Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes

Abstract

Purpose of reviewNearly half of all Americans with chronic kidney disease (CKD) also have type-2-diabetes (T2D). Whereas traditional and emerging pharmacotherapies are increasingly frequently used for the management of CKD in diabetes (CKD/DM), the role of integrated or multimodal interventions including the potentially synergistic and additive effect of diet and lifestyle modifications in addition to pharmacotherapy has not been well examined, in sharp contrast to the well-known integrated approaches to heart disease. Recent findingsLow-carbohydrate low-fat diets are often recommended in T2D, whereas low-protein diets (LPD) are recommended by guidelines for nondiabetic CKD with increasing emphasis on plant-based protein sources. High-protein diets with greater animal protein lead to glomerular hyperfiltration, especially in patients with T2D, and faster decline in renal function. Guidelines provide differing recommendations regarding the amount (low vs high) and source (plant vs animal) of dietary protein intake (DPI) in CKD/DM. Some such as KDIGO recommend 0.8 g/kg/day based on insufficient evidence for DPI restriction in CKD/DM, whereas KDOQI and ISRNM recommend a DPI of 0.6 to <0.8 g/kg/day. A patient-centered plant-focused LPD for the nutritional management of CKD/DM (PLAFOND), a type of PLADO diet comprising DPI of 0.6 to <0.8 g/kg/day with >50% plant-based sources, high dietary fiber, low glycemic index, and 25-35 Cal/kg/day energy, can be implemented by renal dietitians under Medical Nutrition Therapy.

Functional Nutrition, Naturopathic Nutrition, and Integrative and Holistic Renal Nutrition in Kidney Health and Value-Based Kidney Care Models

“…A recently developed example is plant dominant (PLADO) low-protein diets designed for slowing CKD progression and delaying dialysis initiations. [11][12][13] PLADO diet regimens, managed by trained dietitians in the form of medical nutritional therapy (MNT), 9,[14][15][16] can vary in the quantity and quality of protein content and proportion of plant-vs animal-based protein. It has been recommended that more than 2/3 of protein of PLADO regimens should be from plant-proteins to slow CKD progression, as opposed to an often-implemented low potassium "renal diet" that is potassium-centric and hence usually with more than 2/3 of protein from animal-based sources.…”

“…It has been recommended that more than 2/3 of protein of PLADO regimens should be from plant-proteins to slow CKD progression, as opposed to an often-implemented low potassium "renal diet" that is potassium-centric and hence usually with more than 2/3 of protein from animal-based sources. 16 Given individualized approaches under functional and precision nutrition, low and very low protein diets with dietary protein intake (DPI) of 0.6-0.8 g/kg/day and <0.6 g/kg/day, respectively, are recommended for non-dialysis CKD; moderate protein diets (DPI 0.8-1 g/kg/day) are recommended for those at high risk of CKD such as solitary kidney; and high protein diets (DPI >1.2 g/kg/day) are recommended for dialysis dependent patients and acute kidney injury. [17][18][19] PLADO, which is J o u r n a l P r e -p r o o f Functional Nutrition in Kidney Care also consistent with pescatarian or lacto-ovo-vegetarian diets, can be a pure vegan diet in its most extreme form, 13,[20][21][22] or it can be in the form of Plant Focused Nutrition for CKD in Diabetes (PLAFOND), which includes foods with a low glycemic index.…”

“…[17][18][19] PLADO, which is J o u r n a l P r e -p r o o f Functional Nutrition in Kidney Care also consistent with pescatarian or lacto-ovo-vegetarian diets, can be a pure vegan diet in its most extreme form, 13,[20][21][22] or it can be in the form of Plant Focused Nutrition for CKD in Diabetes (PLAFOND), which includes foods with a low glycemic index. 16 PLADO diet regimens including PLAFOND should be provided under MNT with periodic review of renal dietitians that can be in the form in-person visits or telenutrition. 23 Integrative and functional nutrition is an area of renal nutrition and dietetics practice in which critical thinking skills of renal dietitians are especially important to achieve and maintain the expected level of consistency in providing kidney nutrition care and utilizing evidence-based guidelines and emerging scientific data when available.…”

Unleashing the Power of Renal Nutrition in Value-Based Models of Kidney Care Choices: Leveraging Dietitians’ Expertise and Medical Nutrition Therapy to Delay Dialysis Initiation

“…9 Given concerns about the risk of protein-energy wasting, secondary sarcopenia, and cachexia that may ensue in far-advanced CKD if there is inadequate nutrition, the PLADO-based low and very low protein diets may benefit from nutritional supplementation, including essential amino acids and/or keto-analogs of amino acids. [10][11][12] However, clinical trials of low-and very-low protein diets and meta-analyses of these trials have been inconsistent. 13 Another challenge is that half or a higher proportion of persons with advanced CKD have diabetes or suffer from obesity and metabolic syndrome, where obese sarcopenia is more likely and for which higher dietary protein intake is traditionally recommended.…”

“…Higher protein intake may worsen CKD progression and uremic symptoms by increasing the level of nitrogenous endproducts of amino acids leading to higher circulating levels of uremic toxins; 11,14,15 moreover, individual disease states may benefit from distinct nutritional interventions given data supporting ketogenic diet for polycystic kidney disease, gluten-free diet for IgA nephropathy, and lower glycemic index foods for diabetic kidney disease. 12 However, engaged dietitians equipped with well-designed dietary management models can implement patient-centered MNT strategies using telenutrition and other educational and monitoring modalities. 9 Nutritional status can be watched closely by means of screening tools, including the malnutrition-inflammation score (MIS) and MISbased algorithms can be developed to minimize the risk of protein-energy wasting from advanced uremia.…”