Dietary Approaches in the Management of Diabetic Patients with Kidney Disease

Abstract

Chronic kidney disease (CKD) is one of the most prevalent complications of diabetes, and patients with diabetic kidney disease (DKD) have a substantially higher risk of cardiovascular disease and death compared to their non-diabetic CKD counterparts. In addition to pharmacologic management strategies, nutritional and dietary interventions in DKD are an essential aspect of management with the potential for ameliorating kidney function decline and preventing the development of other end-organ complications. Among DKD patients with non-dialysis dependent CKD, expert panels recommend lower dietary protein intake of 0.8 g/kg of body weight/day, while higher dietary protein intake (>1.2 g/kg of body weight/day) is advised among diabetic end-stage renal disease patients receiving maintenance dialysis to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Carbohydrates from sugars should be limited to less than 10% of energy intake, and it is also suggested that higher polyunsaturated and monounsaturated fat consumption in lieu of saturated fatty acids, trans-fat, and cholesterol are associated with more favorable outcomes. While guidelines recommend dietary sodium restriction to less than 1.5–2.3 g/day, excessively low sodium intake may be associated with hyponatremia as well as impaired glucose metabolism and insulin sensitivity. As patients with advanced DKD progressing to end-stage renal disease may be prone to the “burnt-out diabetes” phenomenon (i.e., spontaneous resolution of hypoglycemia and frequent hypoglycemic episodes), further studies in this population are particularly needed to determine the safety and efficacy of dietary restrictions in this population.

Effect of low‐protein intake on all‐cause mortality in subjects with an estimated glomerular filtration rate higher than 60 mL/min/1.73 m2with or without albuminuria

“…However, compared with our study participants who had a protein intake ≥0.8 g/kg/day, the risks of mortality (HR) for those who had a protein intake of 0.6 to <0.8, 0.3 to <0.6 and <0.3 g/kg/day were 1.128 (95% CI 0.922‐1.380), 1.359 (95% CI 1.113‐1.660) and 1.606 (95% CI 1.041‐2.476), respectively (data not shown in the Section 3). Moreover, low‐protein intake in patients with advanced CKD may lead to adverse consequences, such as protein‐energy wasting 12‐14,34 . Based on previous studies and our findings, we suggest that protein restriction in susceptible populations, such as patients with advanced CKD, be applied with caution, ie, it is vital to carefully consider the individual’s nutritional needs.…”

“…Treatment guidelines recommend restriction of protein intake to 0.8 g/kg/day for patients with CKD 9‐14 . Although there has been some evidence in patients with CKD showing that progressive decline in renal function could be slowed with a low‐protein intake, 15‐19 its effect on mortality is not yet clear.…”

“…Diabetes was defined as: (a) diagnosed of diabetes by a medical professional, (b) a prescription for glucose‐lowering drugs or (c) a fasting plasma glucose ≥126 mg/dL or a glycated haemoglobin (HbA1c) ≥6.5%. Low‐protein intake was defined as a protein intake of less than 0.8 g/kg/day 12‐14 . High‐carbohydrate diet was defined as ≥55% of daily calories from carbohydrate 25 .…”

“…In addition to pharmacologic treatment for controlling risk factors, 9,10 guidelines recommend nutritional management for patients with CKD 11,12 to improve outcomes. Protein intake restriction to less than 0.8 g/kg/day for patients with CKD 12‐14 has been suggested in light of the evidence that a low‐protein intake was associated with preservation of renal function 15‐19 . In the Modification of Diet in Renal Disease study 15 conducted in patients with non‐diabetic CKD, assignment to a low‐protein diet appeared to slow the decline in renal function 15,16 .…”

Why the Nutritional Management of Acute Versus Chronic Kidney Disease Should Differ

“…Hence, there are two important but opposing scenarios vis-a-vis the quantity of the dietary protein intake and kidney function: (1) Higher protein intake can increase intraglomerular pressure, which is useful in the short term when we eat a large protein meal with high-protein content, so that we can ensure effective clearance of nitrogenous end products that are produced from eating too much protein, but in the long term, the resultant glomerular hyperfiltration may cause wear and tear and more loss of nephrons in the kidneys. 1,2 (2) Less protein intake, on the other hand, leads to lower amounts of circulating amino acids, tighter afferent arterioles, lower intraglomerular pressure, and decreased GFR in the short term, which may help protect kidney glomeruli and confer kidney health longevity in the long term. 3 As to what types of proteins (animal-versus plant-based) can accentuate or mitigate these effects, there are limited and inconsistent data.…”