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Cecchi S, Di Stante S, Belcastro S, Bertuzzi V, Cardillo A, Diotallevi L, Grabocka X, Kulurianu H, Martello M, Nastasi V, Paci Della Costanza O, Pizzolante F, Di Luca M. Supplemented Very Low Protein Diet (sVLPD) in Patients with Advanced Chronic Renal Failure: Clinical and Economic Benefits. Nutrients 2023; 15:3568. [PMID: 37630758 PMCID: PMC10457928 DOI: 10.3390/nu15163568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
The supplemented very low-protein diet (sVLPD) has proven effective in slowing the progression of stage 5 chronic renal failure and postponing the start of the dialysis treatment. However, sVLPD could expose the patient to the risk of malnutrition. This diet is also difficult to implement due to the required intake of large number of keto-analogue/amino acid tablets. In our Center, the Department of Nephrology and Dialysis of Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, of Italy, respecting the guidelines of normal clinical practice, we prescribed sVLPD (0.3 g/prot/day) supplemented with only essential amino acids without the use of ketoanalogues in stage 5 patients and verified its efficacy, safety and clinical and economic effects. Over the 24 months period of observation the progression of chronic kidney disease (CKD) slowed down (mean eGFR 11.6 ± 3.3 vs. 9.3 ± 2.7 mL/min/1.73 m2, p < 0.001) and the start of the dialysis treatment (adjusted HR = 0.361, CI 0.200-0.650, p = 0.001) was delayed without evidence of malnutrition, in compliant vs. non-compliant patients. This led to a substantial cost reduction for the National Health System. This non-interventional longitudinal observational study is part of standard clinical practice and suggests that VLPD supplemented with essential amino acids could be extensively used to reduce the incidence of dialysis treatments, with a favorable economic impact on the NHS.
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Affiliation(s)
- Sofia Cecchi
- Department of Clinical and Molecular Science, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Silvio Di Stante
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Sara Belcastro
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Veronica Bertuzzi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Assunta Cardillo
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Laura Diotallevi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Xhensila Grabocka
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Hrissa Kulurianu
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Mauro Martello
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Valentina Nastasi
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Osmy Paci Della Costanza
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Francesca Pizzolante
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
| | - Marina Di Luca
- Department of Nephrology and Dialysis, Ospedale Santa Croce, Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, 61032 Fano, Italy (M.D.L.)
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Massini G, Caldiroli L, Molinari P, Carminati FMI, Castellano G, Vettoretti S. Nutritional Strategies to Prevent Muscle Loss and Sarcopenia in Chronic Kidney Disease: What Do We Currently Know? Nutrients 2023; 15:3107. [PMID: 37513525 PMCID: PMC10384728 DOI: 10.3390/nu15143107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Loss of muscle mass is an extremely frequent complication in patients with chronic kidney disease (CKD). The etiology of muscle loss in CKD is multifactorial and may depend on kidney disease itself, dialysis, the typical chronic low-grade inflammation present in patients with chronic kidney disease, but also metabolic acidosis, insulin resistance, vitamin D deficiency, hormonal imbalances, amino acid loss during dialysis, and reduced dietary intake. All these conditions together increase protein degradation, decrease protein synthesis, and lead to negative protein balance. Aging further exacerbates sarcopenia in CKD patients. Nutritional therapy, such as protein restriction, aims to manage uremic toxins and slow down the progression of CKD. Low-protein diets (LPDs) and very low-protein diets (VLPDs) supplemented with amino acids or ketoacids are commonly prescribed. Energy intake is crucial, with a higher intake associated with maintaining a neutral or positive nitrogen balance. Adequate nutritional and dietary support are fundamental in preventing nutritional inadequacies and, consequently, muscle wasting, which can occur in CKD patients. This review explores the causes of muscle loss in CKD and how it can be influenced by nutritional strategies aimed at improving muscle mass and muscle strength.
