraItaly28100
| | - Allison Tong
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum AcademyBariItaly
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Snelson M, Clarke RE, Coughlan MT. Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD? Nutrients 2017; 9:nu9030265. [PMID: 28287463 PMCID: PMC5372928 DOI: 10.3390/nu9030265] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/27/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023] Open
Abstract
Diet is one of the largest modifiable risk factors for chronic kidney disease (CKD)-related death and disability. CKD is largely a progressive disease; however, it is increasingly appreciated that hallmarks of chronic kidney disease such as albuminuria can regress over time. The factors driving albuminuria resolution remain elusive. Since albuminuria is a strong risk factor for GFR loss, modifiable lifestyle factors that lead to an improvement in albuminuria would likely reduce the burden of CKD in high-risk individuals, such as patients with diabetes. Dietary therapy such as protein and sodium restriction has historically been used in the management of CKD. Evidence is emerging to indicate that other nutrients may influence kidney health, either through metabolic or haemodynamic pathways or via the modification of gut homeostasis. This review focuses on the role of diet in the pathogenesis and progression of CKD and discusses the latest findings related to the mechanisms of diet-induced kidney disease. It is possible that optimizing diet quality or restricting dietary intake could be harnessed as an adjunct therapy for CKD prevention or progression in susceptible individuals, thereby reducing the burden of CKD.
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Affiliation(s)
- Matthew Snelson
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
| | - Rachel E Clarke
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
- Department of Physiology, Monash University, Clayton 3800, Australia.
| | - Melinda T Coughlan
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
- Department of Diabetes, Central Clinical School, Monash University, Alfred Medical Research and Education Precinct, Melbourne 3004, Australia.
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Abstract
PURPOSE OF REVIEW The goal of this review is to present an overview of the evidence on the effectiveness of plant-based diets in delaying progression of diabetic kidney disease (DKD). RECENT FINDINGS The ideal quantity of dietary protein has been a controversial topic for patients with DKD. Smaller studies have focused on protein source, plant versus animal, for preventing progression. Limited evidence suggests that dietary patterns that focus on plant-based foods, those that are lower in processed foods, or those that are lower in advanced glycation end products (AGE) may be useful in prevention of DKD progression. Increasing plant-based foods, incorporating diet patterns that limit processed foods, or potentially lowering AGE contents in diets may be beneficial for dietary management of DKD. However, dietary studies specifically targeted at DKD treatment are sparse. Further, large trials powered to assess outcomes including changes in kidney function, end-stage kidney disease, and mortality are needed to provide more substantial evidence for these diets.
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Affiliation(s)
- Ranjani N Moorthi
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
| | - Colby J Vorland
- Department of Nutrition Science, Purdue University, 700 West State Street, West Lafayette, IN, 47907, USA
| | - Kathleen M Hill Gallant
- Department of Nutrition Science, Purdue University, 700 West State Street, West Lafayette, IN, 47907, USA
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Kelly JT, Palmer SC, Wai SN, Ruospo M, Carrero JJ, Campbell KL, Strippoli GFM. Healthy Dietary Patterns and Risk of Mortality and ESRD in CKD: A Meta-Analysis of Cohort Studies. Clin J Am Soc Nephrol 2017; 12:272-279. [PMID: 27932391 PMCID: PMC5293335 DOI: 10.2215/cjn.06190616] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/19/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD are advised to follow dietary recommendations that restrict individual nutrients. Emerging evidence indicates overall eating patterns may better predict clinical outcomes, however, current data on dietary patterns in kidney disease are limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This systematic review aimed to evaluate the association between dietary patterns and mortality or ESRD among adults with CKD. Medline, Embase, and reference lists were systematically searched up to November 24, 2015 by two independent review authors. Eligible studies were longitudinal cohort studies reporting the association of dietary patterns with mortality, cardiovascular events, or ESRD. RESULTS A total of seven studies involving 15,285 participants were included. Healthy dietary patterns were generally higher in fruit and vegetables, fish, legumes, cereals, whole grains, and fiber, and lower in red meat, salt, and refined sugars. In six studies, healthy dietary patterns were consistently associated with lower mortality (3983 events; adjusted relative risk, 0.73; 95% confidence interval, 0.63 to 0.83; risk difference of 46 fewer (29-63 fewer) events per 1000 people over 5 years). There was no statistically significant association between healthy dietary patterns and risk of ESRD (1027 events; adjusted relative risk, 1.04; 95% confidence interval, 0.68 to 1.40). CONCLUSIONS Healthy dietary patterns are associated with lower mortality in people with kidney disease. Interventions to support adherence to increased fruit and vegetable, fish, legume, whole grain, and fiber intake, and reduced red meat, sodium, and refined sugar intake could be effective tools to lower mortality in people with kidney disease.
