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Chen CH, Tsai PH, Tsai WC, Ko MJ, Hsu LY, Chien KL, Hung KY, Wu HY. Efficacy and safety of ketoanalogue supplementation combined with protein-restricted diets in advanced chronic kidney disease: a systematic review and meta-analysis. J Nephrol 2024:10.1007/s40620-024-02065-9. [PMID: 39340710 DOI: 10.1007/s40620-024-02065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 08/08/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND The benefits and harms of protein-restricted diets supplemented with ketoanalogues in patients with chronic kidney disease (CKD) remain uncertain. We aimed to evaluate the effects of ketoanalogues supplemented to protein-restricted diets in patients with advanced CKD. METHODS We conducted systematic literature searches of PubMed, Embase, Scopus, and Cochrane Library up to June 3, 2024. Randomized controlled trials comparing ketoanalogue supplementation with a low- or very low-protein diet versus a low-protein diet alone in stages 3-5 CKD patients were selected. Outcomes included glomerular filtration rate (GFR), end-stage kidney disease (ESKD), all-cause mortality, and blood levels of urea nitrogen, calcium, phosphorus, and albumin. Triceps skin fold, mid-arm muscle circumference, lean body mass, and subjective global assessment were also evaluated. The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42023465754). RESULTS A total of 16 trials comprising 1344 participants were identified, with a median follow-up of 13 months. Compared to a low-protein diet alone, ketoanalogues supplemented to a protein-restricted diet resulted in a significantly higher GFR, decreased levels of urea nitrogen and phosphorus, and increased levels of calcium. Furthermore, ketoanalogues combined with a protein-restricted diet showed a marginally lower risk of ESKD in participants without diabetes. No significant differences were observed in all-cause mortality, albumin, mid-arm muscle circumference, lean body mass, and subjective global assessment. CONCLUSIONS For stages 3-5 CKD patients, ketoanalogues combined with a protein-restricted diet may help postpone initiation of dialysis, improve calcium-phosphate homeostasis, and slow GFR decline, while maintaining a similar nutritional status and survival. Larger, long-term studies are needed to confirm these potential benefits, especially in CKD patients with diabetes.
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Affiliation(s)
- Chih-Heng Chen
- Department of Medical Education, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Family Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Ping-Hsiu Tsai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City, 220, Taiwan
| | - Wan-Chuan Tsai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City, 220, Taiwan
- Center for General Education, Lee-Ming Institute of Technology, New Taipei City, Taiwan
| | - Mei-Ju Ko
- Department of Dermatology, Taipei City Hospital, Taipei City, Taiwan
- Department of Dermatology, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
- University of Taipei, Taipei City, Taiwan
| | - Le-Yin Hsu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Kuo-Liong Chien
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Kuan-Yu Hung
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hon-Yen Wu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City, 220, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan.
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
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2
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Saavedra-Fuentes N, Carmona-Montesinos E, Castañeda-Hernández G, Campos I, Castillo-Salinas JC, Castillo-Tapia JA, Del Castillo-Loreto KG, Falcón-Martínez JC, Fuentes-García R, García de León Guerrero MÁ, García-García V, Gómez-García EF, González-Toledo R, Jaime A, Rely K, Lerma C, Morales-Buenrostro LE, Quilantan-Rodriguez M, Rodriguez-Matías A, Rojas-Rodriguez FO, Valdez-Ortiz R, Wasung M, Ceron-Trujillo B, Ramirez-Ramirez E. Appropriateness of Ketoanalogues of Amino Acids, Calcium Citrate, and Inulin Supplementation for CKD Management: A RAND/UCLA Consensus. Nutrients 2024; 16:2930. [PMID: 39275246 PMCID: PMC11397001 DOI: 10.3390/nu16172930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 08/24/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
BACKGROUND Current treatment for chronic kidney disease (CKD) focuses on improving manifestations and delaying progression. Nutritional approaches play a crucial role in CKD management, and various supplements have become available. Ketoanalogues of amino acids (KAs), calcium citrate, and inulin have been proposed as suitable supplements, yet their widespread use has been limited due to insufficient evidence. This study aimed to generate general guidance statements on the appropriateness of these supplements through a RAND/UCLA consensus process. METHODS A RAND/UCLA consensus panel was convened to evaluate the appropriateness of these supplements in different clinical scenarios. In this study, we present a subgroup analysis focusing on a panel of eleven clinical nephrologists from among the experts. RESULTS Supplementation of low-protein diets (LPDs) and very low-protein diets (VLPDs) with KA was considered appropriate to reduce manifestations and delay CKD outcomes, supplementation with calcium citrate is considered appropriate to reduce CKD manifestations, and supplementation with inulin is considered appropriate to delay CKD outcomes and manage comorbidities. CONCLUSIONS Based on a combination of clinical experience and scientific evidence, the panel reached a consensus that KA supplementation of LPD and VLPD, calcium citrate, and inulin are appropriate in patients with CKD across various scenarios.
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Affiliation(s)
| | | | - Gilberto Castañeda-Hernández
- Pharmacology Department, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City 07360, Mexico
| | - Israel Campos
- Hospital General Dr. Miguel Silva, Morelia 58253, Mexico
| | | | | | | | | | | | | | - Victor García-García
- Nephrology and Transplantation Unit, Unidad Medica de Alta Especialidad 14, Veracruz 91810, Mexico
| | - Erika F Gómez-García
- Medicine and Psychology Department, Universidad Autónoma de Baja California, Tijuana 22390, Mexico
| | | | | | - Kely Rely
- Cost Effectiveness Assessment for Health Technology, Mexico City 09450, Mexico
| | - Claudia Lerma
- Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Luis E Morales-Buenrostro
- Nephrology and Mineral Metabolism Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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3
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Kishi S, Kadoya H, Kashihara N. Treatment of chronic kidney disease in older populations. Nat Rev Nephrol 2024; 20:586-602. [PMID: 38977884 DOI: 10.1038/s41581-024-00854-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 07/10/2024]
Abstract
As the world population ages, an expected increase in the prevalence of chronic kidney disease (CKD) among older individuals will pose a considerable challenge for health care systems in terms of resource allocation for disease management. Treatment strategies for older patients with CKD should ideally align with those applied to the general population, focusing on minimizing cardiovascular events and reducing the risk of progression to kidney failure. Emerging therapies, such as SGLT-2 inhibitors and GLP-1 receptor agonists, hold promise for the effective management of CKD in older individuals. In addition, non-pharmacological interventions such as nutritional and exercise therapies have a crucial role. These interventions enhance the effects of pharmacotherapy and, importantly, contribute to the maintenance of cognitive function and overall quality of life. Various factors beyond age and cognitive function must be taken into account when considering kidney replacement therapy for patients with kidney failure. Importantly, all treatment options, including dialysis, transplantation and conservative management approaches, should be tailored to the individual through patient-centred decision-making. The dynamic integration of digital technologies into medical practice has the potential to transform the management of CKD in the aging population.
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Affiliation(s)
- Seiji Kishi
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroyuki Kadoya
- Department of General Geriatric Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Naoki Kashihara
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan.
- Kawasaki Geriatric Medical Center, Kawasaki Medical School, Okayama, Japan.
