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Table of Contents
SHORT REVIEW
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 41-43

Role of elimination diet in the management of proteinuria


Consultant Nephrologist, Charak Memorial Hospital and Jeewasha Foundation, Pokhara, Nepal

Date of Submission10-Dec-2019
Date of Acceptance24-Dec-2019
Date of Web Publication08-Jan-2020

Correspondence Address:
Dr. Klara Paudel
Charak Memorial Hospital and Jeewasha Foundation, Pokhara
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_55_19

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  Abstract 


This article address issues on what is an elimination diet? What is the scientific background and the evidence for it? The use of elimination diet in gastrointestinal diseases and in IgA nephropathy. In this article, I share my experience on elimination diet in the clinical practice and an ongoing clinical study, the pitfalls and my advices.

Keywords: Elimination diet , IgA nephropathy, proteinuria


How to cite this article:
Paudel K. Role of elimination diet in the management of proteinuria. J Renal Nutr Metab 2019;5:41-3

How to cite this URL:
Paudel K. Role of elimination diet in the management of proteinuria. J Renal Nutr Metab [serial online] 2019 [cited 2020 Jan 28];5:41-3. Available from: http://www.jrnm.in/text.asp?2019/5/2/41/275407



This article addresses issues on (1) What is an elimination diet? (2) What are the scientific background and the evidence for it? (3) The use of elimination diet in gastrointestinal diseases and in immunoglobulin A (IgA) nephropathy. (4) My experience with it in the clinical practice and an ongoing clinical study. (5) What are the pitfalls and my advices?


  What is an Elimination Diet? Top


For centuries, Indian Ayurvedic healing has emphasized the elimination of certain foods and the use of others. In elimination diet, we want to exclude those foods from our diet that are known to have high antigenicity and can trigger immune reaction.

Food sensitivity is not the same as food allergy. Food allergy is driven by IgE and it manifests as allergic reactions, ranging from simple skin rash to anaphylaxis. However, food sensitivity or food intolerance is a more heterogeneous reaction, driven by IgA or IgG. It can manifest up to 3–4 days after the food ingestion. The symptoms are also very heterogeneous, ranging from simple digestive tract problems, such as abdominal pain, reflux, constipation, diarrhea, and nausea, but it can be manifested in all other organ systems, most commonly seen as body ache, joint pains, skin conditions, headaches, mood disorders, attention-deficit/hyperactivity disorder, and all the range of autoimmune manifestations.

There are certain ways to do elimination diet. We can eliminate one or two types of food at a time, or we can exclude all possible foods at once and reintroduce them one by one.

The most commonly eliminated foods are milk and milk products, wheat and all gluten containing grains (rye, barley, etc.), soy and egg.

Other frequently eliminated foods are corn, legumes, peanut and other nuts, fish, seafood, other meats, e.g., beef, pork, chicken, refined sugars, alcohol, and caffeine.


  Method of Elimination Diet Top


First, we should assess all symptoms of the patient and then start with the Elimination Phase by asking the patient to eliminate the mentioned foods from the diet. The diet should be kept for at least 3–4 weeks, and a diary should be kept on symptoms and foods taken. At the end of the period, all symptoms should be evaluated again. Then, we can start with the Reintroduction Phase and reintroduce the eliminated foods one by one into the diet. For example, if we eliminated from the diet diary, gluten, soy, and egg, then we could reintroduce egg first and watch the symptoms for 3–4 days. If elimination diet has been started, then to find out if symptoms such as headache which occurring have improved with it, and if the patient is completely free from headache after 2 weeks on this diet, then when reintroducing the foods, we should mostly watch for recurrence of this symptom (headache). Since it can take up to 3 days for the symptom to recur, we should introduce only one food every 3 days. This way it is easy to know which food is causing which symptom. If symptoms recur, we should stop the culprit food and eliminate it for 3 months. After that the culprit foods' absence for 3 months, it can be reintroduced once more, and if the symptoms appear, then it is advisable to refrain from the culprit food completely.


