Diet in ckd
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This document discusses dietary guidelines for kidney health. It notes that kidneys play a key role in nutrient homeostasis and that loss of kidney function disrupts this. For chronic kidney disease (CKD) patients, guidelines recommend a daily protein intake of 0.6-0.8g/kg, limiting fat intake to 30% of calories, and restricting sodium and phosphorus intake. While protein restriction may slow CKD progression, large trials like MDRD found little overall benefit. A plant-based, low-protein diet that is low in phosphorus and sodium may be most suitable for CKD patients. Focusing on overall dietary patterns like the DASH diet may be more practical than individual nutrient restrictions.
![Ketosteril Arm[KD] and LPD arm
• Therapeutic Intervention The patients in the intervention arm (KD group)
received a vegetarian VLPD (0.3 g protein/kg ideal body wt per day)
supplemented with ketoanalogues of essential amino acids (Ketosteril;
Fresenius Kabi, Bad Homburg, Germany) at 0.125 g/kg ideal dry body wt per
day as recommended by the manufacturer](https://image.slidesharecdn.com/dietinckd-211004145106/85/Diet-in-ckd-21-320.jpg)
Diet in ckd
- 1. DIET IN KIDNEY HEALTH Dr. K Sampathkumar, Sr. Consultant, Nephrology MMHRC, Madurai
- 2. What can I eat/what should I avoid Doc?
- 3. The link between diet and Kidneys Kidneys play a key role in nutritional homeostasis, ranging from regulation of sodium, potassium & phosphate levels to metabolism of amino acid & glucose. Loss of kidney function disrupts this homeostasis and hence require appropriate dietary modifications. Dietary factors may also have a role in progression of kidney disease and its complications
- 4. Overview of Guidelines in CKD: • Daily protein intake of 0.6- 0.8gm/kg • Caloric intake 30-35kcal/kg/day • Fat <30% of total energy intake • Fibres 25-38gms/day • Sodium intake <2–2.3gms/day • Potassium intake to be guided by serum levels • Calcium intake <1500mg/day • Phosphorus intake 0.8-1gm/day
- 5. Can we prevent CKD by drinking more water?
- 6. Water intake and Risk of CKD Polyuria Loss of medullary conc Risk of AKI in volume depletion states Higher ADH levels Higher Uric acid crystals Low medullary Blood flow in VasaRecta Interstitial fibrosis Increased Water intake Decreased
- 11. But India is not Canada or Europe ! Improving water intake reduces incidence of renal calculi
- 12. Protein Restriction –Shifting Focus From Animal Protein( ‘First Class’ ) based diet To Plant Based
- 13. Protein restriction Experimental data suggest daily protein intake >1.5gm/day may cause glomerular hyper filtration & proinflammatory gene expression. Protein restriction mitigates proteinuria besides other benefits including lower urea generation, microbiome modulation, lower phosphorus intake & control of metabolic acidosis. Despite abundant observational studies, no RCT has shown definitive benefit in retarding the progression of CKD.
- 14. Kalantar-Zadeh K, Fouque D. Nutritional Management of Chronic Kidney Disease. N Engl J Med. 2017 Nov 2;377(18):1765-1776
- 16. MDRD Study A: Usual vs Low protein
- 17. • MDRD study A analyzed 585 adults with nondiabetic CKD & mean GFR 39ml/min. Randomly assigned to normal (1.3gm/kg/day) or low (0.58gm/kg/day). Followed up for mean of 2.2 years. • Biphasic response noted with a greater fall in GFR initially in the low protein group which slowed down after 4 months. Little overall benefit of 1.1ml/min/year. • Study B analysed 255 adults with mean GFR of 19ml/min, randomly assigned to low protein (0.58gm/kg/day) or very low protein (0.3gm/kg/day with a keto supplement) • No significant benefit in study B either . Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, Striker G. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994 Mar 31;330(13):877-84
- 18. Limitations of MDRD… Short study period Slow decline in GFR ADPKD with genetically programmed loss of GFR formed 25% Longer follow up of MDRD patients by linking them to national registries over 6 years did show a significant benefit on renal failure and all cause mortality
- 19. Pedrini MT, et al. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med. 1996
- 20. J Am Soc Nephrol 27: 2164–2176, 2016
- 21. Ketosteril Arm[KD] and LPD arm • Therapeutic Intervention The patients in the intervention arm (KD group) received a vegetarian VLPD (0.3 g protein/kg ideal body wt per day) supplemented with ketoanalogues of essential amino acids (Ketosteril; Fresenius Kabi, Bad Homburg, Germany) at 0.125 g/kg ideal dry body wt per day as recommended by the manufacturer
- 24. Number needed to treat to avoid Dialysis- <2 J Am Soc Nephrol 27: 2164–2176, 2016
- 25. Metabolic Acidosis improved in KD arm J Am Soc Nephrol 27: 2164–2176, 2016
- 26. Indian Scenario Protein intake already low in population Avoidance of Dhals,Lentils will lead way for malnutrition Individual diet plan rather than blanket ban on proteins
- 27. Sodium restriction 1 gm of salt contains 0.4gm (17mEq) of Na ion. Post hoc analyses of REIN & HALT-PKD trials showed the benefits of salt restriction on slowing down the progression of CKD Similarly, PURE study & a long term follow up of TOHP I & II suggested increased risk of CV events at higher levels of Na intake (>6gmday). Besides slower progression of CKD & improved CV outcomes, Na restriction also associated with lower BP.