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Affiliation(s)
- Giulia Massini
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Lara Caldiroli
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Paolo Molinari
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Francesca Maria Ida Carminati
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Simone Vettoretti
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
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Use of low-protein staple foods in the dietary management of patients with stage 3-4 chronic kidney disease: a prospective case-crossover study. BMC Nephrol 2022; 23:114. [PMID: 35313803 PMCID: PMC8939078 DOI: 10.1186/s12882-022-02734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Maintaining a low-protein diet (LPD) is important for patients with chronic kidney disease (CKD) to delay renal degradation and alleviate clinical symptoms. For most patients with CKD, it is difficult to maintain the necessary low level of dietary protein intake (DPI). To improve the current dietary management of CKD, we conducted an intervention study by administering low-protein staple foods (LPSF). DESIGN AND METHODS We conducted a prospective case-crossover study among 25 patients with stage 3-4 CKD. During the initial 12 weeks of the study, we instructed the patients regarding a standard LPD according to the recommendations of a renal dietitian. In the second stage of the study, we requested the patients taking low-protein rice or low-protein flour (250 g/d) as an LPSF diet instead of regular staple food daily, and followed these patients up for 12 weeks. We compared the DPI, dietary energy intake (DEI), normalized protein equivalent of total nitrogen appearance (nPNA), serum creatinine levels, and nutritional index between baseline and the end of the study. RESULTS We found no change in dietary variables among the patients during the first 12 weeks of the LPD. After subjecting them to an LPSF diet, the corresponding variables showed a pronounced change. The patients' DPI decreased from 0.88 ± 0.20 to 0.68 ± 0.14 g/kg/d (P < 0.01) and the nPNA value decreased from 0.99 ± 0.18 to 0.87 ± 0.19 g/kg/d (P < 0.01). The high biological value protein intake proportion increased from 42% (baseline) to 57% (P < 0.01) during the 24 weeks. No variation was found in the measured DEI (28.0 ± 5.8 vs 28.6 ± 5.4 kcal/kg/d), nutrition assessment, or renal function and serum creatinine levels. CONCLUSION Our prospective case-crossover study demonstrated that an LPSF diet can help patients with stage 3-4 CKD reduce DPI and nPNA values, improve the proportion of highly bioavailable proteins, ensure adequate calorie intake, and avoid malnutrition. An LPSF diet is an effective and simple therapy for patients with stage 3-4 CKD.
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Inflammation: a putative link between phosphate metabolism and cardiovascular disease. Clin Sci (Lond) 2021; 135:201-227. [PMID: 33416083 PMCID: PMC7796315 DOI: 10.1042/cs20190895] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Dietary habits in the western world lead to increasing phosphate intake. Under physiological conditions, extraosseous precipitation of phosphate with calcium is prevented by a mineral buffering system composed of calcification inhibitors and tight control of serum phosphate levels. The coordinated hormonal regulation of serum phosphate involves fibroblast growth factor 23 (FGF23), αKlotho, parathyroid hormone (PTH) and calcitriol. A severe derangement of phosphate homeostasis is observed in patients with chronic kidney disease (CKD), a patient collective with extremely high risk of cardiovascular morbidity and mortality. Higher phosphate levels in serum have been associated with increased risk for cardiovascular disease (CVD) in CKD patients, but also in the general population. The causal connections between phosphate and CVD are currently incompletely understood. An assumed link between phosphate and cardiovascular risk is the development of medial vascular calcification, a process actively promoted and regulated by a complex mechanistic interplay involving activation of pro-inflammatory signalling. Emerging evidence indicates a link between disturbances in phosphate homeostasis and inflammation. The present review focuses on critical interactions of phosphate homeostasis, inflammation, vascular calcification and CVD. Especially, pro-inflammatory responses mediating hyperphosphatemia-related development of vascular calcification as well as FGF23 as a critical factor in the interplay between inflammation and cardiovascular alterations, beyond its phosphaturic effects, are addressed.