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Affiliation(s)
- Jaimon T. Kelly
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Suetonia C. Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Shu Ning Wai
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Marinella Ruospo
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Alessandria, Italy
- Diaverum Academy, Lund, Sweden
| | - Juan-Jesus Carrero
- Division of Renal Medicine, Department of Clinical Science, Intervention and technology, Karolinska Institutet, Huddinge, Sweden
| | - Katrina L. Campbell
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Giovanni F. M. Strippoli
- Diaverum Academy, Lund, Sweden
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy. Diaverum Academy, Sweden; and
- Sydney School of Public Health, University of Sydney, New South Wales, Australia
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Almario RU, Buchan WM, Rocke DM, Karakas SE. Glucose-lowering effect of whey protein depends upon clinical characteristics of patients with type 2 diabetes. BMJ Open Diabetes Res Care 2017; 5:e000420. [PMID: 28761664 PMCID: PMC5530249 DOI: 10.1136/bmjdrc-2017-000420] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/28/2017] [Accepted: 05/29/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Whey protein (WP) intake has been shown to reduce postprandial glycemia. Majority of WP research in type 2 diabetes (T2DM) involved acute challenge or weight loss studies. It is not known if WP supplementation can provide sustained glucose lowering. Our goal was to investigate the effects of WP on glycemia comprehensively by using continuous glucose monitoring (CGM) while avoiding the confounding effects of variable food intake through controlled feeding. RESEARCH DESIGN AND METHODS This double-blinded and placebo (PL)-controlled study included 22 patients with T2DM patients (11 male, 11 female; age 57.1±12.6 years) on diet or metformin monotherapy. First, one serving (21 g) of WP was compared with PL in parallel-armed acute challenge studies. Next, in a crossover design, each patient underwent CGM twice, over 2 consecutive weeks, 3.5 days each week. Identical diets were provided by the study during both CGM periods. During the first CGM, one serving of either WP or PL was consumed before breakfast and another before dinner. During the second CGM, participants switched to the alternate supplement. Order of the supplements was randomized. RESULTS During acute challenge studies, WP stimulated insulin and glucagon-like peptide (GLP)-1 secretion; suppressed ghrelin (all p<0.05), while PL had no effect. During CGM, glucose response to WP varied depending on the baseline characteristics of the patients. When evaluated using linear regression, the most predictive baseline variables were body mass index (BMI) (p=0.0006), triglycerides (p=8.3×10-5) and GLP-1 (p=0.006). Lower BMI, triglyceride and GLP-1 predicted decreased glucose levels on WP. Obesity, hypertriglyceridemia and high fasting GLP-1 concentrations predicted increased glucose levels. CONCLUSIONS Effects of WP supplementation on glycemia in T2DM depend on the baseline characteristics. Lower body weight, normal triglyceride and lower GLP-1 levels predict glucose lowering. In contrast, obesity, hypertriglyceridemia and high baseline GLP-1 predict increased glucose response.
