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Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Nutrition and Metabolism".

Deadline for manuscript submissions: closed (28 February 2022) | Viewed by 23290

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Special Issue Editors

Prof. Dr. Domenico Santoro

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Guest Editor

Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
Interests: glomerulonephritis; hemodialysis; nutrition in renal disease; vascular access; vitamin D
Special Issues, Collections and Topics in MDPI journals

Dr. Massimo Torreggiani

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Guest Editor

Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue, Le Mans, France
Interests: chronic kidney disease; nutrition in CKD; diabetic nephropathy; ageing; dialysis
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear colleagues,

Chronic kidney disease (CKD) affects about 10% of the population worldwide, exerting a non-negligible impact on healthcare systems; high-income countries spend about 2%–5% of their total healthcare budget on renal replacement therapy. Among the therapies available to mitigate CKD progression and delay the need for renal replacement therapy, nutritional management plays a major role. The recently published update of the KDOQI guidelines on nutrition in CKD has highlighted the importance of diet and advises starting a low-protein diet as early as in CKD stage 3. However, some questions still remain unanswered.

Despite the now widely acknowledged safety and efficacy of a low-protein regimen, concerns still exist about the prescription of such a diet in specific populations. Some authors advise caution in prescribing a low-protein diet to elderly patients on account of the risk of malnutrition. Moreover, less is known in the paediatric or transplant populations. Other open issues include that of pregnant patients for whom a usual diet is rich in proteins. Similarly, in CKD patients practicing sport, nutritional needs should probably be tailored.

In addition to their quantity, the source of protein is also a matter of debate: should we prefer plant-based over animal-derived proteins?

Micronutrient needs and supplementation rely on the demonstration of an inadequate intake or deficiency, but this field is largely unexplored and the recent recommendations are based on “expert opinions” only.

Finally, food preservatives and additives are an almost unexplored field: they may contain not only large amounts of potassium and phosphate, not often disclosed, but also a vast array of potentially toxic substances whose role in the progression of CKD is unknown and could influence the morbidity of kidney disease.

This Special Issue of Nutrients is aimed at shedding some light on these open questions to improve our understanding of the role and limits of nutritional management in CKD. We welcome clinical investigations, laboratory research with translational potential as well as emblematic case studies and reviews that can be useful in everyday practice and above all, benefit our patients.

Prof. Dr. Domenico Santoro
Dr. Massimo Torreggiani
Guest Editors

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Keywords

nutrition in CKD
low-protein diet
chronic kidney disease
dialysis

Published Papers (7 papers)

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Research

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12 pages, 302 KiB

Open AccessArticle

Does Mediterranean Adequacy Index Correlate with Cardiovascular Events in Patients with Advanced Chronic Kidney Disease? An Exploratory Study

by Andreana De Mauri, Deborah Carrera, Matteo Vidali, Marco Bagnati, Roberta Rolla, Sergio Riso, Doriana Chiarinotti and Massimo Torreggiani

Nutrients 2022, 14(9), 1687; https://doi.org/10.3390/nu14091687 - 19 Apr 2022

Cited by 1 | Viewed by 1691

Abstract

The Mediterranean Diet (MD) is a healthy dietary pattern, demonstrated to reduce the risk of cancer, diabetes, cardiovascular and neurodegenerative diseases, and early death. The Mediterranean Adequacy Index (MAI) is used to measure adherence to the MD in perspective studies in the general population and correlates with cardiovascular events. The aim of this study was to calculate the MAI among patients with advanced chronic kidney disease (CKD) and correlate it with traditional uremic, microbiota-derived, and proatherogenic toxins as well as nutritional status, quality of life, and cardiovascular events. A total of 60 adult patients with advanced CKD were enrolled and their MAI was calculated. According to the median value, patients were divided into lower (l-MAI, <1.80) and higher (h-MAI, ≥1.80) MAI groups. Biochemical parameters, microbiota-derived and proatherogenic toxins (p-Cresyl sulphate, Indoxyl-sulphate, and Lipoprotein-associated phospholipase A₂), nutritional status, quality of life, and cardiovascular events that occurred in the previous three years were recorded. The mean value of the MAI was 2.78 ± 2.86. The MAI was significantly higher in foreigners (median (IQR) 6.38 (8.98) vs. 1.74 (1.67), p < 0.001) and diabetic patients. The l-MAI and h-MAI groups had similar routinary blood, p-Cresyl-sulphate, Indoxyl-sulphate, and Lp-PLA₂ as well as nutritional status and quality of life parameters. The MAI was not associated with previous cardiovascular events and did not correlate with cardiovascular events in CKD patients. New and nephro-tailored indexes are warranted to evaluate nutritional therapy in CKD patients. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

