Malnutrition management in children with chronic kidney disease

Chronic kidney disease (CKD) encompasses diverse conditions such as congenital anomalies, glomerulonephritis, and hereditary nephropathies, necessitating individualized nutritional interventions. Early detection is pivotal due to the heightened risk of adverse outcomes, including compromised growth and increased healthcare costs. The nutritional assessment in pediatric CKD employs a comprehensive, multidisciplinary approach, considering disease-specific factors, growth metrics, and dietary habits. The prevalence of malnutrition, as identified through diverse tools and guidelines, underscores the necessity for regular and vigilant monitoring. Nutritional management strategies seek equilibrium in calorie intake, protein requirements, and electrolyte considerations. Maintaining a well-balanced nutritional intake is crucial for preventing systemic complications and preserving the remaining kidney function. The nuanced landscape of enteral nutrition, inclusive of gastrostomy placement, warrants consideration in scenarios requiring prolonged support, with an emphasis on minimizing risks for optimized outcomes. In conclusion, the ongoing challenge of managing nutrition in pediatric CKD necessitates continuous assessment and adaptation. This review underscores the significance of tailored dietary approaches, not only to foster growth and prevent complications but also to enhance the overall quality of life for children grappling with CKD.

Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis

Chronic kidney disease (CKD) affects 9.1% of the population worldwide. CKD may lead to structural and functional gastrointestinal alterations, including impairment in the intestinal barrier, digestion and absorption of nutrients, motility, and changes to the gut microbiome. These changes can lead to increased gastrointestinal symptoms in people with CKD, even in early grades of kidney dysfunction. Gastrointestinal symptoms have been associated with lower quality of life and reduced nutritional status. Therefore, there has been considerable interest in improving gastrointestinal health in this clinical population. Gastrointestinal health can be influenced by lifestyle and medications, particularly in advanced grades of kidney dysfunction. Therapies focused on gastrointestinal health have been studied, including the use of probiotics, prebiotics, and synbiotics, yielding limited and conflicting results. This review summarizes the alterations in the gastrointestinal tract structure and function and provides an overview of potential nutritional interventions that kidney disease professionals can provide to improve gastrointestinal health in individuals with CKD.

Potassium content of the American food supply and implications for the management of hyperkalemia in dialysis: An analysis of the Branded Product Database

Ultraprocessed foods can be a source of potassium additives. Excess potassium consumption can lead to hyperkalemia. How frequently potassium additives are found in the food supply and how they impact potassium content is not well documented. Using the Branded Product Database, ingredient lists were searched for "potassium" to identify products containing additives. For products listing potassium content, accuracy of potassium content reporting and how potassium content differed with additive use was also assessed. A total of 239,089 products were included, 35,102 (14.7%) contained potassium additives, and 13,685 (5.7%) provided potassium content. Potassium additives were most commonly found in dairy products, supplements, and mixed foods (at 37%, 34%, and 28%, respectively). Potassium additives in mixed foods and vegetables and fruits were associated with 71% and 28% more potassium per serving, respectively (p < 0.01). Potassium content increased by 1874 mg (66%) when a 1-day sample menu compared foods with and without additives. Potassium content of foods with and without additives is not well documented. Potassium additives are prevalent and can be associated with increased potassium content. However, more information is needed to better understand how different additives used in different foods change potassium content.

The Gut Microbiome and Symptom Burden After Kidney Transplantation: An Overview and Research Opportunities

Many kidney transplant recipients continue to experience high symptom burden despite restoration of kidney function. High symptom burden is a significant driver of quality of life. In the post-transplant setting, high symptom burden has been linked to negative outcomes including medication non-adherence, allograft rejection, graft loss, and even mortality. Symbiotic bacteria (microbiota) in the human gastrointestinal tract critically interact with the immune, endocrine, and neurological systems to maintain homeostasis of the host. The gut microbiome has been proposed as an underlying mechanism mediating symptoms in several chronic medical conditions including irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, and psychoneurological disorders via the gut-brain-microbiota axis, a bidirectional signaling pathway between the enteric and central nervous system. Post-transplant exposure to antibiotics, antivirals, and immunosuppressant medications results in significant alterations in gut microbiota community composition and function, which in turn alter these commensal microorganisms' protective effects. This overview will discuss the current state of the science on the effects of the gut microbiome on symptom burden in kidney transplantation and future directions to guide this field of study.

Effects of a Personalized Diet on Nutritional Status and Renal Function Outcome in Nephrectomized Patients with Renal Cancer

Nutritional therapy (NT) based on a controlled protein intake represents a cornerstone in managing chronic kidney disease (CKD). However, if a CKD patient is at the same time affected by cancer, oncologists and nutritionists tend to suggest a dietary regimen based on high protein intake to avoid catabolism and malnutrition. International guidelines are not clear when we consider onco-nephrological patients and, as a consequence, no clinical shared strategy is currently applied in clinical practice. In particular, no precise nutritional management is established in nephrectomized patients for renal cell carcinoma (RCC), a specific oncological cohort of patients whose sudden kidney removal forces the remnant one to start a compensatory mechanism of adaptive hyperfiltration. Our study aimed to investigate the efficacy of a low-normal-protein high-calorie (LNPHC) diet based on a Mediterranean model in a consecutive cohort of nephrectomized RCC patients using an integrated nephrologist and nutritionist approach. A consecutive cohort of 40 nephrectomized RCC adult (age > 18) patients who were screened for malnutrition (malnutrition screening tool, MST < 2) were enrolled in a tertiary institution between 2020 and 2022 after signing a specific informed consent form. Each patient underwent an initial nephrological and nutritional evaluation and was subsequently subjected to a conventional CKD LNPHC diet integrated with aproteic foods (0.8 g/Kg/die: calories: 30-35 kcal per kg body weight/die) for a period of 6 months (±2 months). The diet was structured after considering eGFR (CKD-EPI 2021 creatinine formula), comorbidities, and nutritional status. MST, body mass index (BMI), phase angle (PA), fat mass percentage (FM%), fat-free mass index (FFMI), body cell mass index (BCMI), extracellular/intracellular water ratio (ECW/ICW), extracellular matrix/body cell mass ratio (ECM/BCM), waist/hip circumference ratio (WHC), lab test exams, and clinical variables were examined at baseline and after the study period. Our results clearly highlighted that the LNPHC diet was able to significantly improve several nutritional parameters, avoiding malnutrition and catabolism. In particular, the LNPHC diet preserved the BCM index (delta on median, ΔM + 0.3 kg/m2) and reduced the ECM/BCM ratio (ΔM - 0.03 *), with a significant reduction in the ECW/ICW ratio (ΔM - 0.02 *), all while increasing TBW (ΔM + 2.3% *). The LNPHC diet was able to preserve FFM while simultaneously depleting FM and, moreover, it led to a significant reduction in urea (ΔM - 11 mg/dL **). In conclusion, the LNPHC diet represents a new important therapeutic strategy that should be considered when treating onco-nephrological patients with solitary kidney due to renal cancer.

Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease

Chronic kidney disease (CKD) disproportionately affects minorities in the United States, including the Hispanic/Latine population, and is a public health concern in Latin American countries. An emphasis on healthy dietary patterns, including the Mediterranean and the Dietary Approaches to Stop Hypertension (DASH) diets, has been suggested as they are associated with a lower incidence of CKD, slower CKD progression, and lower mortality in kidney failure. However, their applicability may be limited in people from Latin America. The Dieta de la Milpa (Diet of the Cornfield) was recently described as the dietary pattern of choice for people from Mesoamerica (Central Mexico and Central America). This dietary pattern highlights the intake of four plant-based staple foods from this geographical region, corn/maize, common beans, pumpkins/squashes, and chilies, complemented with seasonal and local intake of plant-based foods and a lower intake of animal-based foods, collectively classified into ten food groups. Limited preclinical and clinical studies suggest several health benefits, including cardiometabolic health, but there is currently no data concerning CKD. In this narrative review, we describe and highlight the potential benefits of the Dieta de la Milpa in CKD, including acid-base balance, protein source, potassium and phosphorus management, impact on the gut microbiota, inflammation, and cultural appropriateness. Despite these potential benefits, this dietary pattern has not been tested in people with CKD. Therefore, we suggest key research questions targeting measurement of adherence, feasibility, and effectiveness of the Dieta de la Milpa in people with CKD.

Colonic microflora and plasma metabolite-based comparative analysis of unilateral ureteral obstruction-induced chronic kidney disease after treatment with the Chinese medicine FuZhengHuaYuJiangZhuTongLuo and AST-120

Background

Many researchers have investigated the use of Chinese herbs to delay the progression of chronic kidney disease (CKD) through their effects on colonic microflora and microbiota-derived metabolites. However, whether FuZhengHuaYuJiangZhuTongLuo (FZHY) has effects that are similar to those of AST-120 on CKD needs to be elucidated.