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Affiliation(s)
- Rogelio U Almario
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, The University Of California at Davis, Sacramento, California, USA
| | - Wendy M Buchan
- Department of Family and Consumer Sciences, University of Sacramento, Sacramento, California, USA
| | - David M Rocke
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California, USA
- Department of Biomedical Engineering, University of California, Davis, California, USA
| | - Sidika E Karakas
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, The University Of California at Davis, Sacramento, California, USA
- Department of Veterans Affairs Northern California Health Care System, Sacramento, California, USA
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Piccoli GB, Ventrella F, Capizzi I, Vigotti FN, Mongilardi E, Grassi G, Loi V, Cabiddu G, Avagnina P, Versino E. Low-Protein Diets in Diabetic Chronic Kidney Disease (CKD) Patients: Are They Feasible and Worth the Effort? Nutrients 2016; 8:E649. [PMID: 27775639 PMCID: PMC5084036 DOI: 10.3390/nu8100649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/11/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Low-protein diets (LPDs) are often considered as contraindicated in diabetic patients, and are seldom studied. The aim of this observational study was to provide new data on this issue. It involved 149 diabetic and 300 non-diabetic patients who followed a LPD, with a personalized approach aimed at moderate protein restriction (0.6 g/day). Survival analysis was performed according to Kaplan-Meier, and multivariate analysis with Cox model. Diabetic versus non-diabetic patients were of similar age (median 70 years) and creatinine levels at the start of the diet (2.78 mg/dL vs. 2.80 mg/dL). There was higher prevalence of nephrotic proteinuria in diabetic patients (27.52% vs. 13.67%, p = 0.002) as well as comorbidity (median Charlson index 8 vs. 6 p = 0.002). Patient survival was lower in diabetic patients, but differences levelled off considering only cases with Charlson index > 7, the only relevant covariate in Cox analysis. Dialysis-free survival was superimposable in the setting of good compliance (Mitch formula: 0.47 g/kg/day in both groups): about 50% of the cases remained dialysis-free 2 years after the first finding of e-GFR (estimated glomerular filtration rate) < 15 mL/min, and 1 year after reaching e-GFR < 10 mL/min. In patients with type 2 diabetes, higher proteinuria was associated with mortality and initiation of dialysis. In conclusion, moderately restricted LPDs allow similar results in diabetic and non non-diabetic patients with similar comorbidity.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
- Nephrologie, Centre Hospitalier Le Mans, Le Mans 72100, France.
| | - Federica Ventrella
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Irene Capizzi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Federica N Vigotti
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elena Mongilardi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Giorgio Grassi
- SCDU Endocrinologia, Diabetologia e Metabolismo, Città della Salute e della Scienza Torino, Torino 10100, Italy.
| | - Valentina Loi
- SC Nefrologia, Brotzu Hospital, Cagliari 09134, Italy.
| | | | - Paolo Avagnina
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elisabetta Versino
- SSD Epidemiology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
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Rice endosperm protein slows progression of fatty liver and diabetic nephropathy in Zucker diabetic fatty rats. Br J Nutr 2016; 116:1326-1335. [PMID: 27724997 DOI: 10.1017/s0007114516003512] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We previously reported that rice endosperm protein (REP) has renoprotective effects in Goto-Kakizaki rats, a non-obese diabetic model. However, whether these effects occur in obese diabetes remains unclear. This study aimed to clarify the effects of REP on obese diabetes, especially on fatty liver and diabetic nephropathy, using the obese diabetic model Zucker diabetic fatty (ZDF) rats. In total, 7-week-old male ZDF rats were fed diets containing 20 % REP or casein (C) for 8 weeks. Changes in fasting blood glucose levels and urinary markers were monitored during the experimental period. Hepatic lipids and metabolites were measured and renal glomeruli were observed morphologically. HbA1c levels were significantly lower in rats fed REP, compared with C (P<0·05). Compared with C in the liver, REP prevented lipid accumulation (total lipid, TAG and total cholesterol, P<0·01). Liver metabolome analysis indicated that levels of metabolites associated with glycolysis, the pentose phosphate pathway and carnitine metabolism were significantly greater in the REP group than in the C group (P<0·05), suggesting activation of both glucose catabolism and fatty acid oxidation. The metabolite increases promoted by REP may contribute to suppression of liver lipid accumulation. Urinary excretion of albumin and N-acetyl-β-d-glucosaminidase was significantly reduced in rats fed REP for 8 weeks (P<0·01). In addition, there was a distinct suppression of mesangial matrix expansion and glomerular hypertrophy in response to REP (P<0·01). Thus, REP had preventive effects on obese diabetes, fatty liver and diabetic nephropathy.
