Experts Consensus
kidney_disease_2Chronic Kidney Disease (CKD) is a public health problem and World wide there is a rising incidence and prevalence of kidney failure. Increasing evidence indicates that the adverse outcomes of CKD, such as End-Stage Renal Disease (ESRD), cardiovascular disease and premature death, can be prevented or delayed when the disease is detected in time. Unfortunately, CKD is often "under-diagnosed" and "under-treated", resulting in lost opportunities for prevention. Therapeutic interventions at earlier stages are effective in slowing down the progression of CKD. The major therapeutic strategies that have been tested include strict blood glucose control in diabetes, strict blood pressure control, Angiotensin-Converting Enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARB) as well as dietary protein restriction.

diabetessymptomsThe nutritional support for patients with CKD changes in phases depending on different stages of kidney disease. Especially the protein content of such a diet needs to be regularly changed over time in response to the stages of CKD:

It has been known for over 100 years that dietary protein restriction is an important part of the management of chronic kidney disease patients. Protein-restricted diets have been proposed to patients with chronic kidney disease because the reduction in alimentary protein intake improves many of the uremic symptoms and associated metabolic complications. A principle goal of well-planned, protein-restricted dietary regimen in compliant patients is to decrease the accumulation of nitrogen waste products, hydrogen ions, phosphates and inorganic ions while maintaining an adequate nutritional state.

Protein-restricted diets are associated with their beneficial effects on the progressive loss of renal function accompanied with delaying the start of renal replacement therapy with obvious medical and economic consequences.

Both, hyperfiltration of residual nephrons due to dietary protein loads and severe proteinuria are main causes for the progression of chronic kidney disease that can be limited by protein-restricted diets supplemented with amino and keto acids.Two dietary regimens have been used to treat patients with progressive CKD:
A conventional LPD providing about 0.6 g protein/kg body weight/day.
A VLPD with half the protein content of the conventional low protein diets. Since this level of dietary protein does not provide the daily requirements for essential amino acids – a supplementation of amino acids, respectively their keto acids is necessary. Because the dietary proteins are supplemented their biological value is less important than within the LPDs – and more vegetable proteins can be allowed.

Usually it was assumed that keto acids are mainly beneficial when a VLPD is prescribed. Interestingly, several studies – especially from Prague – suggest that the beneficial effects can also be seen when a LPD is instituted.

A crucial aspect in both kinds of dietary treatment is the adequate intake of energy. The energy requirement is approximately 30 - 35 kcal/kg body weight/day. Due to the fact that nitrogen balance is more positive as energy intake is increased and nitrogen utilization improves – a sufficient energy intake while consuming limited amounts of dietary protein is mandatory.

Common understanding of protein nutrition treatment for chronic kidney disease:
PDF 1. Importance of nutrition treatment in chronic kidney disease
PDF 2. Implementing scheme of nutrition treatment
Patient with chronic kidney disease ( not diabetic nephropathy) before dialysis
Patients with diabetic nephropathy before dialysis
The patients with hemodialysis and peritoneal dialysis
Monitoring diet treatment compliance
Assessment of patient's nutrition state
Appendix 1: Definition and stages of chronic kidney disease (CKD)
Appendix 2: The assessment of glomerular filtration rate (GFR)
Appendix 3: Protein Equivalent of Nitrogen Appearance Rate (PNA) and protein catabolism rate ( PCR )
Appendix 4: Nutrition assessment with SGA (Subjective Global Assessment)
PDF 3. Dialysis Adequacy