Methods

In this study, we compared the effects of FZHY and AST-120 on the colonic microbiota and plasma metabolites in the CKD rat model. We developed a unilateral ureteral obstruction (UUO)-induced CKD rat model and then administered FZHY and AST-120 to these model rats. Non-targeted metabolomic LC-MS analysis, 16S rRNA sequencing, and histopathological staining were performed on plasma, stool, and kidney tissues, respectively, and the joint correlation between biomarkers and metabolites of candidate bacteria was analyzed.

Results

Our results showed that administering FZHY and AST-120 effectively ameliorated UUO-induced abnormal renal function and renal fibrosis and regulated the composition of microbiota and metabolites. Compared to the UUO model group, the p_Firmicutes and o_Peptostreptococcales_Tissierellales were increased, while 14 negative ion metabolites were upregulated and 21 were downregulated after FZHY treatment. Additionally, 40 positive ion metabolites were upregulated and 63 were downregulated. On the other hand, AST-120 treatment resulted in an increase in the levels of g_Prevotellaceae_NK3B31_group and f_Prevotellaceae, as well as 12 upregulated and 23 downregulated negative ion metabolites and 56 upregulated and 63 downregulated positive ion metabolites. Besides, FZHY increased the levels of candidate bacterial biomarkers that were found to be negatively correlated with some poisonous metabolites, such as 4-hydroxyretinoic acid, and positively correlated with beneficial metabolites, such as l-arginine. AST-120 increased the levels of candidate bacterial biomarkers that were negatively correlated with some toxic metabolites, such as glycoursodeoxycholic acid, 4-ethylphenol, and indole-3-acetic acid.

Conclusion

FZHY and AST-120 effectively reduced kidney damage, in which, the recovery of some dysregulated bacteria and metabolites are probably involved. As their mechanisms of regulation were different, FZHY might play a complementary role to AST-120 in treating CKD.

In the "Plant-Based" Era, Patients With Chronic Kidney Disease Should Focus on Eating Healthy

In the era of plant-based diets, it is important for Nephrology providers to know the evidence regarding their healthfulness in patients with chronic kidney disease (CKD). A whole food, plant-based diet, which emphasizes fresh, minimally processed or refined plant-based foods and limits animal products, has shown benefits for patients with CKD. These include reduced dietary acid load, lower bioavailability of potassium and phosphorus, increased dietary fiber intake, nutritional adequacy, and cardiovascular and mortality benefits. Potential drawbacks include the need for specific knowledge, skills, and cost involved in preparing varied, healthy, and appetizing plant-based meals, leading to lower acceptability and accessibility to certain populations. Liberalization of the standard CKD diet to include healthy, minimally processed foods such as fruits, vegetables, nuts, legumes, and whole grains is likely beneficial, though more research is needed to determine whether a plant-based-only diet is the optimal way to achieve healthier eating in patients with CKD.

Re-Thinking Hyperkalaemia Management in Chronic Kidney Disease-Beyond Food Tables and Nutrition Myths: An Evidence-Based Practice Review

Potassium dysregulation can be life-threatening. Dietary potassium modification is a management strategy for hyperkalaemia. However, a 2017 review for clinical guidelines found no trials evaluating dietary restriction for managing hyperkalaemia in chronic kidney disease (CKD). Evidence regarding dietary hyperkalaemia management was reviewed and practice recommendations disseminated. A literature search using terms for potassium, hyperkalaemia, and CKD was undertaken from 2018 to October 2022. Researchers extracted data, discussed findings, and formulated practice recommendations. A consumer resource, a clinician education webinar, and workplace education sessions were developed. Eighteen studies were included. Observational studies found no association between dietary and serum potassium in CKD populations. In two studies, 40-60 mmol increases in dietary/supplemental potassium increased serum potassium by 0.2-0.4 mmol/L. No studies examined lowering dietary potassium as a therapeutic treatment for hyperkalaemia. Healthy dietary patterns were associated with improved outcomes and may predict lower serum potassium, as dietary co-factors may support potassium shifts intracellularly, and increase excretion through the bowel. The resource recommended limiting potassium additives, large servings of meat and milk, and including high-fibre foods: wholegrains, fruits, and vegetables. In seven months, the resource received > 3300 views and the webinar > 290 views. This review highlights the need for prompt review of consumer resources, hospital diets, and health professionals' knowledge.

Mediterranean Diet for Cardiovascular Risk Reduction in Chronic Kidney Disease

The Mediterranean diet is a plant-based healthy diet similar to the vegetarian and the Dietary Approaches to Stop Hypertension diets. Unlike vegetarian and Dietary Approaches to Stop Hypertension diets, the Mediterranean diet encourages a lifestyle associated with physical activity, and social connections. In addition, the Mediterranean diet is not based on restriction of nutrients but does limit intake of processed foods. Prospective studies have confirmed that the Mediterranean diet confers primary and secondary cardiovascular disease prevention in the general population. The benefits of the Mediterranean diet lifestyle include reducing the risk of diabetes mellitus, dyslipidemia, and lowers blood pressure. In adults with CKD, adherence to the Mediterranean diet is associated with a lower risk of CKD progression and its complications such as hyperphosphatemia and metabolic acidosis, and reduces production of uremic toxins and inflammatory mediators when compared to omnivore dietary patterns. Nevertheless, prospective studies are needed to confirm the cardiovascular disease prevention with the Mediterranean diet in adults with CKD. Medical nutrition therapy remains a cornerstone of CKD management, and the Mediterranean diet could be utilized to slow CKD progression and complications.

Health effects of the New Nordic Renal Diet in patients with stage 3 and 4 chronic kidney disease, compared with habitual diet: a randomized trial

BACKGROUND

Chronic kidney disease (CKD) leads to an accumulation of waste products and causes adverse cardiometabolic effects.

OBJECTIVES

We investigated the health effects of the New Nordic Renal Diet (NNRD), a novel meal pattern reduced in phosphorus, protein, and sodium.

METHODS

A 26-wk randomized trial compared the NNRD with a habitual diet. The NNRD group received weekly home deliveries of food and recipes. Monthly study visits included fasting blood samples, 24-h urine samples, blood pressure, and anthropometric measurements. Intention-to-treat analysis used linear mixed-effects models.

RESULTS

Sixty patients, mean estimated glomerular filtration rate (eGFR) 34 mL/min/1.73 m2 and body mass index of 25-27 kg/m2, were included and 58 completed. Metabolic syndrome was present in 53% (NNRD group) and 57% (control group). The NNRD group (n = 30) reduced their 24-h urine phosphorus excretion by 19% (-153 mg; 95% confidence interval [CI]: -210, -95), control group (n = 30) (no change), between-group difference -171 mg (95% CI: -233, -109; P < 0.001). Proteinuria was reduced by 39% in the NNRD group (-0.33 g/d; 95% CI: -0.47, -0.18), control group (no change), between-group difference -0.34 g/d (95% CI: -0.52, -0.17; P < 0.001). Plasma urea was reduced by -1.5 mmol/L in the NNRD group (95% CI: -2.1, -0.9), control group (no change), between-group difference -1.4 mmol/L (95% CI: -2.0, -0.7; P < 0.001). Systolic blood pressure fell by -5.2 mmHg in the NNRD group (95% CI: -8.4, -2.1), control group (no change), between-group difference -3.9 mmHg (95% CI; -7.6, -0.2; P = 0.04). The NNRD group lost -1.7 kg (95% CI: -2.6, -0.8), control group (no change), between-group difference -2.0 kg (95% CI: -3.0, -1.0; P < 0.001). There were no effects on eGFR during the 26-wk intervention.

CONCLUSION

NNRD in moderate CKD reduces phosphorus excretion, proteinuria, systolic blood pressure, and weight, mainly by reducing abdominal fat. This trial was registered at clinicaltrials.gov as NCT04579315.

Cognitive disorders in patients with chronic kidney disease: Approaches to prevention and treatment

BACKGROUND

Cognitive impairment is common in patients with chronic kidney disease (CKD), and early intervention may prevent the progression of this condition.

METHODS

Here, we review interventions for the complications of CKD (anemia, secondary hyperparathyroidism, metabolic acidosis, harmful effects of dialysis, the accumulation of uremic toxins) and for prevention of vascular events, interventions that may potentially be protective against cognitive impairment. Furthermore, we discuss nonpharmacological and pharmacological methods to prevent cognitive impairment and/or minimize the latter's impact on CKD patients' daily lives.

