Special Issue "Renal Nutrition and Metabolism"

A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Clinical Nutrition".

Deadline for manuscript submissions: 30 November 2020.

Special Issue Editor

Prof. Dr. Piergiorgio Messa
Website
Guest Editor
Policlin Milano, Fdn IRCCS Ca Granda Osped Maggiore, Unit Nephrol Dialysis & Renal Transplantat, I-20122 Milan, Italy.
Interests: chronic kidney disease; renal transplantation; nutrition; low protein diet; micronutrients

Special Issue Information

Dear Colleagues,

Medical literature offers strong evidence that dietary habits are associated with the development and possibly the progression of chronic kidney disease (CKD). Therefore, the guidelines of many scientific societies suggest prescribing a low-protein diet to avoid the metabolic consequences of advanced CKD and to slow its progression to end-stage renal disease.

However, there are still some uncertainties regarding the stage of CKD at which starting to restrict protein consumption and whether it is worth-prescribing a progressive restriction that parallels the reduction of the glomerular filtration rate.

Consequently, there are no clear indications about the degree of restriction to adopt in the various stages of CKD (low- vs very-low-protein diet) as well as about possible differences in the quality of protein intake (vegetal or animal origin).

Furthermore, although a hypoproteic diet should not be prescribed in malnourished individuals, there is a substantial lack of information regarding the effect of protein restriction with respect to the onset of malnutrition and sarcopenia in selected categories of patients at risk of malnutrition (i.e., older and frailer individuals). In fact, these individuals have been excluded by most interventional and observational trials. However, since the frail phenotype is present in almost half of elderly CKD patients, the indication for an appropriate dietary prescription in this cohort is a matter of utmost importance.

Another topic that deserves to be explored is the lack of a unanimous definition of malnutrition in the CKD population. In fact, the coexistence of different definitions and clinical scores, validated for the different stages of CKD, is preventing the collection of accurate information on the epidemiology of this phenomenon and generates confusion respect to the nutritional outcomes of patients enrolled in clinical and observational trials.

Another source of confusion derives from the numerous areas of overlap between the current definitions of sarcopenia, malnutrition, and protein-energy wasting syndrome among CKD patients. Although the guidelines strongly indicate to prescribe a low-protein diet in well-nourished patients with advanced CKD, the same guidelines give limited relevance to the intake of the various micronutrients. In fact, although they report the suggested daily intake of microelements, there are no indications about the opportunity of their periodical monitoring and about the necessity of supplementing these nutrients at the different stages of CKD.

Finally, there are a number of unanswered issues in the field of dietary prescription in renal transplanted patients. In fact, it would be very relevant to have an accurate estimation of their nutritional status as well as to explore which nutritional intervention could help to maintain an optimal nutritional status and possibly to prevent or delay the metabolic complications of immunosuppressive therapy.

This Special Issue of Nutrients will address topics, including those mentioned here, that are of the utmost relevance for nutritional evaluation and dietary prescription in patients with various stages of CKD.

Prof. Piergiorgio Messa
Guest Editor

Manuscript Submission Information

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Keywords

  • Chronic kidney disease
  • Renal transplantation
  • Nutrition
  • Low-protein diet
  • Micronutrients

Published Papers (5 papers)