13 pages, 1165 KiB

Open AccessArticle

Probiotics-Supplemented Low-Protein Diet for Microbiota Modulation in Patients with Advanced Chronic Kidney Disease (ProLowCKD): Results from a Placebo-Controlled Randomized Trial

by Andreana De Mauri, Deborah Carrera, Marco Bagnati, Roberta Rolla, Matteo Vidali, Doriana Chiarinotti, Marco Pane, Angela Amoruso and Mario Del Piano

Nutrients 2022, 14(8), 1637; https://doi.org/10.3390/nu14081637 - 14 Apr 2022

Cited by 15 | Viewed by 3816

Abstract

The probiotics-supplemented low-protein diet in chronic kidney disease (ProLowCKD) was a single-centre, double-blind, placebo-controlled, randomised trial that was conducted to investigate whether the association between a low protein diet (LPD) and a new formulation of probiotics (Bifidobacterium longum and Lactobacillus reuteri) was effective at reducing traditional uremic, microbiota-derived, and proatherogenic toxins in sixty patients affected by advanced CKD. After 2 months of a LPD—a reduction in blood urea nitrogen (52 ± 17 vs. 46 ± 15 mg/dL, p = 0.003), total cholesterol (185 ± 41 vs. 171 ± 34 mg/dL, p = 0.001), and triglycerides (194 ± 148 vs. 161 ± 70 mg/dL, p = 0.03) was observed; 57 subjects were then randomized to receive probiotics or a placebo for the subsequent 3 months. A total of 27 patients in the placebo group showed increased serum values of total cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.01), LDL cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.02), lipoprotein-associated phospholipase A₂ (155.4 ± 39.3 vs. 167.5 ± 51.4 nmol/mL/min, p = 0.006), and indoxyl-sulphate (30.1 ± 17.6 vs. 34.5 ± 20.2 μM, p = 0.026), while the 24 subjects in the probiotics group showed a trend in the reduction of microbiota toxins. A reduction of antihypertensive and diuretic medications was possible in the probiotics group. This study shows that associating probiotics to LPD may have an additional beneficial effect on the control and modulation of microbiota-derived and proatherogenic toxins in CKD patients. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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15 pages, 1819 KiB

Open AccessArticle

Spontaneously Low Protein Intake in Elderly CKD Patients: Myth or Reality? Analysis of Baseline Protein Intake in a Large Cohort of Patients with Advanced CKD

by Massimo Torreggiani, Antioco Fois, Maria Rita Moio, Antoine Chatrenet, Béatrice Mazé, Françoise Lippi, Jerome Vigreux, Coralie Beaumont, Giulia Santagati, Noemi Paulin and Giorgina Barbara Piccoli

