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      Nutritional Therapy, Phosphate Control and Renal Protection

      a , b , *

      Nephron Clinical Practice

      S. Karger AG

      Chronic kidney disease, Phosphate, Nutrition

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          Abstract

          Dietary management of chronic kidney disease (CKD) focusses on limiting the intake of substances that might accumulate to toxic levels (such as potassium, phosphorus or salt) and, although still a matter of debate for some, restricting dietary protein to retard kidney damage. Recent evidence brings the opportunity to revisit the role of a healthy diet on disease progression and on some of the cardiometabolic complications of moderate/advanced CKD, such as inflammation or oxidative stress control. This review provides a brief overview of dietary strategies that delay CKD progression and CKD complications, and discusses currently limited data addressing the development of malnutrition and protein-energy wasting before dialysis initiation.

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          Most cited references 45

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          Guidelines for the management of chronic kidney disease.

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            Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.

            Patients with advanced chronic kidney disease (CKD) are in positive phosphorus balance, but phosphorus levels are maintained in the normal range through phosphaturia induced by increases in fibroblast growth factor-23 (FGF23) and parathyroid hormone (PTH). This provides the rationale for recommendations to restrict dietary phosphate intake to 800 mg/d. However, the protein source of the phosphate may also be important. We conducted a crossover trial in nine patients with a mean estimated GFR of 32 ml/min to directly compare vegetarian and meat diets with equivalent nutrients prepared by clinical research staff. During the last 24 hours of each 7-day diet period, subjects were hospitalized in a research center and urine and blood were frequently monitored. The results indicated that 1 week of a vegetarian diet led to lower serum phosphorus levels and decreased FGF23 levels. The inpatient stay demonstrated similar diurnal variation for blood phosphorus, calcium, PTH, and urine fractional excretion of phosphorus but significant differences between the vegetarian and meat diets. Finally, the 24-hour fractional excretion of phosphorus was highly correlated to a 2-hour fasting urine collection for the vegetarian diet but not the meat diet. In summary, this study demonstrates that the source of protein has a significant effect on phosphorus homeostasis in patients with CKD. Therefore, dietary counseling of patients with CKD must include information on not only the amount of phosphate but also the source of protein from which the phosphate derives.
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              Timing of onset of CKD-related metabolic complications.

              Chronic kidney disease (CKD) guidelines recommend evaluating patients with GFR <60 ml/min per 1.73 m(2) for complications, but little evidence supports the use of a single GFR threshold for all metabolic disorders. We used data from the NephroTest cohort, including 1038 adult patients who had stages 2 through 5 CKD and were not on dialysis, to study the occurrence of metabolic complications. GFR was measured using renal clearance of (51)Cr-EDTA (mGFR) and estimated using two equations derived from the Modification of Diet in Renal Disease study. As mGFR decreased from 60 to 90 to <20 ml/min per 1.73 m(2), the prevalence of hyperparathyroidism increased from 17 to 85%, anemia from 8 to 41%, hyperphosphatemia from 1 to 30%, metabolic acidosis from 2 to 39%, and hyperkalemia from 2 to 42%. Factors most strongly associated with metabolic complications, independent of mGFR, were younger age for acidosis and hyperphosphatemia, presence of diabetes for acidosis, diabetic kidney disease for anemia, and both male gender and the use of inhibitors of the renin-angiotensin system for hyperkalemia. mGFR thresholds for detecting complications with 90% sensitivity were 50, 44, 40, 39, and 37 ml/min per 1.73 m(2) for hyperparathyroidism, anemia, acidosis, hyperkalemia, and hyperphosphatemia, respectively. Analysis using estimated GFR produced similar results. In summary, this study describes the onset of CKD-related complications at different levels of GFR; anemia and hyperparathyroidism occur earlier than acidosis, hyperkalemia, and hyperphosphatemia.
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                Author and article information

                Journal
                NEC
                Nephron Clin Pract
                10.1159/issn.1660-2110
                Nephron Clinical Practice
                S. Karger AG
                1660-2110
                2014
                April 2014
                11 January 2014
                : 126
                : 1
                : 1-7
                Affiliations
                aDivision of Nephrology and Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden; bDepartment of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, Milan, Italy
                Author notes
                *Mario Cozzolino, MD, PhD, Renal Division and Laboratory of Experimental Nephrology, Dipartimento di Scienze della Salute, Università di Milano, Via A. di Rudinì 8, IT-20142 Milan (Italy), E-Mail mario.cozzolino@unimi.it
                Article
                357679 Nephron Clin Pract 2014;126:1-7
                10.1159/000357679
                24434650
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Pages: 7
                Categories
                Minireview

                Cardiovascular Medicine, Nephrology

                Nutrition, Phosphate, Chronic kidney disease

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