  Scientific Background Top


Recently, more research is focusing on the intestinal permeability of the gut. Gliadin, the main protein in gluten, is proven to increase the intestinal permeability of some susceptible individuals.[1] Furthermore, stress, pathogenic gut bacteria, or other chemicals can lead to increase in intestinal permeability (“leaky gut syndrome”).[2]

This phenomenon can be intermittent or long standing. When intestinal permeability increases, there is more chance for the immune system to get exposed to partially digested proteins/peptides, particles that are highly antigenic. This exposure can trigger autoimmune processes.[3],[4]

However, most of the time, there are more food components causing antigenicity, and if we consider that in case of leaky gut, whatever we eat can become antigenic due to the contact of partially digested proteins and peptides with the immune system, we can understand that why some people have allergy to multiple substances.

That is why we cannot really expect that there will be only one cause (e.g., only gluten will be the culprit in IgA) and we also cannot expect that all individuals will have the same causes (e.g., all IgA nephropathy is caused by gluten). That is why attempts to prove direct relations have not shown very convincing results. We need to think in a multifarious way.


  Use of Elimination Diet in Gastrointestinal Disorders Top


In the management of eosinophilic esophagitis, elimination diet is part of the standard treatment recommendation.[5] Patients with the diagnosis of irritable bowel syndrome (IBD) were surveyed on their diet habits. Nearly 20% of all patients reported having tried a gluten-free diet and 8% were currently attempting it. More than half of the patients reported symptom improvement, and nearly 40% patients fewer flare-ups of IBD while being on a gluten-free diet.[6] In another study, 45 patients with IBD and diarrhea type were enrolled. Twenty-two of them received gluten containing and 23 received gluten-free diet. Gluten-free diet was associated with less bowel movement per day and lower small bowel permeability as measured by the lactulose and mannitol test. The small bowel permeability was greater in HLA-DQ2/8-positive individuals.[7]


  Experience of Elimination Diet in Immunoglobulin a Nephropathy Top


In this study, 21 patients (10 women and 11 men, mean age 27.7 ± 10 years) with immunohistochemical findings of active IgAN were enrolled. The diet was followed for a 14–24-week period (mean 18.8 ± 6); in all cases, the effects of the treatment were evaluated by clinical and serological parameters, and in 11 patients, the effects of the treatment were evaluated by repeat renal biopsy. Significant reduction of urinary proteins was recorded (P < 0.001); in particular, heavy proteinuria (>1 g/day), present in 12 cases during 6 months preceding the treatment, was markedly reduced or disappeared in 11. At posttreatment control biopsy mesangial and parietal deposits of Igs, complement C5 fraction and fibrinogen were significantly reduced.[8]


  Experience With Gluten Elimination in Immunoglobulin a Nephropathy Top


A study by Coppo et al.[9] was an uncontrolled study on a gluten-free diet given to 29 patients affected with primary focal segmental glomerulosclerosis (FSGS) membranoproliferative glomerulonephritis MN (MPGN) systemic lupus erythematosous (SLE). All of them followed the diet for 6 months, 23 patients for 1 year and 9 for 2–4 years. Mean levels of IgA-containing circulating immune complexes (IgAIC) significantly decreased after 6 months of gluten-free diet (P < 0.01). A decrease in IgAIC levels was evident in 85.7% of the cases with basal-positive data, with complete normalization in 64.3% of them. Mean proteinuria values were found to be significantly decreased after 6 months of the diet, and a reduction was also observed in microscopic hematuria. However, mean blood creatinine levels showed a significant increase over the follow-up period.


