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Dietary Changes to Slow Chronic Kidney Disease Progression

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Presentation on theme: "Dietary Changes to Slow Chronic Kidney Disease Progression"— Presentation transcript:

1 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

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 APOL1 gene mutations in AA pts, their nephrosclerosis may not be d/t HTN

6 Stages of CKD eGFR # of Americans Mortality Risk Stage 1 ≥ 90
7.7 million ~2x Stage 2 7.3 million Stage 3 10 million 25% over 5 years Stage 4 400,000 50% over 5 years Stage 5 < 15 600,000 20% per year 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 NH4+ Excreted Urine NH3 H+ NH4+ Excreted Urine NH3 H+

13 ↑ [NH3] Kidney Tubular Cell H+ot Dog Kidney injury CKD Progression
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 Consider talking about causes of acidosis in CKD

16 Sodium bicarbonate may slow progression in moderate CKD
Control Dialysis free survival Stage 4/5 CKD Serum bicarbonate 16 – 20 Time (months) De Brito-Ashurst et al J Am Soc Neph 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 Low Protein (0.58 gm/kg/day)
*Modification of Diet in Renal Disease GFR ml/min Low Protein (0.58 gm/kg/day) Change in GFR Achieved: 1.11 vs 0.73 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
Supplemented with ketoacid-amino acid combination Achieved 0.69 v 0.46 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 Other Mechanisms?? Fructose 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) Avg American consumes 64 pounds of fructose/yr In 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 rats Normal rats No change in uric acid Nakayama et al. AJP Renal Phys Gersch et al AJP Renal Phys 2007.

36 Gersch et al AJP Renal Phys 2007.

37 Number of sugary soft drinks per day
Non-DM adults NHANES 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 Western Diet DASH Diet Red meat, processed Poultry, fish Refined grains Whole grains High-fat dairy Low-fat dairy Saturated, trans-fats Unsaturated fats High cholesterol Fresh fruit Sugary desserts/drinks Vegetables

44 ‘Westerner’ Diet & CKD progression
Q1 Q2 Q3 Q4 Reference Odds Ratio Nurses Health Study, 30% reduction of GFR Lin et al AJKD 2011.

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

46 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.

47 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 Sneak in 1-2 phosphorus slides

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