Effects of a Supplemented Very Low Protein Diet in Predialysis Patients on the Serum Albumin Level, Proteinuria, and Subsequent Survival on Dialysis

Abstract

A very low protein diet (0.3 g/kg ideal body weight) supplemented with essential amino acids (or ketoanalogues) is seldom employed at present in chronic renal failure for fear of inducing protein deficiency, especially in patients who also have the nephrotic syndrome. Nevertheless, we have used this dietary regimen in predialysis patients for a number of years. We have shown that when these patients reach the end stage, they rarely exhibit hypoalbuminemia, in contrast to the reported 25–50% hypoalbuminemia at the onset of dialysis nationwide. Furthermore, their survival for the first 2 years on dialysis is much improved, in comparison with the national experience, adjusted for age, sex, and cause of renal disease. When nephrotic patients are given this regimen, they exhibit some improvement in parameters of the nephrotic state, but nevertheless progress to dialysis, provided their initial glomerular filtration rate (GFR) is <30 ml/min. However, if their initial GFR is >30 ml/min, they may show gradual but complete remission of the nephrotic syndrome, even when the underlying disease is diabetic nephropathy or focal segmental glomerulosclerosis. We conclude that this dietary regimen is not only safe in patients with renal failure, with or without the nephrotic syndrome, but may be of substantial benefit. The mechanism remains to be explained.

The role of keto acids in the supportive treatment of children with chronic renal failure

“…It was reported that the administration of a keto acidfortified protein-restricted diet for 2-3 years in the predialysis period prevented the development of hypoalbuminemia [18].…”

Current Uses of Dietary Therapy for Patients with Far-Advanced CKD

“…However, substantial data indicate that LPDs and SVLPDs, when properly prescribed, do not engender protein-energy wasting (7,10). These findings raise the possibility that properly prescribed dietary therapy in patients approaching ESRD might reduce their mortality risk after they commence chronic dialysis treatment, a thesis that would seem to be well worth testing (45,46).…”

“…Protein restriction at higher levels of GFR may also ameliorate more subtle uremic symptoms. Current data suggest that patients need a minimum GFR level-possibly a urea clearance $2-3 ml/min per 1.73 m 2 -to do well with dietary therapy (46). Patients being considered for dietary therapy probably should not suffer from severe acute or chronic catabolic illness, should be able to understand the dietary therapy, should Table 3.…”

Opponent’s comments

“…Quite the contrary, as we have indicated, without dietary therapy, the risk of advanced CKD patients developing PEW is quite high [7,8,13,35]. On the other hand, advanced CKD patients who do not have superimposed catabolic illnesses and who adhere to well-designed LPDs or SVLPDs are at low risk for developing severe PEW, and most appear to develop little or no PEW [2,9,36]. Although there are no randomized prospective controlled studies of the effect of dietary therapy in advanced CKD patients on survival.…”

“…Although there are no randomized prospective controlled studies of the effect of dietary therapy in advanced CKD patients on survival. Several post-facto observational studies suggest that the association between mortality rate after commencing chronic dialysis treatments and prescription of SVLPDs to CKD patients is not increased mortality and may be reduced [36,37].…”