Protein restriction in adults with chronic kidney disease, with or without diabetes: Integrated Diabetes and Endocrine Academy (IDEA) consensus statement for Indian patients

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.

Cycloserine induced mania

We report a 21-year-old male who developed manic symptoms after addition of second line anti-tuberculosis treatment for his multidrug resistant tuberculosis. We identified cycloserine as offending drug; and discuss the management and possible neurobiological mechanisms as etiological explanation and implications of manic switch caused by cycloserine.

Serum potassium changes with e.C.T

Serum potassium changes with direct E.C.T. and with modified E.C.T., given under three anaesthetic (thiopentone, diazepam and propanidid) and relaxant (suxamethonium) combinations were studied in 25 patients. Ten patients each, undergoing minor surgical procedures, acted as controls for these three combinations. Modified E.C.T. caused a rise in scram potassium, which, being highest at 3 minutes, was sustained well beyond 10 minutes. Direct E.C.T. caused maximum rise within one minute which, however, came down rapidly. The rise following modified E.C.T. was one and half times more compared to that occurring in controls given only drugs but not E.C.T., in all the three anaesthetic-relaxant combinations. The rise from pre-induction level was maximum following diazepam and minimum with propanidid, thiopentone falling in between. The rise from pre-relaxant level, on the other hand, was maximum with thiopentone and minimum with propanidid.