  My Experience in Nephrotic Syndrome Top


A 26-year-old female who underwent kidney biopsy in 2013 and diagnosed to be having membranous nephropathy with IgG4+, C3 3+, and 24-h protein 7.2 g was given modified Ponticelli regimen. She went into partial remission with proteinuria of 3 g/day. In 2014, she again had a relapse while on prednisolone 10 mg. In 2016, she was not coming for regular follow-ups and had stopped taking medicines. She was generally well but had persistent proteinuria with Polymerase chain reaction (PCR) in the range of 2.0–3.5. On and off, she went into fluid overload, generalized edema, with normal renal function (normal creatinine). She was started on elimination diet, mainly focusing on wheat and diary elimination. After 1 month, PCR decreased to 1.4; after another month, PCR further declined to 0.5 and proteinuria to 0.95 g.


  Ongoing Pilot Study Top


Patients with proteinuria of various origins (FSGS focal segmental glomerulosclerosis (MPGN) membranoproliferative glomerulonephritis (SLE) systemic lupus erythematosous) have been enrolled. Data from the past 6–12 months about proteinuria amount and treatment given were collected. Elimination diet was given for 3 months to see the effect of elimination diet on proteinuria and on re-introduction of foods to see which foods triggered elevation in proteinuria or recurrence of symptoms. The study is on-going.


  Pitfalls and Advices Top


The major pitfall of this diet is that it is difficult to manage without a nutritional counselor. However, educating the patient and the family on what not to eat does not take much time. Since this regimen is not so easy to follow, only some well-motivated patients follow, and it as a lot depends on the willingness and readiness of the individual to change diet to a more restricted diet. Willingness can be increased by proper counseling and information. Sometimes, if the gut heals, these food sensitivities can heal as well. For any patient with autoimmune disease, it is better to avoid gluten and diary for lifetime. We should not think that we need to keep restrict our thinking to maintain healthy kidney, rather we should keep our body healthy by eating healthy and keeping a healthy lifestyle.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lammers KM, Lu R, Brownley J, Lu B, Gerard C, Thomas K, et al. Gliadin induces an increase in intestinal permeability and zonulin release by binding to the chemokine receptor CXCR3. Gastroenterology 2008;135:194-204.e3.  Back to cited text no. 1
    
2.
Fukui H. Increased intestinal permeability and decreased barrier function: Does it really influence the risk of inflammation? Inflamm Intest Dis 2016;1:135-45.  Back to cited text no. 2
    
3.
Mu Q, Kirby J, Reilly CM, Luo XM. Leaky Gut as a danger signal for autoimmune diseases. Front Immunol 2017;8:598.  Back to cited text no. 3
    
4.
Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol 2012;42:71-8.  Back to cited text no. 4
    
5.
Cianferoni A, Shuker M, Brown-Whitehorn T, Hunter H, Venter C, Spergel JM. Food avoidance strategies in eosinophilic oesophagitis. Clin Exp Allergy 2019;49:269-84.  Back to cited text no. 5
    
6.
Herfarth HH, Martin CF, Sandler RS, Kappelman MD, Long MD. Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis 2014;20:1194-7.  Back to cited text no. 6
    
7.
Vazquez-Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, O'Neill J, et al. A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: Effects on bowel frequency and intestinal function. Gastroenterology 2013;144:903-11000.  Back to cited text no. 7
    
8.
Ferri C, Puccini R, Longombardo G, Paleologo G, Migliorini P, Moriconi L, et al. Low-antigen-content diet in the treatment of patients with IgA nephropathy. Nephrol Dial Transplant 1993;8:1193-8.  Back to cited text no. 8
    
9.
Coppo R, Roccatello D, Amore A, Quattrocchio G, Molino A, Gianoglio B, et al. Effects of a gluten-free diet in primary IgA nephropathy. Clin Nephrol 1990;33:72-86.  Back to cited text no. 9
    




 

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Abstract
What is an Elimi...
Method of Elimin...
Scientific Backg...
Use of Eliminati...
Experience of El...
Experience With ...
My Experience in...
Ongoing Pilot Study
Pitfalls and Advices
References

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