Diet as a system: an observational study investigating a multi-choice system of moderately restricted low-protein diets

Abstract

BackgroundThere is no single, gold-standard, low-protein diet (LPD) for CKD patients; the best compliance is probably obtained by personalization. This study tests the hypothesis that a multiple choice diet network allows patients to attain a good compliance level, and that, in an open-choice system, overall results are not dependent upon the specific diet, but upon the clinical characteristics of the patients.MethodsObservational study: Three LPD options were offered to all patients with severe or rapidly progressive CKD: vegan diets supplemented with alpha-ketoacids and essential aminoacids; protein-free food in substitution of normal bread and pasta; other (traditional, vegan non supplemented and tailored). Dialysis-free follow-up and survival were analyzed by Kaplan Meier curves according to diet, comorbidity and age.Compliance and metabolic control were estimated in 147 subjects on diet at March 2015, with recent complete data, prescribed protein intake 0.6 g/Kg/day. Protein intake was assessed by Maroni Mitch formula.ResultsFour hundreds and forty nine patients followed a LPD in December, 2007- March, 2015 (90% moderately restricted LPDs, 0.6 g/Kg/day of protein, 10% at lower targets); age (median 70 (19–97)) and comorbidity (Charlson index: 7) characterized our population as being in line with the usual CKD European population. Median e-GFR at start of the diet was 20 mL/min, 33.2% of the patients were diabetics. Baseline data differ significantly across diets: protein-free schemas are preferred by older, high-comorbidity patients (median age 76 years, Charlson index 8, GFR 20.5 mL/min, Proteinuria: 0.3 g/day), supplemented vegan diets by younger patients with lower GFR and higher proteinuria (median age 65 years, Charlson index 6, GFR 18.9 mL/min; Proteinuria: 1.2 g/day); other diets are chosen by an intermediate population (median age 71 years, Charlson index 6; GFR 22.5 mL/min; Proteinuria: 0.9 g/day); (p <0.001 for age, Charlson index, proteinuria, GFR). Adherence was good, only 1.1% of the patients were lost to follow-up and protein intake was at target in most of the cases with no differences among LPDs (protein intake: 0.47 (0.26–0.86) g/Kg/day). After adjustment for confounders, and/or selection of similar populations, no difference in mortality or dialysis start was observed on the different LPDs. Below the threshold of e-GFR 15 mL/min, 50% of the patients remain dialysis free for at least two years.ConclusionA multiple choice LPD system may allow reaching good adherence, without competition among diets, and with promising results in terms of dialysis-free follow-up. The advantages with respect to a non-customized approach deserve confirmation in further comparative studies or RCTs.

Chronic kidney disease progression: a retrospective analysis of 3-year adherence to a low protein diet

“…Despite the effectiveness and safety of LPD, the adherence to the protein restriction is a key point on the management of nondialysis CKD patients. 12 , 13 , 22 In the present study, demographic factors, such as age and gender, seem not to affect the low protein diet adherence. During the follow-up time, the dietitian improved the nutritional approach to increase the LPD adherence through some strategies: (a) adaptations in usual diet to incorporate the protein restriction to habitual meals and food habits (e.g., options for nocturnal snacking are provided for patients with prefer do not dining); (b) the use of replacement list of food to avoid diet monotony (e.g., one egg can be substituted by half steak portion); (c) use of portion sizes by measuring tools (with use of replicas of food and kitchen utensils) and photograph albums; (d) Analysis of the label of foods to patients learned where find the data about amount of protein per portion of processed foods; (e) stimulation to improve the meals with specific receipts of low protein content.…”

“…8 Thus, studies on the effects of LPD in the CKD progression were performed and generated non-conclusive or biased studies in part due to the diet adherence, 9–11 which is key to success. 12 , 13 …”

Weight Loss in Advanced Chronic Kidney Disease: Should We Consider Individualised, Qualitative, ad Libitum Diets? A Narrative Review and Case Study

“…At referral serum creatinine (sCr) was 5 mg/dL, estimated glomerular filtration rate (eGFR), calculated using the CKD-EPI formula, was 23 mL/min, blood urea nitrogen (BUN) was 75 mg/dL, with sub-nephrotic proteinuria (2.3 g/day). The patient was started on the moderately restricted low-protein diet we generally prescribe (a plant-based diet with protein intake of 0.6 g/kg/day, supplemented with alpha-ketoacids, and amino acids, with two unrestricted meals per week, as elsewhere described in detail [ 38 , 39 ]).…”

Ready to Change: Attitudes of an Elderly CKD Stage 3–5 Population towards Testing Protein-Free Food

“…This is a very important point for future studies; indeed, according to the Italian experience, there is no frequent “compensation” with protein rich food, since these products are rich in calories and, on the contrary, allow eating food of animal origin more freely. The main drawback in the Italian experience was low adherence, due to low palatability, which is one of the reasons why we designed this study [ 8 , 41 ].…”