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4
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Peride I, Anastasiu M, Serban SA, Tiglis M, Ene R, Nechita AM, Neagu TP, Checherita IA, Niculae A. The Key Role of Nutritional Intervention in Delaying Disease Progression and the Therapeutic Management of Diabetic Kidney Disease-A Challenge for Physicians and Patients. J Pers Med 2024; 14:778. [PMID: 39201970 PMCID: PMC11355100 DOI: 10.3390/jpm14080778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/13/2024] [Accepted: 07/20/2024] [Indexed: 09/03/2024] Open
Abstract
Chronic kidney disease (CKD) represents an increasingly common pathology that affects patients' quality of life, and it is frequently associated with a high mortality rate, especially in the final stages of the disease. At the same time, diabetes mellitus is a chronic disease that contributes to the increased number of patients with CKD through diabetic kidney disease (DKD). The alternation of hypoglycemia with hyperglycemia is a condition in the occurrence of microvascular complications of diabetes, including DKD, which involves structural and functional changes in the kidneys. The therapeutic management of diabetic nephropathy is a much-discussed topic, both from nutritional medical recommendations and a pharmacotherapy perspective. The diet starting point for patients with DKD is represented by a personalized and correct adjustment of macro- and micronutrients. The importance of nutritional status in DKD patients is given by the fact that it represents a modifiable factor, which contributes to the evolution and prognosis of the disease. Since, in most cases, it is necessary to restrict many types of food, malnutrition must be considered and avoided as much as possible.
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Affiliation(s)
- Ileana Peride
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Miruna Anastasiu
- “Marie Skłodowska Curie” Children Emergency Clinical Hospital, 077120 Bucharest, Romania
| | | | - Mirela Tiglis
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Razvan Ene
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ana-Maria Nechita
- Department of Nephrology and Dialysis, “St. John” Emergency Clinical Hospital, 042122 Bucharest, Romania
| | - Tiberiu Paul Neagu
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | | | - Andrei Niculae
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Martino FK, Novara G, Nalesso F, Calò LA. Conservative Management in End-Stage Kidney Disease between the Dialysis Myth and Neglected Evidence-Based Medicine. J Clin Med 2023; 13:41. [PMID: 38202048 PMCID: PMC10779521 DOI: 10.3390/jcm13010041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
In the last few decades, the aging of the general population has significantly increased the number of elderly patients with end-stage kidney disease (ESKD) who require renal replacement therapy. ESKD elders are often frail and highly comorbid with social issues and seem to not benefit from dialysis in terms of survival and quality of life. Conservative management (CM) could represent a valid treatment option, allowing them to live for months to years with a modest impact on their habits. Despite these possible advantages, CM remains underused due to the myth of dialysis as the only effective treatment option for all ESKD patients regardless of its impact on quality of life and survival. Both CM and dialysis remain valid alternatives in the management of ESKD. However, assessing comorbidities, disabilities, and social context should drive the choice of the best possible treatment for ESKD, while in elderly patients with short life expectancies, referring them to palliative care seems the most reasonable choice.
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Affiliation(s)
- Francesca K. Martino
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
| | - Giacomo Novara
- Department of Surgery, Oncology and Gastroenterology, Urology Clinic University of Padua, 35124 Padua, Italy
| | - Federico Nalesso
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
| | - Lorenzo A. Calò
- Nephrology, Dialysis, Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35124 Padua, Italy; (F.K.M.); (F.N.)
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Ariyanopparut S, Metta K, Avihingsanon Y, Eiam-Ong S, Kittiskulnam P. The role of a low protein diet supplemented with ketoanalogues on kidney progression in pre-dialysis chronic kidney disease patients. Sci Rep 2023; 13:15459. [PMID: 37726370 PMCID: PMC10509207 DOI: 10.1038/s41598-023-42706-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Abstract
In slowing kidney progression, numerous pre-dialysis chronic kidney disease (CKD) patients could not adhere to the well-established dietary pattern, including a very low protein diet, 0.3-0.4 g/kg/day, plus a full dose ketoanalogues (KAs) of amino acids. We evaluated the role of a low protein diet (LPD), 0.6-0.8 g/kg/day, combined with KAs (LPD-KAs) on CKD progression. We extracted data in the retrospective cohort using electronic medical records (n = 38,005). Participants with LPD-KAs for longer than six months were identified. An unmatched control group, LPD alone, was retrieved from the same database. Cox proportional hazard models were performed to examine the associations between LPD-KAs and outcomes. The primary outcome was either a rapid estimated glomerular filtration rate (eGFR) decline > 5 mL/min/1.73m2/year or commencing dialysis. Other secondary outcomes include changes in proteinuria, serum albumin, and other metabolic profiles were also assessed. A total of 1042 patients were finally recruited (LPD-KAs = 543). Although patients with LPD-KAs had significantly lower eGFR and a prevalence of diabetes, age, and dietary protein intake were comparable between LPD-KAs (0.7 ± 0.2 g/kg/day) and LPD alone groups (0.7 ± 0.3 g/kg/day, p = 0.49). During a median follow-up of 32.9 months, patients treated with LPD-KAs had a significantly lower risk of kidney function decline (HR 0.13; 95% CI 0.09-0.19, p < 0.001) and dialysis initiation (HR 0.24; 95% CI 0.12-0.49, p < 0.001) than LPD alone after adjusting for confounders. The annual rate of eGFR decline in patients receiving LPD-KAs was 4.5 [3.4-5.5] mL/min/1.73m2 compared with 7.7 [6.0-9.4] mL/min/1.73m2 in LPD alone (p = 0.001). According to KAs dose-response analysis, the daily dose of ≤ 5 tablets was conversely associated with a higher risk of the primary endpoint, whereas the association disappeared among patients receiving a dose of > 6 tablets. The spot urine protein creatinine ratio and serum phosphate levels were not significantly different between groups. LPD-KAs could retard kidney progression compared with LPD alone. This favorable effect was significant among CKD patients receiving a daily KAs dose of more than six tablets. Future randomized controlled trials should be performed to verify these findings.
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Affiliation(s)
| | - Kamonchanok Metta
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyawan Kittiskulnam
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Division of Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand.
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7
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Faerber V, Kuhn KS, Garneata L, Kalantar-Zadeh K, Kalim S, Raj DS, Westphal M. The Microbiome and Protein Carbamylation: Potential Targets for Protein-Restricted Diets Supplemented with Ketoanalogues in Predialysis Chronic Kidney Disease. Nutrients 2023; 15:3503. [PMID: 37630693 PMCID: PMC10459041 DOI: 10.3390/nu15163503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
In chronic kidney disease (CKD), metabolic derangements resulting from the interplay between decreasing renal excretory capacity and impaired gut function contribute to accelerating disease progression and enhancing the risk of complications. To protect residual kidney function and improve quality of life in conservatively managed predialysis CKD patients, current guidelines recommend protein-restricted diets supplemented with essential amino acids (EAAs) and their ketoanalogues (KAs). In clinical studies, such an approach improved nitrogen balance and other secondary metabolic disturbances, translating to clinical benefits, mainly the delayed initiation of dialysis. There is also increasing evidence that a protein-restricted diet supplemented with KAs slows down disease progression. In the present review article, recent insights into the role of KA/EAA-supplemented protein-restricted diets in delaying CKD progression are summarized, and possible mechanistic underpinnings, such as protein carbamylation and gut dysbiosis, are elucidated. Emerging evidence suggests that lowering urea levels may reduce protein carbamylation, which might contribute to decreased morbidity and mortality. Protein restriction, alone or in combination with KA/EAA supplementation, modulates gut dysbiosis and decreases the generation of gut-derived uremic toxins associated, e.g., with cardiovascular disease, inflammation, protein energy wasting, and disease progression. Future studies are warranted to assess the effects on the gut microbiome, the generation of uremic toxins, as well as markers of carbamylation.
