Reducing the Dietary Acid Load: How a More Alkaline Diet Benefits Patients With Chronic Kidney Disease

Abstract

It has been proposed that a low-protein diet will slow progression of chronic kidney disease although studies have not always supported this belief. The accepted practice is that 60% to 70% of protein comes from high biological value (HBV) protein, but this limits patient choice and patients struggle to follow the diet. When a diet with only 30% HBV protein was trialed, there was a significant increase in serum bicarbonate, and patients preferred the diet. The dietary advice given in predialysis clinics was changed. HBV protein was restricted to approximately 50% of total protein, bread and cereal foods were allowed freely, and fruits and vegetables (F&V) were encouraged. Patients who followed the diet have seen a slowing of progression and occasionally regression of their renal function. Both observations and scientific literature indicate that this is because of a reduction in the acid content of the diet. When foods are metabolized, most proteins produce acid, and most F&V produce alkali. A typical 21-century diet produces 50 to 100 mEq H per day which the kidney is challenged to excrete. Acid is excreted with phosphate and is limited to about 45 mEq H per day. With chronic kidney disease, this falls progressively to below 20 mEq H per day. Historically, ammonium excretion was believed to be excretion of acid (NH + H → NH), but it is now understood to be a by-product in the neutralization of acid by glutamine. The remaining acid is neutralized or stored within the body. Bone and muscle are lost in order to neutralize the acid. Acid also accumulates within cells, and serum bicarbonate falls. The author postulates that reducing the acid load through a low-protein diet with greater use of vegetable proteins and increased F&V intake will slow progression or occasionally improve renal function while maintaining the nutritional status of the individual.

Diet-Induced Low-Grade Metabolic Acidosis and Clinical Outcomes: A Review

“…In addition, in an attempt to neutralize the H + load, an increase in ammonia production occurs in the proximal tubule, which can cause tubular toxicity and renal damage. These processes, when constantly stimulated, are associated with the increased risk and progression of CKD [39,40,41]. …”

Managing protein‐energy wasting in hemodialysis patients: A comparison of animal‐ and plant‐based protein foods

“…One of the key diet‐related conditions affecting PEW risk is metabolic acidosis . Mild‐moderate metabolic acidosis is common in HD patients, and bicarbonate supplements improves nitrogen balance and muscle strength in CKD patients with metabolic acidosis .…”

“…Mild‐moderate metabolic acidosis is common in HD patients, and bicarbonate supplements improves nitrogen balance and muscle strength in CKD patients with metabolic acidosis . Diet is one of the primary modifiable determinants of metabolic acidosis, contributing an estimated 20‐50 mEq of the 55‐110 mEq of hydrogen ions generated in the body each day . Based on the potential renal acid load equation, which is used to estimate the acid load of foods, animals have a nutrient composition that is more acidic than plants (approx.…”

“…One of the key diet-related conditions affecting PEW risk is metabolic acidosis. 29,30 Mild-moderate metabolic acidosis is common in HD patients, 31 and bicarbonate supplements improves nitrogen balance and muscle strength in CKD patients with metabolic acidosis. 32,33 Diet is one of the primary modifiable determinants of metabolic acidosis, contributing an estimated 20-50 mEq of the 55-110 mEq of hydrogen ions generated in the body each day.…”

Nutrients of Cubiu Fruits (<i>Solanum sessiliflorum</i> Dunal, Solanaceae) as a Function of Tissues and Ripening Stages

“…Macrominerals in fruits may be base-forming elements (e.g., Ca, Mg, and K) and acid-forming elements (e.g., P) [55,56]. The literature shows high contents of P in the pulp of cubiu fruits [4,5,10,57].…”