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Campbell KL, Rangan GK, Lopez-Vargas P, Tong A. KHA-CARI Autosomal Dominant Polycystic Kidney Disease Guideline: Diet and Lifestyle Management. Semin Nephrol 2016; 35:572-581.e17. [PMID: 26718161 DOI: 10.1016/j.semnephrol.2015.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Katrina L Campbell
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia.
| | - Gopala K Rangan
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia
| | - Pamela Lopez-Vargas
- KHA-CARI Guidelines, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia; Sydney School of Public Health, University of Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Short-term safety, tolerability and efficacy of a very low-calorie-ketogenic diet interventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus. Nutr Diabetes 2016; 6:e230. [PMID: 27643725 PMCID: PMC5048014 DOI: 10.1038/nutd.2016.36] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/21/2016] [Accepted: 07/14/2016] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED Brackground:The safety and tolerability of very low-calorie-ketogenic (VLCK) diets are a current concern in the treatment of obese type 2 diabetes mellitus (T2DM) patients. OBJECTIVE Evaluating the short-term safety and tolerability of a VLCK diet (<50 g of carbohydrate daily) in an interventional weight loss program including lifestyle and behavioral modification support (Diaprokal Method) in subjects with T2DM. METHODS Eighty-nine men and women, aged between 30 and 65 years, with T2DM and body mass index between 30 and 35 kg m(-)(2) participated in this prospective, open-label, multi-centric randomized clinical trial with a duration of 4 months. Forty-five subjects were randomly assigned to the interventional weight loss (VLCK diet), and 44 to the standard low-calorie diet. RESULTS No significant differences in the laboratory safety parameters were found between the two study groups. Changes in the urine albumin-to-creatinine ratio in VLCK diet were not significant and were comparable to control group. Creatinine and blood urea nitrogen did not change significantly relative to baseline nor between groups. Weight loss and reduction in waist circumference in the VLCK diet group were significantly larger than in control subjects (both P<0.001). The decline in HbA1c and glycemic control was larger in the VLCK diet group (P<0.05). No serious adverse events were reported and mild AE in the VLCK diet group declined at last follow-up. CONCLUSIONS The interventional weight loss program based on a VLCK diet is most effective in reducing body weight and improvement of glycemic control than a standard hypocaloric diet with safety and good tolerance for T2DM patients.
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Levitsky J, O’Leary J, Asrani S, Sharma P, Fung J, Wiseman A, Niemann C. Protecting the Kidney in Liver Transplant Recipients: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice. Am J Transplant 2016; 16:2532-44. [PMID: 26932352 PMCID: PMC5007154 DOI: 10.1111/ajt.13765] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/12/2016] [Accepted: 02/22/2016] [Indexed: 01/25/2023]
Abstract
Both acute and chronic kidney disease are common after liver transplantation and result in significant morbidity and mortality. The introduction of the Model for End-stage Liver Disease score has directly correlated with an increased prevalence of perioperative renal dysfunction and the number of simultaneous liver-kidney transplantations performed. Kidney dysfunction in this population is typically multifactorial and related to preexisting conditions, pretransplantation renal injury, perioperative events, and posttransplantation nephrotoxic immunosuppressive therapies. The management of kidney disease after liver transplantation is challenging, as by the time the serum creatinine level is significantly elevated, few interventions affect the course of progression. Also, immunological factors such as antibody-mediated kidney rejection have become of greater interest given the rising liver-kidney transplant population. Therefore, this review, assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestine Community of Practice, provides a critical assessment of measures of renal function and interventions aimed at preserving renal function early and late after liver and simultaneous liver-kidney transplantation. Key points and practice-based recommendations for the prevention and management of kidney injury in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.
