Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature

Abstract

Pregnancy is increasingly reported in chronic kidney disease (CKD), reflecting higher awareness, improvements in materno-foetal care, and a more flexible attitude towards “allowing” pregnancy in the advanced stages of CKD. Success is not devoid of problems and an important grey area regards the indications for starting dialysis (by urea level, clinical picture, and residual glomerular filtration rate) and for dietary management. The present case may highlight the role of plant-based diets in dietary management in pregnant CKD women, aimed at retarding dialysis needs. The case. A 28-year-old woman, affected by glomerulocystic disease and unilateral renal agenesis, in stage-4 CKD, was referred at the 6th week of amenorrhea: she weighed 40 kg (BMI 16.3), was normotensive, had no sign of oedema, her serum creatinine was 2.73 mg/dL, blood urea nitrogen (BUN) 35 mg/dL, and proteinuria 200 mg/24 h. She had been on a moderately protein-restricted diet (about 0.8 g/kg/real body weight, 0.6 per ideal body weight) since childhood. Low-dose acetylsalicylate was added, and a first attempt to switch to a protein-restricted supplemented plant-based diet was made and soon stopped, as she did not tolerate ketoacid and aminoacid supplementation. At 22 weeks of pregnancy, creatinine was increased (3.17 mg/dL, BUN 42 mg/dL), dietary management was re-discussed and a plant-based non-supplemented diet was started. The diet was associated with a rapid decrease in serum urea and creatinine; this favourable effect was maintained up to the 33rd gestational week when a new rise in urea and creatinine was observed, together with signs of cholestasis. After induction, at 33 weeks + 6 days, she delivered a healthy female baby, adequate for gestational age (39th centile). Urea levels decreased after delivery, but increased again when the mother resumed her usual mixed-protein diet. At the child’s most recent follow-up visit (age 4 months), development was normal, with normal weight and height (50th–75th centile). In summary, the present case confirms that a moderate protein-restricted diet can be prescribed in pregnancies in advanced CKD without negatively influencing foetal growth, supporting the importance of choosing a plant-based protein source, and suggests focusing on the diet’s effects on microcirculation to explain these favourable results.

Quality or Quantity of Proteins in the Diet for CKD Patients: Does “Junk Food” Make a Difference? Lessons from a High-Risk Pregnancy

“…This patient was also managed in pregnancy by changing her eating behaviour, without changing protein intake, switching from a moderately protein-restricted diet in which at least half of the calories derived from junk food to a plant-based diet, rich in fresh food and vegetables. These 2 cases, coming from differently resourced settings, were both characterized by a rapid decrease in urea level, together with a favourable trend, mainly involving creatinine in the Italian patient and phosphate in the Mexican one [11].…”

Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication

“…Pregnancy in CKD is a condition in which the advantages of the diet for the mother have to be carefully balanced with the theoretical risk for intrauterine growth restriction [ 78 , 79 , 80 , 81 ].…”

Of Mice and Men: The Effect of Maternal Protein Restriction on Offspring’s Kidney Health. Are Studies on Rodents Applicable to Chronic Kidney Disease Patients? A Narrative Review

“…A vegan/vegetarian diet with a 20-25% protein restriction supplemented with keto-analogues in pregnant CKD patients is safe for the mother and the offspring and may help control renal disease without consequences for the newborn [21][22][23][24][25][26].…”

“…The evidence from studies of patients following well-planned plant-based diets in pregnancy is reassuring, but the only clearly proven advantage is a reduction in the risk of large for gestational age babies and, possibly, of gestational diabetes [ 18 , 19 , 20 ]. It is, however, conceivable that other advantages, if they exist, would only be seen in a high-risk situation, like the one that characterizes CKD from its early stages [ 21 , 22 , 23 , 24 , 25 , 26 ].…”