Next Article in Journal
Dietary Recommendations for Post-COVID-19 Syndrome
Previous Article in Journal
Dietary Complex and Slow Digestive Carbohydrates Promote Bone Mass and Improve Bone Microarchitecture during Catch-Up Growth in Rats
Previous Article in Special Issue
Unraveling the Metabolic Hallmarks for the Optimization of Protein Intake in Pre-Dialysis Chronic Kidney Disease Patients
 
 
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Plant-Based Diets and Peritoneal Dialysis: A Review

1
Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
2
Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
3
Department of Medicine, NYC Health + Hospitals/Bellevue, New York, NY 10016, USA
*
Author to whom correspondence should be addressed.
Nutrients 2022, 14(6), 1304; https://doi.org/10.3390/nu14061304
Received: 31 January 2022 / Revised: 5 March 2022 / Accepted: 17 March 2022 / Published: 19 March 2022
(This article belongs to the Special Issue Eating Habits, Nutrition and Chronic Kidney Disease)

Abstract

:
Whole food plant-based diets are gaining popularity as a preventative and therapeutic modality for numerous chronic health conditions, including chronic kidney disease, but their role and safety in end-stage kidney disease patients on peritoneal dialysis (PD) is unclear. Given the general public’s increased interest in this dietary pattern, it is likely that clinicians will encounter individuals on PD who are either consuming, considering, or interested in learning more about a diet with more plants. This review explores how increasing plant consumption might affect those on PD, encompassing potential benefits, including some specific to the PD population, and potential concerns.

1. Introduction

Whole food plant-based diets (WFPBD: a dietary pattern that focuses on unprocessed foods derived from plant sources (fruits, vegetables, whole grains, and legumes) while avoiding animal-based products (meat, fish, dairy, and eggs) and processed plant products (including vegetable oils and most pre-cooked, pre-packaged products sold in grocery stores)) are increasingly recommended for the prevention and management of conditions such as obesity [1], hypertension [2,3], diabetes [4,5], and cardiovascular disease [6,7,8]. There is also increasing evidence that plant-based diets may be beneficial in the prevention [9] and management of chronic kidney disease [10,11,12]. Whether plant-based diets are advantageous in individuals with end-stage kidney disease (ESKD), particularly those on peritoneal dialysis (PD), is unclear.
As of 2018, there were approximately 58,500 individuals on PD in the United States, representing about 10.6% of the total dialysis population [13]. Those on PD have a high mortality rate and a large burden of comorbidities, especially cardiovascular disease [13]. Data from the United States Renal Data System shows 1-, 3-, and 5-year mortality rates for people on peritoneal dialysis to be 10%, 32.4%, and 53.1%, respectively, with cardiovascular disease (CVD) accounting for 41% of deaths [13]. The predominance of CVD (amenable to amelioration with a WFPBD), as a cause of mortality, and the high prevalence of risk factors such as hypertension and diabetes (also amenable to amelioration with a WFPBD) in PD patients [13,14] suggests that dietary intervention may be a strategy to reduce mortality in the PD population.
To date, data on plant-based diets are limited in the PD population, and the interpretation of existing data in any population is complicated by a lack of consistency in the use of the term “plant-based”. They may differ as to the degree of the plant-based component (i.e., totally vs. predominately plant-based, with varying amounts of animal products) and the degree to which the diets consist of whole foods (some diets may be completely plant-based or vegan but contain a large amount of processed foods). Nonetheless, PD patients have several common comorbidities in which a WFPBD may theoretically be of benefit.
Peritonitis is arguably the most concerning complication of PD. Despite a decreasing incidence, peritonitis remains the most common cause of technique failure among individuals using PD [15], and it confers a significant risk of hospitalization and mortality [16]. One potential source of peritonitis in PD patients is the enteric translocation of organisms. While there are currently no data on the association between dietary patterns and peritonitis risk, one can speculate that WFPBDs may offer some protection from this particular route of infection due to beneficial effects on the gut microbiome and dysbiosis. Constipation, fiber deficiency, and hypokalemia are common in PD patients, and eating more plants can help ameliorate all of these, as will be discussed below.
As the popularity of and interest in plant-based eating increases [17,18], it is likely that clinicians will encounter individuals using PD who are either consuming, considering, or simply interested in this dietary pattern. This narrative review explores the current state of knowledge and reviews the potential benefits and concerns of plant-based diets and increasing plant intake in the PD population.

2. Potential Benefits of Plant-Based Diets in the Peritoneal Dialysis Population

2.1. Mortality

To date, no studies have examined the effect of eating a completely WFBPD compared with other dietary patterns on mortality in the ESKD population. In hemodialysis (HD) patients, an increased fruit and vegetable intake (although still within the context of continued consumption of animal products) is associated with a decrease in all-cause mortality [19].
In peritoneal dialysis patients, the data are also limited to an analysis of the degree of plant-based eating (within a dietary pattern that also contains animal products), rather than a completely WFPBD per se. In a retrospective study of 884 Chinese peritoneal dialysis patients, those in the highest tertile of plant protein intake (>57.5% of protein from plant sources) had a 24% decrease in mortality compared to the lowest tertile (<47.7% of protein from plant sources), despite their absolute total protein intake being lower (48.7 vs. 54.7 g per day) [20]. A subgroup analysis in this study showed that not all subjects achieved this benefit. Specifically, the mortality benefit was seen in females, those over 60 years old, and those with a baseline albumin of >3.5 g/dL. This suggests that eating more plants (and hence, more plant-based protein) may help mitigate mortality in the PD population. Prospective (ideally randomized) studies would be needed to further test this hypothesis and to determine which subgroups would derive this benefit.

2.2. Volume Overload and Sodium Intake

Volume overload is common in individuals on PD. The International Society of Peritoneal Dialysis cardiovascular and metabolic guidelines consider its assessment a “vital component in the management of PD patients” [21]. Volume overload decreases survival. In a cohort study of >1000 patients, Van Biesen et al. [22] demonstrated via bioimpedance spectroscopy that volume overload was common upon starting PD and, although improved, persisted even after three years of dialysis, with a mean degree of volume overload of 7.7%. Further analysis showed that those above the 75th percentile of volume overload at one month had a 59% increased risk of mortality [22].
One of the mainstays in controlling volume overload in the PD population is sodium restriction. Günal et al. [23] demonstrated that many PD patients could improve volume status and achieve blood pressure control via meticulous attention to sodium intake (via a “salt-poor diet and not using ready-made food”). Plant-based diets are often lower in sodium than other dietary patterns. Several studies have shown that vegans consume less than half the amount of sodium than that of the reference group of either omnivores [24] or the general population [25]. Given this, one can speculate that a nutritionally adequate plant-based diet may be a beneficial strategy in controlling volume overload in individuals on PD with the caveats that (a) it is possible to eat a high sodium plant-based diet if one relies heavily on processed foods (including meat analogs, which are increasingly available in grocery stores) and (b) a lower sodium diet that comes at the expense of adequate protein or energy intake, which should be avoided as it may increase mortality in the PD population [26]. Finally, it should be noted that plant foods have a higher water content than non-plant foods and may require a reduction in free fluid intake to maintain euvolemia.

2.3. Constipation/Fiber

Constipation is a common problem for those on PD and may have serious consequences due to its effect on the dialysate flow and an increased risk of peritonitis [27]. Although constipation is a multifactorial process, a deficiency of dietary fiber is a major contributing factor. People on PD on average consume between 8 and 9 g of fiber per day [28,29], both well short of that recommended by the Institute of Medicine (25 or 38 g for women and men 19–50 years old, respectively, and 21 or 30 g for those over the age of 50) [30], As such, increasing dietary fiber has been recommended as a first-line therapy for patients with constipation on PD [27], and studies have shown improvement in constipation with this approach [31,32,33].
Although the dietary fiber intake can be increased using supplements, plant-based diets are naturally high in fiber and may also be used to treat constipation. Since fiber is exclusively found in plant-foods, it is not surprising that those consuming plant-based diets have significantly higher daily intakes of fiber compared to those not following this diet plan [34,35], with one study showing that vegans consume 74% more fiber than non-vegetarians [34].
In addition to its role in improving constipation, increased fiber intake may offer other beneficial effects in individuals on peritoneal dialysis. A cross-sectional study showed that those with dietary fiber intake >12.2 g per day had a lower concentration of inflammatory markers in both serum and dialysate [28]. In a cohort study of 881 peritoneal dialysis patients, those in the middle or highest tertile of dietary fiber intake (although still low at 7.8 and 11.8 g/day) showed an increase in albumin over time compared with the lower group [29]. There was also a trend toward increased mortality in the lowest tertile, although this did not achieve significance. From these studies, however, it is not possible to conclude whether fiber per se was offering these benefits or another aspect of consuming higher fiber diets, and further studies would be needed to determine this.