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Affiliation(s)
- Valentin Faerber
- Department of Medical Scientific Affairs, Pharma and Nutrition, Fresenius Kabi Deutschland GmbH, 61352 Bad Homburg, Germany; (K.S.K.); (M.W.)
| | - Katharina S. Kuhn
- Department of Medical Scientific Affairs, Pharma and Nutrition, Fresenius Kabi Deutschland GmbH, 61352 Bad Homburg, Germany; (K.S.K.); (M.W.)
| | - Liliana Garneata
- “Dr. Carol Davila” Teaching Hospital of Nephrology, 4 Calea Grivitei, Sector 1, 010731 Bucharest, Romania;
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine (UCI), Orange, CA 90286, USA;
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University School of Medicine, Washington, DC 20037, USA;
| | - Martin Westphal
- Department of Medical Scientific Affairs, Pharma and Nutrition, Fresenius Kabi Deutschland GmbH, 61352 Bad Homburg, Germany; (K.S.K.); (M.W.)
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8
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Ray S, Singh AK, Mukherjee JJ, Ramachandran R, Sengupta U, Virmani AK, Dutta AR, Sharma SK, Srivastava SL, Batin M. Protein restriction in adults with chronic kidney disease, with or without diabetes: Integrated Diabetes and Endocrine Academy (IDEA) consensus statement for Indian patients. Diabetes Metab Syndr 2023; 17:102785. [PMID: 37210963 DOI: 10.1016/j.dsx.2023.102785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND AIMS Most guidelines recommend protein restriction in adults with chronic kidney disease (CKD), with or without diabetes. However, advising protein restriction for every person with CKD is controversial. We aim to arrive at a consensus on this topic, especially among Indian adults with CKD. METHODS A systematic literature search in the PubMed electronic database was undertaken using specific keywords and MeSH terms until May 1, 2022. All the retrieved literature was circulated and rigorously deliberated upon by the panel members. RESULTS Seventeen meta-analyses that evaluated the outcomes of protein restriction in adults with CKD, with or without diabetes, met our inclusion criteria and were analyzed. A low-protein diet (LPD) in people with stages 3-5 of CKD (who are not on haemodialysis [HD]) reduces the severity of uremic symptoms and the rate of decline in glomerular filtration rate, leading to a delay in dialysis initiation. However, LPD in patients on maintenance HD may not be desirable because HD-induced protein catabolism may lead to protein-energy malnutrition. Since the average protein intake among Indians is much lower than recommended, this must be taken into consideration before recommending LPD for all Indian adults with CKD, particularly those on maintenance HD. CONCLUSION It is essential to assess the nutritional status of people with CKD, particularly in countries like India where average daily protein intake is poor, before recommending guideline-directed protein restriction. The prescribed diet, including the quantity and quality of proteins, should be tailored to the person's habits, tastes, and needs.
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Affiliation(s)
- Subir Ray
- Apollo Multi-speciality Hospitals, Kolkata, West Bengal, India
| | | | | | - Raja Ramachandran
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
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9
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Multi-Mechanistic and Therapeutic Exploration of Nephroprotective Effect of Traditional Ayurvedic Polyherbal Formulation Using In Silico, In Vitro and In Vivo Approaches. Biomedicines 2023; 11:biomedicines11010168. [PMID: 36672676 PMCID: PMC9855918 DOI: 10.3390/biomedicines11010168] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023] Open
Abstract
Based on traditional therapeutic claims, NEERI KFT (a traditional Ayurvedic polyherbal preparation) has been innovatively developed in recent time on the decades of experience for treating kidney dysfunction. Due to the lack of scientific evidence, the present investigations are needed to support the rationale use of NEERI KFT. Considering the facts, the study investigated the nephroprotective effect of NEERI KFT against kidney dysfunction using in silico, in vitro and in vivo approaches. In this study, phytochemical and network pharmacology studies were performed for the developed formulation to evaluate the molecular mechanism of NEERI KFT in the amelioration of kidney disease. In vitro nephroprotective and antioxidant effect of NEERI KFT was determined on HEK 293 cells against cisplatin-induced cytotoxicity and oxidative stress. In vivo nephroprotective effect of NEERI KFT was determined against cisplatin-induced nephrotoxicity in Wistar rats, via assessing biochemical markers, antioxidant enzymes and inflammatory cytokines such as TNF-α, IL-1β, CASP-3, etc. The results showed that the compounds such as gallic acid, caffeic acid and ferulic acid are the major constituents of NEERI KFT, while network pharmacology analysis indicated a strong interaction between polyphenols and several genes (CASPs, ILs, AGTR1, AKT, ACE2, SOD1, etc.) involved in the pathophysiology of kidney disease. In vivo studies showed a significant (p < 0.05) ameliorative effect on biochemical markers and antioxidant enzymes (SOD, CAT, GSH, etc.), and regulates inflammatory cytokine (TNF-α, IL-1β, CASP-3) expression in kidney tissue. Hence, it can be concluded that NEERI KFT subsequently alleviates renal dysfunction mediated by cisplatin via attenuating oxidative and inflammatory stress, thus preserving the normalcy of kidney function.
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10
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Mocanu CA, Cuiban E, Paul R, Radulescu D, Garneata L. A supplemented very low-protein diet could be effective, safe, and feasible in closely monitored patients with advanced CKD. Am J Clin Nutr 2022; 116:836-837. [PMID: 35849018 DOI: 10.1093/ajcn/nqac155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Carmen Antonia Mocanu
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Elena Cuiban
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology and Dialysis, "Sf Ioan Nou" Emergency Clinical Hospital, Bucharest, Romania
| | - Raluca Paul
- "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Daniela Radulescu
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology and Dialysis, "Sf Ioan Nou" Emergency Clinical Hospital, Bucharest, Romania
| | - Liliana Garneata
- From the Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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11
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Esteves GP, Mazzolani BC, Smaira FI, Mendes ES, de Oliveira GG, Roschel H, Gualano B, Pereira RMR, Dolan E. Nutritional recommendations for patients undergoing prolonged glucocorticoid therapy. Rheumatol Adv Pract 2022; 6:rkac029. [PMID: 35539442 PMCID: PMC9080102 DOI: 10.1093/rap/rkac029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/05/2022] [Indexed: 11/14/2022] Open
Abstract
Glucocorticoid (GC) therapy is a common treatment used in rheumatic and autoimmune diseases, owing to its anti-inflammatory and immunosuppressive effects. However, GC therapy can also induce a number of adverse effects, including muscle and bone loss, hypertension, metabolic perturbations and increased visceral adiposity. We review available evidence in this area and provide nutritional recommendations that might ameliorate these adverse effects. Briefly, optimizing calcium, vitamin D, sodium and protein intake and increasing consumption of unprocessed and minimally processed foods, while decreasing the consumption of ultra-processed foods, might counteract some of the specific challenges faced by these patients. Importantly, we identify a dearth of empirical data on how nutritional intervention might impact health-related outcomes in this population. Further research is required to investigate the clinical and therapeutic efficacy of these theory-based recommendations.
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Affiliation(s)
- Gabriel P Esteves
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Fabiana Infante Smaira
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Elizabeth Silva Mendes
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Gabriela Guimarães de Oliveira
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Hamilton Roschel
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Bruno Gualano
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
| | - Rosa Maria R Pereira
- Bone Metabolism Laboratory, Rheumatology Division; Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Eimear Dolan
- Applied Physiology & Nutrition Research Group; School of Physical Education and Sport; Rheumatology Division; Faculdade de Medicina FMUSP
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12
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Associations between dietary patterns and stages of chronic kidney disease. BMC Nephrol 2022; 23:115. [PMID: 35317735 PMCID: PMC8939097 DOI: 10.1186/s12882-022-02739-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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13
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Ketoanalogue Supplementation in Patients with Non-Dialysis Diabetic Kidney Disease: A Systematic Review and Meta-Analyses. Nutrients 2022; 14:nu14030441. [PMID: 35276799 PMCID: PMC8838123 DOI: 10.3390/nu14030441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 01/17/2023] Open
Abstract
The effects of supplemental ketoanalogues (KA) in patients with diabetic kidney disease (DKD) are not well characterized. Several databases for peer-reviewed articles were systematically searched to identify studies reporting outcomes associated with the effects of a low-protein diet (LPD) or very-low protein diet (VLPD) in combination with supplemental KA in adults with DKD. Meta-analyses were conducted when feasible. Of 213 identified articles, 11 could be included in the systematic review. Meta-analyses for renal outcomes (4 studies examining glomerular filtration rate; 5 studies examining 24-h urinary protein excretion), metabolic outcomes (5 studies examining serum urea; 7 studies examining blood glucose), clinical outcomes (6 studies examining blood pressure; 4 studies examining hemoglobin), and nutritional outcomes (3 studies examining serum albumin; 4 studies examining body weight) were all in favor of KA use in DKD patients. Data from individual studies that examined other related parameters also tended to show favorable effects from KA-supplemented LPD/VLPD. The regimens were safe and well tolerated, with no evidence of adverse effects on nutritional status. In conclusion, LPD/VLPD supplemented with KA could be considered effective and safe for patients with non-dialysis dependent DKD. Larger studies are warranted to confirm these observations.
