“Dietaly”: practical issues for the nutritional management of CKD patients in Italy

Abstract

Evidence exists that nutritional therapy induces favorable metabolic changes, prevents signs and symptoms of renal insufficiency, and is able to delay the need of dialysis. Currently, the main concern of the renal diets has turned from the efficacy to the feasibility in the daily clinical practice.Herewith we describe some different dietary approaches, developed in Italy in the last decades and applied in the actual clinical practice for the nutritional management of CKD patients.A step-wise approach or simplified dietary regimens are usually prescribed while taking into account not only the residual renal function and progression rate but also socio-economic, psychological and functional aspects.The application of the principles of the Mediterranean diet that covers the recommended daily allowances for nutrients and protein (0.8 g/Kg/day) exert a favorable effect at least in the early stages of CKD. Low protein (0.6 g/kg/day) regimens that include vegan diet and very low-protein (0.3-0.4 g/Kg/day) diet supplemented with essential amino acids and ketoacids, represent more opportunities that should be tailored on the single patient’s needs.Rather than a structured dietary plan, a list of basic recommendations to improve compliance with a low-sodium diet in CKD may allow patients to reach the desired salt target in the daily eating.Another approach consists of low protein diets as part of an integrated menu, in which patients can choose the “diet” that best suits their preferences and clinical needs.Lastly, in order to allow efficacy and safety, the importance of monitoring and follow up of a proper nutritional treatment in CKD patients is emphasized.

Retarding Chronic Kidney Disease (CKD) Progression: A Practical Nutritional Approach for Non-Dialysis CKD

“…To avoid a negative nitrogen balance with such a reduced protein intake, at least 50% of proteins have to be of high biological value (i.e., meat, fish, eggs), and the energy intake should be normalhigh (30-35 kcal/kg/d) (23). Since adherence to nutritional therapy is low in CKD, only patients compliant with these lowprotein diets may be switched to more restricted, and potentially more effective, dietary regimens.…”

“…While collecting a dietary recall, one can obtain information about the patient's life, practical aspects such who does the shopping and who prepares meals, or the patient's capacity to perform activities of daily living, social relationships, interests, and hobbies. This is important information to provide feasible dietary instructions not too far from the patient's current dietary habits (23).…”

“…Because of the very low nitrogen intake, a high energy intake (never lower than 30-35 kcal/kg/d) is mandatory to maintain a neutral body nitrogen balance. Protein-free artificial foods can be added to this diet, helping to reach such a high energy supply, since these products provide high energy amounts (23).…”

Nutritional Status Disorders in Chronic Kidney Disease: Practical Aspects (Systematic Review)

“…Even when the dietary intake provides all amino acids, the body may suffer from a protein deficiency if the absorption of any amino acid decreases in the intestine, or when it breaks up more than usual under the influence of gut microbiota. In these cases, limited protein synthesis will occur or the body will compensate for the lack of amino acid required for protein biosynthesis by breaking down its own proteins [9,18]. Changes in protein metabolism in uremia are closely related to amino acid metabolism disturbance.…”

“…As a result, the glomerular hypertrophy process as well as the renin-angiotensin-aldosterone system (RAAS) activation decreases, intraglomerular autoregulation normalizes, and intraglomerular and systemic hypertension reduces. LPD also partially corrects such unfavorable uremic, metabolic, and endocrine complications, such as hypoalbuminemia, dyslipidemia, anemia, hyperphosphatemia with parathyroid glands hyperplasia, and thereby it helps to reduce the risk of uremic hyperparathyroidism, vascular calcification, and atherosclerosis [2,8,9]. LPD in combination with ketoanalogs of essential amino acids enhances also antihypertensive and antiproteinuric effects of angiotensin receptor blockers (ARB), corrective action of erythropoietins in anemia, effects of synthetic vitamin D analogs and calcimimetics on hyperparathyroidism symptoms, and hypolipidemic effect of statins [4,10,11].…”