2.4. Gut Microbiome

The human gut microbiome contains trillions of bacteria, along with viruses, fungi, and archaea [36]. The microbiome exists in symbiosis with the host, and it provides many key functions, including those related to immunity; endocrine function; energy biogenesis; biosynthesis of vitamins, steroid hormones, and neurotransmitters; and the metabolism of dietary components, drugs, and branched chain aromatic amino acids [36]. While there is no “gold standard” as to what constitutes a healthy gut microbiome, differences have been noted between healthy individuals and those with a variety of disease states, including chronic kidney disease, and those on dialysis [36,37]. These differences include a decrease in overall diversity and a change in the composition of the microbiome, with different phyla being either more or less represented [37,38,39]. Collectively, this imbalance in the composition and function of the intestinal microbiota is known as dysbiosis, and it is associated with negative consequences to the host [36]. One hypothesized negative effect of dysbiosis is an alteration of the gut epithelial integrity (“leaky gut” or “leaky mucosa”), which may lead to the translocation of bacteria or inflammatory products such as endotoxins [38]. This is directly relevant to individuals on peritoneal dialysis. PD patients have high plasma levels of bacterial-derived fragments [40] and endotoxins [41,42], and some studies have shown an association between these factors and higher rates of inflammation [42,43] and pointedly cardiovascular disease [40,42], which, as noted, earlier is the number one cause of mortality in this population. Changes in gut epithelial integrity are also a concern given the not uncommon occurrence of PD-related enteric peritonitis. Dysbiosis also leads to increased production of the uremic toxins indoxyl sulfate (IS) and p-cresol/p-cresyl sulfate (PCS) [44], which have been associated with progression of kidney disease [45] in those with chronic kidney disease (CKD). Prospective studies have not been done evaluating the role of IS and PCS in individuals on PD, but these data are concerning given the importance of residual kidney function (RKF) in this population. IS and/or PCS have been shown to rise concurrently with RKF loss in those on PD [46] and have been associated with other deleterious outcomes, including technique failure, cardiac events, and mortality [47].
Diet is one of many factors which can affect the microbiome. Vegans have distinctly different microbiomes than due omnivores, whereas the data comparing vegans and vegetarians are less clear [48]. It has not been definitively demonstrated that switching diets to change microbiome composition leads to lasting health benefits. Short term, the microbiome appears to be resilient to dietary intervention, reverting back to its core composition once the intervention ends [49]. Nonetheless, there are data which suggest that a consistent plant-based diet may confer benefits via the microbiome. A small interventional study in which obese subjects ate a vegan diet demonstrated (in addition to improvement in weight, triglycerides, total cholesterol, low-density lipoprotein (LDL)-cholesterol, and hemoglobin A1c) a reduction in the number of pathobionts (organisms that cause harm only under certain circumstances (such as Enterobacteriaceae) [50]. Again, this may be directly relevant in PD, where this class of bacteria may cause peritonitis. The investigators also found a decrease in inflammatory markers [50].
Another postulated benefit of plant-based diets mediated by the microbiome is a decreased production of trimethylamine-N-oxide (TMAO), which mediates atherosclerosis. Vegetarians and vegans have decreased baseline levels of TMAO compared with omnivores, and they produced less of it when challenged with L-carnitine [51]. The potential implication of this is suggested by a recent study showing an association between TMAO with all-cause (all subjects) and cardiovascular mortality (male subjects) in individuals on PD [52].
The microbiome also produces short chain fatty acids (SCFA), including acetate, propionate, and butyrate [53]. Previous research has shown that children consuming a more traditional, plant-based diet produce more SCFA than those on a more Western diet [54]. SCFAs are anti-inflammatory and have a host of beneficial effects, including improved gut epithelial integrity, blood pressure regulation, and improved lipid and glucose homeostasis [53], all of which would be beneficial to the PD population.
Further research on the effects of diet on the microbiome and the microbiome in general is needed in PD patients.

2.5. Hypertension

Hypertension is common in those with ESKD, although the exact prevalence is difficult to determine given the different definitions, techniques, and settings of measurements. Several studies demonstrate that 70–80% of individuals on dialysis (including both HD and PD) are hypertensive and that the majority are uncontrolled [14,55,56]. Plant-based diets are effective in treating hypertension in the general population [2,57], and there is evidence that they benefit hypertensive CKD patients as well. In two separate randomized controlled trials, Goraya et al. [10,11] studied the effect of adding fruits and vegetables to the diets of individuals with CKD 3 and 4 and acidosis. In hypertensive patients with CKD 3 or CKD 4, those whose acidosis was treated with fruits and vegetables had the added benefit of blood pressure reduction when compared with those treated with bicarbonate (CKD 3 and CKD 4 patients) or placebo (CKD 3 patients). As noted above, Günal et al. [23] were able to achieve good hypertension control with a salt-restricted diet, but the dietary pattern(s) consumed were not clear. There have been no randomized controlled trials or cohort studies to date examining the relationship between fruit and vegetable intake or a diet higher in plants and hypertension in individuals on PD.

2.6. Metabolic Acidosis

Metabolic acidosis is common in patients with CKD, and its prevalence increases with CKD severity [58]. The consequences of metabolic acidosis include bone disease, muscle protein catabolism, decreased albumin synthesis, and increased inflammation [59]. Retrospective cohort studies have demonstrated an association between the dietary acid load or degree of metabolic acidosis and worsening kidney function in those with CKD [60,61,62].
Treating metabolic acidosis with sodium bicarbonate preserves kidney function in individuals with CKD [63], but one concern with using pharmacologic bicarbonate is the sodium load. Adjusting the acid content via changes in diet can mitigate this problem. Dietary manipulation requires an appreciation of the acidogenic potential of different foods. On the whole, animal-derived foods such as cheese, meat, and fish tend to be highly acidogenic, whereas plant-based foods tend be less so, with some grains (particularly if highly processed) being an exception [64]. Fruits and vegetables deserve special mention, as they are not only less acidogenic than animal-based foods, but are actually alkaline or acid consuming [64].
In CKD patients, the treatment of metabolic acidosis with fruits and vegetables (in the context of a diet still containing animal protein) leads to a decrease in net acid excretion [65], a reduction in blood pressure and weight, and, in CKD 3 patients, a decrease in the rate of progression of kidney disease similar to that seen with bicarbonate [11].
The relationship between bicarbonate concentration to adverse outcomes is less well-defined in PD patients. A prospective study of >400 PD patients showed that those with a time-averaged serum bicarbonate <24 mEq/L had a higher risk of becoming anuric and of residual kidney function decline compared with those >24 mEq/L [66]. Two small randomized trials have examined using bicarbonate in PD patients with a bicarbonate level <24 mEq/L [67,68]. Both showed an improvement in acidosis. One trial showed a preservation of residual kidney function [67], whereas the other did not, although it did note improvement in nutritional status via the subjective global assessment score [68]. Studies comparing either a plant-based diet or the selective enhancement of fruit and vegetable consumption on acidosis correction and residual kidney function preservation as done in the CKD population have not been done in those on PD.

