EDITORIAL

Nutritional Intervention in Chronic

Kidney Disease

IETARY PROTEIN RESTRICTION has

been prescribed in chronic kidney disease
(CKD) for a century, and a low-protein diet
(LPD) or supplemented very low-protein diet
with ketoanalogs of amino acids (SVLPD) has
been prescribed for four decades. It was argued
that such a regimen may be associated with a deterioration of nutritional status. Such intervention is uncommon now in the United States
and in most European countries, in which a standard diet with 0.8 g/kg/day of protein is commonly used. At the same time, most patients
present signs of protein-energy malnutrition at
the start of renal replacement therapy (RRT),
even if they have consulted a nephrologist in
the preceding months or years. The Comprehensive Dialysis Study, which is part the United States
Renal Data System (USRDS) 2008 data report,
involved a special collection of data on the nutrition, activity, and quality of life of patients who
initiated RRT between 2005 and 2007. The first
results showed that at the start of RRT, 60%
of patients exhibited a serum albumin level lower than 35 g/L, and in 80% of these patients,
the alimentary intake was below the actual
recommendations.1
In contrast, during the last several decades,
no study demonstrated that LPD or SVLPD
was associated with malnutrition. The first and
second analyses of the Modification of Diet in
Renal Diseases (MDRD)-Study concluded that
such a regimen is safe in uncomplicated and
carefully monitored cases. Short-term follow-up

P. C. received a consultancy fee.

This article was published as part of a supplement sponsored by an
unrestricted educational grant from Fresenius Kabi.
2009 by the National Kidney Foundation, Inc. All rights
reserved.
1051-2276/09/1905S-0001$36.00/0
doi:10.1053/j.jrn.2009.06.018

Journal of Renal Nutrition, Vol 19, No 5S (September), 2009: pp S1S2

of SVLPD patients showed no adverse nutritional effects after patients started dialysis, or
during and after transplantation. One could object that these patients were carefully selected
and monitored. This last point is important, because a nutritional survey should be the main
feature of an adequate, long-term follow-up
of CKD patients before RRT. The implementation of nutritional guidelines is associated
with better results.2 A review of the literature
regarding protein intake and CKD confirmed
that nutritional therapy is effective to reduce
comorbidities associated with CKD: nutrition,
phosphate intake, proteinuria, and cardiovascular risk factors.
All the reports from this symposium demonstrate that nutritional intervention in CKD patients is not an outmoded therapy based on
antiquated clinical studies, and that a supplemented, protein-restricted diet has its place in
a therapeutic approach. The long-term followup of patients in previous studies confirmed
the safety and nutritional adequacy of these diets, and recent clinical studies of nondiabetic
and diabetic patients led to the same conclusions. The experimental and clinical studies reported in this issue of the Journal illustrate all
the mechanisms (and new directions) involved
in the beneficial effects of LPDs supplemented
with keto acids/amino acids: the effects on proteinuria and endothelial dysfunction, specific
effects of branched-chain amino acids, effects
of keto acids/amino acids on asymmetric dimethylarginine and body fat mass, and effects on
glomerular structure and renal fibrosis. Clinical
studies confirm previous studies and metaanalyses: SVLPDs delay the time to RRT, and
could be of economic importance. Clinical
studies also confirm the positive effects suggested by experimental data in terms of obese
transplanted patients, diabetic patients, and the
preservation of renal function in peritoneal
dialysis patients. To help nephrologists and
S1

S2

EDITORIAL

dietitians, the expert panel proposes a consensus

statement on keto acid therapy in diabetic or
nondiabetic predialysis patients and in nephrotic
syndrome.
In conclusion, nutritional interventions and
specifically supplemented very low protein diets
have many proven advantages in terms of the
progression of renal failure, better metabolic and
endocrine control, and decreased proteinuria.
Patients are in need of a detailed nutritional
survey by dietitians and nephrologists. This should
be the case for all CKD patients, but especially for
SVLPD patients, to avoid malnutrition. Toward
this goal, all the data reported in this issue by
international experts on this topic will help.

and will offer some new directions for future

research.
Philippe Chauveau, MD
Nephrology Department, Hopital Pellegrin and
Aurad-Aquitaine, Bordeaux, France

References
1. Kutner NG, Johansen KL, Kaysen GA, et al: The Comprehensive Dialysis Study (CDS): a USRDS special study. Clin J Am
Soc Nephrol 4:645650, 2009.
2. Campbell KL, Ash S, Zabel R, McFarlane C, Juffs P,
Bauer JD: Implementation of standardized nutrition guidelines
by renal dietitians is associated with improved nutrition status.
J Ren Nutr 19:136144, 2009.