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Kopple JD, Karupaiah T, Chan M, Burrowes JD, Kirk J, Prest M. Global Renal Internet Course for Dietitians (GRID Course). J Ren Nutr 2021; 32:131-134. [PMID: 33812799 DOI: 10.1053/j.jrn.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/14/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Joel D Kopple
- Division of Nephrology and Hypertension, Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California; The David Geffen School of Medicine at UCLA, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Tilakavati Karupaiah
- School of BioSciences, Faculty of Health & Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
| | - Maria Chan
- Departments of Nutrition and Dietetics and Renal Medicine, The St. George Hospital, Kogarah, New South Wales, Australia
| | - Jerrilynn D Burrowes
- Department of Biomedical, Health and Nutritional Sciences, Long Island University-Post, Greenvale, New York
| | - Judith Kirk
- Division of Solid Organ Transplantation, University of Rochester Medical Center, Rochester, New York
| | - Melissa Prest
- National Kidney Foundation of Illinois, Chicago, Illinois
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Rocchetti MT, Di Iorio BR, Vacca M, Cosola C, Marzocco S, di Bari I, Calabrese FM, Ciarcia R, De Angelis M, Gesualdo L. Ketoanalogs' Effects on Intestinal Microbiota Modulation and Uremic Toxins Serum Levels in Chronic Kidney Disease (Medika2 Study). J Clin Med 2021; 10:jcm10040840. [PMID: 33670711 PMCID: PMC7922022 DOI: 10.3390/jcm10040840] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 02/06/2023] Open
Abstract
Nutritional therapy (NT) is a therapeutic option in the conservative treatment of chronic kidney disease (CKD) patients to delay the start of dialysis. The aim of this study was to evaluate the specific effect of ketoanalogs (KA)-supplemented diets for gut microbiota modulation. In a previous study we observed that the Mediterranean diet (MD) and a KA-supplemented very-low-protein diet (VLPD) modulated beneficially gut microbiota, reducing indoxyl- and p-cresyl-sulfate (IS, PCS) serum levels, and ameliorating the intestinal permeability in CKD patients. In the current study, we added a third diet regimen consisting of KA-supplemented MD. Forty-three patients with CKD grades 3B–4 continuing the crossover clinical trial were assigned to six months of KA-supplemented MD (MD + KA). Compared to MD, KA-supplementation in MD + KA determined (i) a decrease of Clostridiaceae, Methanobacteriaceae, Prevotellaceae, and Lactobacillaceae while Bacteroidaceae and Lachnospiraceae increased; (ii) a reduction of total and free IS and PCS compared to a free diet (FD)—more than the MD, but not as effectively as the VLPD. These results further clarify the driving role of urea levels in regulating gut integrity status and demonstrating that the reduction of azotemia produced by KA-supplemented VLPD was more effective than KA-supplemented MD in gut microbiota modulation mainly due to the effect of the drastic reduction of protein intake rather than the effect of KA.
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Affiliation(s)
- Maria Teresa Rocchetti
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, “AldoMoro” University, 70124 Bari, Italy; (C.C.); (I.d.B.); (L.G.)
- Correspondence:
| | | | - Mirco Vacca
- Department of Soil, Plant and Food Science, “Aldo Moro” University, Bari, Via G. Amendola 165/a, 70126 Bari, Italy; (M.V.); (F.M.C.); (M.D.A.)
| | - Carmela Cosola
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, “AldoMoro” University, 70124 Bari, Italy; (C.C.); (I.d.B.); (L.G.)
| | - Stefania Marzocco
- Department of Pharmacy, University of Salerno, 84084 Fisciano, Italy;
| | - Ighli di Bari
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, “AldoMoro” University, 70124 Bari, Italy; (C.C.); (I.d.B.); (L.G.)
| | - Francesco Maria Calabrese
- Department of Soil, Plant and Food Science, “Aldo Moro” University, Bari, Via G. Amendola 165/a, 70126 Bari, Italy; (M.V.); (F.M.C.); (M.D.A.)
| | - Roberto Ciarcia
- Department of Veterinary Medicine and Animal Productions, Faculty of Veterinary, University of Naples, 80138 Naples, Italy;
| | - Maria De Angelis
- Department of Soil, Plant and Food Science, “Aldo Moro” University, Bari, Via G. Amendola 165/a, 70126 Bari, Italy; (M.V.); (F.M.C.); (M.D.A.)
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, “AldoMoro” University, 70124 Bari, Italy; (C.C.); (I.d.B.); (L.G.)
