The protein-restricted diet appears to play an important role in the progression of chronic kidney disease and the early onset of uremic symptoms, the supplementation of essential amino acids offers apparent security in achieving aggressive protein restrictions. The objective of this document is to carry out a literature review to inform practical use recommendations on this behavior in advanced Renal Disease (CKD).
Materials and methods:
A quick structured search of the literature is carried out, with the selection of systematic reviews and meta-analyzes, from which the answers to the questions with a PICOT structure designed a priori are extracted. The results were submitted to consensus to generate practical recommendations.
Six systematic reviews of the literature were included, with a moderate quality evaluation, the extraction of the information reports an apparent benefit of the very low protein diet with supplementation of alpha-keto-analogues on admission to dialysis or kidney transplantation and a consistent reduction of disease progression. Better clinical trials that integrate outcomes such as quality of life are required.
With low quality of evidence, the very low protein diet, supplemented with alpha-keto analogues, in the properly selected patient, reduces the deterioration of the glomerular filtration rate, seems to reduce admission to dialysis. Regular strict monitoring is recommended, with monitoring of anthropometric measures and malnutrition risk profile.
Inker LA, Astor BC, Fox CH, Isakova T, Lash JP, Peralta CA, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2014;63(5):713-35. https://doi.org/10.1053/j.ajkd.2014.01.416
Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework for moving forward. Kidney international. 2014;85(1):49-61. https://doi.org/10.1038/ki.2013.444
Moist LM, Al-Jaishi AA. Preparation of the Dialysis Access in Stages 4 and 5 CKD. Advances in chronic kidney disease. 2016;23(4):270-5. https://doi.org/10.1053/j.ackd.2016.04.001
Muscaritoli M, Krznaric Z, Singer P, Barazzoni R, Cederholm T, Golay A, et al. Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology. Clinical nutrition (Edinburgh, Scotland). 2017;36(4):939-57. https://doi.org/10.1016/j.clnu.2016.06.022
Kalantar-Zadeh K, Fouque D. Nutritional Management of Chronic Kidney Disease. New England Journal of Medicine. 2017;377(18):1765-76. https://doi.org/10.1056/NEJMra1700312
Mitch W, Walser M. Nitrogen balance of uremic patients receiving branched-chain ketoacids and the hydroxy-analogue of methionine as substitutes for the respective amino acids. Clinical nephrology. 1977;8(2):341-4.
Walser M, Coulter AW, Dighe S, Crantz FR. The effect of keto-analogues of essential amino acids in severe chronic uremia. The Journal of clinical investigation. 1973;52(3):678-90. https://doi.org/10.1172/JCI107229
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ (Clinical research ed). https://doi.org/10.1136/bmj.j4008
Rhee CM, Ahmadi SF, Kovesdy CP, Kalantar-Zadeh K. Low-protein diet for conservative management of chronic kidney disease: a systematic review and meta-analysis of controlled trials. J Cachexia Sarcopenia Muscle. 2018;9(2):235-45. https://doi.org/10.1002/jcsm.12264
Jiang Z, Zhang X, Yang L, Li Z, Qin W. Effect of restricted protein diet supplemented with keto analogues in chronic kidney disease: a systematic review and meta-analysis. International Urology and Nephrology. 2015;48(3):409-18. https://doi.org/10.1007/s11255-015-1170-2
Chewcharat A, Takkavatakarn K, Wongrattanagorn S, Panrong K, Kittiskulnam P, Eiam-Ong S, et al. The Effects of Restricted Protein Diet Supplemented With Ketoanalogue on Renal Function, Blood Pressure, Nutritional Status, and Chronic Kidney Disease-Mineral and Bone Disorder in Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis. J Ren Nutr. 2019. https://doi.org/10.1053/j.jrn.2019.07.005
Hahn D, Hodson EM, Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2018;10:CD001892. https://doi.org/10.1002/14651858.CD001892.pub4
Yan B, Su X, Xu B, Qiao X, Wang L. Effect of diet protein restriction on progression of chronic kidney disease: A systematic review and meta-analysis. PLoS One. https://doi.org/10.1371/journal.pone.0206134