RESULTS

A particular attention on kidney function assessment is suggested during work-up for cognitive impairment. Different approaches are promising to reduce cognitive burden in patients with CKD but the availabe dedicated data are scarce.

CONCLUSIONS

There is a need for studies assessing the effect of interventions on the cognitive function of patients with CKD.

Dietary interventions improve diabetic kidney disease, but not peripheral neuropathy, in a db/db mouse model of type 2 diabetes

Patients with type 2 diabetes often develop the microvascular complications of diabetic kidney disease (DKD) and diabetic peripheral neuropathy (DPN), which decrease quality of life and increase mortality. Unfortunately, treatment options for DKD and DPN are limited. Lifestyle interventions, such as changes to diet, have been proposed as non-pharmacological treatment options for preventing or improving DKD and DPN. However, there are no reported studies simultaneously evaluating the therapeutic efficacy of varying dietary interventions in a type 2 diabetes mouse model of both DKD and DPN. Therefore, we compared the efficacy of a 12-week regimen of three dietary interventions, low carbohydrate, caloric restriction, and alternate day fasting, for preventing complications in a db/db type 2 diabetes mouse model by performing metabolic, DKD, and DPN phenotyping. All three dietary interventions promoted weight loss, ameliorated glycemic status, and improved DKD, but did not impact percent fat mass and DPN. Multiple regression analysis identified a negative correlation between fat mass and motor nerve conduction velocity. Collectively, our data indicate that these three dietary interventions improved weight and glycemic status and alleviated DKD but not DPN. Moreover, diets that decrease fat mass may be a promising non-pharmacological approach to improve DPN in type 2 diabetes given the negative correlation between fat mass and motor nerve conduction velocity.

Nutraceuticals as Alternative Approach against Cadmium-Induced Kidney Damage: A Narrative Review

Cadmium (Cd) represents a public health risk due to its non-biodegradability and long biological half-life. The main target of Cd is the kidney, where it accumulates. In the present narrative review, we assessed experimental and clinical data dealing with the mechanisms of kidney morphological and functional damage caused by Cd and the state of the art about possible therapeutic managements. Intriguingly, skeleton fragility related to Cd exposure has been demonstrated to be induced both by a direct Cd toxic effect on bone mineralization and by renal failure. Our team and other research groups studied the possible pathophysiological molecular pathways induced by Cd, such as lipid peroxidation, inflammation, programmed cell death, and hormonal kidney discrepancy, that, through further molecular crosstalk, trigger serious glomerular and tubular injury, leading to chronic kidney disease (CKD). Moreover, CKD is associated with the presence of dysbiosis, and the results of recent studies have confirmed the altered composition and functions of the gut microbial communities in CKD. Therefore, as recent knowledge demonstrates a strong connection between diet, food components, and CKD management, and also taking into account that gut microbiota are very sensitive to these biological factors and environmental pollutants, nutraceuticals, mainly present in foods typical of the Mediterranean diet, can be considered a safe therapeutic strategy in Cd-induced kidney damage and, accordingly, could help in the prevention and treatment of CKD.

Optimization of potassium management in patients with chronic kidney disease and type 2 diabetes on finerenone

INTRODUCTION

Patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD) are at high risk of CKD progression and cardiovascular events. Despite treatment with renin-angiotensin system inhibitors and SGLT-2 inhibitors, the residual risk is substantial. There is preclinical and clinical evidence supporting a key role of mineralocorticoid receptor in cardiorenal injury in T2DM.

AREAS COVERED

Finerenone is a selective and nonsteroidal mineralocorticoid receptor antagonist that reduces -on preclinical studies- heart and kidney inflammation and fibrosis. Clinical trials have demonstrated that among patients with T2DM and CKD, finerenone reduces CKD progression and the risk of cardiovascular events. The incidence of adverse events is similar than for placebo. Permanent discontinuation of study drug due to hyperkalemia was low (1.7% of finerenone and 0.6% of placebo participants) as was the risk of hyperkalemia-related severe-adverse events (1.1%). We provide an overview of risk factors for hyperkalemia and management of serum potassium in people with CKD and T2DM on finerenone.

EXPERT OPINION

As finerenone increases potassium levels in a predictable way, patients at risk of hyperkalemia can be identified early in clinical practice and monitored for an easy management. This will allow people with T2DM and CKD to safely benefit from improved cardiorenal outcomes.

Assessment of Hydration, Nutritional Status and Arterial Stiffness in Hypertensive Chronic Kidney Disease Patients

The aim of this cross-sectional study was to determine the body fluid volume in patients diagnosed with both chronic kidney disease (CKD) and arterial hypertension (AH), and to investigate the relationship between fluid overload (FO), nutritional status and arterial stiffness in this specific patient population. A total of 169 participants with CKD and AH were enrolled in the study, and data on general parameters, comorbidities, medication use, and laboratory parameters were collected. Body composition was assessed with a Tanita MC 780 device, and data on the central and peripheral systolic and diastolic blood pressure, as well as pulse wave velocity (PWV) and the augmentation index (AIx) were collected with an IEM Mobil-O-Graph 24 h ambulatory blood pressure monitor, which was based on oscillometry. The Mediterranean Diet Serving Score (MDSS) questionnaire was used to determine the adherence to the Mediterranean diet (MeDi). Our results showed that the significant positive predictors of hydration status were the use of diuretics and oral hypoglycemic agents, whereas the negative predictors were female sex, higher body mass index level and use of two or more antihypertensives in the form of a single-pill combination. We also found differences in blood pressure and arterial stiffness parameters in relation to volume status, along with differences based on the presence of diabetes mellitus (DM). In conclusion, these results call for a higher awareness of volume status in the care of CKD patients with AH, especially in those with diabetes mellitus.

Redefying the therapeutic strategies against cardiorenal morbidity and mortality: Patient phenotypes

Chronic kidney disease (CKD) patients face an unacceptably high morbidity and mortality, mainly from cardiovascular diseases. Diabetes mellitus, arterial hypertension and dyslipidemia are highly prevalent in CKD patients. Established therapeutic protocols for the treatment of diabetes mellitus, arterial hypertension, and dyslipidemia are not as effective in CKD patients as in the general population. The role of non-traditional risk factors (RF) has gained interest in the last decades. These entail the deranged clinical spectrum of secondary hyperparathyroidism involving vascular and valvular calcification, under the term “CKD-mineral and bone disorder” (CKD-MBD), uremia per se, inflammation and oxidative stress. Each one of these non-traditional RF have been addressed in various study designs, but the results do not exhibit any applied clinical benefit for CKD-patients. The “crusade” against cardiorenal morbidity and mortality in CKD-patients is in some instances, derailed. We propose a therapeutic paradigm advancing from isolated treatment targets, as practiced today, to precision medicine involving patient phenotypes with distinct underlying pathophysiology. In this regard we propose two steps, based on current stratification management of corona virus disease-19 and sepsis. First, select patients who are expected to have a high mortality, i.e., a prognostic enrichment. Second, select patients who are likely to respond to a specific therapy, i.e., a predictive enrichment.

Mediterranean Dietary Pattern Adjusted for CKD Patients: The MedRen Diet

A number of studies in the general population showed that healthy dietary patterns, such as the Mediterranean Diet, can improve or prevent the development of several chronic diseases and are associated with a significant reduction in all-cause and cardiovascular mortality. The Mediterranean diet may also have favorable effects for the prevention of chronic kidney disease (CKD), but no evidence of renoprotection exists in CKD patients. The Mediterranean Renal (MedRen) diet is an adaptation of the Mediterranean diet recommendations comprising a quantitative reduction in the RDA values of protein, salt and phosphate intake for the general population. Hence, MedRen supplies 0.8 g/Kg of protein, 6 g of salt and less than 800 mg of phosphate daily. Obviously, there is a preference for products of plant origin, which contain more alkali, fibers, unsaturated fatty acids than animal-based food. The MedRen diet can be implemented easily in mild-to-moderate stages of CKD with good results, both in terms of adherence to prescriptions and metabolic compensation. In our opinion, it should be the first step of CKD stage 3 nutritional management. This paper describes the features and reports our experience in the implementation of the MedRen diet as an early nutritional approach to CKD.