3. Potential Disadvantages of Plant-Based Diets in the Peritoneal Dialysis Population

3.1. Potassium/Hyperkalemia

One major concern with advocating plant-based diets in those on dialysis is the risk of hyperkalemia. Fear of hyperkalemia often results in advice to reduce dietary potassium, potentially depriving those with kidney disease of the cardiovascular benefits associated with increased potassium intake [69]. Several considerations may help mitigate this concern.
It is important to note that hypokalemia is not uncommon in those on PD [70,71,72]. An observational cohort study of >100,000 dialysis patients (including >10,000 on PD) found a 4.7-fold increased risk in hypokalemia for those on PD compared to those on HD [72]. Hypokalemia was shown to be a risk factor for all-cause, cardiovascular, and infection-related mortality in individuals on PD, and the increased risk for mortality with a K+ < 3.5 mEq/L was comparable to that with a K+ of 5.5 mEq/L or higher [72]. The increase in mortality, cardiovascular mortality, and infection-related mortality with hypokalemia was also demonstrated in a cohort of Brazilian individuals on PD, in which the authors used a propensity-matched score analysis as an attempt to reduce confounding [73].
Hypokalemia was shown to be a risk factor for peritonitis in a cohort of PD patients in Taiwan, particularly with bacteria of enteric origin [74]. The authors hypothesized that hypokalemia may lead to bowel dysmotility, may be a sign of overall malnutrition, and may be responsible for altering the immunologic defense, leading to translocation of bacteria from the gut into the peritoneum [74].
Whether or not correcting hypokalemia in PD patients leads to improved outcomes has not been evaluated, but it has been estimated that 10–29% of hypokalemic PD patients use potassium supplements [72]. In these patients, diets high in plant-based foods and rich in potassium may be an appropriate (albeit unproven) strategy to help improve serum potassium, while providing benefits such as fiber, alkali, and phytochemicals not found in supplements.
While augmenting dietary potassium in frankly hypokalemic patients, even if not helpful, is unlikely to be harmful, concern may remain for those with a normal serum potassium. Although the safety of plant-based diets has not be evaluated in individuals on PD with normal potassium, some data suggest that these concerns may be unwarranted.
While a plant-based diet is potassium rich, it is often overlooked that animal proteins, such as dairy and meat (especially organ meats), also are high in potassium [69]. Several studies show that the difference in the amount of potassium consumed by vegans and those following other dietary patterns (in the general population) is either not very large or non-existent [24,25,34]. Food additives may be a hidden source of potassium in animal products, surreptitiously increasing its intake, often dramatically [75]. Additives may be a particular concern in low sodium processed foods [76]. Another consideration is the method of cooking and consumption. Boiling fruits or vegetables decreases potassium content, whereas drying them or processing them into juices or sauces increases it [12,69].
Potassium bioavailability may be a consideration. The relationship between potassium intake and serum potassium levels in patients with ESKD on HD does not seem to be linear or robust. In a study of more than 8000 hemodialysis patients, dietary potassium was not associated with serum potassium levels, hyperkalemia, or either cardiac or all-cause mortality [77]. Similarly in a secondary analysis of the Nutritional Inflammatory Evaluation Study, pre-HD potassium levels were not significantly different between quartiles of K+ intake, and when potassium intake was examined as a continuous variable, the absolute difference in serum K+ between the highest and lowest dietary levels was only 0.4 mEq/L [69,78].
For those on PD, there are no studies specifically examining dietary potassium intake and serum potassium. In the study by Liu et al. noted above, there were no differences in serum potassium between the highest and lowest tertile of plant protein intake (again in the context of a diet containing animal products), although dietary potassium was not specifically assessed [20].
Importantly, the bioavailability of potassium changes with the form of potassium in the diet. In those with normal kidney function, eating foods processed such that cell walls are disrupted led to a 25% increase in potassium bioavailability [79]. Several studies in CKD suggest a differential bioavailability of potassium from plant protein and animal protein [80,81].
Again, studies in PD are limited. Blumenkrantz and colleagues [82] reported the results of metabolic balance studies in PD patients consuming diets differing in the amount of protein (1 g/kg/day vs. 1.4 g/kg/day) and potassium (64 mEq/day vs. 84 mEq/day). While the serum potassium values were not reported in the study, the authors commented in the discussion that “Serum potassium levels were normal or in the lower-range of normal in most patients. These findings were present despite the rather high potassium intake, particularly with the higher protein diet.” [82]. Taken together, the available data suggest that in CKD and ESKD patients, including those on PD, consuming a diet high in unprocessed plant foods may not lead to as great an increase in serum K+ as one might initially expect.
How might individuals with potentially severely compromised kidney function maintain normal potassium levels despite increased dietary intake? Alkalemia and insulin tend to promote the cellular uptake of potassium, and the consumption of plant food, particularly fruits and vegetables, may induce both insulin secretion and a more alkalemic (or at least less acidemic) environment [83]. Although the cellular uptake of K+ may temporize, absorbed K+ must eventually be excreted to maintain balance. In individuals without CKD, the kidneys excrete most of the absorbed potassium. In individuals with dialysis-dependent ESKD, dialysis obviously is a major source of K+ removal. CKD patients (receiving dialysis or not) can also augment colonic K+ loss. Early balance studies by Hayes et al. showed that as kidney function worsens, the ability of the colon to excrete potassium in the face of an increased dietary load was higher in those with kidney disease than those without [84]. HD patients were able to increase stool potassium by 3-fold or more compared with normal controls [84]. It is not clear whether PD patients can augment fecal potassium excretion similarly to those on HD, although Blumenkrantz et al. [82] found that PD patients do seem to increase stool K+ excretion to some degree in the face of increased dietary intake, noting that “High fecal potassium losses … in all patients probably helped maintain normal serum potassium concentrations.” A plant-based diet, which is high in fiber, may also augment K+ excretion via increased stool volume, further attenuating a potential rise in serum K+, whereas diets high in potassium from animal sources or chemical additives may not have this effect. Further research is needed to investigate this speculative benefit.

3.2. Phosphorus

As with other CKD patients, hyperphosphatemia is a concern in those on PD, although data regarding phosphorus levels and outcomes are surprisingly scant. Several large epidemiologic studies have shown that phosphorus levels ≥6.4 mg/dL (PD and HD) [85], ≥6.5 mg/dL (PD only) [86], or ≥7 mg/dL (PD only) [87] are associated with all-cause mortality, although no studies have shown that intervention improves outcomes. Despite this, most nephrologists do treat hyperphosphatemia, and the 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) guidelines recommend (albeit with weak evidence) “lowering elevated phosphate levels toward the normal range” for all CKD patients, including those on dialysis [88]. In an effort to control serum phosphorus, dialysis patients are often advised to restrict their dietary intake of phosphorus [88] and prescribed phosphorus binders. The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) showed that approximately 75% of individuals using PD worldwide use phosphorus binders [87]. In addition to the risk of adverse events [89] (mainly gastrointestinal or, in the case of calcium binders, hypercalcemia), phosphorus binders account for almost half of the pill burden for those on PD [90]. Concurrently, people on dialysis are also often counselled to eat high-protein foods, which tend to contain a lot of phosphorus, leading to potential confusion about what to eat and frustration at receiving conflicting information. Despite these efforts, serum phosphorus remains 5.5 mg/dL or above in approximately 37% of PD patients [87].
Over the last decade, the source of phosphorus in CKD patients has received significant attention. The recent Kidney Disease Improving Global Outcomes (KDIGO) guidelines also recommend that the source of phosphorus be considered [88]. It is clear that plant-based phosphorus, by virtue of its inclusion in phytate (which humans cannot readily digest due to the absence of the degrading enzyme phytase), is less absorbable than animal protein, whereas inorganic phosphate added during food processing is nearly completely absorbed [91], although phosphorous bioavailability in plant-based foods can increase depending on processing and preparation methods [92].
In a crossover feeding study in individuals with non-dialysis dependent CKD, Moe et al. [93] showed that for a given load of dietary phosphorus, plant protein leads to lower phosphorus levels than animal protein, although this type of metabolic study has not been conducted in those on PD. In their cohort study of the PD population, Liu et al. [20], found no difference in serum phosphorus in the highest tertile of the plant protein intake compared with the lowest. To date there have been no interventional trials comparing the effects of animal vs. plant protein on serum phosphorus levels in individuals on PD.

3.3. Energy and Protein Intake

PD patients are at high risk for protein energy wasting and undernutrition. A recent meta-analysis found that the median prevalence of protein energy wasting in those on PD was 36% [94]. There are concerns that plant-based diets will not supply enough protein, high quality protein, and/or energy, particularly for those who are strictly vegan.
A recent meta-analysis found that in the general population, while strict vegans did have the lowest total energy intake when compared with other dietary patterns, typically they do meet the recommended daily intake [95]. On average, those consuming a vegan diet also meet their recommended daily protein intake, defined as 0.8 g/kg [96] or >10% of total calories [97], with mean protein intakes averaging approximately 13–14% of the total caloric intake [95,98]. Studies out of Denmark and Belgium showed that vegans consume a mean of 75.5 and 82 g of protein per day compared with 94 and 112 g/day in the general population and meat eaters, respectively, although it must be noted that a small percentage of vegans may not achieve their daily recommended protein intake [24,25].
Another common concern is that plant-based protein is of a lesser biologic value compared with animal protein and that those consuming a primary plant-based diet may not ingest adequate amounts of essential amino acids. While this may be true if the diet does not provide adequate energy or is extremely restrictive and limited to just one or two food sources, this is not an issue in those consuming a varied plant-based diet with an adequate number of calories [98,99]. To date, there are no data showing that those consuming a vegan diet providing adequate energy experience any adverse effects from a protein deficiency or deficiency of any specific amino acid.
Data regarding protein intake and albumin levels in predominantly plant eaters are limited in those on dialysis. Some studies have noted lower albumin levels in vegetarians vs. non vegetarian dialysis patients [100,101], whereas others have not shown a relationship between plant protein intake and serum albumin [20,102]. In their cohort study of 884 PD patients, Liu et al. found that those in the highest tertile of the percent of protein intake from plants had higher albumin levels than those in the lowest tertile, despite lower total protein intake. Interestingly, they also had a higher energy intake as well [20]. Whether diets high in plant protein and those high in animal protein provide equivalent nutrition for those on PD deserves further study.
Protein homeostasis is of particular importance in PD, where there is the added issue of peritoneal protein loss. Albumin loss across the PD membrane averages approximately 5–8 g per day [103], and normally, this loss would be compensated by increased albumin synthesis by the liver, a process which is suppressed by inflammation [104] and chronic acidosis [105]. It is possible (but unproven) that the decrease in inflammation and improvement in acidosis afforded by more plant-based diets may compensate for, or even outweigh, the potential decrease in total protein intake. This deserves further investigation as well.

