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Recommendations Summary

CKD: Protein Intake 2010

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CKD: Protein Intake for eGFR <50ml per minute per 1.73m2

    For adults with chronic kidney disease (CKD) without diabetes,  not on dialysis,  with an eGFR below 50ml per minute per 1.73m2,  the registered dietitian (RD) should recommend or prescribe a protein-controlled diet providing 0.6g-0.8g dietary protein per kg of body weight per day. Clinical judgment should be used when recommending lower protein intakes, considering the client's level of motivation, willingness to participate in frequent follow-up and risk for protein-energy malnutrition. Research reports that protein-restricted diets (0.7g dietary protein per kg of body weight per day, ensuring adequate caloric intake) can slow GFR decline and maintain stable nutrition status in adult non-diabetic patients with CKD.

    Rating: Strong
    Conditional

    CKD: Very-Low-Protein Intake for eGFR <20ml per minute per 1.73m2

    In international settings where keto acid analogs are available, a very-low protein-controlled diet may be considered. For adults with CKD without diabetes,  not on dialysis,  with an eGFR below 20ml per minute per 1.73m2,  a very-low protein-controlled diet providing 0.3g to 0.5g dietary protein per kg of body weight per day with addition of keto acid analogs to meet protein requirements may be recommended. International studies report that additional keto acid analogs and vitamin or mineral supplementation are needed to maintain adequate nutrition status for patients with CKD who consume a very-low-protein controlled diet (0.3g to 0.5g per kg per day).

    Rating: Strong
    Conditional

    CKD: Protein Intake for Diabetic Nephropathy

    For adults with diabetic nephropathy,  the RD should recommend or prescribe a protein-controlled diet providing 0.8g to 0.9g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7g per kg of body weight per day may result in hypoalbuminemia. Research reports that protein-restricted diets improved microalbuminuria.

    Rating: Fair
    Conditional

    CKD: Protein Intake for Kidney Transplant

    For adult kidney transplant recipients (after surgical recovery, with an adequately functioning allograft), the RD should recommend 0.8g to 1.0g per kg of body weight per day for protein intake, addressing specific issues as needed. Adequate, but not excessive, protein intake supports allograft survival and minimizes impact on comorbid conditions.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • For all recommendations, nutrition status must be maintained, including adequate caloric intake and maintenance of lean body mass. See recommendation on Energy Intake.
      • Lower protein and energy intakes can lead to hypoalbuminemia, malnutrition, loss of lean body mass and unintentional weight loss
      • The effect of nephrotic syndrome on degree of proteinuria should be considered when evaluating hypoalbuminemia
      • The effect of diminished appetite secondary to uremia may impact overall intake
      • For CKD patients with hypophosphatemia or hyperphosphatemia, the RD should be aware that protein-controlled diets are typically lower in phosphorus content and therefore protein intake may affect phosphorus management
      • The impact of animal and vegetable protein on renal function should be considered; e.g. consumption of red meat has been shown to increase albuminuria
      • Since fluid retention affects interpretation of weight, the RD should be aware that protein calculations based on weight may need adjustment.

       

    • Conditions of Application

      • For all recommendations, the motivation and willingness of the client to adhere to complicated nutrition regimes and participate in routine follow-up should be considered  
      • For the CKD: Protein Intake (Non-dialysis) for eGFR <50ml per minute per 1.73m2 recommendation, this recommendation applies to adults with CKD without diabetes,  not on dialysis,  with an eGFR below 50ml per minute per 1.73m2
      • For the CKD: Very-Low-Protein Intake (Non-dialysis) for eGFR <20ml per minute per 1.73m2 recommendation, this recommendation applies to adults with CKD without diabetes,  not on dialysis,  with an eGFR below 20ml per minute per 1.73m2
      • For the CKD: Protein Intake for Diabetic Nephropathy recommendation, this recommendation applies to adults with CKD with diabetic nephropathy and assumes glycemic control
      • For the CKD: Protein Intake for Kidney Transplant recommendation, this recommendation applies to adult kidney transplant recipients after surgical recovery, with an adequately functioning graft
      • Current state laws and regulations which define the RD's scope of practice should be checked regarding interpretation of terms such as "write an order, " "order changes, " "initiate, " "recommend, " "prescribe, " etc. Nutrition prescription privileges may be granted to an RD by the governing body of the hospital or other practice settings. The governing body of the hospital or other practice settings via the medical staff bylaws may also designate an RD to receive and implement MD- OR DO-delegated orders or administer disease-specific or condition-specific patient care protocols, as approved and adopted by the facility or institution.
      • For more information, members of the American Dietetic Association can access www.eatright.org/quality.  Under "Quality Management, " topics include Practice Resources, Regulatory, State Resources, Licensure and Accreditation Organization.

    • Potential Costs Associated with Application

      Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      For the CKD: Protein Intake (Non-dialysis) for eGFR <50ml per minute per 1.73m2 and CKD: Very-Low-Protein Intake (Non-dialysis) for eGFR <20ml per minute per 1.73m2 recommendations:

      • Meta-analysis results of nine RCTs published before 1999 suggest that non-diabetic CKD patients who were on dietary protein restriction diets had significantly reduced risk of renal failure (all-cause death or start of dialysis) and significantly reduced rate of GFR decline, compared to those on usual protein diets (Kopple et al, 1989; Walser et al, 1993; Ikizler et al, 1995; Levey et al, 1996; Kasiske et al,  1998; Teschan et al, 1998; Fouque et al, 2000)
      • RCTs (Bernhard et al, 2001; Meloni et al, 2004; Feiten et al, 2005; Mircescu et al, 2007) and other uncontrolled trials (Chauveau et al, 1999; Zakar et al, 2001; Kaizu et al, 2002; Chauveau et al, 2003; Ideura et al, 2007) published after the meta-analysis report consistent findings. These RCTs show that protein-restricted diets,  inclusive of low and very-low protein diets, ranging from 0.3g to 0.7g per kg of body weight per day with total energy intake of 23kcal to 35kcal per kg body weight can slow GFR decline and maintain stable nutrition status in adult non-diabetic patients with chronic kidney disease (CKD).
      • International studies reported additional keto acid analogs and vitamin or mineral supplementation are needed to maintain adequate nutrition status for patients with CKD who consume a very-low protein diet (0.3g to 0.5g per kg body weight per day) (Teplan et al, 2001).
      • Limited evidence suggests that adding keto acid supplements is better than amino acid supplements to slow GFR decline among non-diabetic CKD patients who received a very low-protein diet (0.3g per kg  body weight per day). 

       For the CKD: Protein Intake for Diabetic Nephropathy recommendation:

      • Meta-analysis results of four RCTs and two non-RCTs published before 1996 suggest that patients with diabetic nephropathy who were on dietary protein restriction diets had significantly reduced rates of GFR decline compared to those on usual protein diets (Pedrini et al, 1996; Kasiske et al, 1998). However, seven later RCTs involving about four times more patients than the meta-analysis show conflicting findings. Specifically, more recent RCTs (published after 1999) show that a low-protein diet (0.6g to 0.89g per kg per day) without ketoacid supplementation for up to two years did not significantly alter GFR decline when compared to subjects' usual protein diet (1.0g to 1.4g per kg per day), regardless of the stage of CKD or type of diabetes among patients with diabetic nephropathy (Hansen et al, 1999; Meloni et al, 2002; Pijls et al, 2002; Meloni et al, 2004; Dussol et al, 2005). The reported effects on proteinuria or microalbuminuria were inconsistent across studies. Nutrition status can be maintained with either a low protein or a usual protein diet.
      • Data on the effects of protein-restriction diets on clinical outcomes of renal function are limited. One positive RCT shows that the relative risk of progression to Stage Five CKD or overall mortality was significantly reduced [0.23 (95% CI,  0.07, 0.72),  P=0.01] for type 1 diabetes patients assigned to a low-protein diet (0.89g per kg per day), compared to those assigned to a free-protein diet (Hansen et al, 2002).
      • Results from one RCT suggests that ketoacid supplementation may be needed to preserve renal function among patients who are on a very-low protein diet (0.3g per kg per day) (Prakash et al, 2004).

      For the CKD: Protein Intake for Kidney Transplant recommendation:

      • Results from one study of kidney transplant patients with declined graft function (GFR less than 60ml per minute per 1.73m2) suggest that a low-protein diet (0.55g per kg per day) can reduce proteinuria compared to a high-protein diet (2.0g per kg per day) (Salahudeen et al, 1992)
      • Due to limited research in kidney transplant patients, the Expert Work Group believed that a Consensus recommendation for normal protein allowances was appropriate.

    • Recommendation Strength Rationale

      • For the CKD: Protein Intake (Non-dialysis) for eGFR <50ml per minute per 1.73m2 recommendation, the conclusion statement received Grade I
      • For the CKD: Very-Low-Protein Intake (Non-dialysis) for eGFR <20ml per minute per 1.73m2 recommendation, the conclusion statement received Grade I
      • For the CKD: Protein Intake for Diabetic Nephropathy recommendation, the conclusion statement received Grade II
      • For the CKD: Protein Intake for Kidney Transplant recommendation, the conclusion statement received Grade III.

    • Minority Opinions

      Consensus reached.