[Retarding progression of chronic kidney disease]

Chronic kidney disease (CKD) affects about 10-15% of the German population with a steady increase. It is assumed that CKD will become the 5th most common cause of death worldwide in 2040. CKD is associated with high risk of mortality, morbidity, related in particular to cardiovascular disease, as well as high healthcare costs. Clinical strategies to manage CKD should encompass extensive life-style modification including weight normalization, reduction of dietary protein and salt intakes, regular exercise and avoidance of nicotine. Pharmacologically it includes inhibition of the renin-angiotensin-aldosterone system (RAAS), sodium-glucose co-transporter‑2 (SGLT-2) inhibitors in both diabetes-related and non-diabetic CKD and strategies to control other risk factors such as proteinuria, hyperglycemia and lipid disturbances. Among the various measures aimed at slowing CKD progression, blood pressure control and in particular RAAS inhibitors have received the most attention. Another therapeutic option includes aldosterone inhibition, be it via classical aldosterone-antagonists or the new mineralocorticoid-receptor antagonists. Avoidance of nephrotoxic agents (e.g. non-steroidal anti-inflammatory drugs) seems self-explanatory. Overall, given the often asymptomatic course of CKD in particular in early phases, patient education and self-empowerment as well as treatment in a multidisciplinary team appear essential to stem the tide of patients with advanced kidney damage.

Risks and Benefits of Different Dietary Patterns in CKD

Food has the potential to cause and exacerbate many lifestyle diseases. Or it can be used to prevent and treat illnesses like primary hypertension, the metabolic syndrome, and insulin resistance. In parallel, there is also a growing body of evidence of the role of diet in the treatment of kidney disease and its ensuing complications. Popular diets for this purpose have included low-carbohydrate diets, including the ketogenic diet, and higher carbohydrate diets like Mediterranean diets and other plant-based dietary patterns. Low-carbohydrate diets have not shown harm in patients with kidney disease and may benefit a select few. Mediterranean diets have an established record of cardioprotective benefits but also may be beneficial for the kidney. Intermittent fasting has benefits for metabolic health, but limited research exists on the risk or benefit for patients with kidney disease. Plant-based diets, especially those that are lower in protein, may slow kidney disease progression, mitigate uremia, and delay dialysis initiation. Although each dietary pattern has its unique pros and cons, most healthful dietary patterns favor the inclusion of whole, unprocessed foods, preferably from plant-based sources. In this perspective, we discuss the risks and benefits of major popular diets to help guide health care professionals in treating patients with kidney disease.

The Role of Dietary Potassium in the Cardiovascular Protective Effects of Plant-Based Diets

Dietary intervention is an essential factor in managing a multitude of chronic health conditions such as cardiovascular and chronic kidney disease. In recent decades, there has been a host of research suggesting the potential benefit of plant-based diets in mitigating the health outcomes of these conditions. Plant-based diets are rich in vegetables and fruits, while limiting processed food and animal protein sources. The underlying physiological mechanism involves the interaction of several macronutrients and micronutrients such as plant protein, carbohydrates, and dietary potassium. Specifically, plant-based foods rich in potassium provide cardiorenal protective effects to include urinary alkalization and increased sodium excretion. These diets induce adaptive physiologic responses that improve kidney and cardiovascular hemodynamics and improve overall metabolic health. A shift toward consuming plant-based diets even in subjects with cardiorenal decrements may reduce their morbidity and mortality. Nonetheless, randomized controlled trials are needed to confirm the clinical benefits of plant-based diets.

Adherence to Mediterranean Diet in Individuals on Renal Replacement Therapy

Patients on renal replacement therapy are typically subject to several dietary restrictions; however, this approach has been questioned in recent years, with some suggesting that the Mediterranean diet might be beneficial. Data on the adherence to this diet and factors that influence it are scarce. We conducted a web survey among individuals on renal replacement therapy (dialysis or kidney transplant, KT) using the MEDI-LITE questionnaire to assess adherence to the Mediterranean diet and dietary habits in this population. Adherence to the Mediterranean diet was generally low, and significantly lower among participants on dialysis versus KT recipients (19.4% vs. 44.7%, p < 0.001). Being on dialysis, adopting fluid restrictions, and having a basic level of education were predictors of low adherence to the Mediterranean diet. Consumption of foods typically included in the Mediterranean diet, including fruit, legumes, fish, and vegetables, was generally low, particularly among those on dialysis. There is a need for strategies to improve both the adherence to and the quality of the diet among individuals on renal replacement therapy. This should be a shared responsibility between registered dietitians, physicians, and the patient.

Effect on nutritional status and biomarkers of inflammation and oxidation of an oral nutritional supplement (with or without probiotics) in malnourished hemodialysis patients. A multicenter randomized clinical trial "Renacare Trial"

Background

Malnutrition in patients undergoing hemodialysis is frequent and associated with a reduction in muscular mass and strength, with an increment in biomarkers of inflammation and oxidation.

Materials and methods

Randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups [(1) control (C) individualized diet, (2) oral nutritional supplement-ONS- + placebo-SU- PL-, and (3) ONS + probiotics-SU-PR]; the trial was open regarding the intake of ONS or individualized diet recommendations, but double-blind for the intake of probiotics. We obtained, at baseline and after 3 and 6 months, anthropometric measurements, handgrip strength, bioelectrical impedance analysis (BIA), dietary records, and routine biochemical parameters. Inflammation and oxidation were determined using ELISA techniques (Versamax and ProcartaPlex multiplex Immunoassay). Results were analyzed by intention to treat.

Results

A total of 31 patients (11 corresponding to group C, 10 to SU-PL, and 10 to SU-PR) completed the 6-months trial. The two groups that took supplements significantly increased their protein calorie, fat (total and n-3), and fiber intake. Weight and fat-free mass (FFM) also increased significantly in the groups on supplements, both at 3 and 6 months, and dynamometry did so in the SU-PL group. At month 3, prealbumin and vitamin D were significantly increased in the SU-TOT (SU-PL + SU-PR) group. No changes were observed regarding levels of phosphorus and potassium in any of the groups. Urea increased significantly at 6 months in the SU-PL group. There were significant changes in some inflammation biomarkers in the groups on supplements during the intervention (brain-derived neurotrophic factor, bone morphogenetic protein-2, MCP-1, IL-1-beta, IL-10, IL-4, and IL-8). The total antioxidant capacity (TAC) increased significantly in the supplemented patients, with no significant changes observed in isoprostanes.

Conclusion

The specific ONS improved protein-calorie intake, nutritional status (mainly FFM), and some biomarkers of inflammation/oxidation. The addition of probiotics could have a synergistic effect with ONS in such biomarkers.

Clinical trail registration

https://clinicaltrials.gov/ct2/show/, identifier NCT03924089.

Effects of Lockdown for COVID-19 Pandemic on Chronic Kidney Disease Progression in Children with Congenital Anomalies of the Kidney and Urinary Tract: A Retrospective Pilot Study

The coronavirus disease 2019 (COVID-19) pandemic changed adults and children's lifestyle. We focused our attention on children affected by chronic kidney disease (CKD) due to congenital abnormalities of kidney and urinary tract (CAKUT) and their behavior during the lockdown. Our aims were to evaluate the incidence of CKD progression within 6 months after the end of the first Italian lockdown and the factors associated to it. CKD progression was defined by the transition to higher CKD stage or by the drop in estimated glomerular filtration rate by a 25% or more for patients belonging to CKD stages 1 and 2. We retrospectively selected 21 children with CAKUT and CKD ≥ stage 1 observed within 3 months before and 6 months after the first Italian lockdown. We called them by phone and asked them about their lifestyle before and during lockdown focusing on physical activity, screen time, sweet/candies/sugar-sweetened beverages eaten/drunk and adherence to the Mediterranean diet (MD) (through KIDMED questionnaire). We calculated and analyzed the delta between the pre- and post- lockdown observation of all collected parameters (clinical and biochemical parameters and questionnaires scores). Analyzing the overall cohort, we found significantly increased mean BMI and mean screen time and significantly lower mean physical activity time in post- compared with pre-lockdown observations. Eleven out of twenty-one patients (52.4%) had a worsening of CKD. These patients presented higher delta of levels of uric acid and microalbuminuria and showed minor adherence to the MD and declared to have consumed more sweets or candies or sugar-sweetened beverages/week during the lockdown with a tendentially major increment of BMI compared with patients not presenting CKD progression. In conclusion, the lockdown for COVID-19 pandemic determined increase of BMI in all enrolled patients due to a "forced" negative lifestyle. About half of these patients presented CKD progression. This progression was associated to less adherence to the MD and major consumption of sweets or candies or sugar-sweetened beverages.

Mediterranean Diet and Chronic Kidney Disease (CKD): A Practical Approach

Chronic kidney disease has become a serious public health issue, as well as others health problems such as hypertension, DM, and obesity. Mediterranean diet (MD) can reduce the risk of cardiovascular disease and cancer and can lead to weight loss in obesity. There are studies that suggest that MD could be the diet of choice for patients with CKD for its influence on endothelial function, inflammation, lipid profile and blood pressure. There are few studies that tell us how to adapt MD to this group of patients. This review aims to offer a practical approach to Mediterranean diet adaptation as nutritional treatment in CKD patients.