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Affiliation(s)
- J. Levitsky
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J.G. O’Leary
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - S. Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - P. Sharma
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI
| | - J. Fung
- Department of Surgery, Transplantation Center, The Cleveland Clinic, Cleveland, OH
| | - A. Wiseman
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Denver, CO
| | - C.U. Niemann
- Department of Anesthesia and Surgery, University of California at San Francisco, San Francisco, CA
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Melamed ML, Buttar RS, Coco M. CKD-Mineral Bone Disorder in Stage 4 and 5 CKD: What We Know Today? Adv Chronic Kidney Dis 2016; 23:262-9. [PMID: 27324680 PMCID: PMC5034723 DOI: 10.1053/j.ackd.2016.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/20/2016] [Accepted: 03/29/2016] [Indexed: 11/11/2022]
Abstract
Patients with CKD stages 4 and 5 experience biochemical derangements associated with CKD-mineral bone disorder. Some of the key abnormalities are hyperparathyroidism, hyperphosphatemia, hypocalcemia, and metabolic acidosis. We review the available treatments for these conditions and the evidence behind the treatments. We conclude that there is greater evidence for treating hyperphosphatemia than hyperparathyroidism. Treatment of metabolic acidosis in small clinical trials appears to be safe. We caution the reader about side effects associated with some of these treatments that differ in patients with CKD Stages 4 and 5 compared with patients on dialysis. The use of cinacalcet has been associated with hyperphosphatemia in patients with functioning kidneys. Activated vitamin D therapy has been associated with elevated creatinine levels, which may or may not be a reflection of true decrement in kidney function. Finally, the use of non-calcium-containing phosphate binders may be associated with improved clinical outcomes in patients; however, many more clinical trials are needed in this important area of medicine.
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Affiliation(s)
- Michal L Melamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Rupinder Singh Buttar
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Maria Coco
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Kitada M, Ogura Y, Suzuki T, Sen S, Lee SM, Kanasaki K, Kume S, Koya D. A very-low-protein diet ameliorates advanced diabetic nephropathy through autophagy induction by suppression of the mTORC1 pathway in Wistar fatty rats, an animal model of type 2 diabetes and obesity. Diabetologia 2016; 59:1307-17. [PMID: 27020449 DOI: 10.1007/s00125-016-3925-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/22/2016] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS The efficacy of a low-protein diet (LPD) on diabetic nephropathy is controversial. We aimed to investigate the renoprotective effects of an LPD and the underlying molecular mechanism in a rat model of type 2 diabetes and obesity. METHODS Diabetic male Wistar fatty (fa/fa) rats (WFRs) were treated with a standard diet (23.84% protein) or an LPD (5.77% protein) for 20 weeks from 24 weeks of age. We investigated the effect of the LPD on renal function, fibrosis, tubular cell damage, inflammation, mitochondrial morphology of proximal tubular cells (PTCs), apoptosis, autophagy and activation of mammalian target of rapamycin complex 1 (mTORC1). RESULTS Kidney weight, albuminuria, excretion of urinary liver-type fatty acid binding protein, levels of plasma cystatin C and changes in renal histology, including fibrosis, tubular cell damage and inflammation, were aggravated in WFRs compared with non-diabetic Wistar lean rats (WLRs). Fragmented and swelling mitochondria accumulated in PTCs and apoptosis were enhanced in the kidney of WFRs. Immunohistochemical staining of p62 and p-S6 ribosomal protein (p-S6RP) in the tubular lesions of WFRs was increased compared with WLRs. The LPD intervention clearly ameliorated damage as shown by the assessment of renal function and histology, particularly tubulointerstitial damage in diabetic kidneys. Additionally, the 5.77% LPD, but not the 11.46% LPD, significantly suppressed p-S6RP levels and increased microtubule-associated protein light chain 3-II levels in the renal cortex. The LPD intervention partially decreased HbA1c levels in WFRs, and no differences in mean BP were observed among any of the groups. CONCLUSIONS/INTERPRETATION A very-low-protein diet improved advanced diabetic renal injuries, including tubulointerstitial damage, by restoring autophagy through the suppression of the mTORC1 pathway.
