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Table of Contents
ABSTRACT
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 83-85

Prescribing very low-protein diet


Chief Dietician, Department of Dietetics, Global Hospitals, Mumbai, Maharashtra, India

Date of Web Publication23-Apr-2019

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_13_19

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How to cite this article:
Patel Z. Prescribing very low-protein diet. J Renal Nutr Metab 2018;4:83-5

How to cite this URL:
Patel Z. Prescribing very low-protein diet. J Renal Nutr Metab [serial online] 2018 [cited 2019 May 19];4:83-5. Available from: http://www.jrnm.in/text.asp?2018/4/3/83/256815



A very low-protein diet (vLPD) can be of two types:

  1. vLPD – 0.3 g/kg ideal body weight/day supplemented with essential amino acids (EAAs)
  2. vLPD – 0.3 g/kg ideal body weight/day supplemented with mixture of EAA and ketoanalogs (KAs) of EAA.


Rationale of supplemented vLPD was as follows:

  1. Supplementation with EAAs and their KAs allows prescribing a protein intake below the minimum daily requirement (0.6 g/kg/day) because requirements are met by the supplements
  2. KAs do not contain nitrogen and do not generate nitrogenous by-products. At the same time, KAs are acceptors for amino groups and can be rebuilt to corresponding amino acids. In the transamination reaction which leads to this formation, urea-generating non-EAAs such as glutamine and alanine are used as amino group donators.


[Figure 1] shows the composition of KA tablet. Usually, one tablet is provided for 5-kg weight.
Figure 1: Rate of decline in creatinine clearance in the treatment group and the control group

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  1. a-KA to isoleucine 67 mg
  2. a-KA to leucine 101 mg
  3. a-KA to phenylalanine 68 mg
  4. a-KA to valine 86 mg
  5. a-Hydroxy analog to methionine 59 mg
  6. L-Lysine 75 mg
  7. L-Threonine 53 mg
  8. L-Tryptophan 23 mg
  9. L-Histidine 38 mg
  10. L-Tyrosine 30 mg
  11. Total nitrogen per tablet 36 mg
  12. Calcium per tablet 50 mg



  Indian Experience With Supplemented Very Low-Protein Diet Top


We studied the efficacy and safety of KA-supplemented vLPD in patients with chronic kidney disease (CKD). The study included 29 stable Stage V (nondiabetic) patients with slowly progressive CKD. Fourteen agreed to treatment with KA (treatment group) and 15 did not agree (control group). The patients in both the groups were comparable as regards age, sex, dietary habits, degree of renal dysfunction, and degree of proteinuria. Patients in the treatment group were prescribed 0.3-g/kg/day mixed protein supplemented with KA (Ketosteril 1 tablet/5-kg body weight), whereas patients in the control group were allowed to continue regular diet. Renal function was monitored from 24-h urinary creatinine clearance (CrCl), and protein intake was monitored from urea nitrogen appearance, i.e., 6.25 (24-h urinary urea nitrogen + 0.031 × weight in kg). All were followed monthly for 6 months. The rate of decline in CrCl was 0.09 ml/min/month in the treatment group, whereas it was 0.3 ml/min/month in the control group [Figure 1] and [Figure 2].
Figure 2: Representative case

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Prakash et al.[1] conducted a randomized, double-blind, placebo-controlled trial to evaluate the efficacy of VLPD supplemented with KA in patients with CKD. Thirty-four patients were randomized to two comparable groups in terms of age, sex distribution, etiology of CKD, blood pressure control, use of angiotensin-converting enzyme inhibitors, glomerular filtration rate (GFR), and body mass index (BMI). Participants randomly received either 0.6-g/kg/day protein plus placebo (n = 16) or 0.3-g/kg/day protein plus 1 tablet/5 5 kg of KA (Ketosteril, Fresenius Kabi, Germany) for 9 months. The mean GFR at baseline in the KA group and control group was 28.1 + 8.8 and 28.6 + 17.6 ml/min/1.73 m2, respectively. At the end of the study, it was 27.6 + 10.1 and 22.5 + 15.9 ml/min/1.73 m2, respectively. Thus, there was a significant drop in GFR in the control group compared to the KA group. In both the groups, there was no significant change in the BMI after the study.

Subhramanyam et al.[2] assessed the effect of vLPD supplemented with one KA tablet for every 5-kg body weight (BW) in 56 patients. The blood urea level which was 98.38 ± 42.97 mg/dl at baseline was 102.74 ± 45.98 mg/dL at the end of 1 year. The CrCl which was 17.25 ± 9.25 ml/min at baseline was 18.24 ± 12.12 mL/min at the end of 1 year. There was a decrease in urinary protein excretion. Thus, there was a significant stabilization of renal function.


  What Does Very Low-Protein Diet Look Like? Top


Restrict use of proteins of animal origin (meat, fish, eggs, milk and milk products, cheese, shellfish, fish eggs, etc.) as well as proteins of vegetable origin containing >3–5-g protein for 100-g cooked foods. Unlimited intake of food poor in protein (fresh fruits and vegetables, sugar, honey, jaggery, cooking oil and ghee, potato, sago, arrowroot, and rice in limited amounts) is allowed. The use of starch will provide for adequate calories and also provide variety.

The following are some recipes:

  1. Chapati/khakhra/bhakri/thepla


  2. Ingredients:

    • Rice flour – 10 g
    • Arrowroot flour – 20 g
    • Boil potato – 25 g


    The above recipes provide 126 Kcal and 1 g of protein

  3. Snack recipes (sev/puri/shakarpara/jeera stick)


  4. Ingredients:

    • Rice flour – 10 g
    • Arrowroot flour – 30 g
    • Oil for frying


    The above recipes provide 230 Kcal and 0.6 g of protein

  5. Nonveg recipes (chicken keema aloo/chicken potato gravy/fish in aloo gravy/veg egg bhurji)


  6. Ingredients:

    • Nonveg – 25 g/½ egg
    • Vegetable – 100 g
    • Boiled potato – 100 g
    • Oil for cooking


    The above recipes provide 200 Kcal and 6 g of protein.


Summary

  • Dietary protein restriction retards the progression of CKD. However, it should be used only in those who are nutritionally adequate. It should not induce malnutrition. Refer to [Table 1] and [Table 2] for standard low protein diet
  • Restricting protein intake below 0.6 g/kg/day is possible by supplementing EAA or their KA
  • By restricting N2 intake, there is a reduced generation of uremic toxins and thus improvement in symptoms
  • When closely monitored, nutritional status can be maintained
  • In patients without active underlying disease, KA-supplemented diets significantly delay the need for renal replacement therapy.
Table 1: Standard menu for vegetarians

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Table 2: Standard menu for nonvegetarian

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prakash S, Pande DP, Sharma S, Sharma D, Bal CS, Kulkarni H, et al. Randomized, double-blind, placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure. J Ren Nutr 2004;14:89-96.  Back to cited text no. 1
    
2.
Nayak A, Lakshmi PV, Nayak KS. Treatment of chronic kidney disease patients with a supplemented low protein diet and a supplemented very low protein diet directory of open access journals (Sweden). Kidney Res Clin Pract 2012;31:A61.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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