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Low-salt low-protein diet and blood pressure control in patients with advanced diabetic kidney disease and heavy proteinuria

  • Nephrology - Original Paper
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Abstract

Purpose

To assess the associations between effects of low salt, low protein diet supplemented with keto-analogues (sLPD)—on salt intake, blood pressure (BP) and cardiovascular events (CVEs) in patients with advanced diabetic kidney disease (DKD) and heavy proteinuria.

Methods

Prospective, single-center study (total duration of 15 months), enrolling 92 patients with advanced DKD (median eGFR 11.7 ml/min) and heavy proteinuria (median 4.8 g/g creatininuria). The intervention consisted in a low salt–low protein (0.6 g/kg-day) diet (sLPD) under intensive nutritional counselling, and adjustment of antihypertensive therapy.

The endpoints of this sub-analysis were a salt intake ≤ 5 g/day, a mean blood pressure (MAP) ≤ 97 mmHg, corresponding to KDIGO target of 130/80 mmHg, and the rate of CVEs.

Results

Salt intake decreased with 2.5 g/day and the proportion of patients reaching the salt intake endpoint increased with 58%. A salt intake ≤ 5 g/day was associated with a reduced MAP, BMI, proteinuria, fractional excretion of sodium, and eGFR, suggesting a salt-related volume contraction but was not related to protein intake.

Mean arterial pressure decreased with 13 mmHg. MAP ≤ 97 mmHg was associated with lower proteinuria, salt, and protein intake, but the contribution of salt intake cannot be differentiated from that of protein intake.

CVEs occurred in 20% of patients and were independently related to a lower age and MAP, and increased comorbidities. eGFR only minimally declined and no renal adverse events were noted. sLPD was nutritionally safe.

Conclusions

The multifactorial personalized intervention allowed a stable MAP reduction to KDIGO recommended levels (≤ 97 mmHg), related to the decrease in salt and protein intake. However, BP lower than 130/80 mmHg increased the cardiovascular but not the renal risk in heavy proteinuric patients with advanced DKD.

Trial Registration Number: 0341507433

NCT03415074. Registered 02/02/2015 in US National Library of Medicine, ClinicalTrials.gov (NCT).

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Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

LPD:

Low protein diet

BP:

Blood pressure

CVEs:

Cardiovascular events

eGFR:

Estimated glomerular filtration rate

CKD:

Chronic kidney disease

MAP:

Mean arterial pressure

BMI:

Body mass index

DKD:

Diabetic kidney disease

RRT:

Renal replacement therapy

sLPD:

Low protein diet supplemented with keto-analogues

SGA:

Subjective Global Assessment

RAASi:

Renin angiotensin aldosterone system inhibitors

HbA1c:

Glycated haemoglobin

Bs:

Baseline

EOS:

End of study

SBP:

Systolic blood pressure

DBO:

Diastolic blood pressure

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Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author information

Authors and Affiliations

  1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

    Andreea Mihalache

  2. Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, “Dr Carol Davila” Teaching Hospital of Nephrology, 4 Calea Grivitei, Sector 1, 010731, Bucharest, Romania

    Liliana Garneata

  3. Department of Nephrology, Carol Davila” University of Medicine and Pharmacy, “Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania

    Carmen Antonia Mocanu

  4. Department of Nephrology, Carol Davila” University of Medicine and Pharmacy, “Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania

    Tudor-Petrisor Simionescu

  5. Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, “Dr Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania

    Gabriel Mircescu

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  4. Tudor-Petrisor Simionescu
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Contributions

LG, GM, TPS and CAM designed the study and collected the data. AM, CAM and GM performed the analysis and drafted the manuscript in consultation with LG, CAM and TPS. GM designed the figures. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Liliana Garneata.

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Conflict of interest

Andreea Mihalache, Carmen-Antonia Mocanu, Tudor-Petrișor Simionescu and Gabriel Mircescu have no conflicts of interest to disclose. Liliana Garneata participated in scientific meetings (as a speaker) and at the international advisory board meetings for Ketosteril. Speaker fees and consultancy fees were received from Fresenius Kabi.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of “Dr Carol Davila” Teaching Hospital of Nephrology (Committee’s Reference number 124/2013). All participants provided written informed consent prior to enrolment in the study.

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Mihalache, A., Garneata, L., Mocanu, C.A. et al. Low-salt low-protein diet and blood pressure control in patients with advanced diabetic kidney disease and heavy proteinuria. Int Urol Nephrol 53, 1197–1207 (2021). https://doi.org/10.1007/s11255-020-02717-2

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  • DOI: https://doi.org/10.1007/s11255-020-02717-2

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