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Affiliation(s)
- Munehiro Kitada
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293.
| | - Yoshio Ogura
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293
| | - Taeko Suzuki
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293
| | - Shi Sen
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293
| | - Seon Myeong Lee
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293
| | - Keizo Kanasaki
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293
| | - Shinji Kume
- Department of Medicine, Shiga University of Medical Science, Ōtsu, Shiga, Japan
| | - Daisuke Koya
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan, 920-0293.
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Kovesdy CP, Kalantar-Zadeh K. Back to the future: restricted protein intake for conservative management of CKD, triple goals of renoprotection, uremia mitigation, and nutritional health. Int Urol Nephrol 2016; 48:725-9. [PMID: 26886110 PMCID: PMC5061032 DOI: 10.1007/s11255-016-1224-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 01/18/2016] [Indexed: 01/10/2023]
Abstract
Lowering dietary protein intake (DPI) to approximately 0.6-0.8 g/kgBW/day may be renoprotective through various mechanisms, and it has been recommended in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) as a means to also control various metabolic consequences of advanced CKD, such as uremic symptoms, hyperparathyroidism, hypertension, hyperkalemia, and hyperphosphatemia. A meta-analysis in this issue of the Journal suggests that low-protein diet is effective and safe when used to retard progression of CKD and alleviate uremic complications. A potential deleterious consequence of lowering DPI in this population is the development or worsening of protein-energy wasting (PEW), which can contribute to poor clinical outcomes such as higher mortality and morbidity. There is currently insufficient high-level evidence to determine the ideal level of DPI in patients with NDD-CKD with high risk of PEW. For the time being we recommend a DPI of 0.6-0.8 g/kgBW/day, and increasing this as needed on an individual basis in patients with PEW. Further examination of this dilemma in randomized controlled clinical trials will be necessary.
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Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN, 38163, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, CA, USA.
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Satirapoj B, Prapakorn J, Punpanich D, Pongsuparbchon C, Supasyndh O. The effect of ONCE Renal on minerals and electrolytes in predialysis patients with chronic kidney disease. Int J Nephrol Renovasc Dis 2016; 9:81-6. [PMID: 27103839 PMCID: PMC4827907 DOI: 10.2147/ijnrd.s98179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Malnutrition is one common adverse consequence in patients with advanced chronic kidney disease (CKD), and most patients have a lower-than-normal dietary energy intake. The present study was undertaken to examine whether orally administered ONCE Renal formula (ORF) supplement would improve energy intake without minerals and electrolytes disturbances in predialysis patients with CKD. Methods All eligible nondiabetic patients with CKD received ORF supplement for 1 week. Nutrition markers, renal function, and minerals and electrolytes were evaluated before and after supplementing. All patients kept a 3-day food record and were interviewed by a registered dietitian. Results A total of 29 patients with mean age 64.9±13.3 years were included. Mean estimated glomerular filtration rate was 37.7±12.1 mL/min/1.73 m2. A significant increase was observed in amount of energy, fat, fiber, calcium, and magnesium intake after 1 week of ORF supplement. Moreover, in comparison with baseline values, the patients displayed decreased dietary protein intake and blood urea nitrogen and increased serum magnesium. However, no significant change was found in renal function, nutritional markers (body weight, prealbumin, albumin, and protein equivalence of total nitrogen appearance), serum calcium, phosphorus, sodium, potassium, and bicarbonate. Conclusion In patients with CKD, ingestion of ORF was well tolerated and had a positive effect with an increase in dietary energy, fat, and fiber intake, as well as a decreased dietary protein intake. No mineral or electrolyte abnormalities were observed during the study.