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14
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Yang W. The effect of the diet of nitrogen-free analogs of essential amino acids on chronic kidney disease deterioration: A meta-analysis. Ther Apher Dial 2022; 26:879-888. [PMID: 34997834 DOI: 10.1111/1744-9987.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/22/2021] [Accepted: 12/25/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We performed a meta-analysis to evaluate the effect of the diet of nitrogen-free analogs of essential amino acids on chronic kidney disease deterioration. METHODS A systematic literature search up-to September 2021 was done and 14 studies included 1574 subjects with chronic kidney disease at the start of the study; 786 of them had the very low-protein diets supplemented with nitrogen-free analogs and 788 had the conventional low-protein diet. RESULTS Very low-protein diet supplemented with nitrogen-free analogs had significantly higher estimated glomerular filtration rate, lower serum creatinine, and lower blood urea nitrogen; however, it had no significant difference in serum albumin, serum cholesterol, serum phosphorous, serum calcium, and parathyroid hormone compared to conventional low-protein diet in subjects with chronic kidney disease. CONCLUSION The very low-protein diets supplemented with nitrogen-free analogs had significantly better kidney functions results compared to the conventional low-protein diets in subjects with chronic kidney disease. Further studies are required to validate these findings.
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Affiliation(s)
- Wenjuan Yang
- Clinical Nursing, Higher Vocational Education, Weinan Vocational and Technical College, Weinan, Shaanxi, China
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15
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Li J, Yang J, Zhu B, Fan J, Hu Q, Wang L. Tectorigenin protects against unilateral ureteral obstruction by inhibiting Smad3-mediated ferroptosis and fibrosis. Phytother Res 2021; 36:475-487. [PMID: 34964161 DOI: 10.1002/ptr.7353] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/09/2021] [Accepted: 11/27/2021] [Indexed: 12/20/2022]
Abstract
Renal tubular epithelial cell (TEC) injury and fibrosis are the key factors of the pathogenesis of chronic kidney disease. Here, we reported that tectorigenin is effectively protected against obstructive nephropathy established by unilateral ureteral obstruction (UUO). In vivo, tectorigenin administration significantly alleviated the deteriorations of renal functions including blood urea nitrogen and creatinine. Meanwhile, results from the histology suggested that renal injury characterized by tubular cell damage and fibrosis lesions of kidneys in UUO group were markedly attenuated following tectorigenin treatment. Mechanistically, we found that tectorigenin treatment greatly inhibited Smad3 phosphorylation, and the transcription and protein level of Nox4, a newly identified direct downstream molecule of Smad3 and a modulator of ferroptosis, while it indirectly restored the expression of glutathione peroxidase 4, a negative regulator of ferroptosis. Consistent with in vivo studies, treatment with tectorigenin also suppressed the ferroptosis induced by erastin/RSL3 and fibrosis stimulated by transforming growth factor β1 (TGF-β1) in primary renal TECs. What is more, treatment with ferroptosis inhibitor, ferrostatin-1, also impeded TGF-β1 stimulated the profibrotic effects in TECs, indicating that tectorigenin may relieve fibrosis by inhibiting ferroptosis in TECs. In addition, tectorigenin treatment exhibited a similar tendency, which inhibited Smad3 activation, and the docking analysis revealed that tectorigenin docked well into the Smad3 binding cavity with strong binding affinity (-7.9 kcal/mol). Thus, this study deciphers the protective effect of tectorigenin against obstructive nephropathy through inhibiting Smad3-mediated ferroptosis and fibrosis.
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Affiliation(s)
- Jianchun Li
- Research Center of Intergated Traditional Chinese and Western Medicine, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Jieke Yang
- Research Center of Intergated Traditional Chinese and Western Medicine, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Bingwen Zhu
- Research Center of Intergated Traditional Chinese and Western Medicine, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Junming Fan
- Research Center of Intergated Traditional Chinese and Western Medicine, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
- Chengdu Medical College, Chengdu, China
| | - Qiongdan Hu
- Department of Nephrology, The Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, China
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Li Wang
- Research Center of Intergated Traditional Chinese and Western Medicine, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
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16
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Chen TH, Liu CW, Ho YH, Huang CK, Hung CS, Smith BH, Lin JC. Gut Microbiota Composition and Its Metabolites in Different Stages of Chronic Kidney Disease. J Clin Med 2021; 10:jcm10173881. [PMID: 34501329 PMCID: PMC8432073 DOI: 10.3390/jcm10173881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
A growing body of study have documented the association of gut dysbiosis or fecal metabolites with chronic kidney disease (CKD). However, it is not clear whether the phenomenon simply reflects the microenvironment changes correlated with the CKD severity or contributes to the progression of CKD. In this study, we identified the gut microbiota and metabolite in feces samples correlated with CKD severity using the Nanopore long-read sequencing platform and UPLC-coupled MS/MS approach. A cross-sectional cohort study was performed from 1 June 2020 to 31 December 2020. One hundred and fifty-six clinical participants, including 60 healthy enrollees and 96 Stage 1–5 CKD patients, were enrolled in this study. The ROC curve generated with the relative abundance of Klebsiella pneumonia or S-Adenosylhomocysteine showed a gradual increase with the CKD severity. Our results further revealed the positive correlation of increased K. pneumonia and S-Adenosylhomocysteine in gut environment, which may be of etiological importance to the deterioration of a CKD patient. In that sense, the microbiota or metabolite changes constitute potential candidates for evaluating the progression of CKD.
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Affiliation(s)
- Tso-Hsiao Chen
- Division of Nephrology, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan;
- Department of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Chao-Wei Liu
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (C.-W.L.); (C.-S.H.)
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yi-Hsien Ho
- Department of Laboratory Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan; (Y.-H.H.); (C.-K.H.)
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Chun-Kai Huang
- Department of Laboratory Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan; (Y.-H.H.); (C.-K.H.)
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Ching-Sheng Hung
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (C.-W.L.); (C.-S.H.)
- Department of Laboratory Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan; (Y.-H.H.); (C.-K.H.)
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Barry H. Smith
- Applied Medical Research Inc., Nashville, TN 37219, USA;
| | - Jung-Chun Lin
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (C.-W.L.); (C.-S.H.)