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Verzola D, Picciotto D, Saio M, Aimasso F, Bruzzone F, Sukkar SG, Massarino F, Esposito P, Viazzi F, Garibotto G. Low Protein Diets and Plant-Based Low Protein Diets: Do They Meet Protein Requirements of Patients with Chronic Kidney Disease? Nutrients 2020; 13:E83. [PMID: 33383799 PMCID: PMC7824653 DOI: 10.3390/nu13010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023] Open
Abstract
A low protein diet (LPD) has historically been used to delay uremic symptoms and decrease nitrogen (N)-derived catabolic products in patients with chronic kidney disease (CKD). In recent years it has become evident that nutritional intervention is a necessary approach to prevent wasting and reduce CKD complications and disease progression. While a 0.6 g/kg, high biological value protein-based LPD has been used for years, recent observational studies suggest that plant-derived LPDs are a better approach to nutritional treatment of CKD. However, plant proteins are less anabolic than animal proteins and amino acids contained in plant proteins may be in part oxidized; thus, they may not completely be used for protein synthesis. In this review, we evaluate the role of LPDs and plant-based LPDs on maintaining skeletal muscle mass in patients with CKD and examine different nutritional approaches for improving the anabolic properties of plant proteins when used in protein-restricted diets.
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Affiliation(s)
- Daniela Verzola
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
| | - Daniela Picciotto
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Michela Saio
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Francesca Aimasso
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Francesca Bruzzone
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Samir Giuseppe Sukkar
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Fabio Massarino
- Clinical Nutrition Unit, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy; (F.A.); (F.B.); (S.G.S.); (F.M.)
| | - Pasquale Esposito
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, 16142 Genoa, Italy
| | - Giacomo Garibotto
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (D.V.); (D.P.); (M.S.); (P.E.); (F.V.)
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Lim JH, Chinna K, Khosla P, Karupaiah T, Daud ZAM. Understanding How Nutrition Literacy Links to Dietary Adherence in Patients Undergoing Maintenance Hemodialysis: A Theoretical Exploration Using Partial Least Squares Structural Equation Modeling. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207479. [PMID: 33066603 PMCID: PMC7602379 DOI: 10.3390/ijerph17207479] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/29/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022]
Abstract
Dietary non-adherence is pervasive in the hemodialysis (HD) population. Health literacy is a plausible predictor of dietary adherence in HD patients, but its putative mechanism is scarcely studied. Thus, this study aimed to establish the causal model linking nutrition literacy to dietary adherence in the HD population. This was a multi-centre, cross-sectional study, involving 218 randomly selected multi-ethnic HD patients from nine dialysis centres in Klang Valley, Malaysia. Dietary adherence and self-management skills were assessed using validated End-Stage Renal Disease Adherence Questionnaire and Perceived Kidney/Dialysis Self-Management Scale, respectively. Validated self-developed scales were used to gauge nutrition literacy, dietary knowledge and Health Belief Model constructs. Relationships between variables were examined by multiple linear regressions and partial least squares structural equation modeling. Limited nutrition literacy was evident in 46.3% of the HD patients, associated with older age, lower education level, and shorter dialysis vintage. Dietary adherence rate was at 34.9%. Nutrition literacy (β = 0.390, p < 0.001) was an independent predictor of dietary adherence, mediated by self-efficacy (SIE = 0.186, BC 95% CI 0.110-0.280) and self-management skills (SIE = 0.192, BC 95% CI 0.103-0.304). Thus, nutrition literacy-enhancing strategies targeting self-efficacy and self-management skills should be considered to enhance dietary adherence in the HD population.
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Affiliation(s)
- Jun-Hao Lim
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang 43400, Malaysia;
| | - Karuthan Chinna
- School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia;
| | - Pramod Khosla
- Department of Nutrition and Food Science, Wayne State University, Detroit, MI 48202-0340, USA;
| | - Tilakavati Karupaiah
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia;
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang 43400, Malaysia;
- Research Center of Excellent (RCoE) Nutrition and Non-communicable Diseases, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia
- Correspondence: ; Tel.: +60-397-692-431
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9
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Garibotto G, Picciotto D, Saio M, Esposito P, Verzola D. Muscle protein turnover and low-protein diets in patients with chronic kidney disease. Nephrol Dial Transplant 2020; 35:741-751. [PMID: 32378720 DOI: 10.1093/ndt/gfaa072] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/28/2020] [Indexed: 02/07/2023] Open
Abstract
Adaptation to a low-protein diet (LPD) involves a reduction in the rate of amino acid (AA) flux and oxidation, leading to more efficient use of dietary AA and reduced ureagenesis. Of note, the concept of 'adaptation' to low-protein intakes has been separated from the concept of 'accommodation', the latter term implying a decrease in protein synthesis, with development of wasting, when dietary protein intake becomes inadequate, i.e. beyond the limits of the adaptive mechanisms. Acidosis, insulin resistance and inflammation are recognized mechanisms that can increase protein degradation and can impair the ability to activate an adaptive response when an LPD is prescribed in a chronic kidney disease (CKD) patient. Current evidence shows that, in the short term, clinically stable patients with CKD Stages 3-5 can efficiently adapt their muscle protein turnover to an LPD containing 0.55-0.6 g protein/kg or a supplemented very-low-protein diet (VLPD) by decreasing muscle protein degradation and increasing the efficiency of muscle protein turnover. Recent long-term randomized clinical trials on supplemented VLPDs in patients with CKD have shown a very good safety profile, suggesting that observations shown by short-term studies on muscle protein turnover can be extrapolated to the long-term period.