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Affiliation(s)
- Bancha Satirapoj
- Division of Nephrology, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Janjira Prapakorn
- Research Unit, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Dollapas Punpanich
- Research Unit, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chantima Pongsuparbchon
- Clinical Research Center, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Ouppatham Supasyndh
- Division of Nephrology, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
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Rughooputh MS, Zeng R, Yao Y. Protein Diet Restriction Slows Chronic Kidney Disease Progression in Non-Diabetic and in Type 1 Diabetic Patients, but Not in Type 2 Diabetic Patients: A Meta-Analysis of Randomized Controlled Trials Using Glomerular Filtration Rate as a Surrogate. PLoS One 2015; 10:e0145505. [PMID: 26710078 PMCID: PMC4692386 DOI: 10.1371/journal.pone.0145505] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/04/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE Studies, including various meta-analyses, on the effect of Protein Diet Restriction on Glomerular Filtration Rate (GFR) in Chronic Kidney Disease (CKD) have reported conflicting results. In this paper, we have provided an update on the evidence available on this topic. We have investigated the reasons why the effect has been inconsistent across studies. We have also compared the effect on GFR in various subgroups including type 1 diabetics, type 2 diabetics and non-diabetics. METHOD We searched for Randomized Controlled Trials on this intervention from MEDLINE, EMBASE, and other information sources. The PRISMA guidelines, as well as recommended meta-analysis practices were followed in the selection process, analysis and reporting of our findings. The effect estimate used was the change in mean GFR. Heterogeneity across the considered studies was explored using both subgroup analyses and meta-regression. Quality assessment was done using the Cochrane risk of bias tool and sensitivity analyses. RESULTS 15 randomized controlled trials, including 1965 subjects, were analyzed. The pooled effect size, as assessed using random-effects model, for all the 15 studies was -0.95 ml/min/1.73m2/year (95% CI: -1.79, -0.11), with a significant p value of 0.03. The combined effect estimate for the non-diabetic and type 1 diabetic studies was -1.50 ml/min/1.73m2/year (95% CI: -2.73, -0.26) with p value of 0.02. The effect estimate for the type 2 diabetic group was -0.17 ml/min/1.73m2/year (95% CI: -1.88, 1.55) with p value of 0.85. There was significant heterogeneity across the included studies (I2 = 74%, p value for Q < 0.0001), explained by major variations in the percentage of type 2 diabetic subjects, the number of subjects and overall compliance level to diet prescribed. CONCLUSION Our findings suggest that protein diet restriction slows chronic renal disease progression in non-diabetic and in type 1 diabetic patients, but not in type 2 diabetic patients.
