Nutritional Adequacy of Animal-Based and Plant-Based Asian Diets for Chronic Kidney Disease Patients: A Modeling Study

Plant-based low protein diets (LPDs) have gained popularity for managing chronic kidney disease (CKD) patients. The nutritional adequacy of these and other LPDs prescribed for CKD patients have not been carefully examined. This study assessed the nutrient composition of such LPDs and moderately high protein diets (MHPDs) that might be prescribed for patients in the Asia Pacific region with CKD who are not dialyzed or undergoing maintenance dialysis. Conventional diets containing at least 50% animal-based proteins and plant-based diets were also planned with protein prescriptions of 0.5 to 0.8 g/kg/day and MHPDs with protein prescriptions of 1.0 to 1.2 g/kg/day. Plant-based, lacto-, ovo-, and lacto-ovo-vegetarian and vegan LPDs and MHPDs were planned by replacing some or all of the animal proteins from the conventional diet. With 0.5 g protein/kg/day, all diets were below the Recommended Dietary Allowances (RDA) for at least one essential amino acid (EAA). At a protein prescription of 0.6 g/kg/day, only the conventional LPD met the RDA for all EAAs. This deficiency with the plant-based LPDs persisted even with several plant food substitutions. With a protein prescription ≥0.7 g/kg/day, all the plant-based and vegetarian LPDs provided the RDA for all EAA. The plant-based and vegetarian diets also contained relatively greater potassium, phosphorus, and calcium content but lower long-chain n-3 polyunsaturated fatty acids and vitamin B-12 than the conventional diet. Other essential micronutrients were commonly below the RDA even at higher protein intakes. The low contents of some essential micronutrients were found in both animal-based and plant-based diets. Prescription of all LPDs for CKD patients, especially plant-based and vegetarian LPDs, requires careful planning to ensure the adequacy of all nutrients, particularly essential amino acids. Consideration should be given to supplementing all animal-based and plant-based LPDs and MHPDs with multivitamins and certain trace elements.


Introduction
Chronic kidney disease (CKD) is a global health concern. A recent systematic analysis estimates that 9.1% of the worldwide adult population is affected by CKD, and almost a third of people with CKD live in China and India [1]. A low protein diet (LPD) providing cultural backgrounds. Since there is also little published information concerning the essential nutrient content of animal-based LPDs prescribed for CKD patients, we analyzed the essential nutrients in the more conventional animal-based LPDs and moderately high protein diets (MHPDs) that might be prescribed to Asian CKD patients.

Planning of a Conventional Menu
As a comparator reference diet, we designed a conventional 3-day animal-based menu using 70 kg as the reference body weight for an adult ( Table 1). The LPDs consisted of four protein prescriptions, providing 0.5, 0.6, 0.7, and 0.8 g protein per kg body weight. At least 50% of the protein was high biological value protein derived from animal-based food sources [22]. MHPDs providing 1.0, 1.1, and 1.2 g protein per kg body weight which are often prescribed for maintenance hemodialysis and peritoneal dialysis patients were also analyzed [2,3]. The energy prescription was set at 2100 kcal for all diets, based on 30 kcal per kg body weight. Total carbohydrates contributed 54 to 58% of energy (284-305 g) across all protein prescriptions, while the proportion of total fat in the diets ranged from 30 to 35% of energy (70-82 g). Abbreviations: BW, body weight; EN, energy; LPD, low protein diet; MHPD, moderately high protein diet. * Based on a body weight of 70 kg. † One exchange of cereal contains 15 g carbohydrate, 2 g protein, 0.5 g fat; one exchange of fruit or sugar contains 15 g carbohydrate; one exchange of poultry, fish, or egg contains 7 g protein; one exchange of fat contains 5 g fat; the portion size of one serving of cooked non-starchy vegetable is 1 /2 cup.
We then determined the exchange or serving size for each food group based on the macronutrient distribution across protein prescriptions. All meal plans were fixed to provide three exchanges of fruit and four servings of non-starchy vegetables. For LPDs, there were eight exchanges of cereals or cereal products and 14 exchanges of fat. Variation for the number of protein food exchanges ranged from two to five exchanges with three to five exchanges of sugar. For MHPDs, there were 11 exchanges of cereals or cereal products. The protein foods varied in providing six to eight exchanges with 11 to 13 exchanges of fat.

