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Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 37-38

Attributes of low-protein diet in chronic kidney disease – Exploring the potential

Editor, JRNM, Professor; Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission30-Dec-2019
Date of Acceptance31-Dec-2019
Date of Web Publication08-Jan-2020

Correspondence Address:
Anita Saxena
Professor, Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_62_19

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How to cite this article:
Saxena A. Attributes of low-protein diet in chronic kidney disease – Exploring the potential. J Renal Nutr Metab 2019;5:37-8

How to cite this URL:
Saxena A. Attributes of low-protein diet in chronic kidney disease – Exploring the potential. J Renal Nutr Metab [serial online] 2019 [cited 2020 Mar 28];5:37-8. Available from: http://www.jrnm.in/text.asp?2019/5/2/37/275411

Vascular calcification is common in patients with chronic kidney disease (CKD), appearing in 30%–65% of patients with Stage 3–5 CKD and 50%–80% of patients with Stage 5D CKD. It is associated with increased morbidity and mortality. Several animal models of vascular calcification [1],[2],[3],[4],[5] have demonstrated the development of severe hyperphosphatemia and hyperparathyroidism and provided information on the pathophysiology of vascular calcification. In CKD, mineral bone disorder is a triad of biochemical abnormalities of calcium, phosphorus, and parathyroid hormone, all stemming from inappropriate consumption of protein for one.

Giovannetti and Maggiore [6] suggested that high-energy diet along with restriction in proteins (less than 2 g of nitrogen from high biological value proteins per day) dramatically improved the uremic symptoms and prolonged survival in patients with end-stage renal disease. These reports became the basis for dietary restriction of proteins as a therapy for advanced CKD. More than half a century has elapsed since low-protein diet (LPD) is being practiced as one of the cornerstones in the management of CKD for alleviating uremia,[7],[8] especially in moderate to advance stages and in slowing progression of renal dysfunction and delaying the start of dialysis. Apart from mitigating accumulation of nitrogenous wastes and metabolic disturbances, such diets also reduce the quantities of sulfates, phosphates, potassium, and sodium ingested, thus leading to a more favorable metabolic profile, and possibly improve disease progression. To further reduce nitrogen supply, ketoanalogs can be combined with even lower than recommended protein intake for CKD patients (very low-LPD (vLPD): 50 mg/tablet; dose: 5 mg/kg/g). Several studies have demonstrated not only preserving residual renal function, slowing down rate of progression of disease, delaying onset of dialysis, but also improving well-established complications due to renal insufficiency such as metabolic acidosis, insulin sensitivity, reduction in serum phosphates, and hypertriglyceridemia. LPDs rich in fruits and vegetables have been shown to be effective in reducing net endogenous acid production up to 53% after 6 months (P < 0.0001) and 67% after 12 months (P < 0.0001) and potential renal acid load by 120% after 6 months (P < 0.0001) and 138% after 12 months (P < 0.0001).[9],[10],[11],[12]

It has been suggested that ketoanalog supplements might be considered for maintenance dialysis patients who present with protein-energy wasting. Prescription of a vLPD supplemented with ketoanalogs can be considered for trials of incremental dialysis to delay the loss of residual renal function.[13] vLPD (0.3 g/kg/day) consisting mainly of vegetable proteins and ketoanalogs for 30 days has been used to allow maturation of arteriovenous access and/or completing training for peritoneal dialysis.[14] Ketoacid supplementation, though in infancy in dialysis population, has been shown to have a beneficial impact on inflammation and leptin/adiponectin ratio (LAR) which can possibly have implications on appetite and food intake. A randomized trial on 100 Chinese patients on peritoneal dialysis aimed to evaluate the effects of ketoacid supplementation (12 tablets per day)) on insulin resistance, systemic inflammation, oxidative stress, and endothelial dysfunction. The results showed that high-sensitivity C-reactive protein levels increased in the control group and remained stable in the ketoacid group. The LAR differed between groups (P < 0.001) but remained stable in the ketoacid group and increased in the control group.[15]

Experience with LPDs is limited in women with pregnancy and CKD. In a single-arm, open-intervention study between 2000 and 2012 of a LPD in pregnant patients with Stage 3–5 CKD or severe proteinuria, the median proteinuria was higher in patients on the LPD (1.96 [0.1–6.3] vs. 0.3 [0.1–2.0] g/d; P < 0.001). No significant differences in the gestational period (34 vs. 36) of single-fetus pregnancy (singleton) or cesarean sections (76.2% vs. 50%) were observed. Vegan-vegetarian-supplemented LPDs (with ketoanalog supplementation and 1–3 protein-unrestricted meals allowed per week) in pregnant women with Stage 3–5 CKD reduced the likelihood of small-for-gestational-age babies without detrimental effects on kidney function or proteinuria in the mother.[16]