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Correspondence: ; Tel.: +886-2-2736-1661 (ext. 3330)
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17
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Lin YL, Hou JS, Wang CH, Su CY, Liou HH, Hsu BG. Effects of ketoanalogues on skeletal muscle mass in patients with advanced chronic kidney disease: real-world evidence. Nutrition 2021; 91-92:111384. [PMID: 34273683 DOI: 10.1016/j.nut.2021.111384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/11/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Ketoanalogue (KA) supplementation in patients with chronic kidney disease (CKD) on a restricted protein diet has been shown to maintain their nutritional status in clinical trials. However, a gap existed between the findings of the clinical trials and the real-world practice. The aim of this prospective observational study was to evaluate the KA effect on skeletal muscle mass in patients with stage 4-5 CKD. METHODS Among 170 patients with CKD screened, 148 were recruited. Patients were defined as KA or non-KA users. During a 12-mo follow-up, skeletal muscle and body fat mass were measured via bioelectrical impedance analysis at baseline, 6 mo (n = 108), and 12 mo (n = 85). RESULTS Among the patients (mean age, 66.5 ± 12.9 y), KA users tended to maintain skeletal muscle and body fat mass, whereas non-KA users had a significantly reduced muscle mass (P = 0.011) and body fat gain (P = 0.004). Stratified by median age, in patients ≥68 y of age, non-KA users yielded the most significant muscle mass reduction and fat mass gain, whereas KA users revealed no changes in skeletal muscle and fat mass. CONCLUSION In real-world practice, we concluded that KA supplementation favorably prevents skeletal muscle mass loss and fat mass gain in elderly patients with stage 4-5 CKD.
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Affiliation(s)
- Yu-Li Lin
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jia-Sian Hou
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chih-Hsien Wang
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chen-Ying Su
- Division of Dietetics and Nutrition, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Internal Medicine, Hsin-Jen Hospital, New Taipei City, Taiwan.
| | - Bang-Gee Hsu
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
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18
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Ravid JD, Kamel MH, Chitalia VC. Uraemic solutes as therapeutic targets in CKD-associated cardiovascular disease. Nat Rev Nephrol 2021; 17:402-416. [PMID: 33758363 DOI: 10.1038/s41581-021-00408-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/01/2023]
Abstract
Chronic kidney disease (CKD) is characterized by the retention of a myriad of solutes termed uraemic (or uremic) toxins, which inflict damage to several organs, including the cardiovascular system. Uraemic toxins can induce hallmarks of cardiovascular disease (CVD), such as atherothrombosis, heart failure, dysrhythmias, vessel calcification and dysregulated angiogenesis. CVD is an important driver of mortality in patients with CKD; however, reliance on conventional approaches to managing CVD risk is insufficient in these patients, underscoring a need to target risk factors that are specific to CKD. Mounting evidence suggests that targeting uraemic toxins and/or pathways induced by uraemic toxins, including tryptophan metabolites and trimethylamine N-oxide (TMAO), can lower the risk of CVD in patients with CKD. Although tangible therapies resulting from our growing knowledge of uraemic toxicity are yet to materialize, a number of pharmacological and non-pharmacological approaches have the potential to abrogate the effects of uraemic toxins, for example, by decreasing the production of uraemic toxins, by modifying metabolic pathways induced by uraemic toxins such as those controlled by aryl hydrocarbon receptor signalling and by augmenting the clearance of uraemic toxins.
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Affiliation(s)
- Jonathan D Ravid
- School of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mohamed Hassan Kamel
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, USA. .,Boston Veterans Affairs Healthcare System, Boston, MA, USA. .,Global Co-creation Lab, Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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19
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Apetrii M, Timofte D, Voroneanu L, Covic A. Nutrition in Chronic Kidney Disease-The Role of Proteins and Specific Diets. Nutrients 2021; 13:956. [PMID: 33809492 PMCID: PMC7999704 DOI: 10.3390/nu13030956] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health burden, needing comprehensive management for preventing and delaying the progression to advanced CKD. The role of nutritional therapy as a strategy to slow CKD progression and uremia has been recommended for more than a century. Although a consistent body of evidence suggest a benefit of protein restriction therapy, patients' adherence and compliance have to be considered when prescribing nutritional therapy in advanced CKD patients. Therefore, these prescriptions need to be individualized since some patients may prefer to enjoy their food without restriction, despite knowing the potential importance of dietary therapy in reducing uremic manifestations, maintaining protein-energy status.
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Affiliation(s)
- Mugurel Apetrii
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
| | - Daniel Timofte
- Surgical Department I, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Luminita Voroneanu
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.A.); (L.V.); (A.C.)
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20
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Zheng CM, Hsu YH, Lu CL, Chen HH, Lu KC, Chen JS, Chen KC, Peng CC, Lin YF, Hsu CC, Wu MS, Lin YC. The modulating effect of dietary protein intake on mortality in long-term hemodialysis patients: A nationwide population-based study. Int J Clin Pract 2021; 75:e13747. [PMID: 33010055 DOI: 10.1111/ijcp.13747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS OF THE STUDY A high prevalence of protein-energy wasting and malnutrition among uremic patients is associated with an increase in morbidity and mortality. We aimed to investigate the modulating effect of daily dietary protein intake (DPI) evaluated by normalised protein catabolic rate (nPCR) on mortality in long-term haemodialysis (HD) patient from a nationwide population-based study. METHODS USED TO CONDUCT THE STUDY By Taiwan Renal Registry Data System between 2005 and 2012, we divided the long-term HD patients into average nPCR < 1.2 and nPCR ≥ 1.2 groups according to the current guideline. The relation of nPCR with three-year all-cause and cardiovascular (CV) mortality were evaluated. The cox regression method for predicted mortality by nPCR was used. RESULTS OF THE STUDY Among 88 330 HD patients, 58 122 (65.8%) patients were in average nPCR < 1.2 group and 30 208 (34.2%) in average nPCR ≥ 1.2 group. Both all-cause and cardiovascular (CV) mortality risks were increased in nPCR < 1.2 group after adjusting for demographics and laboratories cofactors in our multivariate cox regression model. Patients with nPCR < 1.2 and albumin ≥ 3.7 had a higher adjusted hazard ratio (aHR) for all-cause and CV mortality (1.16 [95% confidence interval (CI): 1.07-1.25, P < .001]; 1.15 [95% CI: 1.02-1.31, P = .03], respectively), compared with the reference group with nPCR ≥ 1.2 and albumin ≥ 3.7. Interestingly, there was no difference in mortality risk between low DPI subgroup (nPCR < 1.2 and Alb < 3.7) and the reference group (nPCR ≥ 1.2 and Alb < 3.7). Further stratification analysis revealed that low DPI subgroup (nPCR < 1.2, Alb ≥ 3.7 and TC ≥ 150) had an increased risk of both all-cause and CV mortality (aHR 1.14 [95% CI: 1.04-1.25, P = .005]; aHR 1.17 [95% CI: 1.02-1.35, P = .026], respectively). CONCLUSIONS DRAWN FROM THE STUDY Low DPI (as presented by nPCR) independently correlated with all-cause and CV mortality among HD patients. Mortality risks were higher in low DPI patients even with normoalbuminaemia and non-hypocholesterolaemia. Further investigations on the importance of increasing DPI in HD patients is warranted.