- 28. Daily sodium intake of < 2gm is recommended for those with GFR <60 ml/min & hypertension, volume overload or proteinuria. Guidelines not clear for other patients. Studies have suggested a J-shaped associated for dietary sodium intake with intake <3g/day & >5g/day both associated with increased adverse CV events. Ideal intake for patients without hypertension, volume overload or proteinuria would be 3-4g/day. Sodium Intake
- 29. Potassium intake • Potassium rich foods associated with lower incident risk & slower progression of CKD, reduction in systolic BP, lower risk of stroke & higher bone density • In contrast, some cohort studies (CRIC study) have reported higher risk of CKD progression with significantly higher intake of potassium. • Sweet spot probably lies somewhere in between and plasma levels of K may be the best guide dietary intake. Plasma potassium <4mmol/litre & >5.5mol/litre both associated with rapid CKD progression.
- 30. • Low Risk of hyperkalemia and Hyperphosphatemia • Goes intracellular - Alkalinity • Faster colonic excretion due to Dietary fibres • Absence of Phytases – Less P absorption • 4-5 servings per day • Reduced Progression of CKD • GFR > 15 ml.min
- 31. CRIC Study He J, Mills KT, Appel LJ, et al. Urinary Sodium and Potassium Excretion and CKD Progression. J Am Soc Nephrol. 2016
- 32. General consensus from observational studies suggest that high potassium intake in CKD stages 1 & 2 retards progression, whereas beyond stage 3, high potassium intake is associated with more rapid progression and higher all cause mortality. Hence, no potassium restriction is needed for those with GFR > 60ml/min. In CKD stages 3 & 4, 2 to 4 gms per day of K intake is recommended. Further restrictions may be needed in the presence of hyperkalemia.
- 33. Phosphorus Higher phosphorus levels associated with worse cardiovascular outcomes & decreasing bone mineral density. Possible mechanism include accelerated vascular calcification, increased arterial stiffness and induction of FGF23 leading to LVH. A large metaanalysis of 14 studies showed an 18% risk of death for every 1mg/dl increase in serum phosphorus in CKD patients
- 36. Dietary source of P Rice • 16 G /257 mg P • Only 64 mg of P is absorbed ( 25%) Chicken • 16 G/ 120 mg P • 100% of P is absorbed Fish • 16 G/ 180 mg P • 100 % of P is absorbed
- 37. Humans lack Phytase in Gut Food Item Phytic P Phytin P as % of total P Wheat ( Whole ) 238 80 Rice milled 83 40 Bengal gram dhal 133 40 Black gram dhal 169 43 Khesari dhal 108 31 Red gram dhal 170 56 Fish 18 10 Beef 90 28
- 38. P additives in fast foods
- 39. Techniques of P removal from food After prolonged soaking in water, a significant reduction in the P content occurs. Vegetables – 51% legumes- 48%; Meat - 38%; Boiling produces demineralization of P,Ca, Na,K from food stuff
- 40. Benefits of Plant based diets: Differing amino acid profiles may have different effects on renal hemodynamics including reduced expression of RAAS system Higher fibre content • Increased bowel motility & nitrogen excretion, thus decreasing the uremic load. • Lowers cholesterol & reduced incidence of metabolic syndrome • Alters gut microbiome towards more saccharolytic type, which ferment dietary fibres to release short chain FA & promote gut barrier integrity. • Also confer anti-inflammatory properties.
- 41. Plant fats are rich in MUFA/PUFA. • Lowers both cholesterol & body weight • Lower risk of atherosclerosis • Eicosanoids derived from plant fats (omega 3) are less inflammatory • Plants oils are rich sources of antioxidants like Vitamin E Plant are richer in anions than cations, • Generate less acid content. • Main anions in plants include citrate & malate, both metabolized to bicarbonate. Plants are generally low in sodium. Rich in phytochemical, vitamins & mineral. Phosphorus in plant foods are present as phytates. Not easily digested and thus are less bioavailable (20%)
- 42. Dietary Patterns Individual nutrient restrictions while sound in theory, don’t often translate to good practical dietary advice. People often consumed mixed meals. Makes more sense then to prescribe dietary patterns. Several dietary regimens have gained prominence over the last decade including the DASH diet, Mediterranean diet etc.
- 45. Conclusion Moderate protein restriction of 0.8gm/kg/day seems to be beneficial in retarding the progression of CKD, without increased risk of malnutrition. Daily sodium intake 2gms/day is recommended for those with volume overload, hypertension or proteinuria. 3-4gms/day is ideal for others. Potassium rich foods have many health benefits and restriction is usually not instituted till beyond CKD stage 3. Phosphorus intake with its adverse effects on the heart and bone should be restricted to around 800/day in CKD patients.
- 46. Go Green !! Plant based diets may serve as the ideal low protein diets with added benefit low bioavailable phosphorus. Rather than focusing on individual nutrients, it’d be more prudent to focus on dietary patterns. Easier to understand for the patients and ensure better compliance.
- 47. Thank you…
Editor's Notes
- #11: GRAPHICAL ABSTRACT Unless provided in the caption above, the following copyright applies to the content of this slide: © The Author(s) 2021. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)