CKD: Macronutrients: Dietary Patterns (2020)
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CKD: Dietary Patterns: Mediterranean Diet
In adults with CKD 1-5 not on dialysis or posttransplantation, with or without dyslipidemia, we suggest that prescribing a Mediterranean Diet may improve lipid profiles (2C).
CKD: Dietary Patterns: Fruits and Vegetables
In adults with CKD 1-4, we suggest that prescribing increased fruit and vegetable intake may decrease body weight, blood pressure and net acid production (NEAP) (2C).
Risks/Harms of Implementing This Recommendation
- Safety of various dietary patterns, including the DASH and Mediterranean with high intakes of fruit and vegetables in advanced stages of kidney disease.
Conditions of Application
- Safety of various dietary patterns, including the DASH and Mediterranean with high intakes of fruit and vegetables in advanced stages of kidney disease, especially in regard to serum potassium control and adequacy of protein intake.
- Individualized support and follow-up may be required to support patients to implement complex dietary changes.
Potential Costs Associated with Application
There are no obvious costs associated with these interventions.
Dietary patterns reflect the variety of foods which represent habitual dietary intake (Leech, et al. 2015). Particular dietary patterns, including the Mediterranean Diet, the Dietary Approach to Stop Hypertension (DASH), plant-based and diets high in fruits and vegetables (including vegetarian diets) are examples of healthy dietary patterns which have been the subject of interest much in nutritional epidemiology (Hu, et al. 2002, Kelly et al 2017). By taking a whole-of-diet approach, this considers the synergistic effects of nutrients resulting in cumulative effects on health and disease (Hu, et al. 2002).
Chronic Kidney Disease (CKD) presents many challenges for nutrition management, including increased risk of death and appreciable cardiovascular disease (CVD) burden among affected persons. Traditionally, nutrition education has focused on individual nutrients, such as protein, phosphorus, potassium and sodium. Recent evidence has linked healthy dietary patterns with reduced chronic CVD and mortality risk in the healthy population (Estruch, et al. 2013; Salehi-Abargouei, et la. 2013; Sofi, et al. 2014). However, these relationships have not been explored conclusively with the CKD population.
This systematic review focused on controlled trials of dietary patterns. While various dietary patterns were investigated (Fruits and Vegetables, Mediterranean Diet, Low Fructose Diet, Hypolipidemic, Carbohydrate restricted- low iron, polyphenol-enriched diet (CR-LIPE), High-protein/Low-carbohydrate), there was little evidence examining the efficacy of most of these patterns in controlled trials. Hence, only the Mediterranean and High Fruit and Vegetable dietary patterns had sufficient evidence to create recommendations.
Mediterranean Dietary Pattern
One RCT reported on the effect of Mediterranean dietary pattern on eGFR (Mekki, et al. 2010). Mekki et al 2010 indicated an increase in eGFR in both the groups, but stayed unchanged at 90-days (NS) (SMD 0.23, 95% CI -0.39, 0.85). Mediterranean dietary pattern had no clear effect on eGFR at 90 days post intervention in adults with CKD stage 2. Additional research on effect of Mediterranean dietary pattern intake is needed.
Limited evidence from three studies, two of which examined non-dialyzed patients and one of which examined post-transplant patients, demonstrated that the Mediterranean diet improved lipid panel by decreasing total cholesterol (TC), low-density lipoprotein (LDL-C) and triglyceride (TG) level compared to control groups.
Two controlled trials reported on the effect of Mediterranean dietary pattern on lipid profile in non-dialyzed patients (Mekki, et al. 2010; Di Daniele et al. 2014). In the RCT, Mekki et al 2010 (stage 2) reported a 35% reduction in TC (p<0.05) in the Mediterranean diet group, whereas, no change in TC was observed in the control group. LDL-C levels and TG levels were also reduced compared to standard care (Mekki, et al. 2010). In an NRCT, Daniele et al 2014 reported a significant reduction in TC in both Mediterranean diet group and organic Mediterranean diet group. However, most reduction was noted in the organic Mediterranean diet group.
In post-transplant patients, one RCT reported that Mediterranean diet led to significant reduction in TC, TG and LDL-C levels compared with a low fat diet (Stachowska, et al. 2005).
Compared to a control group, the Mediterranean Diet had no clear effect on BP in transplant recipients (Stachowska, et al. 2005) or on CRP levels in stage 2 patients (Mekki, et al. 2010).
However, one NRCT (Daniele et al 2014) reported on the effect of Mediterranean dietary pattern on albuminuria in stage 2 and 3 CKD adults, and both Mediterranean diet groups (normal and organic) had significant reductions in albuminuria values compared to low protein group (Daniele, et al. 2014).
High Fruit and Vegetable Dietary Pattern
In adults with stages 3-4 CKD, fruits and vegetables dietary pattern has mixed effects/uncertain effects on eGFR compared with oral bicarbonate supplementation (Goraya, et al. 2014 and 2013).
Two RCTs reported on the effect of a fruit and vegetable dietary pattern on body weight in adults with CKD. Goraya et al 2014, reported that the group following fruit and vegetable dietary pattern had greater net body weight loss than both oral bicarbonate group and standard care group (p-value < 0.05), also the control group had greater net body weight loss than HCO3 group (p-value < 0.05). Goraya et al 2013, reported lower body weight in adults with CKD stages 3-4 following a fruit and vegetable dietary pattern compared to oral bicarbonate supplementation group at 1-year follow up (p<0.01). (MD= -5.09 kg, 95% CI -7.73, 2.44; I2=56%).
Three studies (2 RCT, 1 NRCT) reported on the effect of increased fruit and vegetable intake on BP in adults with CKD. All three studies indicated that increased intake of fruit and vegetable had a significant effect on lowering systolic BP compared to oral bicarbonate supplement intake group or standard care group. Goraya et al 2014 indicated reductions in systolic BPs in all groups, however, the 3-year value for FV was lower than those in HCO3 and control. Goraya et al 2013, showed that compared to HCO3 group, the fruits and vegetable group had lower systolic BP at 1-year follow up (p-value < 0.01). Goraya et al 2012 (NRCT), showed that fruit and vegetable intake, but not control or HCO3, significantly decreased systolic BP in individuals with CKD Stages 1 and 2 (p-values < 0.001). Pooled analysis of data from Goraya et al 2013 and Goraya et al 2014 indicated a MD (95% CI) of -5.6, CI: -8.3, -2.8 mmHg. Increased intake of fruits and vegetable dietary pattern lowered systolic BP compared to oral bicarbonate supplement intake or standard care group in adults with CKD stages 1-4.
Comparison with Recent Research
A recent systematic review (SR) examined the effect of dietary patterns on CKD outcomes using cohort studies (Kelly, et al. 2017). In agreement with the current analysis of controlled trials, Kelly, et al. found no effect of dietary pattern on CKD progression in studies with follow-ups ranging from 4 to 6.4 years. However, unlike the current SR, Kelly, et al. was able to demonstrate a relationship between a dietary pattern rich in vegetables, fruit, fish, cereals, whole grains, fiber, legumes, and nuts and seeds, and lower in red meat, sodium, and refined sugars in studies reporting outcomes from 4 to 13 years of follow up [RR (95% CI): 0.73 (95% CI, 0.63 to 0.83)] (Kelly, et al. 2017).
A recent Cochrane review of dietary interventions in CKD found from 6 RCTs evaluated on dietary patterns (one study (n=191) of a carbohydrate-restricted low-iron, polyphenol enriched diet, two studies (n=355) of a Mediterranean diet, two studies (n=181) of increased fruit and vegetable intake and one study (n=12) of a high protein/low carbohydrate diet. From this review, dietary interventions had uncertain effects on all-cause mortality and cardiovascular events. However, with low quality evidence, there was reduced systolic and diastolic BP, and higher GFR and albumin levels following dietary interventions (Palmer, et al. 2017).
Although the intervention studies examining dietary patterns in CKD are limited, there is consistent evidence from observational analyses on dietary patterns containing fruits, vegetables, whole grains, lean meats, low fat dairy and low added salt, and improved clinical outcome (notably mortality) in CKD (Kelly, et al. 2017). Another recent study confirmed that nuts, low-fat dairy products, and legumes are protective against development of CKD (Joshi et al 2019). There is therefore a need to undertake future trials to further investigate more holistic dietary interventions over single nutrient approaches in these patients. Dietary pattern may improve addtional outcomes not reported in the systematic review, including constipation.
Recommendation Strength Rationale
The evidence supporting the recommendation is based on Grade III /Grade C or D evidence.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the effect of fruit and vegetable dietary patterns on blood pressure in adults with CKD 1-4?
What is the effect of fruit and vegetable dietary patterns on body weight in adults with CKD 3-4?
What is the effect of the Mediterranean dietary pattern on lipid profile in adults with CKD 1-5D and post-transplant?
What is the effect of acid-base interventions on acid-base levels in adults with CKD 1-5D and post-transplant?
What is the effect of fruit and vegetable dietary patterns on eGFR in adults with CKD 3-4?
What is the effect of fruit and vegetable dietary patterns on albuminuria in adults with CKD 1-4?
What is the effect of the Mediterranean dietary pattern on CRP levels in adults with CKD 2?
What is the effect of the Mediterranean dietary pattern on albuminuria in adults with CKD2-3?
What is the effect of the Mediterranean dietary pattern on blood pressure in adults with CKD post-transplant?
What is the effect of the Mediterranean dietary pattern on lipid profile in adults with CKD 1-5D and post-transplant?
What is the effect of the Mediterranean dietary pattern on eGFR in non-dialyzed adults with CKD?
Goraya N, Simoni J, Jo C,Wesson D. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney International 2012; 81:86-93
Goraya N,Simoni J,Jo C,Wesson D. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clinical journal of the American Society of Nephrology : CJASN 2013; 8:371-81
Goraya N, Simoni J, Jo C, Wesson D. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney International 2014; 86:1031-8
Di Daniele N, Di Renzo L, Noce A, Iacopino L, Ferraro P, Rizzo M, Sarlo F, Domino E, De Lorenzo A. Effects of Italian Mediterranean organic diet vs. low-protein diet in nephropathic patients according to MTHFR genotypes. Journal of Nephrology 2014; 27:529-36
Mekki K, Bouzidi-Bekada N, Kaddous A, Bouchenak M. Mediterranean diet improves dyslipidemia and biomarkers in chronic renal failure patients. Food & Function 2010; 1:110-5
Stachowska E, Gutowska I, Strzelczak A, Wesolowska T, Safranow K, Ciechanowski K, Chlubek D. The use of neural networks in evaluation of the direction and dynamics of changes in lipid parameters in kidney transplant patients on the Mediterranean diet. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2006; 16:150-9
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Estruch R, Ros E, Salas-Salvado J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279-1290.
Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13(1):3-9.
Kelly JT, Palmer SC, Wai SN, et al. Healthy Dietary Patterns and Risk of Mortality and ESRD in CKD: A Meta-Analysis of Cohort Studies. Clinical journal of the American Society of Nephrology : CJASN. 2017;12(2):272-279.
Leech RM, Worsley A, Timperio A, McNaughton SA. Understanding meal patterns: definitions, methodology and impact on nutrient intake and diet quality. Nutr Res Rev. 2015;28(1):1-21.
Palmer SC, Maggo JK, Campbell KL, et al. Dietary Interventions for adults with chronic kidney disease. Cochrane Database Syst Rev. 2017;4:CF011998.
Salehi-Abargouei A, Maghsoudi Z, Shirani F, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH)-style diet on fatal or nonfatal cardiovascular diseases--incidence: a systematic review and meta-analysis on observational prospective studies. Nutrition. 2013;29(4):611-618.
Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr. 2014;17(12):2769-2782.