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      Low protein diets in patients with chronic kidney disease: a bridge between mainstream and complementary-alternative medicines?

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          Abstract

          Dietary therapy represents an important tool in the management of chronic kidney disease (CKD), mainly through a balanced reduction of protein intake aimed at giving the remnant nephrons in damaged kidneys a “functional rest”. While dialysis, transplantation, and pharmacological therapies are usually seen as “high tech” medicine, non pharmacological interventions, including diets, are frequently considered lifestyle-complementary treatments. Diet is one of the oldest CKD treatments, and it is usually considered a part of “mainstream” management. In this narrative review we discuss how the lessons of complementary alternative medicines (CAMs) can be useful for the implementation and study of low-protein diets in CKD. While high tech medicine is mainly prescriptive, prescribing a “good” life-style change is usually not enough and comprehensive counselling is required; the empathic educational approach, on which CAMs are mainly, though not exclusively based, may support a successful personalized nutritional intervention.

          There is no gold-standard, low-protein diet for all CKD patients: from among a relatively vast choice, the best compliance is probably obtained by personalization. This approach interferes with the traditional RCT-based analyses which are grounded upon an assumption of equal preference of treatments (ideally blinded). Whole system approaches and narrative medicine, that are widely used in the study of CAMs, may offer ways to integrate EBM and personalised medicine in the search for innovative solutions respecting individualization, but gaining sound data, such as with partially-randomised patient preference trials.

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          Most cited references154

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          Randomized, Controlled Trials, Observational Studies, and the Hierarchy of Research Designs

          New England Journal of Medicine, 342(25), 1887-1892
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            GFR decline as an end point for clinical trials in CKD: a scientific workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration.

            The US Food and Drug Administration currently accepts halving of glomerular filtration rate (GFR), assessed as doubling of serum creatinine level, as a surrogate end point for the development of kidney failure in clinical trials of kidney disease progression. A doubling of serum creatinine level generally is a late event in chronic kidney disease (CKD); thus, there is great interest in considering alternative end points for clinical trials to shorten their duration, reduce sample size, and extend their conduct to patients with earlier stages of CKD. However, the relationship between lesser declines in GFR and the subsequent development of kidney failure has not been well characterized. The National Kidney Foundation and Food and Drug Administration sponsored a scientific workshop to critically examine available data to determine whether alternative GFR-based end points have sufficiently strong relationships with important clinical outcomes of CKD to be used in clinical trials. Based on a series of meta-analyses of cohorts and clinical trials and simulations of trial designs and analytic methods, the workshop concluded that a confirmed decline in estimated GFR of 30% over 2 to 3 years may be an acceptable surrogate end point in some circumstances, but the pattern of treatment effects on GFR must be examined, specifically acute effects on estimated GFR. An estimated GFR decline of 40% may be more broadly acceptable than a 30% decline across a wider range of baseline GFRs and patterns of treatment effects on GFR. However, there are other circumstances in which these end points could lead to a reduction in statistical power or erroneous conclusions regarding benefits or harms of interventions. We encourage careful consideration of these alternative end points in the design of future clinical trials.
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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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                Author and article information

                Contributors
                gbpiccoli@yahoo.it
                Irene.capizzi@gmail.com
                fedenow@inwind.it
                filomena.leone@unito.it
                dalex.c@virgilio.it
                dgiuffrida@inwind.it
                martanazha@libero.it
                sinona.roggero@unito.it
                nicoletta.colombi@unito.it
                Giuseppe.mauro@unito.it
                natascia.castelluccia@unito.it
                adamasco.cupisti@med.unipi.it
                paolo.avagnina@unito.it
                Journal
                BMC Nephrol
                BMC Nephrol
                BMC Nephrology
                BioMed Central (London )
                1471-2369
                8 July 2016
                8 July 2016
                2016
                : 17
                : 76
                Affiliations
                [ ]Department of Clinical and Biological Sciences, SS Nephrology, ASOU san Luigi, University of Torino, Torino, Italy
                [ ]Nephrologie, CH du Mans, Le Mans, France
                [ ]Department of Surgery, SS Dietetics, città della salute e della scienza, University of Torino, Torino, Italy
                [ ]Department of Experimental and Clinical Medicine, SCDU Nephrology, University of Pisa, Pisa, Italy
                [ ]Department of Clinical and Biological Sciences and of Oncology, Library, ASOU san Luigi, University of Torino, Torino, Italy
                [ ]Department of Clinical and Biological Sciences, SSD Clinical Nutrition, ASOU san Luigi, University of Torino, Torino, Italy
                Article
                275
                10.1186/s12882-016-0275-x
                4939031
                27391228
                5e95ffbb-8801-48a3-acd0-a58bc190a79b
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 13 July 2015
                : 14 June 2016
                Funding
                Funded by: ex 60% University of Torino
                Categories
                Review
                Custom metadata
                © The Author(s) 2016

                Nephrology
                Nephrology

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