Reference Menus
The approach to menu construction was centered on typical dietary patterns of Indian and Southern Chinese ethnic groups by reference to the patient education materials and the menus designed for patients with CKD from North Indian (Indraprastha Apollo Hospital, New Delhi, India), South Indian (Apollo Hospital Chennai, Tamil Nadu, India), and southern China (Guangzhou Red Cross Hospital, Guangzhou, China) hospitals These menus were obtained via personal communications with the dietitians (Anita Jatana, Apollo Hospital, New Delhi, India and Daphnee DK, Apollo Hospital, Chennai, Tamil Nadu, India) and a nephrologist (Prof. Dr. Tan Rong Shao, Guangzhou Red Cross Hospital, Guangzhou, China) living and working in these areas.
The cereals and cereal products group consisted primarily of rice, which is the staple food for Asians. Other cereal products on the menu included dosa, biscuits, and rice noodles. We included fruits and vegetables common to the Asian region, such as papaya, banana, pear, apple, mango, orange, okra, cucumber, eggplant, cabbage, and spinach. For LPDs, the preparation method for fish and poultry dishes was mainly deep-frying. Beverages such as tea, typically consumed with sugar in India, although not China was featured in the menu to promote adequacy towards the energy prescription without exceeding the protein limit.

Protein Food Substitutions in Plant-Based and Vegetarian Diets
We planned a menu for a plant-based and four vegetarian diets by substituting the animal-based protein in the conventional menu with plant-based protein such as soy products (i.e., tofu and tempeh), lentils (dhal), or beans. Other food groups on the plant-based and vegetarian menu remained the same as the conventional menu. Constructed menus are provided as supplementary material (Table S1). Menu details for each plant-based and vegetarian diet are as below: Model 1: The plant-based diet was planned according to the principles of the plantdominant (PLADO) diet proposed by Kalantar-Zadeh et al. [13]. This diet consisted of about 70% plant-based protein. For instance, a menu with a total protein content of 49 g/day would comprise 35 g protein from plant-based food and 14 g protein from animal-based food. Therefore, any animal-based food such as chicken, fish, or pork from the conventional menu was substituted with a plant-based food so that the animal-based food provided only 30% of total protein.
Model 2: A vegan diet that excluded all food derived from animals, including egg and dairy products. All animal-based protein was substituted with such plant-based protein as tofu, soybean milk, lentils, and chickpeas.
Model 3: An ovo-vegetarian diet that excluded all food derived from animals except for eggs. All animal-based protein, except eggs, was substituted with plant-based protein, and at least one exchange of egg (i.e., one whole egg or the whites from two eggs) was included in the daily diet. The maximum number of eggs included in the menu was three exchanges per day.
Model 4: A lacto-vegetarian diet that excluded all food derived from animals except for dairy products (such as milk, paneer, and curd). All animal-based protein, except dairy products, was substituted with plant-based protein, and at least one exchange of dairy products (i.e., 8 ounces or 240 mL milk) was included in the daily diet. The maximum number of dairy products included in the menu was two exchanges per day.
Model 5: A lacto-ovo vegetarian diet that excluded all food derived from animals except egg and dairy products. All animal-based protein was substituted with plant-based protein, and at least one exchange of egg and dairy products was included in the daily diet. The maximum number of egg and dairy products included in the menu was three and two exchanges per day, respectively.

Nutrient Analyses
The nutrient profile of all menus was analyzed using the Nutritionist Pro Software (Axxya Systems LLC, Redmond, WA, USA), which refers to the FoodData Central Database of the United States Department of Agriculture [23]. We omitted salt and seasonings in the menu construction and nutrient analysis because the use of these condiments varied by individual preferences and cooking practices, which did not reflect the nutrient composition differences caused by the substitution of animal-based protein with plant-based protein. Therefore, the sodium content of all menus reflected the sodium naturally found in foods. Similarly, the potassium content reflected the natural presence of potassium in foods as a salt substitute such as potassium chloride was not included in the menu planning and nutrient analysis. We presented the exact value of the phosphorus content of all diets that was reported in the database without factoring in the bioavailability of phosphorus sources. The phosphorus content may be underestimated because phosphorus-containing food additives were not accounted for in the food composition database.