Hyperkalemia: Prevalence, Predictors and Emerging Treatments

It is well established that an elevated potassium level (hyperkalemia) is associated with a risk of adverse events including morbidity, mortality and healthcare system cost. Hyperkalemia is commonly encountered in many chronic conditions including kidney disease, diabetes and heart failure. Furthermore, hyperkalemia may result from the use of renin-angiotensin-aldosterone system inhibitors (RAASi), which are disease-modifying treatments for these conditions. Therefore, balancing the benefits of optimizing treatment with RAASi while mitigating hyperkalemia is crucial to ensure patients are optimally treated. In this review, we will briefly discuss the definition, causes, epidemiology and consequences of hyperkalemia. The majority of the review will be focused on management of hyperkalemia in the acute and chronic setting, emphasizing contemporary approaches and evolving data on the relevance of dietary restriction and the use of novel potassium binders.

Mediterranean Diet and Obesity-related Disorders: What is the Evidence?

PURPOSE OF REVIEW

Obesity is a chronic disease, a major public health problem due to its association with non-communicable diseases and all-cause mortality. Indeed, people with obesity are at increased risk for a variety of obesity-related disorders including hypertension, dyslipidemia, type 2 diabetes mellitus, cardiovascular disease, and several cancers. Many popular diets with very different macronutrient composition, including the Mediterranean diet (MD), have been used, proposed, and studied for prevention and management of obesity. In particular, MD has been the subject of countless studies over the years and now boasts a large body of scientific literature. In this review, we aimed to update current knowledge by summarizing the most recent evidence on the effect of MD on obesity and obesity-related disorders.

RECENT FINDINGS

The negative effects of obesity are partly reversed by substantial weight loss that can be achieved with MD, especially when low-calorie and in combination with adequate physical activity. In addition, the composition of MD has been correlated with an excellent effect on reducing dyslipidemia. It also positively modulates the gut microbiota and immune system, significantly decreasing inflammatory mediators, a common ground for many obesity-related disorders. People with obesity are at increased risk for a variety of medical disorders including hypertension, dyslipidemia, type 2 diabetes mellitus, and cardiovascular disease. Therefore, there is an inevitable need for measures to manage obesity and its related disorders. At this point, MD has been proposed as a valuable nutritional intervention. It is characterized by a high consumption of vegetables, fruit, nuts, cereals, whole grains, and extra virgin olive oil, as well as a moderate consumption of fish and poultry, and a limited intake of sweets, red meat, and dairy products. MD proves to be the healthiest dietary pattern available to tackle obesity and prevent several non-communicable diseases, including cardiovascular disease and type 2 diabetes.

Quality of Life of Hemodialysis Patients in Greece: Associations with Socio-Economic, Anthropometric and Nutritional Factors

Chronic kidney disease (CKD) is a serious public health problem that, in recent decades, has taken on significant dimensions with serious effects on the quality of life (QoL) of patients. The purpose of this cross-sectional study is to evaluate the QoL of a sample of hemodialysis patients in Greece and the possible correlations with socio-economic and anthropometric factors, as well as with adherence to the Mediterranean Diet (MD). During September-November 2019, one-hundred and five (n = 105) patients with end-stage CKD (63.4 ± 13.09 years of age) who were regularly monitored in five public and private hemodialysis units in the region of Attica, completed a demographic questionnaire, the MedDietScore questionnaire, and the KDQOL-SF questionnaire. Females presented worse QoL than males (p < 0.05), and older patients presented worse QoL than younger patients (p < 0.01). Patients of higher educational status presented better QoL scores than those of lower educational status (p < 0.01), while those with low financial status presented lower QoL scores than patients of middle and high financial status (p < 0.01). Obese patients had lower QoL scores than overweight patients (p < 0.05), and overweight males scored higher than normal weight males (p < 0.05). Age was negatively correlated to the total and most of the scales of QoL (p < 0.01). A majority of the patients (90.5%) showed a moderate adherence to MD, although "work status" was the only QoL scale that was correlated to MD. Age, educational status and financial status accounted for 28.1% of the variance in the KDQOL-SF total score. Hemodialysis patients need support in various levels, such as social, financial and educational, as well as nutritional counseling to adopt a balanced diet and maintain a healthy weight, in order to achieve a better quality of life.

Low intake of β carotene and dietary fiber from vegetables and fruits in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) occasionally need to restrict their consumption of vegetables and fruits. However, recent evidence suggests that plant-based diets have beneficial effects in patients with CKD. We aimed to determine the sufficiency of β carotene and dietary fiber intake in patients with CKD. We conducted a cross-sectional study among 4476 patients registered in the Fukuoka Kidney Disease Registry (FKR) study, a Japanese prospective cohort study of patients with CKD. Data from 3545 patients were analyzed after excluding cases with insufficient information. We evaluated the relationship between CKD stages and the intake of vegetables and fruits. The intake of β carotene and dietary fiber in CKD stages was evaluated using analysis of covariance. As the CKD stage advanced, the intake of vegetables, green leafy vegetables, and fruits significantly decreased (P-value for all trends < 0.01). The intake of vegetables significantly decreased as the CKD stage advanced (P for trend < 0.01). After adjusting for confounding factors, the intake of β carotene and dietary fiber also decreased (both P < 0.01) as the CKD stage advanced. Patients with CKD had insufficient vegetable and fruit intake and a lack of β carotene and dietary fiber from vegetables and fruits.

Retrospective analysis on the effect of Reverse Diabetes2 Now on kidney function in patients with type 2 diabetes with impaired kidney function

Objective

Type 2 diabetes is one of the main causes of kidney damage. Recent intervention studies suggest that the progression of type 2 diabetes can be halted, or even brought into remission by lifestyle interventions. In a pragmatic trial, the Reverse Diabetes2 Now programme (RD2N, NL: Keer Diabetes2 Om), a multicomponent lifestyle intervention, reduced the need for bloodglucose lowering medications up to 24 months.

Research design and methods

Here, we retrospectively investigate the effect of RD2N on markers of kidney function in patients selected for impaired kidney function at baseline (eGFR <70 mL/min/1.73 m² (n=45). Baseline data were retrieved from the intervention database and follow-up data on renal markers were collected from routine medical records. Wilcoxon non-parametric tests were used to assess changes over 6 and 12 months.

Results

After 6 months median eGFR increased significantly from 62.0 (IQR 55.5-65.0) to 69.0 (IQR 55.0-76.5) mL/min/1.73 m² (p=0.002). Median albumin/creatinine ratio (n=26) remained within the normal range (<3 mg/mmol). The effect on eGFR was similar after exclusion of patients in whom medication was changed (median eGFR 62.0 ((IQR 59.5-66.0) to 69.0 (IQR 60.0-77.0) mL/min/1.73 m², p=0.006, n=29), suggesting that the effect on eGFR is not related to medication changes. At 12 months, eGFR was not significantly changed (n=22, median eGFR 63.5 mL/min/1.73 m² (IQR 58.5-71.0), p=0.067).

Conclusions

The retrospective nature of this study and the despite guidelines limited availability of renal markers in routine type 2 diabetes care are limiting. Nevertheless, these data support a favourable effect of RD2N on renal function. Further research, with proper documentation of renal function, urinary protein excretion and dietary intake, is needed to substantiate these results, ideally in a large-scale prospective cohort study.

Can Mediterranean Diet Have a Positive Impact on Kidney Health? A Pending Answer to a Long-Time Question

Dietary studies conducted in chronic kidney disease (CKD) patients were focused on the quantities of single nutrients, however it is possible that the excessive attention put on the restriction of proteins, sodium, potassium and phosphorus may compromise the overall quality of the diet in terms of micronutrients and palatability. Instead, concentrating on the nutritional quality healthy dietary patterns, may provide a better approach to improve nutritional prescriptions in CKD patients. All these dietary regimens share common features as reduced content of red meat, salt and saturated fatty acids, and higher fiber content, but may differ in terms of single nutrients consumption. In particular, Mediterranean Diet (Med Diet) has been associated with reduced incidence of diabetes, cardiovascular diseases and obesity, all conditions that are also strictly related to CKD. Given its low content of animal proteins and high contents of fiber it is possible that Med Diet may exert also positive effects on CKD as well as on its metabolic complications. In this review we summarize the role of Med Diet in primary prevention of CKD and on its progression.