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Affiliation(s)
- Giacomo Garibotto
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Daniela Picciotto
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Michela Saio
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Pasquale Esposito
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Daniela Verzola
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
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10
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Nutritional Therapy Modulates Intestinal Microbiota and Reduces Serum Levels of Total and Free Indoxyl Sulfate and P-Cresyl Sulfate in Chronic Kidney Disease (Medika Study). J Clin Med 2019; 8:jcm8091424. [PMID: 31510015 PMCID: PMC6780815 DOI: 10.3390/jcm8091424] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023] Open
Abstract
In chronic kidney disease (CKD), the gut-microbiota metabolites indoxyl sulfate (IS) and p-cresyl sulfate (PCS) progressively accumulate due to their high albumin-binding capacity, leading to clinical complications. In a prospective crossover controlled trial, 60 patients with CKD grades 3B–4 (GFR = 21.6 ± 13.2 mL/min) were randomly assigned to two dietary regimens: (i) 3 months of free diet (FD) (FD is the diet usually used by the patient before being enrolled in the Medika study), 6 months of very low protein diet (VLPD), 3 months of FD and 6 months of Mediterranean diet (MD); (ii) 3 months of FD, 6 months of MD, 3 months of FD, and 6 months of VLPD. VLPD reduced inflammatory Proteobacteria and increased Actinobacteria phyla. MD and VLPD increased some butyrate-forming species of Lachnospiraceae, Ruminococcaceae, Prevotellaceae, Bifidobacteriaceae, and decrease the pathobionts Enterobacteriaceae. The increased level of potential anti-inflammatory Blautia and Faecalibacterium, as well as butyrate-forming Coprococcus and Roseburia species in VLPD was positively associated with dietary intakes and it was negatively correlated with IS and PCS. Compared to FD and MD, VLPD showed a lower amount of some Lactobacillus, Akkermansia, Streptococcus, and Escherichia species. MD and VLPD reduced both the total and free serum IS (MD −36%, −40% and VLPD −69%, −73%, respectively) and PCS (MD −38%, −44% and VLPD −58%, −71%, respectively) compared to FD. VLPD reduced serum D-lactate compared to MD and FD. MD and, to a greater extent, VLPD are effective in the beneficial modulation of gut microbiota, reducing IS and PCS serum levels, and restoring intestinal permeability in CKD patients.