We also calculated the Potential Renal Acid Load (PRAL) based on the nutrient composition of all types of LPDs and MHPDs using the formula as described by Remer et al. [24]: A diet with a positive PRAL value indicates acid is produced while a diet with a negative PRAL value indicates base is produced.

Defining Nutritional Reference Values
We determined the adequacy of EAAs by referencing the Recommended Dietary Allowance (RDA) for adults (19 years and older) [25]. The recommendation for eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) was set at 250 mg/day [26]. The adequacy of dietary fiber was based on the Adequate Intake (AI) for total dietary fiber, which was 14 g/1000 kcal [25]. Since the energy prescription was 2100 kcal, the AI of the fiber was set at 29 g/day. We determined the adequacy of thiamine, riboflavin, niacin, folate, cobalamin, magnesium, copper, iron, and zinc according to their RDAs, while the AI for manganese was used as the reference value to determine adequacy [27][28][29]. CKD-specific recommendations were used as reference values for selected nutrients such as sodium, calcium, and pyridoxine [3,30]. There was no specific reference value for dietary phosphorus and potassium because the recommendation of the updated Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline is to adjust the dietary intake of these two minerals to maintain serum phosphate and potassium within the normal range [3].

Results
The composition of macronutrients in the LPDs (0.5-0.8 g protein/kg/day) is presented in Table 2. The energy ranged from 2016-2229 kcal or 29-32 kcal/kg based on the reference body weight of 70 kg. The vegan LPDs had the greatest carbohydrate and fiber, whereas the lacto-ovo LPDs had the highest fat content. Only the conventional and PLADO LPDs met the WHO recommendations for EPA and DHA, while the EPA and DHA content in vegan and lacto-vegetarian LPDs was almost negligible. At the dietary protein prescription of 0.5 g/kg/day, no diet met the RDA for threonine, leucine, lysine, and histidine. Furthermore, the PLADO, lacto-vegetarian, ovo-vegetarian, and vegan diets did not meet the RDA for methionine + cysteine. The percent adequacy for these EAAs according to their RDA is presented in Figure 1A. At the dietary protein prescription of 0.6 g/kg/day, the conventional diet met the RDA for all EAAs. The PLADO, ovo-vegetarian, lacto-vegetarian, and lacto-ovo-vegetarian diets were below the RDA only for lysine, whereas the vegan diet did not meet the RDAs for lysine and methionine + cysteine. The percent of adequacy for these EAAs according to the RDAs is presented in Figure 1B. With diets at 0.7 g protein/kg/day and greater, all plant-based and vegetarian diets as well as the conventional diet met the RDA for all EAAs.
The composition of macronutrients in the MHPDs (1.0-1.2 g/kg/day) is presented in Table 3. The energy ranged from 2079-2410 kcal or 20-34 kcal/kg based on the reference body weight of 70 kg. The vegan MHPDs had the greatest amount of carbohydrate and dietary fiber, whereas the lacto-ovo MHPDs had the highest fat content. Only the conventional and PLADO MHPDs met the WHO recommendations for EPA and DHA, whereas the EPA and DHA content in the vegan and lacto-vegetarian LPDs were almost negligible. All MHPDs met the RDA for each EAA.
The macromineral, trace element, and vitamin content of LPDs and MHPDs are presented in Tables 4 and 5, respectively. The plant-based and vegetarian diets contained a greater amount of potassium, phosphorus, and calcium than the conventional diet. On the other hand, the conventional diet contained a relatively greater amount of sodium compared to the plant-based and vegetarian diets, although the sodium content was still below the amount usually recommended for CKD patients [3]. The plant-based and vegetarian LPDs, but not the conventional LPD, met the RDA for copper, whereas all MHPDs met the RDA for copper. All LPDs and MHPDs also met the AI for manganese. No LPD met the RDA for zinc, whereas only vegan MHPDs (≥1.0 g/kg/day), lacto-ovo-vegetarian MHPDs (≥1.1 g/kg/day), lacto-vegetarian MHPDs (≥1.1 g/kg/day), and ovo-vegetarian MHPDs (≥1.2 g/kg/day) were adequate. Similarly, no LPD met the RDA for magnesium, but vegan MHPDs (≥1.0 g/kg/day), lacto-vegetarian MHPDs (≥1.1 g/kg /day), and ovo-vegetarian MHPDs (≥1.2 g/kg /day) met the RDA for magnesium. All LPDs and MHPDs met the RDA for iron for both men and women above 50 years old (8 mg/day), whereas vegan diets (≥0.6 g/kg/day), ovo-vegetarian diets (≥0.7 g/kg/day), ovo-vegetarian diets (≥0.8 g/kg/day), PLADO diets (≥0.8 g/kg/day) and lacto-ovo-vegetarian diets (≥1.0 g/kg/day), but not the conventional diet, met the iron RDA for only women 19-50 years old (18 mg/day) [29].
For the B vitamins, all LPDs and MHPDs met the RDA for thiamine and folate, whereas no LPD or MHPD met the CKD-specific recommendation for pyridoxine. No LPD met the RDA for riboflavin except the lacto-ovo vegetarian LPDs (≥0.6 g/kg/day). The ovovegetarian and lacto-vegetarian diets at a protein prescription ≥1.1 g/kg/day met the RDA for riboflavin. None of the ovo-vegetarian and lacto-ovo-vegetarian diets met the RDA for niacin, whereas conventional LPDs (≥0.6 g/kg/day), PLADO LPDs (≥0.7 g/kg/day), vegan MHPDs (≥1.1 g/kg/day), and lacto-vegetarian MHPDs (≥1.2 g/kg/day) met the RDA for niacin. With regard to the RDA for cobalamin, none of the ovo-vegetarian, lacto-vegetarian, and vegan LPDs or MHPDs met this RDA, whereas the conventional diets (≥0.6 g/kg/day), PLADO diets (≥0.6 g/kg/day), and lacto-ovo-vegetarian diets (≥0.7 g/kg/day) met the RDA for cobalamin. Figure 2 shows the PRAL of all types of LPDs and MHPDs. All PLADO, lactovegetarian, and vegan diets had negative PRAL, though at a decreasing trend when the protein prescription increased. The ovo-vegetarian diets had negative PRAL values at protein prescriptions from 0.5 to 1.1 g/kg body weight/day, and the PRAL value became positive at protein prescription of 1.2 g/kg body weight/day. The conventional and lactoovo-vegetarian diets had negative PRAL values at protein prescription below 0.8 g/kg body weight/day, and the PRAL values became positive at 1.0 g protein/kg body weight/day and above. Table 3. Macronutrients, essential amino acids, and long-chain n-3 polyunsaturated fatty acids of conventional, plant-based, and vegetarian moderately high protein diets.

Discussion
The World Health Organization recommends that the safe level of protein intake for healthy adults is 0.83 g/kg body weight per day, for proteins with protein digestibilitycorrected amino acid score value of 1.0 [31]. The LPDs (0.6-0.8 g/kg) prescribed to nondialysis dependent CKD patients have been recommended to include at least 50% high biological value protein to ensure the adequacy of dietary needs [22]. Our LPD food pattern modeling concurred with this recommendation, since only the conventional LPD (0.6 g/kg/day) containing at least 50% of the animal-based protein met the RDA for all EAAs. However, the plant-based and vegetarian diets only met the RDA for all EAA with the protein prescription of >0.7 g/kg and above, and these EAAs are likely to be deficient when the protein intake is restricted to 0.6 g per kg body weight.
Plant proteins typically are less abundant than animal proteins in certain EAAs, especially methionine and lysine [15]. A cross-sectional study comparing the dietary intake and plasma concentration of amino acids among healthy men based on their habitual dietary intakes reported that vegans had the lowest dietary intake and plasma concentrations of lysine and methionine compared to meat-eaters, fish-eaters, and vegetarians [32]. Table 6 shows the content of selected EAA of proteins from different food sources in one exchange (7 g protein). For an LPD providing 0.6 g protein/kg/day or 42 g/day (using the reference body weight of 70 kg), three exchanges (21 g protein) of animal protein, such as fish or poultry, provide about 55-75% of the RDA for leucine, lysine, and methionine plus cysteine. However, when the animal proteins are substituted with plant protein such as tofu, lentils, or beans, the content of EAAs are expected to be lower, since three exchanges of these plant proteins provide only 50-55% of the RDA for leucine and lysine, and 30-40% of the RDA for methionine plus cysteine. As the protein prescription becomes higher (≥0.7 g/kg/day) and more plant proteins can be included in the diet, it is then possible for the diet to meet the RDAs for all EAAs. Table 6. Selected essential amino acids of protein food sources (7 g protein).

Fish (King Mackerel) Chicken Egg Whole Milk Tofu Lentils Chickpeas
Barsotti et al. [16] and Soraka et al. [18] demonstrated that a vegetarian LPD with a protein prescription of 0.70-0.75 g per kg body weight could meet their reported requirements for all EAAs. The authors noted that the patients prescribed with these diets did not experience a deterioration in nutritional status, even though the vegetarian LPD was proportionally lower in lysine, leucine, and methionine in comparison to both animal-based diets of lower protein content and the RDAs. There are several possible explanations for these observations. First, the RDA for a nutrient is determined if the dietary intake provides nutritionally sufficient amounts of that nutrient for about 97% of a normal population [25]. By this criterion, most people could ingest less than the RDA of a given nutrient and yet still receive a sufficient amount of that nutrient to be nutritionally adequate for them. Secondly, patients' actual dietary protein intake might be more than what they were prescribed, at least some of the time [33]. Third, a limitation may arise from their nutritional assessment approach to determining patients' protein-energy status which was not sufficiently sensitive as it relied only on body weight and serum proteins, whilst the patient's vitamin, mineral, and trace element status were not evaluated by these studies.
To the best of our knowledge, the lowest protein content for a vegan diet for CKD patients that has been previously examined was 0.7 g/kg body weight/day, and the methods for assessing nutritional status in these patients were quite imprecise [16]. As shown in Table 6, plant proteins are inherently low in lysine and methionine. Therefore, achieving the RDA of these EAAs is very unlikely when the diet is low in protein (0.6 g/kg) and contains exclusively plant proteins at the same time. The PLADO low protein diet (0.6 g/kg) consisting of only 30% animal proteins was also deficient in lysine. In fact, our data indicate that the conventional low protein diet (0.6 g/kg) with 50% animal proteins also marginally met the RDA for lysine (108%). Nonetheless, many nitrogen balance studies indicate that a 0.60 g protein/kg/day diet providing about 50% of protein of high biological value (i.e., animal protein) will maintain neutral or positive nitrogen balance in advanced CKD patients who are not undergoing dialysis therapy [22,34].
Although the data from this food pattern modeling indicated that a well-planned plantbased or vegetarian LPD (≥0.7 g/kg/day) can meet the RDA for all EAAs, the RDA is not CKD-specific. It is possible that there are alterations in the dietary requirements for some EAAs in people with CKD, especially if such individuals have comorbid conditions [35][36][37][38]. Patients with advanced CKD have altered plasma and tissue amino acid profiles [39][40][41]. There is evidence for intracellular taurine depletion in nondialyzed CKD and maintenance hemodialysis patients [35,36,42], and plant foods are markedly deficient in taurine [43]. Therefore, a plant-based or a vegan diet may be unable to supply a sufficient amount of taurine or other sulfur containing amino acids to maintain normal cellular taurine levels [44], and CKD and chronic dialysis patients consuming vegan diets could be at risk for taurine deficiency. Future studies are indicated to confirm that these plant-based and especially vegan LPDs are nutritionally adequate for CKD patients. These considerations also suggest that CKD and chronic dialysis patients adhering to a vegan LPD should be monitored especially closely to assess their nutritional status and to prevent proteinenergy wasting. This issue may be especially challenging in low-and middle-income Asian countries with limited dietitian accessibility [45] and where malnutrition risk may be particularly high, chronic infections such as tuberculosis are endemic [46], and populations have marginal protein intakes [47].
A recent review of observation studies by Picard et al. [48] reported that free-living CKD patients consuming vegetarian or plant-based diets had a significantly lower selfreported dietary protein intake. However, the effects of this lower protein intake on the patients' protein-energy status were not carefully assessed; only serum albumin levels were reported, and serum albumin, which was not different in the patients consuming the animal-based vs. the plant-based diets, is rather a more sensitive indicator of inflammation than nutritional status [49]. Nevertheless, this review supports the contention that CKD patients prescribed LPDs, and especially plant-based or vegetarian LPDs, should be counselled by experienced dietitians, and their protein-energy status should be periodically monitored [48]. An epidemiological study of Chinese maintenance hemodialysis patients suggested that the proportion of plant-based proteins in their diet bore a U-curve relationship with adjusted all-cause mortality and cardiovascular mortality [49]. The lowest adjusted mortality rates were observed in the maintenance dialysis patients who ingested plant-based and animal-based proteins in approximately a 0.45 ratio. Hence, 55 percent of the food intake was animal-based for this data. This study was limited by the fact that the assessment of food intake was made for three separate 24 h periods at the beginning of the median follow-up period of 28 months [50].
The preceding discussion indicates that plant-based LPDs may place CKD patients at increased risk for nutritional deficiencies, especially if these diets provide less than 0.7 g protein/kg/day. However, plant-based diets might also increase the intake of other nutrients to unwanted levels. For CKD patients, this may be particularly the case for potassium and phosphorus, which could exacerbate electrolyte imbalances in patients with CKD [10]. Indeed, the vegetarian LPDs and MHPDs contained greater amounts of potassium and phosphorus than the conventional and plant-based diets, as shown in Tables 4 and 5. This is especially true for the vegan diets. The sodium content of these diets reflected only the sodium found naturally in foods, and the amount was substantially lower than what a person would normally consume. As condiments and seasonings were not included in nutrient analysis, the potassium and phosphorus contents were also underestimated because certain condiments commonly used in Chinese cuisine such as soy sauce, oyster sauce, and fish sauce also contain significant amounts of potassium and phosphorus [51].
In this study, we did not include vegetarian meat substitutes that may contain substantial amounts of sodium, potassium, and phosphorus [52]. In addition, these plant-based meat alternatives are low in certain nutrients such as zinc, calcium, and vitamin B12 [53]. Therefore, natural or unprocessed plant-based proteins were chosen. Although the phosphorus of plant-based foods is generally believed to have lower bioavailability (10-30%) due to the phytates in these diets, a review of human intervention studies suggests that a much greater amount of phytate-phosphorus is absorbed (at least 50%). Commercial food processing also increases the amount of bioavailable phosphorus. Therefore, the phosphorus of plant proteins, particularly those that are highly processed, should not be assumed to be poorly absorbed [54]. Nevertheless, the phosphorus bioavailability of plant foods is still lower than animal foods. On the other hand, the dairy products included in the lacto-and lacto-ovo vegetarian diets are significant sources of dietary phosphorus and calcium. The high dietary calcium content might increase the risk of calcium deposition in tissues, which is a not an uncommon occurrence amongst advanced CKD patients [55].
Plant-based and vegetarian diets may also lack some other essential nutrients that are more prevalent in foods of animal origin, such as long-chain n-3 PUFAs and vitamin B-12 or cobalamin [56]. A cross-sectional study showed that fish-eaters had a greater dietary intake of long-chain n-3 PUFAs than vegetarians or vegans. However, the difference in plasma long-chain n-3 PUFAs status between fish-eaters and vegetarians or vegans was smaller than expected, possibly due to a greater estimated precursor-product ratio of dietary α-linolenic acid to long-chain n-3 PUFAs among vegetarians or vegans [57]. Therefore, patients adhering to a plant-based or vegetarian diet should be encouraged to consume foods high in α-linolenic acid to ensure optimal plasma n-3 PUFAs status. On the other hand, since vitamin B-12 is obtained exclusively from animal sources, CKD patients adhering to a vegetarian diet must consume vitamin B-12 fortified foods or dietary supplements to prevent deficiency [5].
