Optimising nutrition in chronic renal insufficiency—progression of disease
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There is a lack of evidence to support the belief that dietary measures are beneficial in slowing the progression of chronic renal insufficiency (CRI). We prospectively monitored nutrient intakes and progression of CRI over a 2-year period in children aged 2–16 years with differing levels of severity of CRI, as part of their ongoing joint medical/dietetic care. Children were grouped following [51Cr]-labelled EDTA glomerular filtration rate (GFR, ml/min per 1.73 m2) estimations, into ‘normal’ kidney function [GFR >75, mean 106 (SD 19.5), n =58], providing baseline data only, mild (GFR 51–75, n =25), moderate (GFR 25–50, n =21), and severe (GFR <25, n =19) CRI. Children with CRI were followed for 2 years, with 51 completing the study (19 mild, 19 moderate, 13 severe CRI) and were excluded if they subsequently required dialysis. Regular medical and dietary advice was provided and yearly 3-day semi-quantitative dietary diaries and baseline and 6-monthly measurements of blood pressure and urinary protein/creatinine ratio were obtained. Mean reductions in estimated GFR over 2 years were –9.4, −5.8, and –6.0 ml/min per 1.73 m2 for mild, moderate, and severe CRI, respectively. Mean systolic blood pressure standard deviation score (SDS) fell significantly in all groups by 0.7 SDS, whereas there was little change in proteinuria. From reported dietary intakes, median sodium intakes increased (+10 mmol/day) and protein intakes decreased (−0.4 g/kg per day). Median phosphate intakes did not change significantly, whereas calcium intakes fell in all groups, with an overall median of –20% reference nutrient intake (RNI) (F =33.3, P <0.001). Of children with moderate CRI, 65% finished with calcium intakes below 80% RNI, and parathyroid hormone (PTH) concentrations significantly increased in this group (F =6.0, P =0.021). Higher phosphate and sodium intakes were associated with greater deterioration in estimated GFR in children with mild CRI (r 2=0.30, P =0.02; r 2=0.31, P =0.02, respectively). There was no such correlation for protein intake or PTH. This study emphasises the need for a joint medical and dietetic approach and indicates a number of interventions other than protein restriction, which could be commenced early in children with CRI in an attempt to delay progression.
KeywordsChronic renal insufficiency Disease progression Dietary restriction Phosphorus Sodium Protein Calcium
We would like to thank Dr. Sarah Lewis, Senior Lecturer in Medical Statistics, Division of Respiratory Medicine at Nottingham City Hospital for her review of the statistical methods used in this study.
- 2.Locatelli F, Del Vecchio L, Pozzoni P (2002) The importance of early detection of chronic kidney disease. Nephrol Dial Transplant 17:2–7Google Scholar
- 3.Wingen A-M, Mehls O (2002) Nutrition in children with preterminal chronic renal failure. Myth or important therapeutic aid? Pediatr Nephrol 17:111–120Google Scholar
- 5.Kopple JD, Levey AS, Greene T, Chumlea WC, Gassman JJ, Hollinger DL, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang S-R, Zimmer GS on behalf of the Modification of Diet in Renal Disease Study Group (1997) Effect of dietary protein restriction on nutritional status in the Modification of Diet in Renal disease Study. Kidney Int 52:778–791PubMedGoogle Scholar
- 12.Coleman JE (2001) The Kidney. In: Shaw V, Lawson M (eds) Clinical paediatric dietetics, 2nd edn. Blackwell, Oxford, pp 125–142Google Scholar
- 13.Department of Health (1991) Dietary reference values for food energy and nutrients for the United Kingdom. HMSO, LondonGoogle Scholar
- 15.Renal Association (1997) Treatment of adult patients with renal failure—recommended standards and audit measures, 2nd edn. Royal College of Physicians and the Renal Association, LondonGoogle Scholar
- 17.D’Amico G, Gentile MG, Fellin G, Manna G, Cofano F (1994) Effect of dietary protein restriction on the progression of renal failure: a prospective randomized study. Nephrol Dial Transpl 9:1590–1594Google Scholar
- 18.Khlar S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, Striker G, and the Modification of Diet in Renal Disease Study Group (1994) Effects of dietary protein restriction and blood pressure control on the progression of chronic renal disease. N Engl J Med 330:877–884CrossRefPubMedGoogle Scholar
- 21.Maschio G, Alberti D, Locatelli F, Mann JFE, Motelese M, Ponticelli C, Ritz E, Janin G, Zucchelli P, and the ACE Inhibition in Progressive Renal Insufficiency (AIPRI) Study Group (1999) Angiotensin-converting inhibitors and kidney protection: The AIPRI trial. J Cardiovasc Pharmacol 33:S16–S20CrossRefPubMedGoogle Scholar
- 23.Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER, Simons-Morton DG, Karanja N, Lin P-H (2001) Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Engl J Med 344:3–10CrossRefPubMedGoogle Scholar
- 31.Ratsch IM, Catassi C, Verrina E, Gusmano R, Appiani A, Bettinelli A, Picca S, Rizzoni G, Fabien-Bach C, Wingen A-M, Mehls O, Giorgi PL (1992) Energy and nutrient intake of patients with mild to moderate chronic renal failure compared with healthy children: an Italian multicentre study. Eur J Pediatr 151:701–705PubMedGoogle Scholar