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Affiliation(s)
- Cai-Mei Zheng
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Ho Hsu
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Lin Lu
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Hsi-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kuo-Cheng Lu
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Jin-Shuen Chen
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Chou Chen
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Urology, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chiung-Chi Peng
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yuh-Feng Lin
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Maioli, Taiwan
| | - Mai-Szu Wu
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yen-Chung Lin
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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21
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Guo JCL, Pan HC, Yeh BY, Lu YC, Chen JL, Yang CW, Chen YC, Lin YH, Chen HY. Associations Between Using Chinese Herbal Medicine and Long-Term Outcome Among Pre-dialysis Diabetic Nephropathy Patients: A Retrospective Population-Based Cohort Study. Front Pharmacol 2021; 12:616522. [PMID: 33679399 PMCID: PMC7930622 DOI: 10.3389/fphar.2021.616522] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Chronic kidney disease (CKD) has become a worldwide burden due to the high co-morbidity and mortality. Diabetic nephropathy (DN) is one of the leading causes of CKD, and pre-dialysis is one of the most critical stages before the end-stage renal disease (ESRD). Although Chinese herbal medicine (CHM) use is not uncommon, the feasibility of using CHM among pre-dialysis DN patients remains unclear. Materials and methods: We analyzed a population-based cohort, retrieved from Taiwan’s National Health Insurance Research Database, to study the long-term outcome of using CHM among incident pre-dialysis DN patients from January 1, 2004, to December 31, 2007. All patients were followed up to 5 years or the occurrence of mortality. The risks of all-cause mortality and ESRD were carried out using Kaplan-Meier and competing risk estimation, respectively. Further, we demonstrated the CHM prescriptions and core CHMs using the Chinese herbal medicine network (CMN) analysis. Results: A total of 6,648 incident pre-dialysis DN patients were analyzed, including 877 CHM users and 5,771 CHM nonusers. With overlap weighing for balancing all accessible covariates between CHM users and nonusers, we found the use of CHM was associated with lower all-cause mortality (0.22 versus 0.56; log-rank test: p-value <0.001), and the risk of mortality was 0.42 (95% CI: 0.36–0.49; p-value <0.001) by adjusting all accessible covariates. Further, the use of CHM was associated with a lower risk of ESRD (cause-specific hazard ratio: 0.59, 95%CI: 0.55–0.63; p-value <0.001). Also, from the 5,901 CHM prescriptions, we found Ji-Sheng-Shen-Qi-Wan, Astragalus mongholicus Bunge or (Astragalus membranaceus (Fisch.) Bge.), Plantago asiatica L. (or Plantago depressa Willd.), Salvia miltiorrhiza Bunge, and Rheum palmatum L. (or Rheum tanguticum (Maxim. ex Regel) Balf., Rheum officinale Baill.) were used as core CHMs for different CHM indications. Use of core CHMs was associated with a lower risk of mortality than CHM users without using core CHMs. Conclusions: The use of CHM seemed feasible among pre-dialysis DN patients; however, the beneficial effects still need to be validated by well-designed clinical trials.
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Affiliation(s)
- Jenny Chun-Ling Guo
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Heng-Chih Pan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Bo-Yan Yeh
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen Chu Lu
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiun-Liang Chen
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Yang
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chun Chen
- School of Medicine, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsuan Lin
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-Yu Chen
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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22
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Chen HY, Sun CY, Lee CC, Wu IW, Chen YC, Lin YH, Fang WC, Pan HC. Ketoanalogue supplements reduce mortality in patients with pre-dialysis advanced diabetic kidney disease: A nationwide population-based study. Clin Nutr 2021; 40:4149-4160. [PMID: 33597108 DOI: 10.1016/j.clnu.2021.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/23/2020] [Accepted: 01/28/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Metabolism dysregulation and protein energy wasting occur in patients with chronic kidney disease (CKD) and are associated with poor survival, especially in patients prior to starting dialysis. Accumulating evidence indicates that dietary supplementation with ketoanalogues (KAs, a mixture of branched-chain amino acids) exerts a variety of beneficial effects for patients with CKD. However, the role of KAs in diabetic kidney disease (DKD), one of the major causes of CKD, is still controversial. The aim of this study was to explore the impact of KA supplements on survival in patients with stage 5 DKD who have not yet started dialysis (DKD-5-ND). METHODS We analyzed a nationwide cohort retrieved from the National Health Insurance Research Database in Taiwan to study the long-term impact of KA supplements in patients with DKD-5-ND. We enrolled 15,782 incident pre-dialysis DKD patients between January 1, 2004 and December 31, 2007. Landmark analysis was used to eliminate immortal bias, and overlap weighting was used to balance differences between the KA users and nonusers in the beginning. The primary study endpoint was all-cause mortality, and the occurrence of permanent dialysis (presenting the end-stage renal disease, ESRD) and major adverse cardiovascular events (MACEs) was also evaluated. All patients were followed for five years or until death. RESULTS The prevalence of KA usage in the DKD-5-ND patients was 6.3%. The 5-year all-cause mortality rate in the KA users was lower than that in the nonusers (34.7% vs 42.7%). After adjusting for known covariates, the KA users still had a lower risk of mortality (adjusted hazard ratio [aHR]: 0.73, 95% confidence interval [CI]: 0.66-0.82). In addition, the incidence of ESRD was also slightly lower among the KA users (90.9% for users vs 91.2% for nonusers, adjusted cause-specific hazard ratio [aCSHR]: 0.65, 95% CI: 0.61-0.69), and the occurrence of MACEs was lower (adjusted incidence rate ratios [aIRR]: 0.76, 95% CI: 0.67-0.86). Although the all-cause mortality was higher among patientsolder than 70 years (60.5% for KA users vs 46.5% for nonusers) the risk reduction seemed prominent among older patients (aHR: 0.65, 95% CI: 0.56-0.76 for patients aged ≥70 years; aHR: 0.82, 95% CI: 0.71-0.96 for patients aged < 70 years). The reduction in risks of mortality was consistent in subgroup analysis and sensitivity tests. CONCLUSIONS The use of KA supplements seemed to be beneficial for patients with DKD-5-ND; further in-depth analysis of using KA for these patients is warranted.
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Affiliation(s)
- Hsing-Yu Chen
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiao-Yin Sun
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chin-Chan Lee
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - I-Wen Wu
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yung-Chang Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yi-Hsuan Lin
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Ching Fang
- Department of Family Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Heng-Chih Pan
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.
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23
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Noce A, Marrone G, Ottaviani E, Guerriero C, Di Daniele F, Pietroboni Zaitseva A, Di Daniele N. Uremic Sarcopenia and Its Possible Nutritional Approach. Nutrients 2021; 13:nu13010147. [PMID: 33406683 PMCID: PMC7824031 DOI: 10.3390/nu13010147] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 12/11/2022] Open
Abstract
Uremic sarcopenia is a frequent condition present in chronic kidney disease (CKD) patients and is characterized by reduced muscle mass, muscle strength and physical performance. Uremic sarcopenia is related to an increased risk of hospitalization and all-causes mortality. This pathological condition is caused not only by advanced age but also by others factors typical of CKD patients such as metabolic acidosis, hemodialysis therapy, low-grade inflammatory status and inadequate protein-energy intake. Currently, treatments available to ameliorate uremic sarcopenia include nutritional therapy (oral nutritional supplement, inter/intradialytic parenteral nutrition, enteral nutrition, high protein and fiber diet and percutaneous endoscopic gastrectomy) and a personalized program of physical activity. The aim of this review is to analyze the possible benefits induced by nutritional therapy alone or in combination with a personalized program of physical activity, on onset and/or progression of uremic sarcopenia.
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Affiliation(s)
- Annalisa Noce
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
- Correspondence: (A.N.); (G.M.); Tel.: +39-06-2090-2194 (A.N.); +39-06-2090-2191 (G.M.)
| | - Giulia Marrone
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
- Correspondence: (A.N.); (G.M.); Tel.: +39-06-2090-2194 (A.N.); +39-06-2090-2191 (G.M.)
| | - Eleonora Ottaviani
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
| | - Cristina Guerriero
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
| | - Francesca Di Daniele
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Anna Pietroboni Zaitseva
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
| | - Nicola Di Daniele
- UOC of Internal Medicine-Center of Hypertension and Nephrology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (E.O.); (C.G.); (F.D.D.); (A.P.Z.); (N.D.D.)
