MANAGEMENT OF DIET IN CHRONIC KIDNEY DISEASE

Satria Eureka N, Febria…, Khofi Hadidi

ABSTRACT
Dietary modification has long been considered a modifiable risk factor for the progression of
chronic kidney disease (CKD), however evidence on nutrition prescription is limited. Diet is
considered one of the cornerstones in the treatment of CKD. Recent international CKD
guidelines and literature was reviewed to address the following question “What is the
appropriate nutrition prescription for patients with chronic kidney disease?” Databases
included in the search were google search engine from 2005 to 2014. International guidelines
pertaining to nutrition prescription in CKD were also reviewed from 2008 to 2012. Eleven
papers and three guidelines were reviewed by three reviewers. The evidence from eleven papers
was tabulated under the following headings: protein, malnutrition, obesity, sodium, fat, (fibre…
belum nemu kayaknya), salt, phosphate, sugar and fluid was compared to international
guidelines. The overall aim additional research is urgently needed given the potential of adverse
outcomes for the CKD patient.

Keyword: chronic kidney disease; management diet; nutrition prescription

Introduction
End stage renal disease (ESRD) patients are known to have a higher risk of mortality than the
healthy population. Cardiovascular events are a major cause of this high mortality, more than
40% of all patients with ESRD die of cardiac causes [1A]. Chronic kidney disease (CKD) is a
prevalent chronic condition and the incidence of End-Stage Renal Disease (ESRD) is expected to
continue to climb in the coming decade [1]. In the United States, cardiovascular disease accounts
for almost 50% of deaths in patients with renal disease (USRDS, 2006), malnutrition [2] and is a
public health burden particularly in those patients who progress to end stage renal failure (or
ESRD) and require kidney replacement therapy (dialysis) or transplantation [4].
The prevalence of CKD has reached epidemic proportions with 10% - 13% of the populations of
Korea, Taiwan, Iran, Japan, China, Canada, India and the USA being affected. This number will
undoubtedly rise in coming years if the prevalence of diabetes and hypertension continue to
increase [3]. Furthermore, the increase in the elderly population and the wider availability of
therapy such as dialysis and kidney transplantation, contribute to the increasing prevalence of
patients with CKD [5].
CKD poses a significant public health issue and optimal treatment and management of this
disease is indicated [6]. In CKD, nutrition and diet play an important role both in prevention of
disease progression and in symptom management. The Scottish Intercollegiate Guidelines
Network A national clinical guideline (12) and Caring for Australians with Renal Impairment
(also known as CARI guidelines)(7) are designed to be employed by dietitians in clinical practice
as the basis of nutritional management of patients with CKD and are based on the nutrition
component of several recognized international guidelines. The evidence used, dates from
published guidelines from 2008 to 2012 and together with new literature these need to be
reflected in dietetic practice, specifically the nutrition intervention or prescription employed by
clinical dietitians.

Methodes
literature review of studies was designed to answer the clinical question.Databases included in
the search were google search engine from 2005 to 2014. International guidelines pertaining to
nutrition prescription in CKD were also reviewed from 2008 to 2012. Eleven papers and three
guidelines were reviewed by three reviewers. The evidence from eleven papers was tabulated
under the following headings: protein, malnutrition, obesity, sodium, fat, (fibre…belum nemu
kayaknya), salt, phosphate, sugar and fluid. The research aims and outcome measures reported
on were used to assess applicability of the studies. Reference lists of retrieved papers were also
reviewed and studies. Result included where relevant in addition to this literature search, hand
searches of recognised international guidelines published since 2008 and pertaining to nutrition
were conducted.
RESULT
There is evidence that for those patients with ESRD either Stage 4 or 5, a very low protein diet
(0.3 g/kg/day) with added keto-analogues and adequate energy (35 kcal/day) can delay dialysis
with no adverse effect on mortality [27]. Elderly patients with glomerular filtration rate (GFR)
between 5 and 7 mL/min on a similar diet, when compared to those on dialysis, had better
outcomes with an improved survival of 3.6% (95% CI, −17 to +10; p = 0.002) [28]. In dialysis,
protein intakes of >1.2 g/kg/day resulted in significant increases in body mass index (BMI,
kg/m2) of 0.97 (p < 0.001) [29]. The association between protein intake and all-cause mortality
and cardiovascular mortality amongst a large retrospective cohort, found that survival was best at
protein intakes between 1.0 and 1.4 g/kg/day and that intakes <0.8 g/kg/day and >1.4 g/kg/day
were associated with increased mortality. However, this effect was diminished significantly when
adjusted for malnutrition inflammation complex syndrome [30].

Discussion
The CARI guidelines state clearly that restriction of diet runs the risk of precipitating
malnutrition and thus has promoted moderate restrictions in protein, phosphate and sodium in the
pre-dialysis period to levels commensurate with the general population [15]. The studies,
specifically looking at dietitian led control of phosphate intake, showed promise but further
studies need to beconducted on the frequency of dietetic counseling to ensure long term impact
on dietary control [49,50].

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