Nutrients 2021, 13(12), 4371; https://doi.org/10.3390/nu13124371 - 6 Dec 2021

Cited by 7 | Viewed by 2940

Abstract

The recent guidelines on nutritional management of chronic kidney disease (CKD) advise a reduction in protein intake as early as CKD stage 3, regardless of age, to slow kidney function impairment. However, since elderly patients are usually considered as having a spontaneously reduced protein intake, nutritional interventions to reduce protein intake are often considered futile. This study aimed to assess the baseline protein intake of elderly CKD patients referred for nephrology care, and explore the need for dietary evaluations, focusing on the current recommendations for protein restriction in CKD. This is an observational study of CKD patients followed in the unit dedicated to advanced CKD patients in Le Mans, France. Patients with stages 3 to 5 not on dialysis were included. All patients were evaluated by an expert dietician to assess their baseline protein intake, whenever possible on the basis of a 7-days diet journal; when this was not available, dietary recall or analysis of delivered meals was employed. Demographic characteristics, underlying kidney disease, Charlson Comorbidity Index (CCI), Malnutrition-Inflammation Score (MIS), Subjective Global Assessment (SGA) and clinical and laboratory data were recorded. Between 15 November 2017 and 31 December 2020, 436 patients were evaluated in the unit. Their age distribution was as follows: “young”: <60 (n = 62), “young-old”: 60–69 (n = 74), “old”: 70–79 (n = 108), “old-old”: 80–89 (n = 140) and “oldest-old”: ≥90 (n = 54). The prevalence of vascular nephropathies was higher in patients older than 70 years compared to younger ones, as did CCI and MIS (p < 0.001). Moderate nutritional impairment (SGA: B) was higher in elderly patients, reaching 53.7% at ≥90, while less than 3% of patients in the overall cohort were classified as SGA C (p < 0.001). The median protein intake was higher than the recommended one of 0.8 g/kg/day in all age groups; it was 1.2 g/kg/day in younger patients and 1.0 thereafter (p < 0.001). Patient survival depended significantly on age (p < 0.001) but not on baseline protein intake (p = 0.63), and younger patients were more likely to start dialysis during follow-up (p < 0.001). Over half of the patients, including the old-old and oldest-old, were still on follow-up two years after referral and it was found that survival was only significantly associated with age and comorbidity and was not affected by baseline protein intake. Our study shows that most elderly patients, including old-old and extremely old CKD patients, are spontaneously on diets whose protein content is higher than recommended, and indicates there is a need for nutritional care for this population. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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10 pages, 970 KiB

Open AccessArticle

Supplemented Low-Protein Diet May Delay the Need for Preemptive Kidney Transplantation: A Nationwide Population-Based Cohort Study

by Chieh-Li Yen, Pei-Chun Fan, George Kuo, Chao-Yu Chen, Ya-Lien Cheng, Hsiang-Hao Hsu, Ya-Chun Tian, Antoine Chatrenet, Giorgina Barbara Piccoli and Chih-Hsiang Chang

Nutrients 2021, 13(9), 3002; https://doi.org/10.3390/nu13093002 - 28 Aug 2021

Cited by 2 | Viewed by 2732

Abstract

Background: Although several studies suggest the benefit of a low-protein diet supplemented with amino acids and keto acids (sLPD) in delaying the initiation of hemodialysis, evidence on whether these nutritional approaches could delay the timing of preemptive transplantation is lacking. Methods: Retrospective nationwide cohort study, from Taiwan’s National Health Insurance Research Database. Patients having undergone a first preemptive kidney transplantation between 2001 and 2017 were identified and divided into two groups according to the presence of sLPD treatment or not. The primary outcome was the time between the diagnosis of advanced CKD and transplantation. Secondary outcomes were post-transplantation adverse events. Results: A total of 245 patients who received their first preemptive kidney transplantation were identified from the nationwide database; 63 of them had been on an sLPD prior to transplantation (sLPD group). The duration between the day of advanced CKD diagnosis and the day of transplantation was significantly longer in the sLPD group compared with the non-sLPD group (median duration: 345 vs. 220 days, p = 0.001). The risk of post-transplantation adverse events did not differ between the two groups. Conclusions: Within the limits of its observational, retrospective design, this is the first study to suggest that nutritional management with sLPDs can safely delay the timing of preemptive kidney transplantation. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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Review

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20 pages, 346 KiB

Open AccessReview

The Effect of Nutrition and Exercise on Body Composition, Exercise Capacity, and Physical Functioning in Advanced CKD Patients

