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 patientsBone protectionReduce protein catabolismConsider talking about causes of acidosis in CKD
16 Sodium bicarbonate may slow progression in moderate CKD ControlDialysis free survivalStage 4/5 CKDSerum bicarbonate 16 – 20Time (months)De Brito-Ashurst et al J Am Soc Neph 2009.
17 Sodium bicarbonate may slow progression in early CKD Stage 2 hypertensive CKD patientsAlbuminuriaNormal serum bicarbonateMahajan et al Kidney International 2010
18 Summary of Sodium Bicarbonate Sodium bicarbonate reduces acid load to the kidneyReduces renal ammonia productionReduces complement-mediated kidney injuryCan we reduce dietary acid load?Reduce protein intakeIncrease fruits and vegetables
19 Low protein diet in CKD Improves: Phosphorus BP H+ Proteinuria Insulin sensitivityDisadvantages:Protein-energy malnutritionDecreased muscleComplexInconvenient
20 MDRD* Study – Study A Low Protein (0.58 gm/kg/day) *Modification of Diet in Renal DiseaseGFR ml/minLow Protein (0.58 gm/kg/day)Change in GFRAchieved: 1.11 vs 0.73Usual Protein (1.3 gm/kg/day)Klahr et al. NEJM 1994
21 ESRDp=NS for bothESRD or DeathLevey et al AJKD 2006.
22 MDRD Study – Study B GFR 13-24 ml/min Low Protein (0.58 gm/kg/day Supplemented with ketoacid-amino acid combinationAchieved 0.69 v 0.46Very Low Protein (0.28 gm/kg/dayKlahr et al. NEJM 1994
24 Low protein diet - Summary Theoretically beneficialClinical trials inconclusiveUnlikely to be replicatedPersonal recommendationSubstitute red meat with poultry, fish, plant protein
25 Fruits & Vegetables – Interventional Study Key entry criteriaStage 4 CKD (GFR 15 – 29)Metabolic acidosis (Bicarb < 22)InterventionSodium bicarbonate (1meq/kg/day) orFruits and vegetables (reduce acid load by ½)Goraya et al Kidney Int 2013.
26 F/V Strategy Apples Apricots Oranges Peaches Pears Raisins StrawberriesCarrotsCauliflowerEggplantLettucePotatoesSpinachTomatoesZucchiniEnough given for all household membersProvided free from local food bankGoraya et al Kidney Int 2013.
34 Fructose Primary sources in Western diet High fructose corn syrupTable sugar (sucrose)Avg American consumes 64 pounds of fructose/yrIn large quantities, systemic levels high enough to be filtered by kidney
35 Nakayama et al. AJP Renal Phys 2010. Gersch et al AJP Renal Phys 2007. CKD ratsNormal ratsNo change in uric acidNakayama et al. AJP Renal Phys Gersch et al AJP Renal Phys 2007.
44 ‘Westerner’ Diet & CKD progression Q1Q2Q3Q4ReferenceOdds RatioNurses Health Study, 30% reduction of GFRLin et al AJKD 2011.
45 ‘DASHier’ Diet & CKD progression Q1Q2Q3Q4ReferenceOdds RatioNurses Health StudyLin et al AJKD 2011.
46 Conclusion High H+ & fructose cause kidney injury in CKD Average American diet high in bothIt is sensible to increase fruits & vegetables, reduce animal protein, and eliminate sugary foods/drinks.
47 Summary - Dietary Recommendations for CKD Stop soda, fruit drinksRare dessertsFresh fruit and vegetables (monitor K+)Fish, chicken breastPlant based protein, nutsLess red meat, processed/canned foodsLow fat milk (monitor phosphorus)Low saltSneak in 1-2 phosphorus slides