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Kelly JT, Campbell KL, Carrero JJ. Primary Versus Secondary Prevention of Chronic Kidney Disease: The Case of Dietary Protein. J Ren Nutr 2019; 28:225-228. [PMID: 29935606 DOI: 10.1053/j.jrn.2018.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jaimon T Kelly
- Faculty of Health Sciences and Medicine, Bond University, Australia
| | | | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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Otero Alonso P, Pérez Fontán M, López Iglesias A, García Falcón T, Rodríguez-Carmona A. High rates of protein intake are associated with an accelerated rate of decline of residual kidney function in incident peritoneal dialysis patients. Nephrol Dial Transplant 2019; 34:1394-1400. [PMID: 30615149 DOI: 10.1093/ndt/gfy393] [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: 08/30/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preservation of residual kidney function (RKF) is a relevant objective in peritoneal dialysis (PD) patients. The influence of dietary protein intake (PI) on this variable has not been adequately investigated. METHODS Following an observational design, we studied 336 patients incident on PD, with a minimum follow-up of 6 months. The main study variable was the mean PI [normalized rate of protein nitrogen appearance (nPNA)] during the first 4 months on PD. The main outcome variables were the absolute rate of decline of RKF and the proportion of patients presenting a >50% decay of their RKF during the first year of follow-up. We applied univariate and multivariate strategies of analysis, taking into consideration the main control variables bearing a correlation with nPNA and/or RKF. RESULTS Mean nPNA (first 4 months) was 1.23 ± 0.33 g/kg/day, while the overall rate of decline of RKF was -0.13 ± 0.29 mL/min/month; 69 patients (25.1%) had lost >50% of their initial RKF by the end of the first year. Univariate analysis disclosed consistent associations between the main study variable on one hand and baseline RKF (r = 0.32, P < 0.0005) and its rate of decline (r = -0.23, P < 0.0005) on the other. The latter two variables were also significantly correlated (r = -0.36, P < 0.0005). Multivariate analysis identified mean nPNA as an independent predictor of the rate of decline of RKF [odds ratio 1.09 per 0.10 g/kg/day, 95% confidence interval (CI) 0.99-1.19, P = 0.058] and, in particular, of the probability of losing >50% of the baseline RKF during the first year of treatment (odds ratio 1.15 per 0.10 g/kg/day, 95% CI 1.04-1.27, P = 0.006). CONCLUSION Higher rates of PI during the first months of therapy are associated with a faster decline of RKF among patients incident on PD. Our results underline the convenience of keeping an adequate balance between sufficient protein ingestion, to prevent malnutrition and wasting, and sensible restriction in stable, adequately nourished individuals with rates of intake in the higher range or above-recommended allowances.
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Ladsten T, Sarakatsannis Z. Your Guide to Create a Balanced Kidney-Friendly Meal. J Ren Nutr 2019; 29:e9-e11. [DOI: 10.1053/j.jrn.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/12/2018] [Indexed: 11/11/2022] Open
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Di Micco L, Di Lullo L, Bellasi A, Di Iorio BR. Very Low Protein Diet for Patients with Chronic Kidney Disease: Recent Insights. J Clin Med 2019; 8:jcm8050718. [PMID: 31137545 PMCID: PMC6572310 DOI: 10.3390/jcm8050718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/30/2022] Open
Abstract
Use of nutritional therapy (NT) in chronic kidney disease (CKD) patients is still debated among nephrologists, but it represents a fundamental point in the conservative treatment of CKD. It has been used for years and it has new goals today, such as (1) the reduction of edema, diuretics, and blood pressure values with a low sodium-content diet; (2) the dose reduction of phosphate levels and phosphate binders; (3) the administration of bicarbonate with vegetables in order to correct metabolic acidosis and delay CKD progression; (4) the reduction of the number and the doses of drugs and chemical substances; and (5) the lowering of urea levels, the cure of intestinal microbioma, and the reduction of cyanates levels (such as indoxyl-sulphate and p-cresol sulphate), which are the most recent known advantages achievable with NT. In conclusion, NT and especially very low protein diet (VLPD) have several beneficial effects in CKD patients and slows the progression of CKD.
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Affiliation(s)
- Lucia Di Micco
- Nefrology and Dialysis, AORN "San Giuseppe Moscati, 83100 Avellino AV, Italy.
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Rome, Italy.
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, 24127 Bergamo BG, Italy.
| | - Biagio R Di Iorio
- Nephrology and Dialysis, AORN "Antonio Cardarelli", 80131 Napoli, Italy.
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Laboux T, Azar R. [Dietary control of metabolic acidosis in chronic kidney disease]. Nephrol Ther 2019; 15:491-497. [PMID: 31056406 DOI: 10.1016/j.nephro.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023]
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease. Although it is known to appear at advanced stages, many studies suggest a state of "global protonic retention" starting at early stages of the disease, responsible of tissue damage, particularly musculoskeletal, alteration of protidic metabolism and endocrine disorders, promoting malnutrition and chronic inflammation, and finally increasing mortality. The majority of international recommandations suggest of supplementation by alkali, most of the time by sodium bicarbonate, to struggle against this complication. An interesting alternative to correct acidosis would consist on the modulation of the endogenous production of acid by playing with the alimentary incomes. In fact, it has been demonstrated that some different types of food produce or consume protons during their metabolism. Low protein diet and rich fresh fruits and vegetables diet would manage to correct at least as well as the supplementation by sodium bicarbonate the metabolic acidosis, and to struggle against its complications, noteworthy by slowing the decline of glomerular filtration rate by limiting the toxic adaptative fibrotic mechanisms, demonstrated by the decrease of urinary tubulo-interstitial suffering markers. Of the condition of being well led, those diets do not seem to expose patients to an over-risk of malnutrition or hyperkaliemia. They therefore appear to be an attractive alternative, efficiency and safe, to fight against chronic kidney disease metabolic acidosis and its complications.
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Affiliation(s)
- Timothée Laboux
- Service de néphrologie-transplantation, hôpital Claude-Huriez, centre hospitalier régional universitaire de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France.
| | - Raymond Azar
- Service de néphrologie-hémodialyse, centre hospitalier de Dunkerque, 130, avenue Louis-Herbeaux, 59240 Dunkerque, France
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Accuracy of a Nutrient Database in Estimating the Dietary Phosphorus-to-Protein Ratio and Using a Boiling Method in Low-Phosphate Hospital Diets. Sci Rep 2018; 8:15246. [PMID: 30323203 PMCID: PMC6189135 DOI: 10.1038/s41598-018-33657-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/03/2018] [Indexed: 01/12/2023] Open
Abstract
The use of the dietary phosphorus-to-protein ratio (PPR) to reduce dietary phosphorus while maintaining protein intake is valuable for nutritional management in the dialysis population, but the actual PPR values in hospital meals have not been determined. We aimed to determine the accuracy of a nutrient database for estimating the PPR in low-phosphate hospital diets compared with the accuracy of chemical analysis and produce hospital diets with low-phosphate content by boiling meat for 30 minutes before cooking. The phosphorus and protein content of 26 cooked dishes selected from the hospital menu was estimated using a food composition table (FCT) and sent for chemical analysis. Comparisons of FCT-based estimated values with measured values for every 100 g of tested foods revealed an overestimation for the PPR both in plant-based dishes (mean difference ± SD, 4.1 ± 14.6 mg/g, P = 0.06), and in meats (2.1 ± 2.3 mg/g, P = 0.06). By boiling meats, we crafted diets with PPR as low as 8 mg/g. Caution should be exercised in estimating the PPR using a FCT in hospital diets and boiling should be used to prepare hospital meals. Such diets will be promoted for dialysis patients in both inpatient and outpatient settings.
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Koppe L, Fouque D. The Role for Protein Restriction in Addition to Renin-Angiotensin-Aldosterone System Inhibitors in the Management of CKD. Am J Kidney Dis 2018; 73:248-257. [PMID: 30149957 DOI: 10.1053/j.ajkd.2018.06.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 06/18/2018] [Indexed: 01/13/2023]
Abstract
In experimental studies a low-protein diet (LPD) and renin-angiotensin-aldosterone system (RAAS) inhibitors are both reported to slow the progression of chronic kidney disease (CKD) and reduce proteinuria. RAAS activity contributes to increased blood pressure, fluid retention, and positive sodium balance, but also to kidney damage by enhancing glomerular capillary filtration pressure and synthesis of profibrotic molecules such as transforming growth factor β. It has been well established that an LPD decreases glomerular hyperfiltration and the generation of uremic toxins, as well as the burden of acid load, phosphorus, and sodium. In different animal CKD models, a significant reduction in proteinuria and glomerulosclerosis has been achieved when an RAAS inhibitor and LPD were combined. To date, high-quality intervention trials investigating this combined strategy are lacking. We summarize the experimental and clinical studies that have examined a potential additive action of these therapies on CKD progression. We outline potential mechanisms of action and additive efficacy of an LPD and RAAS inhibitors in CKD, with a particular emphasis on phosphate levels, uremic toxin production, acid load, and salt intake. Finally, although the evidence is inadequate to recommend combining RAAS inhibitors and an LPD to slow the progression of CKD, we provide a perspective to support a large-scale randomized clinical trial to study this combination.
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Affiliation(s)
- Laetitia Koppe
- University Lyon, CARMEN, Department of Nephrology, Centre Hospitalier Lyon Sud, Pierre-Benite, France
| | - Denis Fouque
- University Lyon, CARMEN, Department of Nephrology, Centre Hospitalier Lyon Sud, Pierre-Benite, France.
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