3.4. Other Considerations

Vitamin D deficiency is common in those on PD [106], and this may be an additional concern in strict vegans [107]. This concern is not trivial, as vitamin D deficiency in the PD population has been associated with numerous adverse consequences [108,109,110], including peritonitis [111]. Since Vitamin D deficiency is so common, careful monitoring and intervention are required in all individuals on PD, irrespective of dietary patterns. Vitamin B-12 is absent from a plant-based diet, and any individual consuming such a diet should take a supplement. Studies have also shown that vegans may have lower selenium, vitamin A, and iodine levels than non-vegans, although the clinical significance of this is not certain [25].
Figure 1 summarizes the potential advantages and disadvantages of plant-based diets in peritoneal dialysis.

4. Conclusions

Plant-based diets may benefit individuals on peritoneal dialysis. They have been associated with improved mortality, and they may help mitigate issues common in those on PD, such as constipation, volume and sodium overload, hypertension, and metabolic acidosis, as well as exert beneficial effects on the gut microbiome. While there are concerns regarding the effects of a plant-based diet on total energy and protein intake; malnutrition; and serum potassium, phosphorus, and albumin, these have not been borne out by available data. More research is needed to determine whether the potential benefits of plant-based diets will correspond to improved outcomes in the peritoneal dialysis population and whether the potential disadvantages are truly a clinical concern.

Author Contributions

Conceptualization, S.E.L. and S.J.; writing—original draft preparation, S.E.L. and S.J.; writing—review and editing, S.E.L. and S.J. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Acknowledgments

The authors wish to acknowledge Thu Le for thoughtful review of the manuscript.

Conflicts of Interest

S.E.L. has received an honorarium for consulting from Ultragenyx, Relypsa, and Citiustech. S.J. has received an honorarium for consulting from Insyght Interactive, Otsuka, AstraZeneca, and Vifor Pharma.

