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Piccoli GB, Cederholm T, Avesani CM, Bakker SJL, Bellizzi V, Cuerda C, Cupisti A, Sabatino A, Schneider S, Torreggiani M, Fouque D, Carrero JJ, Barazzoni R. Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN. Clin Nutr 2023; 42:443-457. [PMID: 36857954 DOI: 10.1016/j.clnu.2023.01.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient's preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.
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Affiliation(s)
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Uppsala University. Theme Inflammation & Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Carla Maria Avesani
- Department of Clinical Science, Technology and Intervention, Division of Renal Medicine and Baxter Novum, Karolinska Institute, Stockholm, Sweden
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Vincenzo Bellizzi
- Nephrology and Dialysis Division - Department of Medical Sciences, Hospital "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Alice Sabatino
- UO Nefrologia, Azienda Ospedaliera- Universitaria Parma, Parma, Italy
| | - Stephane Schneider
- Gastroenterology and Nutrition, Nice University Hospital, Université Côte d'Azur, Nice, France
| | - Massimo Torreggiani
- Néphrologie et dialyse, Centre Hospitalier Le Mans, Avenue Rubillard, 72037, Le Mans, France
| | - Denis Fouque
- Renal Department, Lyon SUD Hospital, Hospices Civils de Lyon, Université de Lyon, Pierre Benite, France
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
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Tallman DA, Khor BH, Karupaiah T, Khosla P, Chan M, Kopple JD. Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients. J Ren Nutr 2023; 33:249-260. [PMID: 36460269 DOI: 10.1053/j.jrn.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/11/2022] [Accepted: 10/28/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES The nutritional adequacy of both animal-based and plant-based low protein diets (LPDs) and moderate protein diets that are recommended for patients with chronic kidney disease have not been well examined. We therefore analyzed the nutrient content of three representative LPDs and moderate protein diets (lacto-ovo vegetarian, omnivorous, and vegan) containing foods that are likely to be prescribed for nondialyzed chronic kidney disease or chronic dialysis patients in the United States to determine the nutritional adequacy at different levels of protein intake. METHODS Theoretical 3-day menus were developed as per current renal dietary guidelines to model each diet at 7 different levels of protein intake (0.5-1.2 g/kilograms body weight/day [g/kg/d]). The diets were analyzed for their content of essential amino acids (EAAs) and other essential nutrients. RESULTS At an a priori recognized inadequate dietary protein level of 0.5 g/kg/d, all 3 diets failed to meet the Recommended Dietary Allowances (RDAs) for the following EAAs: histidine, leucine, lysine, and threonine. The omnivorous LPD met both the RDA and Estimated Average Requirement at levels of 0.6 g protein/kg/d or more. The lacto-ovo and vegan diets at 0.6 and 0.8 g protein/kg/d, respectively, were below the RDA for lysine. The amounts of several other vitamins and minerals were not uncommonly reduced below the RDA or Adequate Intake with all 3 LPDs. CONCLUSION In comparison to omnivorous LPDs, both vegan and lacto-ovo LPDs are more likely to be deficient in several EAAs and other essential nutrients. To provide sufficient amounts of all EAA, vegan and lacto-ovo LPDs must be carefully planned to include adequate amounts of appropriate dietary sources. Supplements of some other essential nutrients may be necessary with all three LPDs.
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Affiliation(s)
- Dina A Tallman
- Department of Nutrition and Food Science, Wayne State University, Detroit, Michigan
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Tilakavati Karupaiah
- School of Biosciences, Faculty of Health Sciences, Taylors University, Subang Jaya, Malaysia
| | - Pramod Khosla
- Department of Nutrition and Food Science, Wayne State University, Detroit, Michigan
| | - Maria Chan
- Department of Nutrition and Dietetics, The St. George Hospital, Kogarah, Australia
| | - Joel D Kopple
- Division of Nephrology and Hypertension and the Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, California.
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Kalantar-Zadeh K, Bellizzi V, Piccoli GB, Shi Y, Lim SK, Riaz S, Arronte RU, Lau WP, Fouque D. Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis. J Ren Nutr 2023:S1051-2276(23)00022-5. [PMID: 36796502 DOI: 10.1053/j.jrn.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Orange County, California
| | - Vincenzo Bellizzi
- Nephrology and Dialysis Division, Department of Medical Sciences, Hospital Sant'Anna e San Sebastiano, Caserta, Italy
| | - Giorgina B Piccoli
- Service de Néphrologie, Department of Medicine, Centre Hospitalier Le Mans, Le Mans, France
| | - Yunying Shi
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Soo Kun Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sumira Riaz
- Royal National Orthopaedic Hospital, London, UK
| | | | - Wai Pooi Lau
- Department of Dietetics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Université Claude Bernard Lyon 1, Cardiometabolism and Nutrition (CarMeN), Lyon, France.
