Effects of Mediterranean Diet, DASH Diet, and Plant-Based Diet on Outcomes among End Stage Kidney Disease Patients: A Systematic Review and Meta-Analysis
, Charat Thongprayoon 1, Supawit Tangpanithandee 1,2, Pajaree Krisanapan 1,3, Jing Miao 1, Michael A. Mao 4 and Wisit Cheungpasitporn 1,*Round 1
Reviewer 1 Report
Dear authors,
your manuscript with the title of "Effects of Mediterranean Diet, DASH diet, and Plant-based Diet on Outcomes among End Stage Kidney Disease Patients" is of great interest, as it presents evidence that Mediterranean diet and plant-based diets are of no harm on end stage renal disease patients. Meaning that although these type of diets are high in potassium and quite low in protein (just opposite the current dietary guidelines), they have no association with hyperkalemia. In the contrary, one study showed that Mediterranean diet adherence was found to be associated with reduced risk of left ventricular hypertrophy.
My only comment for the manuscript is that the introduction does not provide the current literature concerning the effect of Mediterranean diet on chronic kidney disease and especially the end stage renal disease (ESRD) patients.
Although the systematic review failed to show any survival benefit of these dietary patterns, I feel that these were just preliminary data, as the number of relevant studies existing and included in the meta-analysis are limited. Therefore, your manuscript is an important first attempt to exculpate these healthy dietary patterns in ESRD.
Author Response
Response to Reviewer#1
Your manuscript with the title of "Effects of Mediterranean Diet, DASH diet, and Plant-based Diet on Outcomes among End Stage Kidney Disease Patients" is of great interest, as it presents evidence that Mediterranean diet and plant-based diets are of no harm on end stage renal disease patients. Meaning that although these type of diets are high in potassium and quite low in protein (just opposite the current dietary guidelines), they have no association with hyperkalemia. In the contrary, one study showed that Mediterranean diet adherence was found to be associated with reduced risk of left ventricular hypertrophy.
Response:
We thank you for reviewing our manuscript and for your critical evaluation.
Comment #1
My only comment for the manuscript is that the introduction does not provide the current literature concerning the effect of Mediterranean diet on chronic kidney disease and especially the end stage renal disease (ESRD) patients
Response:
We appreciate the reviewer’s important comments and we agree with the reviewer. We have additionally revised the introduction of the manuscript as suggested. The following text has been added as suggested.
“Mediterranean diet adherence is shown to be associated with reduced mortality among patients with chronic kidney disease (CKD) [12] and evidence also suggests that it may prevent or decrease progression of CKD [13]. Recent systematic review also showed that each one-point higher adherence to Mediterranean diet was associated with 10% re-duction of progression of CKD [14]. However, the effects of the DASH diet on clinical out-comes among ESKD patients are inconsistent and remains unclear if it has any beneficial effect in this population [15-21]. Current dietary guidelines for ESKD patients usually recommend restriction of specific nutrients (sodium, potassium, phosphorus, etc.) and recommends high protein and calorie intake[22-24]. However, there is limited evidence showing the clinical benefits of restricted nutrients in ESKD patients. Literature has been inconsistent regarding the benefits of a DASH diet in the chronic kidney disease population, and only a small number of studies are available in ESKD patients.[15-21] In this systematic review, we evaluated the impact of a DASH, Mediterranean, or plant-based diet on the clinical outcomes including all-cause and cardiovascular mortality, left ventricular hypertrophy (LVH), and hyperkalemia in ESKD patients”.
Comment #2
Although the systematic review failed to show any survival benefit of these dietary patterns, I feel that these were just preliminary data, as the number of relevant studies existing and included in the meta-analysis are limited. Therefore, your manuscript is an important first attempt to exculpate these healthy dietary patterns in ESRD.
Response: We appreciate the reviewer’s kind comments. We additionally included this important point in the limitation of our study as suggested. . The following text has been added as suggested.
“In addition, while this current study is the first systematic review and meta-analysis that summarizes all available data on Mediterranean, DASH, or plant-based diet in ESKD patients, the number of relevant studies existing and included in the meta-analysis are limited, and thus future studies with long-term follow-up are required.”
Thank you for your time and consideration. We greatly appreciated the reviewer's and editor's time and comments to improve our manuscript. The manuscript has been improved considerably by the suggested revisions.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
This study evaluated the impact of Mediterranean, DASH, and plant-based diet on outcomes among ESKD patients. While this systematic review demonstrated no significant associations of Mediterranean, DASH, and plant-based diet with reduced all-cause mortality or cardiovascular mortality, there were also no evidence that suggested harmful effects of these diets on ESKD patients. Despite being on a Mediterranean, DASH, or plant-based diet that is rich in potassium, ESKD patients did not develop hyperkalemia compared to controls. This review may provide evidence against the commonly accepted blanket practice of dietary modifications in ESKD patients that includes the avoidance of many plant-based diets due to concern of hyperkalemia.
Mediterranean, DASH, and plant-based diet all emphasize increased fruits and vegetables. As there are few studies included, it is recommended to set the treatment group as Mediterranean, DASH, and plant based diet, and the control group as non above diet for comparison, so as to expand the number of studies included.
Author Response
Response to Reviewer#2
This study evaluated the impact of Mediterranean, DASH, and plant-based diet on outcomes among ESKD patients. While this systematic review demonstrated no significant associations of Mediterranean, DASH, and plant-based diet with reduced all-cause mortality or cardiovascular mortality, there were also no evidence that suggested harmful effects of these diets on ESKD patients. Despite being on a Mediterranean, DASH, or plant-based diet that is rich in potassium, ESKD patients did not develop hyperkalemia compared to controls. This review may provide evidence against the commonly accepted blanket practice of dietary modifications in ESKD patients that includes the avoidance of many plant-based diets due to concern of hyperkalemia.
Response: Thank you for reviewing our manuscripts and critical evaluation. We appreciate the reviewer find the findings of our study important and provides evidence of Mediterranean, DASH, or plant-based diet in ESKD patients.
Comment #1
Mediterranean, DASH, and plant-based diet all emphasize increased fruits and vegetables. As there are few studies included, it is recommended to set the treatment group as Mediterranean, DASH, and plant-based diet, and the control group as non above diet for comparison, so as to expand the number of studies included.
Response: We appreciate the reviewer’s important comments. We have look into the combination of Mediterranean, DASH, and plant-based diet as treatment group, however, there is significant heterogeneity among combined groups and thus the analysis is not completely valid. We agree that there are limited number of studies. We added this important point in the limitation of the study as suggested.
“While this current study is the first systematic review and meta-analysis that summarizes all available data on Mediterranean, DASH, or plant-based diet in ESKD patients, the number of relevant studies existing and included in the meta-analysis are limited, and thus future studies with long-term follow-up are required.”
Thank you for your time and consideration. We greatly appreciated the reviewer's and editor's time and comments to improve our manuscript. The manuscript has been improved considerably by the suggested revisions.
Author Response File: Author Response.pdf