by Maryam Ekramzadeh, Domenico Santoro and Joel D. Kopple

Nutrients 2022, 14(10), 2129; https://doi.org/10.3390/nu14102129 - 20 May 2022

Cited by 12 | Viewed by 3939

Abstract

Patients with stages 4 and 5 chronic kidney disease (CKD), and particularly chronic dialysis patients, commonly are found to have substantially reduced daily physical activity in comparison to age- and sex-matched normal adults. This reduction in physical activity is associated with a major decrease in physical exercise capacity and physical performance. The CKD patients are often physically deconditioned, and protein energy wasting (PEW) and frailty are commonly present. These disorders are of major concern because physical dysfunction, muscle atrophy, and reduced muscle strength are associated with poor quality of life and increased morbidity and mortality in CKD and chronic dialysis patients. Many randomized controlled clinical trials indicate that when CKD and chronic dialysis are provided nutritional supplements or undergo exercise training their skeletal muscle mass and exercise capacity often increase. It is not known whether the rise in skeletal muscle mass and exercise capacity associated with nutritional support or exercise training will reduce morbidity or mortality rates. A limitation of these clinical trials is that the sample sizes of the different treatment groups were small. The aim of this review is to discuss the effects of nutrition and exercise on body composition, exercise capacity, and physical functioning in advanced CKD patients. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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13 pages, 1654 KiB

Open AccessReview

Dietary Management of Chronic Kidney Disease and Secondary Hyperoxaluria in Patients with Short Bowel Syndrome and Type 3 Intestinal Failure

by Maciej Adler, Ewen C. Millar, Kevin A. Deans, Massimo Torreggiani and Francesca Moroni

Nutrients 2022, 14(8), 1646; https://doi.org/10.3390/nu14081646 - 14 Apr 2022

Cited by 3 | Viewed by 2763

Abstract

Short gut syndrome can lead to type 3 intestinal failure, and nutrition and hydration can only be achieved with parenteral nutrition (PN). While this is a lifesaving intervention, it carries short- and long-term complications leading to complex comorbidities, including chronic kidney disease. Through a patient with devastating inflammatory bowel disease’s journey, this review article illustrates the effect of short gut and PN on kidney function, focusing on secondary hyperoxaluria and acute precipitants of glomerular filtration. In extensive small bowel resections colon in continuity promotes fluid reabsorption and hydration but predisposes to hyperoxaluria and stone disease through the impaired gut permeability and fat absorption. It is fundamental, therefore, for dietary intervention to maintain nutrition and prevent clinical deterioration (i.e., sarcopenia) but also to limit the progression of renal stone disease. Adaptation of both enteral and parenteral nutrition needs to be individualised, keeping in consideration not only patient comorbidities (short gut and jejunostomy, cirrhosis secondary to PN) but also patients’ wishes and lifestyle. A balanced multidisciplinary team (renal physician, gastroenterologist, dietician, clinical biochemist, pharmacist, etc.) plays a core role in managing complex patients, such as the one described in this review, to improve care and overall outcomes. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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17 pages, 664 KiB

Open AccessReview

Role of Zinc in Diabetic Kidney Disease

by Guido Gembillo, Luca Visconti, Alfio Edoardo Giuffrida, Vincenzo Labbozzetta, Luigi Peritore, Antonella Lipari, Vincenzo Calabrese, Giorgina Barbara Piccoli, Massimo Torreggiani, Rossella Siligato and Domenico Santoro

Nutrients 2022, 14(7), 1353; https://doi.org/10.3390/nu14071353 - 24 Mar 2022

Cited by 15 | Viewed by 4361

Abstract

Diabetic Kidney Disease (DKD) represents the most common cause of Chronic Kidney Disease (CKD) in developed countries. Approximately 30% to 40% of diabetes mellitus (DM) subjects develop DKD, and its presence significantly increases the risk for morbidity and mortality. In this context, Zinc seems to have a potential role in kidney and body homeostasis in diabetic individuals as well as in patients at a high risk of developing this condition. This essential element has functions that may counteract diabetes-related risk factors and complications, which include stabilization of insulin hexamers and pancreatic insulin storage and improved glycemic control. In our review, we analyzed the current knowledge on the role of zinc in the management of renal impairment in course of DM. Several studies underline the critical role of zinc in reducing oxidative stress levels, which is considered the common denominator of the mechanisms responsible for the progression of kidney disease. Reaching and maintaining a proper serum zinc level could represent a valuable target to reduce symptoms related to DM complications and contrast the progression of kidney impairment in patients with the high risk of developing end-stage renal disease. In conclusion, analyzing the beneficial role of zinc in this review would advance our knowledge on the possible strategies of DM and DKD treatment. Full article

(This article belongs to the Special Issue Clinical Experiences and Open Issues in Multidisciplinary Dietary Management of CKD)

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