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Affiliation(s)
- Mahesh Shumsher Rughooputh
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (MSR); (RZ); (YY)
| | - Rui Zeng
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (MSR); (RZ); (YY)
| | - Ying Yao
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Clinical Nutrition, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * E-mail: (MSR); (RZ); (YY)
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48
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Effects of Low-Protein Diets Supplemented with Ketoacid on Expression of TGF-β and Its Receptors in Diabetic Rats. BIOMED RESEARCH INTERNATIONAL 2015; 2015:873519. [PMID: 26788514 PMCID: PMC4693005 DOI: 10.1155/2015/873519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 11/26/2015] [Indexed: 01/04/2023]
Abstract
TGF-β1 has been recognized as a key mediator in DN. This study aimed to observe the effects of low-protein diets supplemented with ketoacid on mRNA and protein expression of TGF-β and TβRI and t TβRII receptors in the renal tissue of diabetic rats. A diabetes model was established in 72 male SD rats. They were then equally randomized to three groups: NPD group, LPD group, and LPD + KA group. Additional 24 male SD rats receiving normal protein diets were used as the control. Eight rats from each group were sacrificed at weeks 4, 8, and 12 after treatment, from which SCr, BUN, serum albumin, and 24 h urinary protein excretion were collected. The expressions of TGF-β1, TβRI, and TβRII in LPD and LPD + KA groups were significantly lower than those in NPD group and lower in LPD + KA group than those in LPD group. Low-protein diets supplemented with ketoacid have been demonstrated to provide a protective effect on the renal function as represented by reduced SCr, BUN, and urinary protein excretion, probably through downregulating the gene expression of TGF-β1 and its receptors in LPD + KA group.
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Piccoli GB, Grassi G, Cabiddu G, Nazha M, Roggero S, Capizzi I, De Pascale A, Priola AM, Di Vico C, Maxia S, Loi V, Asunis AM, Pani A, Veltri A. Diabetic Kidney Disease: A Syndrome Rather Than a Single Disease. Rev Diabet Stud 2015; 12:87-109. [PMID: 26676663 PMCID: PMC5397985 DOI: 10.1900/rds.2015.12.87] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/15/2015] [Accepted: 04/22/2015] [Indexed: 12/13/2022] Open
Abstract
The term "diabetic kidney" has recently been proposed to encompass the various lesions, involving all kidney structures that characterize protean kidney damage in patients with diabetes. While glomerular diseases may follow the stepwise progression that was described several decades ago, the tenet that proteinuria identifies diabetic nephropathy is disputed today and should be limited to glomerular lesions. Improvements in glycemic control may have contributed to a decrease in the prevalence of glomerular lesions, initially described as hallmarks of diabetic nephropathy, and revealed other types of renal damage, mainly related to vasculature and interstitium, and these types usually present with little or no proteinuria. Whilst glomerular damage is the hallmark of microvascular lesions, ischemic nephropathies, renal infarction, and cholesterol emboli syndrome are the result of macrovascular involvement, and the presence of underlying renal damage sets the stage for acute infections and drug-induced kidney injuries. Impairment of the phagocytic response can cause severe and unusual forms of acute and chronic pyelonephritis. It is thus concluded that screening for albuminuria, which is useful for detecting "glomerular diabetic nephropathy", does not identify all potential nephropathies in diabetes patients. As diabetes is a risk factor for all forms of kidney disease, diagnosis in diabetic patients should include the same combination of biochemical, clinical, and imaging tests as employed in non-diabetic subjects, but with the specific consideration that chronic kidney disease (CKD) may develop more rapidly and severely in diabetic patients.
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Affiliation(s)
- Giorgina B. Piccoli
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Giorgio Grassi
- SCDU Endocrinologia, Diabetologia e Metabolismo, Citta della Salute e della Scienza Torino, Italy
| | | | - Marta Nazha
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Simona Roggero
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Irene Capizzi
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Agostino De Pascale
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
| | - Adriano M. Priola
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
| | - Cristina Di Vico
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | | | | | - Anna M. Asunis
- SCD Anatomia Patologica, Brotzu Hospital, Cagliari, Italy
| | | | - Andrea Veltri
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
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Abstract
IN BRIEF For the goals of reducing diabetic kidney disease (DKD) onset and progression, approaches to nutritional therapy are a subject of much debate. This article discusses selected nutrients that have a role in affecting DKD outcomes and introduces application of newer, individualized concepts for healthful eating, as supported by clinical evidence relevant to patients with DKD. Selected aspects of management of advanced DKD are also reviewed.
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