Adherence to the Mediterranean Diet Is Associated with a More Favorable Left Ventricular Geometry in Patients with End-Stage Kidney Disease

Introduction. The aim of the study was to examine the impact of adherence to a Mediterranean-style diet (MD) on left ventricular hypertrophy (LVH) and cardiac geometry in chronic kidney disease patients on dialysis (CKD-5D), given the high prevalence of cardiovascular morbidity in this population. Methods. n = 127 (77 men and 50 women) CKD-5D patients (69 on hemodialysis and 58 on peritoneal dialysis) with a mean age of 62 ± 15 years were studied. An MD adherence score (MDS) (range 0−55, 55 representing maximal adherence) was estimated with a validated method. Echocardiographic LVH was defined by LV mass index (LVMI) > 95 g/m2 in women and >115 g/m2 in men. Based on LVMI and relative wall thickness (RWT), four LV geometric patterns were defined: normal (normal LVMI and RWT), concentric remodeling (normal LVMI and increased RWT > 0.42), eccentric LVH (increased LVMI and normal RWT), and concentric LVH (increased LVMI and RWT). Results. Patients with LVH (n = 81) as compared to patients with no LVH (n = 46) were older in age (66 ± 13 vs. 55 ± 16 years; p < 0.001) had lower MDS (24 ± 2.7 vs. 25 ± 4.3; p < 0.05) and higher malnutrition-inflammation score (5.0 ± 2.7 vs. 3.9 ± 1.9; p < 0.05), body mass index (27.5 ± 4.9 vs. 24.1 ± 3.5 kg/m2; p < 0.001), prevalence of diabetes (79% vs. 20%; p < 0.05), coronary artery disease (78% vs. 20%; p < 0.05) and peripheral vascular disease (78% vs. 20%; p < 0.01). In a multivariate logistic regression analysis adjusted for all factors mentioned above, each 1-point greater MDS was associated with 18% lower odds of having LVH (OR = 0.82, 95% CI: 0.69−0.98; p < 0.05). MDS was inversely related to LVMI (r = −0.273; p = 0.02), and in a multiple linear regression model (where LVMI was analyzed as a continuous variable), MDS emerged as a significant (Β = −2.217; p < 0.01) independent predictor of LVH. Considering LV geometry, there was a progressive decrease in MDS from the normal group (25.0 ± 3.7) to concentric remodeling (25.8 ± 3.0), eccentric (24.0 ± 2.8), and then concentric (23.6 ± 2.7) group (p < 0.05 for the trend). Conclusions. The greater adherence to an MD is associated with lesser LVH, an important cardiovascular disease risk factor; MD preserves normal cardiac geometry and may confer protection against future cardiac dysfunction in dialysis patients.

Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD)

Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.

Does the Mediterranean diet reduce the odds of diabetic nephropathy in women? A case–control study

Background

In recent decades, the prevalence of chronic diseases such as diabetes is increasing. One of the major complications of diabetes is diabetic nephropathy (DN), so it is important to find a way that can delay or control the onset of DN. Therefore, in this study, we investigated the relationship between the Mediterranean diet (MED) and the odds of DN.

Methods

This case–control study was performed among 210 women (30–65 years) who were referred to the Kowsar Diabetes Clinic in Semnan, Iran. Biochemical variables and anthropometric measurements were assessed. The food frequency questionnaire (FFQ) was used to calculate dietary intakes. Data from dietary intakes based on the FFQ were used to evaluate the MED score. Logistic regression was used to examine the associations.

Results

Our results showed that in the crude model with higher adherence to the MED (OR: 0.272; 95% CI: 0.154, 0.481; P = 0.001), the odds of DN has reduced by 73%, and in model 1, after controlling for potential confounders, with higher adherence to the MED (OR: 0.239; 95% CI: 0.128, 0.447; P = 0.001), the odds of DN has reduced by 76% compared to low adherence. Also, in model 1, significant associations were observed between high consumption of grains (OR: 0.360; 95% CI: 0.191, 0.676; P = 0.001), legumes (OR: 0.156; 95% CI: 0.083, 0.292; P = 0.001), vegetables (OR: 0.273; 95% CI: 0.149, 0.501; P = 0.001), fruits (OR: 0.179; 95% CI: 0.093, 0.347; P = 0.001), fish (OR: 0.459; 95% CI: 0.254, 0.827; P = 0.01), and reduced odds of DN (P &lt; 0.05).

Conclusion

We observed that with higher adherence to the MED, the odds of DN had reduced through mechanisms. However, additional studies are needed to confirm these findings.

Obesity and Lifestyle Habits among Kidney Transplant Recipients

Background: Obesity may negatively impact clinical outcomes in kidney transplant (KT) recipients. Limited information is available on the prevalence of obesity in this population, and on the lifestyle habits associated with obesity. Methods: we conducted an online, anonymous survey to assess of the proportion of KT recipients with obesity, adherence to the Mediterranean diet (i.e., a dietary regimen with proven renal and cardiovascular outcomes) using the MEDI-Lite questionnaire, and level of physical activity using the International Physical Activity Questionnaire (IPAQ) short form among KT recipients. Results: 255 KT recipients participated. Median (25th−75th quartile) age was 56.0 (48.0; 62.0) years, 43.9% female, median BMI 23.9 (21.6; 26.5) kg/m2. The proportion of KT recipients with obesity was 9.8% (95% confidence interval, 6.4 to 14.1%). Adequate adherence to the Mediterranean diet (Medi-Lite score >9) was overall low (44.7%; 40.0 vs. 45.2% in those with or without obesity, respectively; p = 0.618). In participants with obesity the Medi-Lite score inversely correlated with BMI (R = −0.45; p < 0.025). Overall, 30.6% of participants had a low level of physical activity (44.0 vs. 29.1% of those with or without obesity, respectively; p = 0.125). The amount of energy expended walking was significantly lower among participants with obesity (462 (0.0; 1436) vs. 1056 (433; 2005) METs/week, p = 0.017). Conclusions: the burden of obesity among KT recipients is similar to that of the general population. Adherence to the Mediterranean diet was generally low, and nearly one-third of participants had a low level of physical activity. Building specialized multidisciplinary teams to manage obesity in KT recipients is urgently needed.

Dietary Acid Load (DAL), Glycated Hemoglobin A1c (HbA1c), and Metabolic Syndrome (MeS) Mediate the Association of the Adherence to the Dietary Approaches to Stopping Hypertension (DASH) and Mediterranean Diet (MeD) With Nonalcoholic Fatty Liver Disease

The study aimed to investigate the association of adults adhering to Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diet (MeD) with nonalcoholic fatty liver disease (NAFLD) using structural equation modeling (SEM) in Iran. In this population-based cross-sectional study, 3,220 adults (44.65% female) aged ≥18 years were selected from the Amol Cohort Study (AmolCS). The dietary intakes were assessed by a validated 168-item semi-quantitative food-frequency questionnaire (FFQ). Residual method energy adjustment of MeD and DASH scores were calculated. Demographic characteristics and anthropometric and laboratory measurements were collected. NAFLD was diagnosed by an expert radiologist via ultrasound sonography. Based on the primary hypothesis, DASH, MeD, and NAFLD were fitted into models. Metabolic syndrome (MeS) as a potential risk factor directly affected NAFLD risk in all these models. In both genders, the higher adherence to DASH negatively affected NAFLD risk indirectly through the two following paths. (1) Dietary acid load (DAL) and metabolic syndrome (2) DAL and hemoglobin A1c (HbA1c). In addition, the higher DAL positively affected NAFLD risk among male participants indirectly via increasing HbA1c level and MeS (from DAL to HbA1c: β = 0.07, P < 0.001; from HbA1c to MeS: β = 0.10, P < 0.001). Similarly, in both genders, the relationship between MeD and NAFLD was mediated through (1) DAL, HbA1c, and MeS and (2) DAL and MeS. Further, among male participants, the MeD and NAFLD risk were also associated via the mediators of HbA1c and MeS. In female participants, the higher MeD score was directly associated with a reduction of NAFLD risk (β = -0.07, P = 0.008). The present study found three important mediators, including DAL, HbA1c, and MeS, in the association of DASH and MeD scores with NAFLD risk. Preventive and therapeutic interventions should target the mediators, including DAL, HbA1c, MeS, and its components, to reduce NAFLD incidence in the general population.

Potassium and fiber: a controversial couple in the nutritional management of children with chronic kidney disease

BACKGROUND

Fruit and vegetable intake is commonly discouraged in children with chronic kidney disease (CKD) to avoid hyperkalemia. However, direct evidence in support of this widespread practice is lacking. Furthermore, the resultant restricted fiber exposure may deprive CKD patients from potential health benefits associated with the latter. Therefore, we investigated associations between dietary potassium intake, fiber intake, and serum potassium levels in pediatric CKD.

METHODS

This study is a longitudinal analysis of a 2-year, prospective, multi-institutional study, following children with CKD at 3-month intervals. At each visit, dietary potassium and fiber intake were assessed, using 24-h recalls and 3-day food records. On the same occasion, serum potassium concentrations were determined. Associations between dietary potassium intake, dietary fiber intake, and serum potassium concentrations were determined using linear mixed models.

