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Dietary Changes to Slow Chronic Kidney Disease Progression

Dietary Changes to Slow Chronic Kidney Disease Progression. Kalani Raphael, MD MS Division of Nephrology & Hypertension University of Utah Salt Lake City VA Health Care System. I have no financial relationships to disclose. Objectives. Overview of chronic kidney disease (CKD)

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Dietary Changes to Slow Chronic Kidney Disease Progression

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  1. Dietary Changes to Slow Chronic Kidney Disease Progression Kalani Raphael, MD MSDivision of Nephrology & Hypertension University of Utah Salt Lake City VA Health Care System

  2. I have no financial relationships to disclose

  3. Objectives • Overview of chronic kidney disease (CKD) • Promising dietary intervention targets • Dietary acid • Fructose • Dietary recommendations for CKD patients

  4. CKD Diagnosis • Glomerular filtration rate (GFR) < 60 ml/min OR • Evidence of kidney injury when GFR ≥ 60 ml/min • Examples of kidney injury: • Albuminuria ≥ 30 mg/gm • Polycystic kidney disease • Glomerular hematuria (IgA nephropathy)

  5. Causes of CKD Hypertension Diabetes Cystic kidney disease Glomerulonephritis Interstitial nephritis Reflux Obstruction

  6. Stages of CKD Levey et al. Kidney Int, 2011.

  7. CKD - A Significant Burden • 25 million Americans have CKD • 12% of US population • Advancing CKD ☞ poor outcomes • ESRD accounts for 6% of Medicare budget • Kidney transplantation – scarce resource

  8. Strategies to slow CKD progression • ACE-I or ARB • Blood pressure control < 140/90 < 130/80 • Glucose control

  9. Diet? Exercise? Vitamins?

  10. Reduce Dietary Acid intake

  11. Acid • A major function of kidney is to regulate H+ • Avg renal acid burden = 1 meq H+ per kg/day • Sources of acid • Diet • Protein: Red meat > fish > plant • Endogenous production • Ketoacids, lactic acid

  12. H+ot Dogs Urine Urine H+ H+ NH3 NH3 H+ H+ NH4+ NH4+ NH3 NH3 H+ H+ NH4+ NH4+ NH3 NH3 NH4+ NH4+ H+ H+ NH3 NH3 NH4+ NH4+ NH3 NH3 NH4+ NH4+ H+ H+ Excreted Excreted

  13. Kidney Tubular Cell H+ot Dog ↑ [NH3] Complement Activation Endothelin-1 Kidney injury CKD Progression

  14. Does reducing renal acid burden slow CKD progression?

  15. Sodium Bicarbonate • Alkaline agent • Neutralizes non-volatile acid • Typically prescribed when serum bicarbonate < 22 mmol/L in CKD patients • Bone protection • Reduce protein catabolism

  16. Sodium bicarbonate may slow progression in moderate CKD Sodium bicarbonate Control Dialysis free survival Stage 4/5 CKD Serum bicarbonate 16 – 20 Time (months) De Brito-Ashurst et al J Am SocNeph 2009.

  17. Sodium bicarbonate may slow progression in early CKD Stage 2 hypertensive CKD patients Albuminuria Normal serum bicarbonate Mahajan et al Kidney International 2010

  18. Summary of Sodium Bicarbonate • Sodium bicarbonate reduces acid load to the kidney • Reduces renal ammonia production • Reduces complement-mediated kidney injury • Can we reduce dietary acid load? • Reduce protein intake • Increase fruits and vegetables

  19. Low protein diet in CKD Improves: • Phosphorus • BP • H+ • Proteinuria • Insulin sensitivity Disadvantages: • Protein-energy malnutrition • Decreased muscle • Complex • Inconvenient

  20. MDRD* Study – Study A *Modification of Diet in Renal Disease GFR 25-55 ml/min Low Protein (0.58 gm/kg/day) Change in GFR Usual Protein (1.3 gm/kg/day) Klahr et al. NEJM 1994