References

  1. Turner-McGrievy, G.; Mandes, T.; Crimarco, A. A plant-based diet for overweight and obesity prevention and treatment. J. Geriatr. Cardiol. JGC 2017, 14, 369–374. [Google Scholar] [PubMed]
  2. Joshi, S.; Ettinger, L.; Liebman, S.E. Plant-Based Diets and Hypertension. Am. J. Lifestyle Med. 2019, 14, 397–405. [Google Scholar] [CrossRef] [PubMed]
  3. Campbell, E.K.; Fidahusain, M.; Campbell Ii, T.M. Evaluation of an Eight-Week Whole-Food Plant-Based Lifestyle Modification Program. Nutrients 2019, 11, 2068. [Google Scholar] [CrossRef][Green Version]
  4. Barnard, N.D.; Cohen, J.; Jenkins, D.J.; Turner-McGrievy, G.; Gloede, L.; Green, A.; Ferdowsian, H. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: A randomized, controlled, 74-wk clinical trial. Am. J. Clin. Nutr. 2009, 89, 1588–1596. [Google Scholar] [CrossRef]
  5. McMacken, M.; Shah, S. A plant-based diet for the prevention and treatment of type 2 diabetes. J. Geriatr. Cardiol. JGC 2017, 14, 342–354. [Google Scholar]
  6. Patel, H.; Chandra, S.; Alexander, S.; Soble, J.; Williams, K.A. Plant-Based Nutrition: An Essential Component of Cardiovascular Disease Prevention and Management. Curr. Cardiol. Rep. 2017, 19, 104. [Google Scholar] [CrossRef]
  7. Satija, A.; Hu, F.B. Plant-based diets and cardiovascular health. Trends Cardiovasc. Med. 2018, 28, 437–441. [Google Scholar] [CrossRef]
  8. Ornish, D.; Scherwitz, L.W.; Billings, J.H.; Gould, K.L.; Merritt, T.A.; Sparler, S.; Armstrong, W.T.; Ports, T.A.; Kirkeeide, R.L.; Hogeboom, C.; et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998, 280, 2001–2007. [Google Scholar] [CrossRef]
  9. Kim, H.; Caulfield, L.E.; Garcia-Larsen, V.; Steffen, L.M.; Grams, M.E.; Coresh, J.; Rebholz, C.M. Plant-Based Diets and Incident CKD and Kidney Function. Clin. J. Am. Soc. Nephrol. 2019, 14, 682. [Google Scholar] [CrossRef][Green Version]
  10. Goraya, N.; Simoni, J.; Jo, C.-H.; Wesson, D.E. A Comparison of Treating Metabolic Acidosis in CKD Stage 4 Hypertensive Kidney Disease with Fruits and Vegetables or Sodium Bicarbonate. Clin. J. Am. Soc. Nephrol. 2013, 8, 371–381. [Google Scholar] [CrossRef]
  11. Goraya, N.; Simoni, J.; Jo, C.-H.; Wesson, D.E. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney Int. 2014, 86, 1031–1038. [Google Scholar] [CrossRef] [PubMed][Green Version]
  12. Joshi, S.; Hashmi, S.; Shah, S.; Kalantar-Zadeh, K. Plant-based diets for prevention and management of chronic kidney disease. Curr. Opin. Nephrol. Hypertens. 2020, 29, 16–21. [Google Scholar] [CrossRef]
  13. United States Renal Data System: 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States; National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda, MD, USA, 2020.
  14. Cocchi, R.; Degli Esposti, E.; Fabbri, A.; Lucatello, A.; Sturani, A.; Quarello, F.; Boero, R.; Bruno, M.; Dadone, C.; Favazza, A.; et al. Prevalence of hypertension in patients on peritoneal dialysis: Results of an Italian multicentre study. Nephrol. Dial. Transplant. 1999, 14, 1536–1540. [Google Scholar] [CrossRef] [PubMed][Green Version]
  15. Chen, J.H.C.; Johnson, D.W.; Hawley, C.; Boudville, N.; Lim, W.H. Association between causes of peritoneal dialysis technique failure and all-cause mortality. Sci. Rep. 2018, 8, 3980. [Google Scholar] [CrossRef] [PubMed][Green Version]
  16. Htay, H.; Cho, Y.; Pascoe, E.M.; Darssan, D.; Nadeau-Fredette, A.C.; Hawley, C.; Clayton, P.A.; Borlace, M.; Badve, S.V.; Sud, K.; et al. Center Effects and Peritoneal Dialysis Peritonitis Outcomes: Analysis of a National Registry. Am. J. Kidney Dis. 2018, 71, 814–821. [Google Scholar] [CrossRef]
  17. IPSOS. Retail Performance, Vegan Trends in the U.S. Available online: https://www.ipsos-retailperformance.com/en/vegan-trends/ (accessed on 3 March 2022).
  18. Wunsch, N.-G. Percentage of U.S. Consumers Interested in Alternative Diets 2018, by Generation. Available online: https://www.statista.com/statistics/875526/share-alternative-diet-us-generation/ (accessed on 3 March 2022).
  19. Saglimbene, V.M.; Wong, G.; Ruospo, M.; Palmer, S.C.; Garcia-Larsen, V.; Natale, P.; Teixeira-Pinto, A.; Campbell, K.L.; Carrero, J.-J.; Stenvinkel, P.; et al. Fruit and Vegetable Intake and Mortality in Adults undergoing Maintenance Hemodialysis. Clin. J. Am. Soc. Nephrol. 2019, 14, 250–260. [Google Scholar] [CrossRef][Green Version]
  20. Liu, X.; Hu, Z.; Xu, X.; Li, Z.; Chen, Y.; Dong, J. The associations of plant-based protein intake with all-cause and cardiovascular mortality in patients on peritoneal dialysis. Nutr. Metab. Cardiovasc. Dis. 2020, 6, 967–976. [Google Scholar] [CrossRef]
  21. Wang, A.Y.; Brimble, K.S.; Brunier, G.; Holt, S.G.; Jha, V.; Johnson, D.W.; Kang, S.W.; Kooman, J.P.; Lambie, M.; McIntyre, C.; et al. ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part I—Assessment and Management of Various Cardiovascular Risk Factors. Perit. Dial. Int. 2015, 35, 379–387. [Google Scholar] [CrossRef][Green Version]
  22. Van Biesen, W.; Verger, C.; Heaf, J.; Vrtovsnik, F.; Britto, Z.M.L.; Do, J.Y.; Prieto-Velasco, M.; Martínez, J.P.; Crepaldi, C.; De Los Ríos, T.; et al. Evolution Over Time of Volume Status and PD-Related Practice Patterns in an Incident Peritoneal Dialysis Cohort. Clin. J. Am. Soc. Nephrol. 2019, 14, 882–893. [Google Scholar] [CrossRef][Green Version]
  23. Günal, A.I.; Duman, S.; Özkahya, M.; Töz, H.; Asçi, G.; Akçiçek, F.; Basçi, A. Strict volume control normalizes hypertension in peritoneal dialysis patients. Am. J. Kidney Dis. 2001, 37, 588–593. [Google Scholar] [CrossRef]
  24. Clarys, P.; Deliens, T.; Huybrechts, I.; Deriemaeker, P.; Vanaelst, B.; De Keyzer, W.; Hebbelinck, M.; Mullie, P. Comparison of Nutritional Quality of the Vegan, Vegetarian, Semi-Vegetarian, Pesco-Vegetarian and Omnivorous Diet. Nutrients 2014, 6, 1318–1332. [Google Scholar] [CrossRef]
  25. Kristensen, N.B.; Madsen, M.L.; Hansen, T.H.; Allin, K.H.; Hoppe, C.; Fagt, S.; Lausten, M.S.; Gøbel, R.J.; Vestergaard, H.; Hansen, T.; et al. Intake of macro- and micronutrients in Danish vegans. Nutr. J. 2015, 14, 115. [Google Scholar] [CrossRef][Green Version]
  26. Dong, J.; Li, Y.; Yang, Z.; Luo, J. Low dietary sodium intake increases the death risk in peritoneal dialysis. Clin. J. Am. Soc. Nephrol. 2010, 5, 240–247. [Google Scholar] [CrossRef] [PubMed][Green Version]
  27. Kosmadakis, G.; Albaret, J.; Da Costa Correia, E.; Somda, F.; Aguilera, D. Constipation in Peritoneal Dialysis Patients. Perit. Dial. Int. 2019, 39, 399–404. [Google Scholar] [CrossRef] [PubMed][Green Version]
  28. Erthal Leinig, C.; Pecoits-Filho, R.; Kunii, L.; Claro, L.M.; Merlin, J.; Almeida, N.R.; Carvalho, C.R.S.; Moraes, T.P. Low-Fiber Intake Is Associated with High Production of Intraperitoneal Inflammation Biomarkers. J. Ren. Nutr. 2019, 29, 322–327. [Google Scholar] [CrossRef] [PubMed]
  29. Xu, X.; Li, Z.; Chen, Y.; Liu, X.; Dong, J. Dietary fibre and mortality risk in patients on peritoneal dialysis. Br. J. Nutr. 2019, 122, 996–1005. [Google Scholar] [CrossRef][Green Version]
  30. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids; National Academies Press: Washington, DC, USA, 2005. [Google Scholar]
  31. Meksawan, K.; Chaotrakul, C.; Leeaphorn, N.; Gonlchanvit, S.; Eiam-Ong, S.; Kanjanabuch, T. Effects of Fructo-Oligosaccharide Supplementation on Constipation in Elderly Continuous Ambulatory Peritoneal Dialysis Patients. Perit. Dial. Int. 2016, 36, 60–66. [Google Scholar] [CrossRef][Green Version]
