Abstract
The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an “option” in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management.
Highlights
The type and quality of the diet that a patient follows is not trivial; it is a cornerstone in the management of many diseases, as it is the case of chronic kidney disease (CKD) [1]
The rationale, safety, and efficacy of low protein diets (LPDs) delaying the start of dialysis are supported by various trials, leading to propose them with an evidence graded as 1A in the 2020 National Kidney Foundation-Kidney Disease Outcome Quality Initiative (NKF-KDOQI) Clinical Practical Nutrition Guideline [7]
A secondary analysis of the Modification of Diet in Renal Disease (MDRD) study showed that a reduction of 0.2 g/kg b.w./day of protein per year was associated with lower serum concentrations of urea and phosphate, and higher levels of bicarbonate in patients with CKD stages 3–5, randomized to LPD or very low protein diet (VLPD) + keto analogues [39]
Summary
The type and quality of the diet that a patient follows is not trivial; it is a cornerstone in the management of many diseases, as it is the case of chronic kidney disease (CKD) [1]. Careful nutritional assessment and wise and adapted dietary prescriptions, supplying enough energy to cover needs, may prevent PEW since LPDs can reduce intoxication and correct several metabolic abnormalities and symptoms. Another commonly reported concern is that patients will not comply with dietary prescriptions [15]. We discuss the importance of LPDs in CKD through the lens of a pharmacological approach, and summarize the mechanisms of LPDs’ action, indications, contra-indications, dosages, unwanted side effects, and special warnings
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