Li A, Lee HY, Lin YC. The Effect of Ketoanalogues on Chronic Kidney Disease Deterioration: A Meta-Analysis. Nutrients. 2019;11(5). https://doi.org/10.3390/nu11050957
Garneata L, Stancu A, Dragomir D, Stefan G, Mircescu G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. Journal of the American Society of Nephrology : JASN. 2016;27(7):2164-76. https://doi.org/10.1681/ASN.2015040369
Goraya N, Wesson DE. Dietary Protein as Kidney Protection: Quality or Quantity? Journal of the American Society of Nephrology. 2016;27(7):1877-9. https://doi.org/10.1681/ASN.2015111286
Cianciaruso B, Pota A, Pisani A, Torraca S, Annecchini R, Lombardi P, et al. Metabolic effects of two low protein diets in chronic kidney disease stage 4-5--a randomized controlled trial. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2008;23(2):636-44. https://doi.org/10.1093/ndt/gfm576
Zhang J, Xie H, Fang M, Wang K, Chen J, Sun W, et al. Keto-supplemented Low Protein Diet: A Valid Therapeutic Approach for Patients with Steroid-resistant Proteinuria during Early-stage Chronic Kidney Disease. The journal of nutrition, health & aging. 2016;20(4):420-7. https://doi.org/10.1007/s12603-015-0612-y
Mircescu G, Garneata L, Stancu SH, Capusa C. Effects of a supplemented hypoproteic diet in chronic kidney disease. J Ren Nutr. 2007;17(3):179-88. https://doi.org/10.1053/j.jrn.2006.12.012
Bellizzi V, Di Iorio BR, De Nicola L, Minutolo R, Zamboli P, Trucillo P, et al. Very low protein diet supplemented with ketoanalogs improves blood pressure control in chronic kidney disease. Kidney international. 2007;71(3):245-51. https://doi.org/10.1038/sj.ki.5001955
Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney international. 1985;27(1):58-65. https://doi.org/10.1038/ki.1985.10
Pedrini M, Levey A, Lau J, et al. The Effect of the Dietary Protein Restriction on the Progression of Diabetic and no Diabetic Renal Diseases: A Meta-Analysis. Ann Intern Med 1996; 124 (17): 627-632 https://doi.org/10.7326/0003-4819-124-7-199604010-00002
Fouque_D, Wang_PH, Laville_M, Boissel_JP. Low protein diets for chronic renal failure in non-diabetic adults. Cochrane Database of Systematic Reviews 2000, Issue 4. https://doi.org/10.1002/14651858.CD001892
Fouque_D, Laville_M, Boissel_J-P. Low protein diets for chronic kidney disease in non-diabetic adults. Cochrane Database of Systematic Reviews 2006, Issue 1. https://doi.org/10.1002/14651858.CD001892.pub2
Fouque_D, Laville_M. Low protein diets for chronic kidney disease in non-diabetic adults. Cochrane Database of Systematic Reviews 2009, Issue 2. https://doi.org/10.1002/14651858.CD001892.pub3
Moe Sh, Zidehsarai M, Chambers M, et al. Vegetarian Compared with Meat Dietary Protein Source and Phosphorus Homeostasis in Chronic Kidney Disease. Clin J Am Soc Nephrol 6: 257-264, 2011 https://doi.org/10.2215/CJN.05040610
Malvy D. Maingourd C, Pengloan J, et al. Effects of Severe Protein Restriction with Ketoanalogues in Advanced Renal Failure. J Am Coll Nutr 1999; 18(5): 481-486 https://doi.org/10.1080/07315724.1999.10718887
Klahr S, Levey A, Beck G, et al. The Effects of Dietary Protein Restriccion and Blood Pressure Control on the Progresion of Chronic Renal Disease. N Engl J Med. 194, March 31; 330 (13): 877-884 https://doi.org/10.1056/NEJM199403313301301
Kovesdy C, Kopel J, Kalantar Zadeh K. Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: reconciling low protein intake with. Am J Clin Nutr 2013;97:1163-77. https://doi.org/10.3945/ajcn.112.036418
Chauveu P, Venderly B, Haggan W, et al. Body Composition of Patients on a Very Low-Protein Diet: A Two-Year Survey With DEXA. Journal of Renal Nutrition, Vol 13, No 4 (October), 2003: pp 282-287 https://doi.org/10.1016/S1051-2276(03)00117-1
MilanovaL, Fomin V, Moiseev S, Effect of essential amino acid ?etoanalogues and protein restriction diet on morphogenetic proteins (FGF-23 and ?lotho) in 3b-4 stages chronic ?idney disease patients: a randomized pilot study. Clinical and Experimental Nephrology (2018) 22:1351-1359 https://doi.org/10.1007/s10157-018-1591-1
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