  32. Sutton, D.; Dumbleton, S.; Allaway, C. Can Increased Dietary Fibre Reduce Laxative Requirement in Peritoneal Dialysis Patients? J. Ren. Care 2007, 33, 174–178. [Google Scholar] [CrossRef] [PubMed]
  33. Sutton, D.; Ovington, S.; Engel, B. A Multi-Centre, Randomised Trial to Assess Whether Increased Dietary Fibre Intake (Using a Fibre Supplement or High-Fibre Foods) Produces Healthy Bowel Performance and Reduces Laxative Requirement in Free Living Patients on Peritoneal Dialysis. J. Ren. Care 2014, 40, 157–163. [Google Scholar] [CrossRef]
  34. Allès, B.; Baudry, J.; Méjean, C.; Touvier, M.; Péneau, S.; Hercberg, S.; Kesse-Guyot, E. Comparison of Sociodemographic and Nutritional Characteristics between Self-Reported Vegetarians, Vegans, and Meat-Eaters from the NutriNet-Santé Study. Nutrients 2017, 9, 1023. [Google Scholar] [CrossRef]
  35. Davey, G.K.; Spencer, E.A.; Appleby, P.N.; Allen, N.E.; Knox, K.H.; Key, T.J. EPIC-Oxford: Lifestyle characteristics and nutrient intakes in a cohort of 33,883 meat-eaters and 31,546 non meat-eaters in the UK. Public Health Nutr. 2003, 6, 259–269. [Google Scholar] [CrossRef] [PubMed]
  36. Lynch, S.V.; Pedersen, O. The Human Intestinal Microbiome in Health and Disease. N. Engl. J. Med. 2016, 375, 2369–2379. [Google Scholar] [CrossRef][Green Version]
  37. Armani, R.G.; Ramezani, A.; Yasir, A.; Sharama, S.; Canziani, M.E.F.; Raj, D.S. Gut Microbiome in Chronic Kidney Disease. Curr. Hypertens. Rep. 2017, 19, 29. [Google Scholar] [CrossRef]
  38. Anders, H.J.; Andersen, K.; Stecher, B. The intestinal microbiota, a leaky gut, and abnormal immunity in kidney disease. Kidney Int. 2013, 83, 1010–1016. [Google Scholar] [CrossRef] [PubMed][Green Version]
  39. Crespo-Salgado, J.; Vehaskari, V.M.; Stewart, T.; Ferris, M.; Zhang, Q.; Wang, G.; Blanchard, E.E.; Taylor, C.M.; Kallash, M.; Greenbaum, L.A.; et al. Intestinal microbiota in pediatric patients with end stage renal disease: A Midwest Pediatric Nephrology Consortium study. Microbiome 2016, 4, 50. [Google Scholar] [CrossRef] [PubMed][Green Version]
  40. Szeto, C.C.; Kwan, B.C.; Chow, K.M.; Kwok, J.S.; Lai, K.B.; Cheng, P.M.; Pang, W.F.; Ng, J.K.; Chan, M.H.; Lit, L.C.; et al. Circulating bacterial-derived DNA fragment level is a strong predictor of cardiovascular disease in peritoneal dialysis patients. PLoS ONE 2015, 10, e0125162. [Google Scholar] [CrossRef][Green Version]
  41. Grant, C.; Harrison, L.; Hoad, C.; Marciani, L.; Cox, E.; Buchanan, C.; Costigan, C.; Francis, S.; Lai, K.B.; Szeto, C.C.; et al. Endotoxemia in Peritoneal Dialysis Patients: A Pilot Study to Examine the Role of Intestinal Perfusion and Congestion. Perit. Dial. Int. 2017, 37, 111–115. [Google Scholar] [CrossRef] [PubMed]
  42. Szeto, C.C.; Kwan, B.C.; Chow, K.M.; Lai, K.B.; Chung, K.Y.; Leung, C.B.; Li, P.K. Endotoxemia is related to systemic inflammation and atherosclerosis in peritoneal dialysis patients. Clin. J. Am. Soc. Nephrol. 2008, 3, 431–436. [Google Scholar] [CrossRef]
  43. Kwan, B.C.; Chow, K.M.; Leung, C.B.; Law, M.C.; Cheng, P.M.; Yu, V.; Li, P.K.; Szeto, C.C. Circulating bacterial-derived DNA fragments as a marker of systemic inflammation in peritoneal dialysis. Nephrol. Dial. Transpl. 2013, 28, 2139–2145. [Google Scholar] [CrossRef][Green Version]
  44. Lau, W.L.; Savoj, J.; Nakata, M.B.; Vaziri, N.D. Altered microbiome in chronic kidney disease: Systemic effects of gut-derived uremic toxins. Clin. Sci. 2018, 132, 509–522. [Google Scholar] [CrossRef][Green Version]
  45. Wu, I.W.; Hsu, K.H.; Lee, C.C.; Sun, C.Y.; Hsu, H.J.; Tsai, C.J.; Tzen, C.Y.; Wang, Y.C.; Lin, C.Y.; Wu, M.S. p-Cresyl sulphate and indoxyl sulphate predict progression of chronic kidney disease. Nephrol. Dial. Transpl. 2011, 26, 938–947. [Google Scholar] [CrossRef] [PubMed][Green Version]
  46. Viaene, L.; Meijers, B.K.; Bammens, B.; Vanrenterghem, Y.; Evenepoel, P. Serum concentrations of p-cresyl sulfate and indoxyl sulfate, but not inflammatory markers, increase in incident peritoneal dialysis patients in parallel with loss of residual renal function. Perit. Dial. Int. 2014, 34, 71–78. [Google Scholar] [CrossRef] [PubMed][Green Version]
  47. Lin, C.J.; Pan, C.F.; Chuang, C.K.; Liu, H.L.; Sun, F.J.; Wang, T.J.; Chen, H.H.; Wu, C.J. Gastrointestinal-related uremic toxins in peritoneal dialysis: A pilot study with a 5-year follow-up. Arch. Med. Res. 2013, 44, 535–541. [Google Scholar] [CrossRef] [PubMed]
  48. Glick-Bauer, M.; Yeh, M.C. The health advantage of a vegan diet: Exploring the gut microbiota connection. Nutrients 2014, 6, 4822–4838. [Google Scholar] [CrossRef][Green Version]
  49. Martínez, I.; Muller, C.E.; Walter, J. Long-term temporal analysis of the human fecal microbiota revealed a stable core of dominant bacterial species. PLoS ONE 2013, 8, e69621. [Google Scholar] [CrossRef]
  50. Kim, M.S.; Hwang, S.S.; Park, E.J.; Bae, J.W. Strict vegetarian diet improves the risk factors associated with metabolic diseases by modulating gut microbiota and reducing intestinal inflammation. Environ. Microbiol. Rep. 2013, 5, 765–775. [Google Scholar] [CrossRef]
  51. Koeth, R.A.; Wang, Z.; Levison, B.S.; Buffa, J.A.; Org, E.; Sheehy, B.T.; Britt, E.B.; Fu, X.; Wu, Y.; Li, L.; et al. Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat. Med. 2013, 19, 576–585. [Google Scholar] [CrossRef][Green Version]
  52. Fu, D.; Shen, J.; Li, W.; Wang, Y.; Zhong, Z.; Ye, H.; Huang, N.; Fan, L.; Yang, X.; Yu, X.; et al. Elevated Serum Trimethylamine N-Oxide Levels Are Associated with Mortality in Male Patients on Peritoneal Dialysis. Blood Purif. 2021, 50, 837–847. [Google Scholar] [CrossRef]
  53. Nogal, A.; Valdes, A.M.; Menni, C. The role of short-chain fatty acids in the interplay between gut microbiota and diet in cardio-metabolic health. Gut Microbes 2021, 13, 1–24. [Google Scholar] [CrossRef]
  54. De Filippo, C.; Cavalieri, D.; Di Paola, M.; Ramazzotti, M.; Poullet, J.B.; Massart, S.; Collini, S.; Pieraccini, G.; Lionetti, P. Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. Proc. Natl. Acad. Sci. USA 2010, 107, 14691–14696. [Google Scholar] [CrossRef][Green Version]
  55. Agarwal, R. Epidemiology of interdialytic ambulatory hypertension and the role of volume excess. Am. J. Nephrol. 2011, 34, 381–390. [Google Scholar] [CrossRef] [PubMed][Green Version]
  56. Agarwal, R.; Nissenson, A.R.; Batlle, D.; Coyne, D.W.; Trout, J.R.; Warnock, D.G. Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am. J. Med. 2003, 115, 291–297. [Google Scholar] [CrossRef]
  57. Appel, L.J.; Moore, T.J.; Obarzanek, E.; Vollmer, W.M.; Svetkey, L.P.; Sacks, F.M.; Bray, G.A.; Vogt, T.M.; Cutler, J.A.; Windhauser, M.M.; et al. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. N. Engl. J. Med. 1997, 336, 1117–1124. [Google Scholar] [CrossRef][Green Version]
  58. Moranne, O.; Froissart, M.; Rossert, J.; Gauci, C.; Boffa, J.-J.; Haymann, J.P.; M’rad, M.B.; Jacquot, C.; Houillier, P.; Stengel, B.; et al. Timing of Onset of CKD-Related Metabolic Complications. J. Am. Soc. Nephrol. 2009, 20, 164–171. [Google Scholar] [CrossRef][Green Version]
  59. Wesson, D.E.; Buysse, J.M.; Bushinsky, D.A. Mechanisms of Metabolic Acidosis–Induced Kidney Injury in Chronic Kidney Disease. J. Am. Soc. Nephrol. 2020, 31, 469–482. [Google Scholar] [CrossRef] [PubMed][Green Version]