RESULTS

Fifty-two CKD patients (7 transplant recipients, none on dialysis) aged 9 [4;14] years with an estimated glomerular filtration rate (eGFR) of 49 [25;68] mL/min/1.73 m² were included. For every g/day decrease in dietary potassium intake, the estimated mean daily fiber intake was 5.1 g lower (95% confidence interval (CI), 4.3-5.9 g/day; p < 0.001). Neither dietary potassium intake (p = 0.40) nor dietary fiber intake (p = 0.43) was associated with circulating potassium in a model adjusted for time point, eGFR, treatment with a renin-angiotensin-aldosterone system blocker, serum bicarbonate concentration, and body surface area.

CONCLUSIONS

Dietary potassium and fiber intake are closely related but were not associated with circulating potassium levels in pediatric CKD. A higher-resolution version of the graphical abstract is available as Supplementary information.

Vegetarian Diet Was Associated With a Lower Risk of Chronic Kidney Disease in Diabetic Patients

Introduction

Diabetes mellitus (DM) is a pathological hyperglycemic state related to the dysregulation of insulin. Chronic kidney disease (CKD) is a common chronic complication in diabetic patients. A vegetarian diet could be one of the preventive strategies for the occurrence of CKD in patients with diabetes mellitus. However, it is still unknown whether a vegetarian diet lowers the occurrence of CKD in DM patients.

Research Design and Methods

This retrospective study was conducted at Taipei Tzu Chi Hospital from 5 September 2005 to 31 December 2016. Subjects with an HbA1c level > 6.5% or previous history of diabetes mellitus elder than 40 years were grouped based on self-reported dietary habits (vegetarians, lacto-ovo vegetarians and omnivores) in the structured questionnaire. Structural equation modeling (SEM) was applied to estimate the direct and indirect effects of variables on the occurrence of chronic kidney disease.

Results

Among these 2,797 subjects, the participants were grouped into dietary habits as vegans (n = 207), lacto-ovo vegetarians (n = 941) and omnivores (n = 1,649). The incidence of overall CKD was higher in the omnivore group [36.6% vs 30.4% (vegans) and 28.5% (lacto-ovo vegetarian), p < 0.001]. In the SEM model, after adjusting for age and sex, the lacto-ovo vegetarian [OR: 0.68, 95% confidence interval (CI): 0.57–0.82] and vegan groups (OR 0.68, 95% CI: 0.49–0.94) were both associated with a lower risk of CKD occurrence than the omnivore group. The vegan diet and lacto-ovo diet lowered the risk related to a high BMI (OR: 0.45, p < 0.001, OR: 0.58, p < 0.001) and hyperuricemia (OR: 0.53, p < 0.001; OR: 0.55, p < 0.001) for the occurrence of CKD.

Conclusion

Vegetarian dietary habits were associated with a lower occurrence of CKD in DM patients.

Associations of dietary patterns and pre-eclampsia: a matched case-control study

Little is known about the effects of dietary patterns on prevalent pre-eclampsia in Chinese population. This study aimed to investigate the associations between dietary patterns and the odds of pre-eclampsia among Chinese pregnant women. A 1:1 age- and gestational week-matched case-control study was conducted between March 2016 and February 2019. A total of 440 pairs of pre-eclampsia cases and healthy controls were included. Dietary intakes were assessed by a seventy-nine-item FFQ and subsequently grouped into twenty-eight distinct groups. Factor analysis using the principal component method was adopted to derive the dietary patterns. Conditional logistic regression was used to analyse the associations of dietary patterns with prevalent pre-eclampsia. We identified four distinct dietary patterns: high fruit-vegetable, high protein, high fat-grain and high salt-sugar. We found that high fruit-vegetable dietary pattern (quartile (Q)4 v. Q1, OR 0·71, 95 % CI 0·55, 0·92, Ptrend = 0·013) and high protein dietary pattern (Q4 v. Q1, OR 0·72, 95 % CI 0·54, 0·95, Ptrend = 0·011) were associated with a decreased odds of pre-eclampsia in Chinese pregnant women. Whereas high fat-grain dietary pattern showed a U-shaped association with pre-eclampsia, the lowest OR was observed in the third quartile (Q3 v. Q1, OR 0·75, 95 % CI 0·57, 0·98, Ptrend = 0·111). No significant association was observed for high salt-sugar dietary pattern. In conclusion, pregnancy dietary pattern characterised by high fruit-vegetable or high protein was found to be associated with a reduced odds of pre-eclampsia in Chinese pregnant women.

Does Mediterranean Adequacy Index Correlate with Cardiovascular Events in Patients with Advanced Chronic Kidney Disease? An Exploratory Study

The Mediterranean Diet (MD) is a healthy dietary pattern, demonstrated to reduce the risk of cancer, diabetes, cardiovascular and neurodegenerative diseases, and early death. The Mediterranean Adequacy Index (MAI) is used to measure adherence to the MD in perspective studies in the general population and correlates with cardiovascular events. The aim of this study was to calculate the MAI among patients with advanced chronic kidney disease (CKD) and correlate it with traditional uremic, microbiota-derived, and proatherogenic toxins as well as nutritional status, quality of life, and cardiovascular events. A total of 60 adult patients with advanced CKD were enrolled and their MAI was calculated. According to the median value, patients were divided into lower (l-MAI, <1.80) and higher (h-MAI, ≥1.80) MAI groups. Biochemical parameters, microbiota-derived and proatherogenic toxins (p-Cresyl sulphate, Indoxyl-sulphate, and Lipoprotein-associated phospholipase A2), nutritional status, quality of life, and cardiovascular events that occurred in the previous three years were recorded. The mean value of the MAI was 2.78 ± 2.86. The MAI was significantly higher in foreigners (median (IQR) 6.38 (8.98) vs. 1.74 (1.67), p < 0.001) and diabetic patients. The l-MAI and h-MAI groups had similar routinary blood, p-Cresyl-sulphate, Indoxyl-sulphate, and Lp-PLA2 as well as nutritional status and quality of life parameters. The MAI was not associated with previous cardiovascular events and did not correlate with cardiovascular events in CKD patients. New and nephro-tailored indexes are warranted to evaluate nutritional therapy in CKD patients.

Nutrition Knowledge as a Driver of Adherence to the Mediterranean Diet in Italy

Background

An optimal Nutrition knowledge (NK) among the population could result in greater Adherence to the Mediterranean Diet (AMD), a recognized dietary pattern capable of preventing chronic food-related diseases. This study aimed to evaluate the association between NK and AMD in Italy.

Methods

A national representative sample of 2,869 adults took part in an assessment that was carried out through a self-administrated questionnaire including sections relating to NK and AMD. AMD was evaluated following the PREDIMED PLUS methodology. Descriptive statistics were provided, and ordinal measures of NK score and AMD were calculated based on quartiles of the quantitative scores. A contingency analysis was performed to check associations between variables.

Results

In Italy, the average NK score was 50 ± 13.3, equivalent to 56.8% of correct answers. The average value of AMD was 6.8, corresponding to 40% of the maximum score with 31.4% of the population demonstrating low AMD, 31.3% in the lower-middle range, 24% in the medium-high range, and only 13.3% reporting a high AMD. A significant association between NK and AMD was found; respondents who reported the lowest AMD corresponded to those with the lowest NK (36.7%; p < 0.05) and similarly, those with the highest level of adherence to MD also achieved the highest NK scores (41.7%; p < 0.05).

Conclusion

This study showed that AMD in Italy is generally low, and the strong association between NK and AMD demonstrated that there is a clear connection between a healthy dietary pattern and the nutrition literacy of the population. Those with the highest AMD corresponded to the highest NK and, conversely, those with the lowest AMD displayed the lowest NK. The study also highlighted that socioeconomic aspects were strong determinants of both AMD and NK.

Associations between dietary patterns and stages of chronic kidney disease

BACKGROUND

Studies have revealed that patients with chronic kidney disease (CKD) have dietary patterns different from those of the general population. However, no studies have compared the dietary patterns of between patients with early-stages (stages 1-3a) and late-stages (stages 3b-5) of CKD. Our objective was to investigate the associations between dietary patterns in early and late-stage CKD.

METHODS

We analyzed 4480 participants with CKD at various stages based on the data recorded between 2007 and 2016 from the database of the American National Health and Nutrition Examination Survey.