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Low-Protein Diet: History and Use of Processed Low-Protein Rice for the Treatment of Chronic Kidney Disease. Foods 2021; 10:foods10102255. [PMID: 34681304 PMCID: PMC8534812 DOI: 10.3390/foods10102255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022] Open
Abstract
The epidemiology of chronic kidney disease (CKD) shows increasing trends in prevalence and mortality and has become the leading health problem worldwide. Reducing the amount of proteins ingested from rice is an easy way to control the total intake of proteins, saving energy sources, particularly in rice-eating countries. In Japan, low-protein white rice had been developed, but the taste and function were not satisfactory for CKD patients. We reviewed the brief history of low-protein dietary therapy for renal diseases and the recent development of low-protein processed brown rice (LPBR). The new LPBR is characterized by a low-protein content, the same energy content as white rice, low potassium and phosphorus contents, and high amounts of dietary fibers, γ-oryzanol, and antioxidant activity. Dietary fibers and γ-oryzanol would stabilize intestinal microbiota and improve uremic dysbiosis and leaky gut syndrome. All these features suggest that the health benefits of LPBR extend to preventing CKD progression and enhancing the quality of life (QOL) of patients with CKD.
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Piccoli GB, Di Iorio BR, Chatrenet A, D'Alessandro C, Nazha M, Capizzi I, Vigotti FN, Fois A, Maxia S, Saulnier P, Cabiddu G, Cupisti A. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (TOrino-Pisa study). Nephrol Dial Transplant 2020; 35:790-802. [PMID: 31435654 DOI: 10.1093/ndt/gfz147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/27/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Concerns about adherence and quality of life (QoL) limit the diffusion of low-protein diets (LPDs) as a way to slow chronic kidney disease (CKD) progression and postpone dialysis. The aim of this multicentre study is to assess dietary satisfaction in stable CKD patients. METHODS This was a multicentre cross-sectional study with long-term follow-up data. Prevalent patients on LPD for at least 6 months were selected in four Italian centres. QoL was assessed using the World Health Organization Quality of Life questionnaire, and diet satisfaction with the Modification of Diet in Renal Disease satisfaction questionnaire. Comorbidity was assessed by Charlson Comorbidity Index, estimated glomerular filtration rate (eGFR) was calculated by the CKD Epidemiology Collaboration equation and protein intake by Maroni-Mitch formula. Survival was analysed with Kaplan-Meier curves and Cox Proportional Hazard Model. RESULTS Four hundred and twenty-two CKD Stages 3-5 patients were enrolled. Over 95% were on moderately restricted diets (0.6 g/kg/day). Compliance was good (protein intake: 0.59 g/kg/day at baseline, 0.72 at the end of follow-up). Median dietary satisfaction was 4 on a 1-5 scale. QoL was not affected by the type of diet, but was influenced by age, comorbidity and setting of care. Two years later, at the end of follow-up, 66.6% of the patients were still on a diet; the main causes of discontinuation were dialysis and death. The dropout rate was low (5.5%); in Cox analysis, patient and renal survival were influenced by age and eGFR, but not by QoL, setting of care or type of diet. CONCLUSIONS LPDs are compatible with high dietary satisfaction and minimal dropout, at least in patients who are able to follow such a diet for at least 6 months.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antoine Chatrenet
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Marta Nazha
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Irene Capizzi
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | | | - Antioco Fois
- Department of Specialized Medicine, Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Stefania Maxia
- Nephrology, Department of Medicine, Ospedale Brotzu, Cagliari, Italy
| | | | | | - Adamasco Cupisti
- Nephrology, Department of Medicine, University of Pisa, Pisa, Italy
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Piccoli GB, Breuer C, Cabiddu G, Testa A, Jadeau C, Brunori G. Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline. J Clin Med 2018; 7:jcm7080199. [PMID: 30081442 PMCID: PMC6111293 DOI: 10.3390/jcm7080199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/21/2018] [Accepted: 08/01/2018] [Indexed: 12/18/2022] Open
Abstract
Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | | | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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Verseput C, Piccoli GB. Eating Like a Rainbow: The Development of a Visual Aid for Nutritional Treatment of CKD Patients. A South African Project. Nutrients 2017; 9:nu9050435. [PMID: 28452932 PMCID: PMC5452165 DOI: 10.3390/nu9050435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/11/2017] [Accepted: 04/17/2017] [Indexed: 12/21/2022] Open
Abstract
Providing nutritional education for chronic kidney disease (CKD) patients in South Africa is complicated by several conditions: the population is composed of diverse ethnic groups, each with its own culture and food preferences; eleven languages are spoken and illiteracy is common in the lower socio-economic groups. Food preparation and storage are affected by the lack of electricity and refrigeration, and this contributes to a monotonous diet. In traditional African culture, two meals per day are often shared "from the pot", making portion control difficult. There is both under- and over-nutrition; late referral of CKD is common. Good quality protein intake is often insufficient and there are several misconceptions about protein sources. There is a low intake of vegetables and fruit, while daily sodium intake is high, averaging 10 g/day, mostly from discretionary sources. On this background, we would like to describe the development of a simplified, visual approach to the "renal diet", principally addressed to illiterate/non-English speaking CKD patients in Southern Africa, using illustrations to replace writing. This tool "Five steps to improve renal diet compliance", also called "Eating like a Rainbow", was developed to try to increase patients' understanding, and has so far only been informally validated by feedback from users. The interest of this study is based on underlining the feasibility of dietary education even in difficult populations, focusing attention on this fundamental issue of CKD care in particular in countries with limited access to chronic dialysis.
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Affiliation(s)
- Cecile Verseput
- RD Consultant Renal Dietitian, 6 Janet Street, Glenvista, Johannesburg 2091, South Africa.
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France.
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