  60. Banerjee, T.; Crews, D.C.; Wesson, D.E.; Tilea, A.M.; Saran, R.; Ríos-Burrows, N.; Williams, D.E.; Powe, N.R. High Dietary Acid Load Predicts ESRD among Adults with CKD. J. Am. Soc. Nephrol. 2015, 26, 1693–1700. [Google Scholar] [CrossRef][Green Version]
  61. Dobre, M.; Yang, W.; Chen, J.; Drawz, P.; Hamm, L.L.; Horwitz, E.; Hostetter, T.; Jaar, B.; Lora, C.M.; Nessel, L.; et al. Association of Serum Bicarbonate with Risk of Renal and Cardiovascular Outcomes in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am. J. Kidney Dis. 2013, 62, 670–678. [Google Scholar] [CrossRef][Green Version]
  62. Driver, T.H.; Shlipak, M.G.; Katz, R.; Goldenstein, L.; Sarnak, M.J.; Hoofnagle, A.N.; Siscovick, D.S.; Kestenbaum, B.; De Boer, I.H.; Ix, J.H. Low Serum Bicarbonate and Kidney Function Decline: The Multi-Ethnic Study of Atherosclerosis (MESA). Am. J. Kidney Dis. 2014, 64, 534–541. [Google Scholar] [CrossRef][Green Version]
  63. De Brito-Ashurst, I.; Varagunam, M.; Raftery, M.J.; Yaqoob, M.M. Bicarbonate Supplementation Slows Progression of CKD and Improves Nutritional Status. J. Am. Soc. Nephrol. 2009, 20, 2075–2084. [Google Scholar] [CrossRef][Green Version]
  64. Passey, C. Reducing the Dietary Acid Load: How a More Alkaline Diet Benefits Patients with Chronic Kidney Disease. J. Ren. Nutr. 2017, 27, 151–160. [Google Scholar] [CrossRef][Green Version]
  65. Goraya, N.; Simoni, J.; Jo, C.; Wesson, D.E. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int. 2012, 81, 86–93. [Google Scholar] [CrossRef][Green Version]
  66. Chang, T.I.; Kang, E.W.; Kim, H.W.; Ryu, G.W.; Park, C.H.; Park, J.T.; Yoo, T.-H.; Shin, S.K.; Kang, S.-W.; Choi, K.H.; et al. Low Serum Bicarbonate Predicts Residual Renal Function Loss in Peritoneal Dialysis Patients. Medicine 2015, 94, e1276. [Google Scholar] [CrossRef]
  67. Liu, X.Y.; Gao, X.M.; Zhang, N.; Chen, R.; Wu, F.; Tao, X.C.; Li, C.J.; Zhang, P.; Yu, P. Oral Bicarbonate Slows Decline of Residual Renal Function in Peritoneal Dialysis Patients. Kidney Blood Press. Res. 2017, 42, 565–574. [Google Scholar] [CrossRef]
  68. Szeto, C.-C.; Wong, T.Y.-H.; Chow, K.-M.; Leung, C.-B.; Li, P.K.-T. Oral Sodium Bicarbonate for the Treatment of Metabolic Acidosis in Peritoneal Dialysis Patients: A Randomized Placebo-Control Trial. J. Am. Soc. Nephrol. 2003, 14, 2119–2126. [Google Scholar] [CrossRef][Green Version]
  69. Palmer, B.F.; Colbert, G.; Clegg, D.J. Potassium Homeostasis, Chronic Kidney Disease, and the Plant-Enriched Diets. Kidney360 2020, 1, 65–71. [Google Scholar] [CrossRef]
  70. Goncalves, F.A.; De Jesus, J.S.; Cordeiro, L.; Piraciaba, M.C.T.; De Araujo, L.; Steller Wagner Martins, C.; Dalboni, M.A.; Pereira, B.J.; Silva, B.C.; Moysés, R.M.A.; et al. Hypokalemia and hyperkalemia in patients on peritoneal dialysis: Incidence and associated factors. Int. Urol. Nephrol. 2020, 52, 393–398. [Google Scholar] [CrossRef]
  71. Szeto, C.-C.; Chow, K.-M.; Kwan, B.C.-H.; Leung, C.-B.; Chung, K.-Y.; Law, M.-C.; Li, P.K.-T. Hypokalemia in Chinese Peritoneal Dialysis Patients: Prevalence and Prognostic Implication. Am. J. Kidney Dis. 2005, 46, 128–135. [Google Scholar] [CrossRef] [PubMed]
  72. Torlén, K.; Kalantar-Zadeh, K.; Molnar, M.Z.; Vashistha, T.; Mehrotra, R. Serum Potassium and Cause-Specific Mortality in a Large Peritoneal Dialysis Cohort. Clin. J. Am. Soc. Nephrol. 2012, 7, 1272–1284. [Google Scholar] [CrossRef][Green Version]
  73. Ribeiro, S.C.; Figueiredo, A.E.; Barretti, P.; Pecoits-Filho, R.; De Moraes, T.P. Low Serum Potassium Levels Increase the Infectious-Caused Mortality in Peritoneal Dialysis Patients: A Propensity-Matched Score Study. PLoS ONE 2015, 10, e0127453. [Google Scholar] [CrossRef] [PubMed]
  74. Chuang, Y.-W.; Shu, K.-H.; Yu, T.-M.; Cheng, C.-H.; Chen, C.-H. Hypokalaemia: An independent risk factor of enterobacteriaceae peritonitis in CAPD patients. Nephrol. Dial. Transplant. 2009, 24, 1603–1608. [Google Scholar] [CrossRef][Green Version]
  75. Parpia, A.S.; L’Abbé, M.; Goldstein, M.; Arcand, J.; Magnuson, B.; Darling, P.B. The Impact of Additives on the Phosphorus, Potassium, and Sodium Content of Commonly Consumed Meat, Poultry, and Fish Products Among Patients with Chronic Kidney Disease. J. Ren. Nutr. 2018, 28, 83–90. [Google Scholar] [CrossRef] [PubMed]
  76. Picard, K. Potassium Additives and Bioavailability: Are We Missing Something in Hyperkalemia Management? J. Ren. Nutr. 2019, 29, 350–353. [Google Scholar] [CrossRef] [PubMed]
  77. Bernier-Jean, A.; Wong, G.; Saglimbene, V.; Ruospo, M.; Palmer, S.C.; Natale, P.; Garcia-Larsen, V.; Johnson, D.W.; Tonelli, M.; Hegbrant, J.; et al. Dietary Potassium Intake and All-Cause Mortality in Adults Treated with Hemodialysis. Clin. J. Am. Soc. Nephrol. 2021, 16, 1851–1861. [Google Scholar] [CrossRef]
  78. Noori, N.; Kalantar-Zadeh, K.; Kovesdy, C.P.; Murali, S.B.; Bross, R.; Nissenson, A.R.; Kopple, J.D. Dietary potassium intake and mortality in long-term hemodialysis patients. Am. J. Kidney Dis. 2010, 56, 338–347. [Google Scholar] [CrossRef][Green Version]
  79. Naismith, D.J.; Braschi, A. An investigation into the bioaccessibility of potassium in unprocessed fruits and vegetables. Int. J. Food Sci. Nutr. 2008, 59, 438–450. [Google Scholar] [CrossRef] [PubMed]
  80. Scialla, J.J.; Appel, L.J.; Wolf, M.; Yang, W.; Zhang, X.; Sozio, S.M.; Miller, E.R., 3rd; Bazzano, L.A.; Cuevas, M.; Glenn, M.J.; et al. Plant protein intake is associated with fibroblast growth factor 23 and serum bicarbonate levels in patients with chronic kidney disease: The Chronic Renal Insufficiency Cohort study. J. Ren. Nutr. 2012, 22, 379–388. [Google Scholar] [CrossRef][Green Version]
  81. Tyson, C.C.; Lin, P.-H.; Corsino, L.; Batch, B.C.; Allen, J.; Sapp, S.; Barnhart, H.; Nwankwo, C.; Burroughs, J.; Svetkey, L.P. Short-term effects of the DASH diet in adults with moderate chronic kidney disease: A pilot feeding study. Clin. Kidney J. 2016, 9, 592–598. [Google Scholar] [CrossRef][Green Version]
  82. Blumenkrantz, M.J.; Kopple, J.D.; Moran, J.K.; Coburn, J.W. Metabolic balance studies and dietary protein requirements in patients undergoing continuous ambulatory peritoneal dialysis. Kidney Int. 1982, 21, 849–861. [Google Scholar] [CrossRef][Green Version]
  83. St-Jules, D.E.; Goldfarb, D.S.; Sevick, M.A. Nutrient Non-equivalence: Does Restricting High-Potassium Plant Foods Help to Prevent Hyperkalemia in Hemodialysis Patients? J. Ren. Nutr. 2016, 26, 282–287. [Google Scholar] [CrossRef] [PubMed][Green Version]
  84. Hayes, C.; McLeod, M.; Robinson, R. An extravenal mechanism for the maintenance of potassium balance in severe chronic renal failure. Trans. Assoc. Am. Physicians 1967, 80, 207–216. [Google Scholar]
  85. Rivara, M.B.; Ravel, V.; Kalantar-Zadeh, K.; Streja, E.; Lau, W.L.; Nissenson, A.R.; Kestenbaum, B.; De Boer, I.H.; Himmelfarb, J.; Mehrotra, R. Uncorrected and Albumin-Corrected Calcium, Phosphorus, and Mortality in Patients Undergoing Maintenance Dialysis. J. Am. Soc. Nephrol. 2015, 26, 1671–1681. [Google Scholar] [CrossRef][Green Version]
  86. Liu, C.T.; Lin, Y.C.; Lin, Y.C.; Kao, C.C.; Chen, H.H.; Hsu, C.C.; Wu, M.S. Roles of Serum Calcium, Phosphorus, PTH and ALP on Mortality in Peritoneal Dialysis Patients: A Nationwide, Population-based Longitudinal Study Using TWRDS 2005–2012. Sci. Rep. 2017, 7, 33. [Google Scholar] [CrossRef] [PubMed][Green Version]
  87. Lopes, M. Association of Single and Serial Measures of Serum Phosphorus with Adverse Outcomes in Patients on Peritoneal Dialysis: Results from the International PDOPPS, “Protect the Memrane” Free Comincation Session. In Proceedings of the 58th ERA-EDTA Congress, Fully Virtual, 5–8 June 2021. [Google Scholar]
