CKD: Macronutrients: Protein Amount, Diabetes Mellitus (2020)
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.
CKD: Protein Restriction, Non-Dialysis, Diabetic
In adults with CKD 3-5 and who have diabetes, it is reasonable to prescribe, under close supervision, a dietary protein intake of 0.6–0.8 g /kg body weight per day to maintain a stable nutritional status and optimize glycemic control (OPINION).
CKD: Dietary Protein Intake, Maintenance Hemodialysis and Peritoneal Dialysis, Diabetic
In adults with CKD 5D and who have diabetes, it is reasonable to prescribe a dietary protein intake of 1.0 -1.2 g /kg body weight per day to maintain a stable nutritional status. For patients at risk of hyper and/or hypoglycemia, higher levels of dietary protein intake may need to be considered to maintain glycemic control (OPINION).
Risks/Harms of Implementing This Recommendation
For all recommendations, nutrition status must be maintained, including adequate caloric intake and maintenance of lean body mass.
Conditions of Application
Nutrition education and medical nutrition therapy are key in helping these patients manage their dietary intake. Patients should be monitored routinely to assess whether energy and protein requirements are being met satisfactorily. Changes in nutritional status should be treated and the protein prescription modified accordingly. Maintaining glycemic control is key in this population.
Potential Costs Associated with Application
Although costs of medical nutrition therapy sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.
Nutrition plays a significant role in the management of individuals with diabetic kidney disease (DKD) in conjunction with pharmacological interventions. The goal is to maintain optimal glycemic control and at the same time maintain adequate protein and energy intake to achieve optimal nutritional status. There are previous guidelines that suggest that 0.8 g/kg body weight/day among those with CKD stages 1-4 and also for CKD stage 5 (KDOQI 2007). However, KDIGO guidelines suggested that more liberalization with protein restriction and recommended that 0.8 g/kg body weight/day be maintained and avoiding levels above 1.3 g/kg/body weight (KDIGO 2012).
Evidence from controlled trials in this non-dialyzed DKD population has been conflicting (Walker et al 1989, Zeller et al 1991, Dullart et al 1993, Raal et al 1994, Hansen et al 2002, Pijls et al 2002, Meloni et al 2002, Dussol et al 2005). Recent meta-analysis does show small beneficial impact of low protein diet on eGFR decline, however, the heterogeneity was really high (the type of diabetes, stages of CKD, types on interventions, duration, adherence to recommendations) (Robertson et al 2007, Nezu et al 2013).
For the DKD patients receiving dialysis, evidence from observational studies indicated low dietary protein intake is associated with higher hospitalization rates and higher risk of mortality (Kalantar-Zadeh et al 2003, Ravel et al 2013). The KDOQI guideline for dialysis patients suggests dietary protein intake of >1.2 g/kg body weight/day to manage the protein catabolism and losses of protein in dialysate.
Ko et al 2017, conducted an extensive review of existing guidelines and original research in patients with DKD and indicated that dietary protein intake of 0.8 g/kg body weight/day was advised for DKD not on dialysis and dietary protein intake >1.2 g/kg body weight/day was advised for DKD patients on dialysis.
Recommendation Strength Rationale
These statements are based on workgroup expertise in the area.
- 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).
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Walker JD, Bending JJ, Dodds RA, Mattock MB, Murrells TJ, Keen H, Viberti GC. Restriction of dietary protein and progression of renal failure in diabetic nephropathy. Lancet 1989, 2, 1411–1415.
Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson, H.R. Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. N Engl J Med 1991, 324, 78–84.
Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of protein-restricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and hypertension. Diabetes Care 1993, 16, 483–492.
Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L, Panz VR. Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: A 6-mo prospective study. Am J Clin Nutr 1994, 60, 579–585.
Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int 2002, 62, 220–228.
Pijls LT, de Vries H, van Eijk JT, Donker AJ. Protein restriction, glomerular filtration rate and albuminuria in patients with type 2 diabetes mellitus: A randomized trial. Eur J Clin Nutr 2002, 56, 1200–1207.
Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone-Gallucci M, Casciani CU. Severe dietary protein restriction in overt diabetic nephropathy: Benefits or risks? J. Ren. Nutr 2002, 12, 96–101.
Dussol B, Iovanna C, Raccah D, Darmon P, Morange S, Vague P, Vialettes B, Oliver C, Loundoun A, Berland Y. A randomized trial of low-protein diet in type 1 and in type 2 diabetes mellitus patients with incipient and overt nephropathy. J Ren Nutr 2005, 15, 398–406.
Robertson L, Waugh N, Robertson A. Protein restriction for diabetic renal disease. Cochrane Database Syst. Rev. 2007.
Nezu U, Kamiyama H, Kondo Y, Sakuma M, Morimoto T, Ueda S. Effect of low-protein diet on kidney function in diabetic nephropathy: Meta-analysis of randomised controlled trials. BMJ 2013, 3, e002934.
Kalantar-Zadeh K, Supasyndh O, Lehn RS, McAllister CJ, Kopple JD. Normalized protein nitrogen appearance is correlated with hospitalization and mortality in hemodialysis patients with Kt/V greater than 1.20. J Ren Nutr 2003, 13, 15–25.
Ravel VA, Molnar MZ, Streja E, Kim JC, Victoroff A, Jing J, Benner D, Norris KC, Kovesdy CP, Kopple JD, et al. Low protein nitrogen appearance as a surrogate of low dietary protein intake is associated with higher all-cause mortality in maintenance hemodialysis patients. J Nutr 2013, 143, 1084–1092.
Ko GJ, Kalantar-Zadeh K, Goldstein-Fuchs J, Rhee CM. Dietary Approaches in the Management of Diabetic Patients with Kidney Disease. Nutrients. 2017;9(8):824.