  21. ESRD p=NS for both ESRD or Death Levey et al AJKD 2006.

  22. MDRD Study – Study B GFR 13-24 ml/min Low Protein (0.58 gm/kg/day Very Low Protein (0.28 gm/kg/day Klahr et al. NEJM 1994

  23. ESRD Death Menon et al AJKD 2009.

  24. Low protein diet - Summary • Theoretically beneficial • Clinical trials inconclusive • Unlikely to be replicated • Personal recommendation • Substitute red meat with poultry, fish, plant protein

  25. Fruits & Vegetables – Interventional Study Key entry criteria • Stage 4 CKD (GFR 15 – 29) • Metabolic acidosis (Bicarb < 22) Intervention • Sodium bicarbonate (1meq/kg/day) or • Fruits and vegetables (reduce acid load by ½) Goraya et al Kidney Int 2013.

  26. F/V Strategy • Apples • Apricots • Oranges • Peaches • Pears • Raisins • Strawberries • Carrots • Cauliflower • Eggplant • Lettuce • Potatoes • Spinach • Tomatoes • Zucchini Enough given for all household members Provided free from local food bank Goraya et al Kidney Int 2013.

  27. Due to ↓NH4+ Goraya et al Kidney Int 2013.

  28. Other findings Bicarbonate and fruits/vegetables reduce urinary: • Albumin No hyperkalemia observed in F/V group • Pts had K < 4.7 at baseline Goraya et al Kidney Int 2013.

  29. Augmenting diet with fruits & vegetables • Reduces acid burden • Reduces renal ammonia production • Normalizes serum bicarbonate • Ameliorates kidney injury

  30. Practical Recommendation F/V • Increase fruits/veg in the diet • Caution if K is > 5.0 • Reduce K with diuretics

  31. Reduce fructose intake

  32. Fructose Uric Acid HTN CKD Fructose

  33. Fructose Other Mechanisms?? Uric Acid Inflammation Oxidative stress Reduced NO Kidney Injury CKD Progression

  34. Fructose • Primary sources in Western diet • High fructose corn syrup • Table sugar (sucrose) • AvgAmerican consumes 64 pounds of fructose/yr • In large quantities, systemic levels high enough to be filtered by kidney

  35. CKD rats Normal rats Nakayama et al. AJP Renal Phys 2010. Gersch et al AJP Renal Phys 2007.

  36. Gersch et al AJP Renal Phys 2007.

  37. p<0.001 Number of sugary soft drinks per day Shohan et al PLOS One 2008.

  38. Shohan et al PLOS One 2008.

  39. Low fructose diet – interventional study • 28 non-DM CKD stage 2 or 3 • Basal fructose intake (~60 gm/day) • 6 wk low fructose (~12 gm/day) • Designed to reduce by 80% • Return to basal diet for 6 wks (~53 gm/day) • No diff in caloric intake • Reduce consumption of sucrose-sweetened and artificially sweetened drinks & foods

  40. Brymora et al Nephrol Dial Trans 2012.

  41. Summary - Fructose Low fructose diet… • Improves uric acid, BP • May reduce renal inflammation • No long-term interventional studies • It’s not good for you.

  42. Dietary recommendations for ckd patients

  43. ‘Westerner’ Diet & CKD progression Q2 Q4 Q1 Q3 Reference Odds Ratio Lin et al AJKD 2011.

  44. ‘DASHier’ Diet & CKD progression Q2 Q4 Q1 Q3 Reference Odds Ratio Lin et al AJKD 2011.

  45. Conclusion • High H+ & fructose cause kidney injury in CKD • Average American diet high in both • It is sensible to increase fruits & vegetables, reduce animal protein, and eliminate sugary foods/drinks.

  46. Summary - Dietary Recommendations for CKD • Stop soda, fruit drinks • Rare desserts • Fresh fruit and vegetables (monitor K+) • Fish, chicken breast • Plant based protein, nuts • Less red meat, processed/canned foods • Low fat milk (monitor phosphorus) • Low salt

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