On the other hand, it is worthwhile to highlight that the planned plant-based and vegetarian diets contained a relatively greater amount of dietary fiber than the conventional diet that was basically animal-based. Meta-analyses of experimental studies have demonstrated the benefits of dietary fiber supplements (dosage ranging from 7 to 50 g/day) in reducing serum urea, creatinine, and p-cresyl sulphate [58,59]. In our study, the fiber content of the plant-based or vegetarian LPDs (0.5-0.8 g/kg/day) was greater than the conventional LPDs by 8-20 g/day. In addition, plant proteins such as beans, legumes, and lentils have a lower PRAL than animal proteins such as meat, cheese, and eggs [60]. Both epidemiological studies [61,62] and clinical trials [63,64] have indicated that even mild acidosis can be associated with more rapid progression of CKD, and a diet that is low in its PRAL may slow such progression [65,66]. However, our study showed that the PRAL values of the conventional LPDs were not substantially higher than the plant-based or vegetarian diets when the protein content was low (0.5-0.6 g/kg body weight/day).
Plant proteins also do not contain cholesterol and have a lower saturated fat content than animal proteins. However, the evidence does not indicate that advanced CKD or chronic dialysis patients who ingest lower cholesterol diets or who are taking statins have less cardiovascular disease or reduced mortality [67]. Consumption of plant-based foods is proposed to confer planetary benefits as negative impacts of large-scale meat production on the environment in terms of the land use, water use, and the emission of greenhouse gases have been highlighted [68]. It should be considered though that for many Asian countries, animal proteins are often derived from seafood, poultry or pork, rather than from cattle [69]. With caution, plant proteins may be encouraged for individuals with CKD as long as the diet is carefully planned to ensure that the overall nutritional adequacy is met. As our study suggests, the 0.60 g protein/kg/day diet, it may be difficult to ensure sufficient amounts of all of the EAAs without including animal protein.
Our study had some limitations. Firstly, the LPD and MHPD modeling was based on an ideal menu planning that is theoretical in nature and therefore may not necessarily reflect habitual dietary intakes of any individual CKD patient. Secondly, the modeling study was based on food choices commonly consumed in Asian cuisine, mainly Chinese and Indian. Therefore, these findings may not be generalized to other Asian food cultures, but analysis of these Chinese and Indian hospital-based diets may provide useful insights to food choices across the Asian spectrum. In addition, we determined the amino acid content using a food composition database (FoodData Central) rather than by direct laboratory analytical procedures. In addition, variability in the composition of foods may exist between regions and between countries. However, this concern also raises the possibility that some foodstuffs might contain fewer essential nutrients than is reported in this database. Moreover, we did not include protein-free products (e.g., pasta, bread, and flour) in planning the LPDs, which, if included, would reduce the proportion of protein from cereals and allow the inclusion of a greater amount of protein food sources for the LPDs. However, such products are atypical to Asian societies and therefore have limited availability in food retail, whereas rice is the staple cereal of choice in the Asian region [70]. Lastly, the actual phosphorus content of the diets may be substantially higher than is indicated in the food composition database because the widely prevalent use of phosphorus-based additives was not taken into account and potentially available in readyto-use spice powders, flavorings, and ultraprocessed foods available to Indian and Chinese societies. Moreover, the varying bioavailability of phosphorus in different food sources was not addressed in our calculations.

Conclusions
Our food pattern modeling indicated that the Asian plant-based and vegetarian diets providing 0.7 g protein/kg/day or more could meet the RDA for all EAAs. However, at the protein prescription of 0.6 g/kg/day, only the conventional diet consisting of 50% high biological protein from animal-based foods is able to meet the RDA of all EAAs, while the vegetarian or plant-based LPDs are likely to be deficient in EAAs. Therefore, a higher protein level (at least 0.7 g protein/kg/day) should be considered for individuals who wish to adhere to vegetarian or plant-based diets, and these diets must be carefully planned because the protein prescription is still below the RDA. With regards to macrominerals, plant-based and vegetarian diets contained a considerable amount of potassium, phosphorus, and calcium as compared to the conventional diet. The conventional diet was low in essential nutrients such as zinc, copper, magnesium, riboflavin, and pyridoxine while plant-based and vegetarian diets were low in n-3 long-chain polyunsaturated fatty acids, magnesium, riboflavin, niacin, pyridoxine, and cobalamin. The use of a multivitamin and trace element supplement should be considered with these diets. The foregoing data indicate that prescription of all LPDs for CKD patients requires careful planning and continued monitoring.

Data Availability Statement:
No new data were created in this study. Data sharing is not applicable to this article.