RESULTS

In total, 3683 and 797 participants had early and late-stage CKD, respectively. Through principal components analysis, the dietary intake dimension was reduced from 63 variables to 3 dietary patterns. We adopted logistic regression for analysis. The three dietary patterns are as follows: (1) saturated fatty acids and mono-unsaturated fatty acids (MUFA); (2) vitamins and minerals; and (3) cholesterols and polyunsaturated fatty acids (PUFA). These 3 patterns explained > 50% of dietary nutrient intake. Results indicated that among participants with dietary patterns 2 (vitamins and minerals) and 3 (cholesterols and PUFA), those with low intakes were more likely to have late-stage CKD. The odds ratios for patterns 2 and 3 were 1.74 (95% CI: 1.21-2.50) and 1.66 (95% CI: 1.13-2.43), respectively.

CONCLUSIONS

This study revealed that intakes of vitamins and minerals and cholesterols and PUFA were associated with the stages of CKD.

Effects and safety of traditional Chinese medicine on the gut microbiota of an adult with chronic kidney disease: A protocol for systematic review and meta-analysis

BACKGROUND

Studies have reported that changes in the abundance of gut microbiota may explain the medically helpful responses towards traditional Chinese medicine (TCM), an essential part of alternative and complementary medicine, in treating chronic kidney disease (CKD). This study aimed to illuminate the changes in the abundance of gut microbiota of TCM with CKD.

METHODS

The meta-analysis was performed in the PubMed, Web of Science, EMBASE CNKI, WanFang, VIP, and CBM databases, from its inception to October 2021 to discriminate randomized controlled trials and examine the effects of TCM on CKD. Two researchers independently performed literature selection, data extraction, and quality assessment. The risk of bias of the included studies was estimated by taking into consideration the characteristics including random sequence generation, allocation concealment, blinding of patients, blinding of outcome assessment, completeness of outcome data, selective reporting, and other bias using Cochrane Collaboration's tool for assessing the risk of bias.

RESULTS AND CONCLUSIONS

From the perspective of intestinal flora, this study will provide high-quality evidence for the effectiveness and safety of TCM for CKD. It provides a new therapeutic approach for treating CKD with Chinese herbal medicine combined with Western medicine.

INPLASY REGISTRATION NUMBER

INPLASY2021100118.

Mediterranean Diet Adherence and Nutritional Status in Dalmatian Diabetic Hypertensive Patients Regarding Presence of Chronic Kidney Disease—Is There Any Difference?

In recent years, the Mediterranean diet has emerged as one of the dietary patterns that could have positive effects on overall health as well in the treatment of non-communicable chronic diseases. The aim of this cross-sectional study was to determine differences in adherence to the Mediterranean diet (MeDi) and nutritional status in patients with type 2 diabetes mellitus (T2DM) and arterial hypertension (AH) regarding the presence of chronic kidney disease (CKD). Two hundred and forty-eight Dalmatian diabetic hypertensive patients (DDHP) were included, and 164 (66.1%) of them had CKD. Data about anthropometric parameters, clinical and laboratory parameters, as well as lifestyle questionnaire and Mediterranean Diet Serving Score (MDSS) were collected for each study participant. Furthermore, body composition was assessed using MC-780 Multi Frequency Segmental Body Mass Analyzer (Tanita). Body mass index (BMI) as well as waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. Results showed that only 8.9% of DDHP were adherent to the MeDi without significant differences regarding the presence of CKD. Therefore, only 9.1% of participants with CKD were adherent to the MeDi. Dietary recommendations were received by 52.8% of DDHP and 49.4% with CKD, while only 12.8% of those with CKD were adherent to the given recommendations. The results showed that 88.3% of DDHP and 87.8% of the DDHP with CKD were overweight or obese. Statically significant lower frequency of nut intake suggested by the MeDi was found in those participants with CKD (p = 0.02). Therefore, the significant associations between adherence to each MeDi component as well as MDSS score with the development of CKD among all study subjects were not found. In conclusion, the results showed a low level of nutritional care in our region and low adherence to MeDi among DDHP. According to the results, there is an urgent need to improve nutritional care in our region, with a special focus on the MeDi for this especially vulnerable population of patients.

The Mediterranean Diet Protects Renal Function in Older Adults: A Prospective Cohort Study

Background: Chronic kidney disease entails a high disease burden that is progressively increasing due to population aging. However, evidence on the effect of the Mediterranean diet on renal function is limited, in particular among older adults in Mediterranean countries. Methods: Prospective cohort study with 975 community-dwelling adults aged ≥ 60 recruited during 2008–2010 in Spain and followed up to 2015. At baseline, food consumption was obtained using a validated dietary history. Two Mediterranean dietary patterns were used: (i) An a priori-defined pattern, the Mediterranean Diet Adherence Screener (MEDAS score: low adherence: 0–5 points; moderate: 6–8 points; high: 9–14 points); (ii) An a posteriori Mediterranean-like dietary pattern, based on 36 food groups, which was generated using factor analysis. Renal function decline was calculated as an estimated glomerular filtration rate (eGFR) decrease ≥1 mL/min/1.73 m2 per year of follow-up. Results: A total of 104 cases of renal function decline occurred. Compared with participants with a low MEDAS adherence, the multivariable-adjusted odds ratios (95% confident interval) for renal function decline risk were 0.63 (0.38–1.03) for moderate adherence, and 0.52 (0.29–0.95) for high adherence (p-trend: 0.015). Multivariable-adjusted odds ratios (95% confidence interval) for renal function decline risk according to increasing quartiles of the adherence to the a posteriori Mediterranean-like dietary pattern were 1.00, 0.67 (0.38–1.20), 0.65 (0.35–1.19), and 0.47 (0.23–0.96) (p-trend: 0.042). Conclusion: A higher adherence to a Mediterranean diet was associated with a lower risk of renal function decline in older adults, suggesting benefits to health of this dietary pattern in Mediterranean countries.

UMOD and you! Explaining a rare disease diagnosis

The precise molecular genetic diagnosis of a rare inherited disease is nearly always a prolonged odyssey. Fortunately, modern molecular testing strategies are allowing more diagnoses to be made. There are many different rare inherited kidney diseases and both the genetic heterogeneity of these conditions and the clinical diversity often leads to confusing nomenclature. Autosomal dominant tubulointerstitial kidney disease (ADTKD) is an example of this. ADTKD, an inherited kidney disease that leads to worsening of kidney function over time, often culminating in end stage kidney disease, accounting for around 2% of this cohort. UMOD is the most common gene implicated in this disorder but there are at least 6 subtypes. At present, there are no specific treatments for ADTKD. Here, we review the current understanding of this condition and provide patient-centred information to allow conceptual understanding of this disease to allow better recognition, diagnosis and management.

Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

A Narrative Review of Chronic Kidney Disease in Clinical Practice: Current Challenges and Future Perspectives

Chronic kidney disease (CKD) is a complex disease which affects approximately 13% of the world's population. Over time, CKD can cause renal dysfunction and progression to end-stage kidney disease and cardiovascular disease. Complications associated with CKD may contribute to the acceleration of disease progression and the risk of cardiovascular-related morbidities. Early CKD is asymptomatic, and symptoms only present at later stages when complications of the disease arise, such as a decline in kidney function and the presence of other comorbidities associated with the disease. In advanced stages of the disease, when kidney function is significantly impaired, patients can only be treated with dialysis or a transplant. With limited treatment options available, an increasing prevalence of both the elderly population and comorbidities associated with the disease, the prevalence of CKD is set to rise. This review discusses the current challenges and the unmet patient need in CKD.

Metabolic Acidosis in Chronic Kidney Disease: Pathogenesis, Clinical Consequences, and Treatment

The kidneys play an important role in regulating the acid-base balance. Metabolic acidosis is common in chronic kidney disease (CKD) patients and can lead to poor outcomes, such as bone demineralization, muscle mass loss, and worsening of renal function. Metabolic acidosis is usually approached with evaluating the serum bicarbonate levels but should be assessed by counting blood pH. Current guidelines recommend oral bicarbonate supplementation to maintain the serum bicarbonate levels within the normal range. However, a slow decline in the glomerular filtration rate might occur, even though the serum bicarbonate levels were in the normal range. Because the serum bicarbonate levels decrease when metabolic acidosis advances, other biomarkers are necessary to indicate acid retention for early diagnosis of metabolic acidosis. For this, urine citrate and ammonium excretion may be used to follow the course of CKD patients. Metabolic acidosis can be treated with an increased fruit and vegetable intake and oral alkali supplementation. Previous studies have suggested that administration of oral sodium bicarbonate may preserve kidney function without significant increases in blood pressure and body weight. Veverimer, a non-absorbed, counterion-free, polymeric drug, is emerging to treat metabolic acidosis, but further researches are awaited. Further studies are also needed to clarify the target therapeutic range of serum bicarbonate and the drugs used for metabolic acidosis.