Pediatric Nephrology

, Volume 19, Issue 11, pp 1253–1261 | Cite as

Optimising nutrition in chronic renal insufficiency—progression of disease

  • Lisa J. Norman
  • Ian A. Macdonald
  • Alan R. Watson
Original Article


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.


Chronic 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.


  1. 1.
    Khlar S, Morrissey J (2003) Progression of chronic renal disease. Am J Kidney Dis 41:S3–S7PubMedGoogle Scholar
  2. 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. 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
  4. 4.
    Wingen A-M, Fabien-Bach C, Schaefer F, Mehls O (1997) Randomised multicentre study of a low-protein diet on the progression of chronic renal failure in children. Lancet 349:1117–1123CrossRefPubMedGoogle Scholar
  5. 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
  6. 6.
    Coyne T, Olson M, Bradham K, Garcon M, Gregory P, Scherch L for the MDRD study (1995) Dietary satisfaction correlated with adherence in the Modification of Diet in Renal Disease Study. J Am Diet Assoc 95:1301–1306CrossRefPubMedGoogle Scholar
  7. 7.
    Hellerstein S, Holliday MA, Grupe WE, Fine RN, Fennell RS, Chesney RW, Chan JCM (1987) Nutritional management of children with chronic renal failure: summary of the task force on nutritional management of children with chronic renal failure. Pediatr Nephrol 1:195–211PubMedGoogle Scholar
  8. 8.
    Norman LJ, Coleman JE, Macdonald IA, Tomsett AM, Watson AR (2000) Nutrition and growth in relation to severity of renal disease in children. Pediatr Nephrol 15:259–265CrossRefPubMedGoogle Scholar
  9. 9.
    Fivush BA, Jabs K, Neu AM, Sullivan EK, Feld LG, Kohaut E, Fine R (1998) Chronic renal insufficiency in children and adolescents: the 1996 annual report of NAPRTCS. Pediatr Nephrol 12:328–337CrossRefPubMedGoogle Scholar
  10. 10.
    Counahan R, Chantler C, Ghazali S, Kirkwood B, Rose F, Barratt TM (1976) Estimation of glomerular filtration rate from plasma creatinine concentration in children. Arch Dis Child 51:875–878PubMedGoogle Scholar
  11. 11.
    Nelson M, Nettleton PA (1980) Dietary survey methods—a semi-weighed technique for measuring dietary intake within families. J Hum Nutr 34:325–348PubMedGoogle Scholar
  12. 12.
    Coleman JE (2001) The Kidney. In: Shaw V, Lawson M (eds) Clinical paediatric dietetics, 2nd edn. Blackwell, Oxford, pp 125–142Google Scholar
  13. 13.
    Department of Health (1991) Dietary reference values for food energy and nutrients for the United Kingdom. HMSO, LondonGoogle Scholar
  14. 14.
    Man SA de, Andre J-L, Bachmann H, Grobbee DE, Ibsen KK, Laaser U, Lippert P, Hofman A (1991) Blood pressure in childhood: pooled findings of six European studies. J Hypertens 9:109–114PubMedGoogle Scholar
  15. 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
  16. 16.
    Elises JS, Griffiths PD, Hocking MD, Taylor CM, White RHR (1988) Simplified quantification of urinary protein excretion in children. Clin Nephrol 30:225–229PubMedGoogle Scholar
  17. 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. 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
  19. 19.
    Peterson JC, Adler S, Burkart JM, Greene T, Hebert LA, Hunsicker L, King AJ, Khlar S, Massry SG, Seifter JL (1995) Blood pressure control, proteinuria and the progression of renal disease. Ann Intern Med 123:754–762PubMedGoogle Scholar
  20. 20.
    Iseki K, Ikemiya Y, Iseki C, Takishita S (2003) Proteinuria and the risk of developing end-stage renal disease. Kidney Int 63:1468–1474PubMedGoogle Scholar
  21. 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
  22. 22.
    World Health Organization (1999) International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens 17:151–183CrossRefPubMedGoogle Scholar
  23. 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
  24. 24.
    Sinaiko AR, Gomez-Marin O, Prineas RJ (1993) Effect of low sodium diet or potassium supplementation on adolescent blood pressure. Hypertension 21:989–994PubMedGoogle Scholar
  25. 25.
    Korhonen MH, Litmanen H, Rauramaa R, Vaisanen SB, Niskanen L, Uusitupa MIJ (1999) Adherence to the salt restriction diet among people with mildly elevated blood pressure. Eur J Clin Nutr 53:880–885CrossRefPubMedGoogle Scholar
  26. 26.
    Kist-van Holte tot Echten JE, Nauta J, Hop WCJ, Jong MCJW de, Reitsma-Bierens WCC, Ploos van Amstel SLB, Acker KJ van, Noordzij CM, Wolff ED (1993) Protein restriction in chronic renal failure. Arch Dis Child 68:371–375PubMedGoogle Scholar
  27. 27.
    Levey AS, Adler S, Caggiula AW, England BK, Greene T, Hunsicker L, Kusek JW, Rogers NL, Teschan PE (1996) Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study. Am J Kidney Dis 27:652–663PubMedGoogle Scholar
  28. 28.
    Foreman JW, Abitbol CL, Trachtman H, Garin EH, Feld LG, Strife F, Massie MD, Boyle RM, Chan JCM (1996) Nutritional intake in children with renal insufficiency: a report of the Growth Failure in Children with Renal Diseases Study. J Am Coll Nutr 15:579–585PubMedGoogle Scholar
  29. 29.
    Walser M (1980) Does dietary therapy have a role in the predialysis patient. Am J Clin Nutr 33:1629–1637PubMedGoogle Scholar
  30. 30.
    Maschio G, Oldrizzi L, Tessitore N, D’Angelo A, Valvo E, Lupo A, Loschiavo C, Fabris A, Gammaro L, Ruigiu C, Panzetta G (1982) Effects of dietary protein and phosphorus restriction on the progression of early renal failure. Kidney Int 22:371–376PubMedGoogle Scholar
  31. 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
  32. 32.
    Martinez I, Saracho R, Montenegro J, Llach F (1997) The importance of dietary calcium and phosphorus in the secondary hyperparathyroidism of patients with early renal failure. Am J Kidney Dis 29:496–502PubMedGoogle Scholar
  33. 33.
    Barsotti G, Giannoni A, Morelli E, Lazzeri M, Vlamis I, Baldi R, Giovannetti S (1984) The decline of renal function slowed by very low phosphorus intake in chronic renal patients following a low nitrogen diet. Clin Nephrol 21:54–59PubMedGoogle Scholar
  34. 34.
    Kopple JD, Greene T, Chumlea WC, Hollinger DL, Maroni BJ, Merrill D, Scherch L, Schulman G, Wang S-R, Zimmer GS (2000) Relationship between nutritional status and glomerular filtration rate: Results from the MDRD Study. Kidney Int 57:1688–1703CrossRefPubMedGoogle Scholar

Copyright information

© IPNA 2004

Authors and Affiliations

  • Lisa J. Norman
    • 1
    • 3
  • Ian A. Macdonald
    • 2
  • Alan R. Watson
    • 1
  1. 1.Children and Young People’s Kidney UnitNottingham City HospitalNottinghamUK
  2. 2.School of Biomedical Sciences, Medical SchoolUniversity of NottinghamUK
  3. 3.Department of Nutrition and DieteticsNottingham City PCTNottinghamUK

Personalised recommendations