  88. KDIGO. 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int. Suppl. 2017, 7, 1–59. [Google Scholar] [CrossRef][Green Version]
  89. Palmer, S.C.; Gardner, S.; Tonelli, M.; Mavridis, D.; Johnson, D.W.; Craig, J.C.; French, R.; Ruospo, M.; Strippoli, G.F. Phosphate-Binding Agents in Adults with CKD: A Network Meta-analysis of Randomized Trials. Am. J. Kidney Dis. 2016, 68, 691–702. [Google Scholar] [CrossRef][Green Version]
  90. Chiu, Y.-W.; Teitelbaum, I.; Misra, M.; De Leon, E.M.; Adzize, T.; Mehrotra, R. Pill Burden, Adherence, Hyperphosphatemia, and Quality of Life in Maintenance Dialysis Patients. Clin. J. Am. Soc. Nephrol. 2009, 4, 1089–1096. [Google Scholar] [CrossRef]
  91. Kalantar-Zadeh, K.; Gutekunst, L.; Mehrotra, R.; Kovesdy, C.P.; Bross, R.; Shinaberger, C.S.; Noori, N.; Hirschberg, R.; Benner, D.; Nissenson, A.R.; et al. Understanding Sources of Dietary Phosphorus in the Treatment of Patients with Chronic Kidney Disease. Clin. J. Am. Soc. Nephrol. 2010, 5, 519–530. [Google Scholar] [CrossRef]
  92. Calvo, M.S.; Uribarri, J. Contributions to total phosphorus intake: All sources considered. Semin. Dial. 2013, 26, 54–61. [Google Scholar] [CrossRef]
  93. Moe, S.M.; Zidehsarai, M.P.; Chambers, M.A.; Jackman, L.A.; Radcliffe, J.S.; Trevino, L.L.; Donahue, S.E.; Asplin, J.R. Vegetarian Compared with Meat Dietary Protein Source and Phosphorus Homeostasis in Chronic Kidney Disease. Clin. J. Am. Soc. Nephrol. 2011, 6, 257–264. [Google Scholar] [CrossRef] [PubMed][Green Version]
  94. Carrero, J.J.; Thomas, F.; Nagy, K.; Arogundade, F.; Avesani, C.M.; Chan, M.; Chmielewski, M.; Cordeiro, A.C.; Espinosa-Cuevas, A.; Fiaccadori, E.; et al. Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies from the International Society of Renal Nutrition and Metabolism. J. Ren. Nutr. 2018, 28, 380–392. [Google Scholar] [CrossRef] [PubMed]
  95. Bakaloudi, D.R.; Halloran, A.; Rippin, H.L.; Oikonomidou, A.C.; Dardavesis, T.I.; Williams, J.; Wickramasinghe, K.; Breda, J.; Chourdakis, M. Intake and adequacy of the vegan diet. A systematic review of the evidence. Clin. Nutr. 2021, 40, 3503–3521. [Google Scholar] [CrossRef] [PubMed]
  96. The Food and Nutrition Board, Institute of Medicine, National Academies. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Total Water and Macronutrients. Available online: https://ods.od.nih.gov/HealthInformation/Dietary_Reference_Intakes.aspx (accessed on 12 January 2022).
  97. The Food and Nutrition Board, Institute of Medicine, National Academies. Dietary Reference Intakes (DRIs): Acceptable Macronutrient Distribution Ranges. Available online: https://www.ncbi.nlm.nih.gov/books/NBK56068/table/summarytables.t5/?report=objectonly (accessed on 12 January 2022).
  98. Mariotti, F.; Gardner, C.D. Dietary Protein and Amino Acids in Vegetarian Diets—A Review. Nutrients 2019, 11, 2661. [Google Scholar] [CrossRef][Green Version]
  99. Joshi, S.; Shah, S.; Kalantar-Zadeh, K. Adequacy of Plant-Based Proteins in Chronic Kidney Disease. J. Ren. Nutr. 2019, 29, 112–117. [Google Scholar] [CrossRef] [PubMed]
  100. Chen, M.Y.; Ou, S.H.; Yen, M.C.; Lee, M.S.; Chen, N.C.; Yin, C.H.; Chen, C.L. Vegetarian diet in dialysis patients: A significant gap between actual intake and current nutritional recommendations. Medicine 2021, 100, e24617. [Google Scholar] [CrossRef] [PubMed]
  101. Ou, S.H.; Chen, M.Y.; Huang, C.W.; Chen, N.C.; Wu, C.H.; Hsu, C.Y.; Chou, K.J.; Lee, P.T.; Fang, H.C.; Chen, C.L. Potential Role of Vegetarianism on Nutritional and Cardiovascular Status in Taiwanese Dialysis Patients: A Case-Control Study. PLoS ONE 2016, 11, e0156297. [Google Scholar] [CrossRef]
  102. He, Y.; Lu, Y.; Yang, S.; Li, Y.; Yang, Y.; Chen, J.; Huang, Y.; Lin, Z.; Li, Y.; Kong, Y.; et al. Dietary Plant Protein and Mortality Among Patients Receiving Maintenance Hemodialysis: A Cohort Study. Am. J. Kidney Dis. 2021, 78, 649–657. [Google Scholar] [CrossRef]
  103. Blumenkrantz, M.J.; Gahl, G.M.; Kopple, J.D.; Kamdar, A.V.; Jones, M.R.; Kessel, M.; Coburn, J.W. Protein losses during peritoneal dialysis. Kidney Int. 1981, 19, 593–602. [Google Scholar] [CrossRef] [PubMed][Green Version]
  104. Kaysen, G.A. Biological basis of hypoalbuminemia in ESRD. J. Am. Soc. Nephrol. 1998, 9, 2368–2376. [Google Scholar] [CrossRef]
  105. Ballmer, P.E.; McNurlan, M.A.; Hulter, H.N.; Anderson, S.E.; Garlick, P.J.; Krapf, R. Chronic metabolic acidosis decreases albumin synthesis and induces negative nitrogen balance in humans. J. Clin. Investig. 1995, 95, 39–45. [Google Scholar] [CrossRef]
  106. Shah, N.; Bernardini, J.; Piraino, B. Prevalence and correction of 25(OH) vitamin D deficiency in peritoneal dialysis patients. Perit. Dial. Int. 2005, 25, 362–366. [Google Scholar] [CrossRef]
  107. Hansen, T.H.; Madsen, M.T.B.; Jørgensen, N.R.; Cohen, A.S.; Hansen, T.; Vestergaard, H.; Pedersen, O.; Allin, K.H. Bone turnover, calcium homeostasis, and vitamin D status in Danish vegans. Eur. J. Clin. Nutr. 2018, 72, 1046–1105. [Google Scholar] [CrossRef]
  108. Liu, G.L.; Pi, H.C.; Hao, L.; Li, D.D.; Wu, Y.G.; Dong, J. Vitamin D Status Is an Independent Risk Factor for Global Cognitive Impairment in Peritoneal Dialysis Patients. PLoS ONE 2015, 10, e0143782. [Google Scholar] [CrossRef] [PubMed][Green Version]
  109. Pérez Fontán, M.; Borràs Sans, M.; Bajo Rubio, M.A.; Rodriguez-Carmona, A.; Betriu, A.; Valdivielso, J.M.; Fernández, E. Low Serum Levels of Vitamin D are Associated with Progression of Subclinical Atherosclerotic Vascular Disease in Peritoneal Dialysis Patients: A Prospective, Multicenter Study. Nephron 2017, 136, 111–120. [Google Scholar] [CrossRef] [PubMed][Green Version]
  110. Zhang, C.; Wang, J.; Xie, X.; Sun, D. Low serum vitamin D concentration is correlated with anemia, microinflammation, and oxidative stress in patients with peritoneal dialysis. J. Transl. Med. 2021, 19, 411. [Google Scholar] [CrossRef] [PubMed]
  111. Pi, H.C.; Ren, Y.P.; Wang, Q.; Xu, R.; Dong, J. Serum 25-Hydroxyvitamin D Level Could Predict the Risk for Peritoneal Dialysis-Associated Peritonitis. Perit. Dial. Int. 2015, 35, 729–735. [Google Scholar] [CrossRef][Green Version]
Figure 1. Potential benefits and concerns of increased plant consumption in peritoneal dialysis. CKD: Chronic kidney disease, PD: Peritoneal dialysis, HD: hemodialysis, TMAO: trimethylamine-N-oxide, IS: indoxyl sulfate, and PCS: p-cresol/p-cresyl sulfate.
Figure 1. Potential benefits and concerns of increased plant consumption in peritoneal dialysis. CKD: Chronic kidney disease, PD: Peritoneal dialysis, HD: hemodialysis, TMAO: trimethylamine-N-oxide, IS: indoxyl sulfate, and PCS: p-cresol/p-cresyl sulfate.
Nutrients 14 01304 g001
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Liebman, S.E.; Joshi, S. Plant-Based Diets and Peritoneal Dialysis: A Review. Nutrients 2022, 14, 1304. https://doi.org/10.3390/nu14061304

AMA Style

Liebman SE, Joshi S. Plant-Based Diets and Peritoneal Dialysis: A Review. Nutrients. 2022; 14(6):1304. https://doi.org/10.3390/nu14061304

Chicago/Turabian Style

Liebman, Scott E., and Shivam Joshi. 2022. "Plant-Based Diets and Peritoneal Dialysis: A Review" Nutrients 14, no. 6: 1304. https://doi.org/10.3390/nu14061304

Note that from the first issue of 2016, MDPI journals use article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop