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Hansen NM, Rix M, Kamper AL, Feldt-Rasmussen B, Christoffersen C, Astrup A, Salomo L. Study protocol: long-term effect of the New Nordic Renal Diet on phosphorus and lipid homeostasis in patients with chronic kidney disease, stages 3 and 4: a randomised controlled trial. BMJ Open 2021; 11:e045754. [PMID: 34462278 PMCID: PMC8407220 DOI: 10.1136/bmjopen-2020-045754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) causes severe disturbances in phosphate metabolism. New Nordic Renal Diet (NNRD) is a new dietary concept designed by the present research group that aims to offer patients with moderate CKD a whole food approach with a markedly reduction in dietary phosphorus intake, corresponding to 850 mg/day. The present protocol describes a randomised controlled trial aiming to test the long-term effects of dietary intervention with NNRD versus a non-restricted habitual diet on important parameters of phosphorus and lipid homeostasis. METHODS AND ANALYSIS This trial will be executed at the Department of Nephrology, Rigshospitalet, University of Copenhagen, Denmark. Sixty patients aged >18 years with CKD stages 3 and 4 (estimated glomerular filtration rate between 15 and 45 mL/min) will be recruited and randomly assigned to the intervention or control group. The other inclusion criterion includes a medically stable condition for at least 2 months prior to the start of the study. Exclusion criteria are treatment with phosphate binders, metabolic disorders that require specific dietary regulation, pregnancy and breast feeding, any types of food allergies or those who are vegans. The observation period is 26 weeks including seven study visits at the outpatient clinic combined with a weekly telephone consultation in both groups. A follow-up visit 3 months after study completion finalises the intervention. The primary outcome is the difference in the change in 24-hour urine phosphorus excretion from baseline to week 26 between the two study groups. Secondary outcomes include changes in phosphate-related and lipid metabolism-related blood and urine biochemistry, blood pressure and body composition. Moreover, we wish to explore adherence to the diet as well as quality of life. ETHICS AND DISSEMINATION The study has been approved by the Scientific Ethical Committee of the Capital Region of Denmark and the Danish Data Protection Agency. The results of the studies will be presented at national and international scientific meetings, and publications will be submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (wwwclinicaltrialsgov) Registry (NCT04579315). PROTOCOL VERSION The protocol, version 2, has been approved by the Ethical Committee Denmark on 18 September 2020. The protocol has also been approved by Data Protection Regulation and Data Protection Law on 15 September 2020. This study protocol is in accordance with the Standard Protocol Items: Recommendations for International Trials.
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Affiliation(s)
| | - Marianne Rix
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Louise Salomo
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
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Byrne FN, Gillman BA, Kiely M, Palmer B, Shiely F, Kearney PM, Earlie J, Bowles MB, Keohane FM, Connolly PP, Wade S, Rennick TA, Moore BL, Smith ON, Sands CM, Slevin O, McCarthy DC, Brennan KM, Mellett H, Dahly D, Bergin E, Casserly LF, Conlon PJ, Hannan K, Holian J, Lappin DW, O'Meara YM, Mellotte GJ, Reddan D, Watson A, Eustace J. Pilot Randomized Controlled Trial of a Standard Versus a Modified Low-Phosphorus Diet in Hemodialysis Patients. Kidney Int Rep 2020; 5:1945-1955. [PMID: 33163715 PMCID: PMC7609990 DOI: 10.1016/j.ekir.2020.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/09/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The standard low-phosphorus diet restricts pulses, nuts, and whole grains and other high phosphorus foods to control hyperphosphatemia. We conducted a randomized controlled trial to evaluate the effectiveness, safety, and tolerability of the modified diet, which introduced some pulses and nuts, increased the use of whole grains, increased focus on the avoidance of phosphate additives, and introduced the prescription of low-biological-value protein such as bread. METHODS We conducted a multicenter, pragmatic, parallel-arm, open-label, randomized controlled trial of modified versus standard diet in 74 adults on hemodialysis with hyperphosphatemia over 1 month. Biochemistry was assessed using monthly laboratory tests. Dietary intake was assessed using a 2-day record of weighed intake of food, and tolerability was assessed using a patient questionnaire. RESULTS There was no significant difference in the change in serum phosphate between the standard and modified diets. Although total dietary phosphorus intake was similar, phytate-bound phosphorus, found in pulses, nuts, and whole grains, was significantly higher in the modified diet (P < 0.001). Dietary fiber intake was also significantly higher (P < 0.003), as was the percentage of patients reporting an increase in bowel movements while following the modified diet (P = 0.008). There was no significant difference in the change in serum potassium or in reported protein intake between the 2 diets. Both diets were similarly well tolerated. CONCLUSION The modified low phosphorus diet was well tolerated and was associated with similar phosphate and potassium control but with a wider food choice and greater fiber intake than the standard diet.
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Affiliation(s)
- Fiona N. Byrne
- Department of Nutrition and Dietetics, Cork University Hospital, Cork, Ireland
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Health Research Board, Clinical Research Facility, Cork, Ireland
| | - Barbara A. Gillman
- Department of Nutrition and Dietetics, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Renal Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mairead Kiely
- School of Food and Nutritional Sciences University College Cork, Cork, Ireland
| | - Brendan Palmer
- Health Research Board, Clinical Research Facility, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | - Frances Shiely
- Health Research Board, Clinical Research Facility, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | | | | | - Maria B. Bowles
- Department of Nutrition and Dietetics, University Hospital Limerick, Limerick, Ireland
- Departments of Nephrology and Internal Medicine, University Hospital Limerick, Limerick, Ireland
| | - Fiona M. Keohane
- Department of Nutrition and Dietetics, Cork University Hospital, Cork, Ireland
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
| | - Pauline P. Connolly
- Department of Nutrition and Dietetics, Cavan General Hospital, Cavan, Ireland
- Department of Medicine, Cavan General Hospital, Cavan, Ireland
| | - Sarah Wade
- Department of Nutrition and Dietetics, St. Vincent’s University Hospital Dublin, Dublin, Ireland
- Department of Nephrology, St. Vincent’s University Hospital Dublin, Dublin, Ireland
| | - Theresa A. Rennick
- Department of Nutrition and Dietetics, Midland Regional Hospital, Tullamore, Ireland
- Department of Nephrology, Midland Regional Hospital, Tullamore, Ireland
| | - Bernice L. Moore
- Department of Nutrition and Dietetics, Beaumont Hospital, Dublin, Ireland
- Beaumont Hospital Kidney Center, Beaumont Hospital, Dublin, Ireland
| | - Oonagh N. Smith
- Department of Nutrition and Dietetics, Beaumont Hospital, Dublin, Ireland
- Beaumont Hospital Kidney Center, Beaumont Hospital, Dublin, Ireland
| | - Celene M. Sands
- Department of Nutrition and Dietetics, Mayo University Hospital, Mayo, Ireland
| | - Orla Slevin
- Department of Nutrition and Dietetics, Galway University Hospitals, Galway, Ireland
- Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | | | | | - Halóg Mellett
- Department of Nutrition and Dietetics, Tallaght University Hospital, Dublin, Ireland
- Department of Nephrology, Tallaght University Hospital, Dublin, Ireland
| | - Darren Dahly
- Health Research Board, Clinical Research Facility, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | - Eoin Bergin
- Department of Nephrology, Midland Regional Hospital, Tullamore, Ireland
| | - Liam F. Casserly
- Departments of Nephrology and Internal Medicine, University Hospital Limerick, Limerick, Ireland
| | - Peter J. Conlon
- Beaumont Hospital Kidney Center, Beaumont Hospital, Dublin, Ireland
| | - Kieran Hannan
- Department of Medicine, Cavan General Hospital, Cavan, Ireland
| | - John Holian
- Department of Nephrology, St. Vincent’s University Hospital Dublin, Dublin, Ireland
| | - David W. Lappin
- Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Yvonne M. O'Meara
- Department of Renal Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Donal Reddan
- Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Alan Watson
- Department of Nephrology, St. Vincent’s University Hospital Dublin, Dublin, Ireland
| | - Joseph Eustace
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Health Research Board, Clinical Research Facility, Cork, Ireland
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Byrne FN, Gillman B, Kiely M, Bowles M, Connolly P, Earlie J, Murphy J, Rennick T, Reilly EO, Shiely F, Kearney P, Eustace J. Translation of Nutrient Level Recommendations to Control Serum Phosphate Into Food-Based Advice. J Ren Nutr 2020; 31:43-48. [PMID: 32631781 DOI: 10.1053/j.jrn.2020.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/08/2020] [Accepted: 04/12/2020] [Indexed: 02/08/2023] Open
Abstract
The control of hyperphosphatemia is key to the management of chronic kidney disease mineral and bone disorder. Dietary restriction of phosphorus is essential to control hyperphosphatemia. Guidelines for chronic kidney disease and end-stage kidney disease generally provide high-level guidance on whether a nutrient should be restricted e.g, restrict dietary phosphorus. Dietitians translate such guidance into nutrient-based strategies and finally into food-based practical dietary advice for patients to follow. The practical aspects of dietary advice are not well described in the literature, neither are the challenges of concurrently altering 1 nutrient e.g., phosphorus while continuing to restrict others e.g., potassium, while maintaining overall nutritional adequacy and quality of life. In this article, we describe how we translated updated nutrient level recommendations into practical dietary advice to be delivered at the bedside.
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Affiliation(s)
- Fiona N Byrne
- Department of Nutrition & Dietetics, Cork University Hospital, Cork, Ireland; Department of Renal Medicine, Cork University Hospital, Cork, Ireland; Health Research Board, Clinical Research Facility, Cork, Ireland.
| | - Barbara Gillman
- Department of Nutrition & Dietetics, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mairead Kiely
- School of Food and Nutritional Sciences University College Cork, Cork, Ireland
| | - Maria Bowles
- Department of Nutrition & Dietetics, University Hospital Limerick, Limerick Ireland
| | - Pauline Connolly
- Department of Nutrition & Dietetics, Cavan General Hospital, Cavan Ireland
| | - Joyce Earlie
- Beacon Renal, Sandyford & Tallaght, Dublin, Ireland
| | - Jean Murphy
- Department of Nutrition & Dietetics, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Theresa Rennick
- Department of Nutrition & Dietetics, Midland Regional Hospital, Tullamore, Ireland
| | | | - Frances Shiely
- Health Research Board, Clinical Research Facility, Cork, Ireland; School of Public Health, University College Cork, Cork, Ireland
| | | | - Joseph Eustace
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland; Health Research Board, Clinical Research Facility, Cork, Ireland
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