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24
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Hsu CK, Su SC, Chang LC, Shao SC, Yang KJ, Chen CY, Chen YT, Wu IW. Effects of Low Protein Diet on Modulating Gut Microbiota in Patients with Chronic Kidney Disease: A Systematic Review and Meta-analysis of International Studies. Int J Med Sci 2021; 18:3839-3850. [PMID: 34790060 PMCID: PMC8579282 DOI: 10.7150/ijms.66451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/09/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Although associations between low protein diet (LPD) and changes of gut microbiota have been reported; however, systematic discernment of the effects of LPD on diet-microbiome-host interaction in patients with chronic kidney disease (CKD) is lacking. Methods: We searched PUBMED and EMBASE for articles published on changes of gut microbiota associated with implementation of LPD in CKD patients until July 2021. Independent researchers extracted data and assessed risks of bias. We conducted meta-analyses of combine p-value, mean differences and random effects for gut microbiota and related metabolites. Study heterogeneity was measured by Tau2 and I2 statistic. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Five articles met inclusion criteria. The meta-analyses of gut microbiota exhibited enrichments of Lactobacillaceae (meta-p= 0.010), Bacteroidaceae (meta-p= 0.048) and Streptococcus anginosus (meta-p< 0.001), but revealed depletion of Bacteroides eggerthii (p=0.017) and Roseburia faecis (meta-p=0.019) in LPD patients compared to patients undergoing normal protein diet. The serum IS levels (mean difference: 0.68 ug/mL, 95% CI: -8.38-9.68, p= 0.89) and pCS levels (mean difference: -3.85 ug/mL, 95% CI: -15.49-7.78, p < 0.52) did not change between groups. We did not find significant differences on renal function associated with change of microbiota between groups (eGFR, mean difference: -7.21 mL/min/1.73 m2, 95% CI: -33.2-18.79, p= 0.59; blood urea nitrogen, mean difference: -6.8 mg/dL, 95% CI: -46.42-32.82, p= 0.74). Other clinical (sodium, potassium, phosphate, albumin, fasting sugar, uric acid, total cholesterol, triglycerides, C-reactive protein and hemoglobin) and anthropometric estimates (body mass index, systolic blood pressure and diastolic blood pressure) did not differ between the two groups. Conclusions: This systematic review and meta-analysis suggested that the effects of LPD on the microbiota were observed predominantly at the families and species levels but minimal on microbial diversity or richness. In the absence of global compositional microbiota shifts, the species-level changes appear insufficient to alter metabolic or clinical outputs.
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Affiliation(s)
- Cheng-Kai Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Chi Su
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Lun-Ching Chang
- Department of Mathematical Sciences, Florida Atlantic University, Florida, US
| | - Shih-Chieh Shao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kai-Jie Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chun-Yu Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yih-Ting Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - I-Wen Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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25
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Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is highly prevalent in elderly patients. There is growing recognition of the importance of attention to dietary protein intake (DPI) in this population given their predisposition to age-related changes in kidney function and coexisting comorbidities (i.e., hypertension). We reviewed the impact of DPI on kidney health and survival and the role of dietary protein management in older CKD patients. RECENT FINDINGS While kidney function parameters including glomerular filtration rate (GFR) and renal plasma flow are slightly lower in elderly patients irrespective of CKD status, the kidneys' ability to compensate for increased DPI by augmentation of GFR is preserved until 80 years of age or less. However, long-term consumption of high DPI in individuals of older age and/or with CKD may contribute to kidney function deterioration over time. Prescription of a plant-dominant low-protein diet of 0.6-0.8 g/kg/day with more than 50% from plant sources or very low protein diets less than 0.45 g/kg/day supplemented with essential amino acids or their keto-analogues may be effective in preserving kidney function in older patients and their younger counterparts, while also monitoring for development of protein-energy wasting (PEW). SUMMARY Using tailored precision nutrition approaches in prescribing plant-dominant low DPI that also maintains adequate energy and nitrogen balance may ameliorate kidney function decline while also preventing development of PEW in elderly patients with CKD.
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Affiliation(s)
- Yoko Narasaki
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Connie M Rhee
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Holly Kramer
- Department of Public Health Sciences
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood
- Hines VA Medical Center, Hines, Illinois, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
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26
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Elango R. Methionine Nutrition and Metabolism: Insights from Animal Studies to Inform Human Nutrition. J Nutr 2020; 150:2518S-2523S. [PMID: 33000159 DOI: 10.1093/jn/nxaa155] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/16/2020] [Accepted: 05/08/2020] [Indexed: 12/18/2022] Open
Abstract
Methionine is a nutritionally indispensable amino acid, and is unique among indispensable amino acids due to its sulfur atom. Methionine is involved in cysteine synthesis via the transsulfuration pathway, which is rate limiting for the key antioxidant molecule, glutathione. Methionine is also the primary methyl donor in the body through S-adenosylmethionine via the transmethylation pathway, which is involved in the synthesis of several key metabolites including creatine and phosphatidylcholine. Methionine can also be remethylated from homocysteine, in the presence of betaine via choline and/or folate. Thus methionine demands from a dietary perspective are regulated not only by the presence of cysteine in the body, but also by the demands in vivo for the various metabolites formed from it, and also by the presence of these compounds in foods. Indeed, methionine, cysteine, and the various methyl donors/acceptors vary in human foods, and thus regulate methionine availability, especially under conditions of growth and development. Much of our understanding of methionine nutrition and metabolism arises from experiments in animal models. This is because most animal feed formulations are plant-based and plant sources are relatively low in methionine and cysteine amounts. Thus, this brief review will touch on some broad aspects of human methionine nutrition, including requirements in different life stages, disease, and bioavailability, with some examples from the insights/lessons learned from experiments initially conducted in animals.
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Affiliation(s)
- Rajavel Elango
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada; and the Department of Pediatrics, and School of Population and Public Health, University of British Columbia, British Columbia, Canada
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27
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Compositional and Functional Adaptations of Intestinal Microbiota and Related Metabolites in CKD Patients Receiving Dietary Protein Restriction. Nutrients 2020; 12:nu12092799. [PMID: 32932711 PMCID: PMC7551076 DOI: 10.3390/nu12092799] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 12/13/2022] Open
Abstract
The relationship between change of gut microbiota and host serum metabolomics associated with low protein diet (LPD) has been unraveled incompletely in CKD patients. Fecal 16S rRNA gene sequencing and serum metabolomics profiling were performed. We reported significant changes in the β-diversity of gut microbiota in CKD patients having LPD (CKD-LPD, n = 16). We identified 19 genera and 12 species with significant differences in their relative abundance among CKD-LPD patients compared to patients receiving normal protein diet (CKD-NPD, n = 27) or non-CKD controls (n = 34), respectively. CKD-LPD had a significant decrease in the abundance of many butyrate-producing bacteria (family Lachnospiraceae and Bacteroidaceae) associated with enrichment of functional module of butanoate metabolism, leading to concomitant reduction in serum levels of SCFA (acetic, heptanoic and nonanoic acid). A secondary bile acid, glyco λ-muricholic acid, was significantly increased in CKD-LPD patients. Serum levels of indoxyl sulfate and p-cresyl sulfate did not differ among groups. The relationship between abundances of microbes and metabolites remained significant in subset of resampling subjects of comparable characteristics. Enrichment of bacterial gene markers related to D-alanine, ketone bodies and glutathione metabolism was noted in CKD-LPD patients. Our analyses reveal signatures and functions of gut microbiota to adapt dietary protein restriction in renal patients.