In this issue three articles, one on “very low protein diet (vLPD) in chronic kidney disease, role of Ketoanalogues in disease retardation”, second on “Uremic toxins, oxidative stress, and inflammation in chronic kidney disease” and the third on “Nutritional challenges in malnutrition, inflammation, and atherosclerosis (MIA) syndrome”have been published as “Classroom Reading” which deal with simple basic concepts on the topics mentioned.

  References Top

Katsumata K, Kusano K, Hirata M, Tsunemi K, Nagano N, Burke SK, et al. Sevelamer hydrochloride prevents ectopic calcification and renal osteodystrophy in chronic renal failure rats. Kidney Int 2003;64:441-50.  Back to cited text no. 1
Price PA, Roublick AM, Williamson MK. Artery calcification in uremic rats is increased by a low protein diet and prevented by treatment with ibandronate. Kidney Int 2006;70:1577-83.  Back to cited text no. 2
Cozzolino M, Dusso AS, Liapis H, Finch J, Lu Y, Burke SK, et al. The effects of sevelamer hydrochloride and calcium carbonate on kidney calcification in uremic rats. J Am Soc Nephrol 2002;13:2299-308.  Back to cited text no. 3
Hirata M, Katsumata K, Endo K, Fukushima N, Ohkawa H, Fukagawa M, et al. In subtotally nephrectomized rats 22-oxacalcitriol suppresses parathyroid hormone with less risk of cardiovascular calcification or deterioration of residual renal function than 1,25(OH) 2 vitamin D3. Nephrol Dial Transplant 2003;18:1770-6.  Back to cited text no. 4
Moe SM, Chen NX, Seifert MF, Sinders RM, Duan D, Chen X, et al. A rat model of chronic kidney disease-mineral bone disorder. Kidney Int 2009;75:176-84.  Back to cited text no. 5
Giovannetti S, Maggiore Q. A low-Nitrogen diet with proteins of high biological value for severe chronic uraemia. Lancet 1964;1:1000-3.  Back to cited text no. 6
Ikizler TA. Safety of low-protein diets and ketoanalogue supplementation in CKD. Kidney Int Rep 2018;3:510-2.  Back to cited text no. 7
Saxena A, Gupta A, Sachan T, Pandey CM. Role of ketoanalogues In chronic kidney disease stages 1-3. Nephrol Urol Open 2018;1:17-20.  Back to cited text no. 8
Bellizzi V, Calella P, Carrero JJ, Fouque D. Very low-protein diet to postpone renal failure: Pathophysiology and clinical applications in chronic kidney disease. Chronic Dis Transl Med 2018;4:45-50.  Back to cited text no. 9
Fouque D, Chen J, Chen W, Garneata L, Hwang SJ, Kalantar-Zadeh K, et al. Adherence to ketoacids/essential amino acids-supplemented low protein diets and new indications for patients with chronic kidney disease. BMC Nephrol 2016;17:63.  Back to cited text no. 10
Fouque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauveau P, Cuppari L, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008;73:391-8.  Back to cited text no. 11
Dong J, Li YJ, Xu R, Ikizler TA, Wang HY. Ketoacid supplementation partially improves metabolic parameters in patients on peritoneal dialysis. Perit Dial Int 2015;35:736-42.  Back to cited text no. 12
Zhang M, Wang M, Li H, Yu P, Yuan L, Hao C, et al. Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients. Am J Nephrol 2014;40:140-50.  Back to cited text no. 13
Duenhas M, Gonçalves E, Dias M, Leme G, Laranja S. Reduction of morbidity related to emergency access to dialysis with very low protein diet supplemented with ketoacids (VLPD+KA). Clin Nephrol 2013;79:387-93.  Back to cited text no. 14
Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 2010;363:609-19.  Back to cited text no. 15
Piccoli GB, Leone F, Attini R, Parisi S, Fassio F, Deagostini MC, et al. Association of low-protein supplemented diets with fetal growth in pregnant women with CKD. Clin J Am Soc Nephrol 2014;9:864-73.  Back to cited text no. 16


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