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28
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Long-Term Effects of Ketoanalogues on Mortality and Renal Outcomes in Advanced Chronic Kidney Disease Patients Receiving a Low-Protein Diet. Nutrients 2020; 12:nu12092708. [PMID: 32899821 PMCID: PMC7551296 DOI: 10.3390/nu12092708] [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: 07/19/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022] Open
Abstract
The effects of ketoanalogues (KA) supplementation on mortality and progression to dialysis in patients with pre-dialysis stage 5 chronic kidney disease (CKD) receiving a low-protein diet (LPD) remain ambiguous. From Taiwan’s National Health Insurance Research Database during 1996–2011, 165 patients with pre-dialysis CKD on an LPD (0.6 g/kg/day) with KA supplementation were matched with 165 patients with pre-dialysis CKD on an LPD without KA supplementation. Of the 165 patients with advanced CKD receiving KA supplementation, 34 (20.6%) died, and 124 (75.2%) underwent long-term dialysis during the study period. There was no significant difference in mortality between the KA-user group and the KA-nonuser group (adjusted hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.68–2.93; p = 0.355). KA supplementation significantly increased long-term dialysis risk (adjusted HR, 1.41; 95% CI, 1.04–1.90; p = 0.025) and combined outcome risk (defined as long-term dialysis and death; adjusted HR, 1.37; 95% CI, 1.02–1.83; p = 0.034). KA supplementation also increased long-term dialysis risk (adjusted HR, 1.49; 95% CI, 1.00–2.20; p = 0.048) in the subgroup of pre-dialysis patients with diabetes mellitus (DM), but not in those patients without DM. In conclusion, KA supplementation might increase long-term dialysis risk in patients with advanced CKD receiving an LPD, but it did not increase mortality.
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Torreggiani M, Fois A, D’Alessandro C, Colucci M, Orozco Guillén AO, Cupisti A, Piccoli GB. Of Mice and Men: The Effect of Maternal Protein Restriction on Offspring's Kidney Health. Are Studies on Rodents Applicable to Chronic Kidney Disease Patients? A Narrative Review. Nutrients 2020; 12:E1614. [PMID: 32486266 PMCID: PMC7352514 DOI: 10.3390/nu12061614] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/20/2022] Open
Abstract
In the almost 30 years that have passed since the postulation of the "Developmental Origins of Health and Disease" theory, it has been clearly demonstrated that a mother's dietary habits during pregnancy have potential consequences for her offspring that go far beyond in utero development. Protein malnutrition during pregnancy, for instance, can cause severe alterations ranging from intrauterine growth retardation to organ damage and increased susceptibility to hypertension, diabetes mellitus, cardiovascular diseases and chronic kidney disease (CKD) later in life both in experimental animals and humans. Conversely, a balanced mild protein restriction in patients affected by CKD has been shown to mitigate the biochemical derangements associated with kidney disease and even slow its progression. The first reports on the management of pregnant CKD women with a moderately protein-restricted plant-based diet appeared in the literature a few years ago. Today, this approach is still being debated, as is the optimal source of protein during gestation in CKD. The aim of this report is to critically review the available literature on the topic, focusing on the similarities and differences between animal and clinical studies.
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Affiliation(s)
- Massimo Torreggiani
- Nephrology and Dialysis, Centre Hospitalier Le Mans, Avenue Roubillard 194, 72000 Le Mans, France; (A.F.); (G.B.P.)
| | - Antioco Fois
- Nephrology and Dialysis, Centre Hospitalier Le Mans, Avenue Roubillard 194, 72000 Le Mans, France; (A.F.); (G.B.P.)
| | - Claudia D’Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (C.D.); (A.C.)
| | - Marco Colucci
- Unit of Nephrology and Dialysis, ICS Maugeri S.p.A. SB, Via S. Maugeri 10, 27100 Pavia, Italy;
| | | | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (C.D.); (A.C.)
| | - Giorgina Barbara Piccoli
- Nephrology and Dialysis, Centre Hospitalier Le Mans, Avenue Roubillard 194, 72000 Le Mans, France; (A.F.); (G.B.P.)
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, 10100 Torino, Italy
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Gluba-Brzozka A, Franczyk B, Rysz J. Cholesterol Disturbances and the Role of Proper Nutrition in CKD Patients. Nutrients 2019; 11:E2820. [PMID: 31752189 PMCID: PMC6893650 DOI: 10.3390/nu11112820] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 11/10/2019] [Indexed: 12/21/2022] Open
Abstract
Chronic kidney disease (CKD) is a widespread disease with increasing prevalence in the modern society. Lipid disturbances are common in this group of patients. In most patients with CKD atherogenic dyslipidemia is observed. Dyslipidemia in patients with renal diseases increases the risk of cardiovascular diseases and it accelerates the progression of chronic kidney disease to its end stage. The amelioration of dyslipidemia and the lowering of oxidative stress, inflammatory processes, insulin sensitivity and remnant lipoproteins levels may lead to the reduction in cardiovascular burden. Nutritional interventions can strengthen the beneficial effect of treatment and they play an important role in the preservation of overall well-being of the patients with CKD since the aim of appropriate diet is to reduce the risk of cardiovascular events, prevent malnutrition, and hamper the progression of kidney disease. The management of dyslipidemia, regardless of the presence of chronic kidney disease, should be initiated by the introduction of therapeutic lifestyle changes. The introduction of diet change was shown to exert beneficial effect on the lipid level lowering that reaches beyond pharmacological therapy. Currently available evidence give the impression that data on dietary interventions in CKD patients is not sufficient to make any clinical practice guidelines and is of low quality.
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Affiliation(s)
- Anna Gluba-Brzozka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (B.F.); (J.R.)
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Ketoacid Analogues Supplementation in Chronic Kidney Disease and Future Perspectives. Nutrients 2019; 11:nu11092071. [PMID: 31484354 PMCID: PMC6770434 DOI: 10.3390/nu11092071] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/14/2022] Open
Abstract
Diet is a key component of care during chronic kidney disease (CKD). Nutritional interventions, and, specifically, a restricted protein diet has been under debate for decades. In order to reduce the risk of nutritional disorders in very-low protein diets (VLDP), supplementation by nitrogen-free ketoacid analogues (KAs) have been proposed. The aim of this review is to summarize the potential effects of this dietary therapy on renal function, uremic toxins levels, and nutritional and metabolic parameters and propose future directions. The purpose of this paper is also to select all experimental and randomized clinical studies (RCTs) that have compared VLDP + KA to normal diet or/and low protein diet (LPD). We reviewed the SCOPUS, WEB of SCIENCES, CENTRAL, and PUBMED databases from their inception to 1 January, 2019. Following duplicate removal and application of exclusion criteria, 23 RCTs and 12 experimental studies were included. LPD/VLPD + KAs appear nutritionally safe even if how muscle protein metabolism adapts to an LPD/VLPD + KAs is still largely unknown. VLPD + KAs seem to reduce uremic toxins production but the impact on intestinal microbiota remains unexplored. All studies observed a reduction of acidosis, phosphorus, and possibly sodium intake, while still providing adequate calcium intake. The impact of this diet on carbohydrate and bone parameters are only preliminary and need to be confirmed with RCTs. The Modification of Diet in Renal Disease study, the largest RCTs, failed to demonstrate a benefit in the primary outcome of the decline rate for the glomerular filtration rate. However, the design of this study was challenged and data were subsequently reanalyzed. However, when adherent patients were selected, with a rapid rate of progression and a long-term follow up, more recent meta-analysis and RCTs suggest that these diets can reduce the loss of the glomerular filtration rate in addition to the beneficial effects of renin-angiotensin-aldosterone system (RAAS) inhibitors. The current evidence suggests that KAs supplemented LPD diets should be included as part of the clinical recommendations for both the nutritional prevention and metabolic management of CKD. More research is needed to examine the effectiveness of KAs especially on uremic toxins. A reflection about the dose and composition of the KAs supplement, the cost-effective features, and their indication to reduce the frequency of dialysis needs to be completed.
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32
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New Insights into Cholesterol Functions: A Friend or an Enemy? Nutrients 2019; 11:nu11071645. [PMID: 31323871 PMCID: PMC6682969 DOI: 10.3390/nu11071645] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
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