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Research

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Open AccessArticle
Compositional and Functional Adaptations of Intestinal Microbiota and Related Metabolites in CKD Patients Receiving Dietary Protein Restriction
Nutrients 2020, 12(9), 2799; https://doi.org/10.3390/nu12092799 - 12 Sep 2020
Abstract
The relationship between change of gut microbiota and host serum metabolomics associated with low protein diet (LPD) has been unraveled incompletely in CKD patients. Fecal 16S rRNA gene sequencing and serum metabolomics profiling were performed. We reported significant changes in the β-diversity of [...] Read more.
The relationship between change of gut microbiota and host serum metabolomics associated with low protein diet (LPD) has been unraveled incompletely in CKD patients. Fecal 16S rRNA gene sequencing and serum metabolomics profiling were performed. We reported significant changes in the β-diversity of gut microbiota in CKD patients having LPD (CKD-LPD, n = 16). We identified 19 genera and 12 species with significant differences in their relative abundance among CKD-LPD patients compared to patients receiving normal protein diet (CKD-NPD, n = 27) or non-CKD controls (n = 34), respectively. CKD-LPD had a significant decrease in the abundance of many butyrate-producing bacteria (family Lachnospiraceae and Bacteroidaceae) associated with enrichment of functional module of butanoate metabolism, leading to concomitant reduction in serum levels of SCFA (acetic, heptanoic and nonanoic acid). A secondary bile acid, glyco λ-muricholic acid, was significantly increased in CKD-LPD patients. Serum levels of indoxyl sulfate and p-cresyl sulfate did not differ among groups. The relationship between abundances of microbes and metabolites remained significant in subset of resampling subjects of comparable characteristics. Enrichment of bacterial gene markers related to D-alanine, ketone bodies and glutathione metabolism was noted in CKD-LPD patients. Our analyses reveal signatures and functions of gut microbiota to adapt dietary protein restriction in renal patients. Full article
(This article belongs to the Special Issue Renal Nutrition and Metabolism)
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Open AccessArticle
Long-Term Effects of Ketoanalogues on Mortality and Renal Outcomes in Advanced Chronic Kidney Disease Patients Receiving a Low-Protein Diet
Nutrients 2020, 12(9), 2708; https://doi.org/10.3390/nu12092708 - 04 Sep 2020
Abstract
The effects of ketoanalogues (KA) supplementation on mortality and progression to dialysis in patients with pre-dialysis stage 5 chronic kidney disease (CKD) receiving a low-protein diet (LPD) remain ambiguous. From Taiwan’s National Health Insurance Research Database during 1996–2011, 165 patients with pre-dialysis CKD [...] Read more.
The effects of ketoanalogues (KA) supplementation on mortality and progression to dialysis in patients with pre-dialysis stage 5 chronic kidney disease (CKD) receiving a low-protein diet (LPD) remain ambiguous. From Taiwan’s National Health Insurance Research Database during 1996–2011, 165 patients with pre-dialysis CKD on an LPD (0.6 g/kg/day) with KA supplementation were matched with 165 patients with pre-dialysis CKD on an LPD without KA supplementation. Of the 165 patients with advanced CKD receiving KA supplementation, 34 (20.6%) died, and 124 (75.2%) underwent long-term dialysis during the study period. There was no significant difference in mortality between the KA-user group and the KA-nonuser group (adjusted hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.68–2.93; p = 0.355). KA supplementation significantly increased long-term dialysis risk (adjusted HR, 1.41; 95% CI, 1.04–1.90; p = 0.025) and combined outcome risk (defined as long-term dialysis and death; adjusted HR, 1.37; 95% CI, 1.02–1.83; p = 0.034). KA supplementation also increased long-term dialysis risk (adjusted HR, 1.49; 95% CI, 1.00–2.20; p = 0.048) in the subgroup of pre-dialysis patients with diabetes mellitus (DM), but not in those patients without DM. In conclusion, KA supplementation might increase long-term dialysis risk in patients with advanced CKD receiving an LPD, but it did not increase mortality. Full article
(This article belongs to the Special Issue Renal Nutrition and Metabolism)
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Open AccessArticle
Urinary Excretion of N1-Methylnicotinamide and N1-Methyl-2-Pyridone-5-Carboxamide and Mortality in Kidney Transplant Recipients
Nutrients 2020, 12(7), 2059; https://doi.org/10.3390/nu12072059 - 10 Jul 2020
Cited by 1
Abstract
It is unclear whether niacin nutritional status is a target for improvement of long-term outcome after renal transplantation. The 24-h urinary excretion of N1-methylnicotinamide (N1-MN), as a biomarker of niacin status, has previously been shown to be negatively [...] Read more.
It is unclear whether niacin nutritional status is a target for improvement of long-term outcome after renal transplantation. The 24-h urinary excretion of N1-methylnicotinamide (N1-MN), as a biomarker of niacin status, has previously been shown to be negatively associated with premature mortality in kidney transplant recipients (KTR). However, recent evidence implies higher enzymatic conversion of N1-MN to N1-methyl-2-pyridone-5-carboxamide (2Py) in KTR, therefore the need exists for interpretation of both N1-MN and 2Py excretion for niacin status assessment. We assessed niacin status by means of the 24-h urinary excretion of the sum of N1-MN and 2Py (N1-MN + 2Py), and its associations with risk of premature mortality in KTR. N1-MN + 2Py excretion was measured in a longitudinal cohort of 660 KTR with LS-MS/MS. Prospective associations of N1-MN + 2Py excretion were investigated with Cox regression analyses. Median N1-MN + 2Py excretion was 198.3 (155.9–269.4) µmol/day. During follow-up of 5.4 (4.7–6.1) years, 143 KTR died, of whom 40 due to an infectious disease. N1-MN + 2Py excretion was negatively associated with risk of all-cause mortality (HR 0.61; 95% CI 0.47–0.79; p < 0.001), and infectious mortality specifically (HR 0.47; 95% CI 0.29–0.75; p = 0.002), independent of potential confounders. Secondary analyses showed effect modification of hs-CRP on the negative prospective association of N1-MN + 2Py excretion, and sensitivity analyses showed negative and independent associations of N1-MN and 2Py excretion with risk of all-cause mortality separately. These findings add further evidence to niacin status as a target for nutritional strategies for improvement of long-term outcome in KTR. Full article
(This article belongs to the Special Issue Renal Nutrition and Metabolism)
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Open AccessArticle
Dietary Patterns Based on Estimated Glomerular Filtration Rate and Kidney Function Decline in the General Population: The Lifelines Cohort Study
Nutrients 2020, 12(4), 1099; https://doi.org/10.3390/nu12041099 - 16 Apr 2020
Cited by 1
Abstract
No specific dietary patterns have been established that are linked with loss of kidney function. We aimed to identify an estimated glomerular filtration rate-based dietary pattern (eGFR-DP) and to evaluate its association with eGFR decline and chronic kidney disease (CKD) incidence in the [...] Read more.
No specific dietary patterns have been established that are linked with loss of kidney function. We aimed to identify an estimated glomerular filtration rate-based dietary pattern (eGFR-DP) and to evaluate its association with eGFR decline and chronic kidney disease (CKD) incidence in the general population. We included 78,335 participants from the Lifelines cohort in the Northern Netherlands. All participants had an eGFR >60 mL/min/1.73 m2 at baseline and completed a second visit five years later. The eGFR-DP was constructed at baseline using a 110-item food frequency questionnaire by reduced rank regression, stratified by sex. Logistic regression was performed to evaluated the association between the eGFR-DP score and either a ≥20% eGFR decline or incident CKD. Among women, eGFR-DP were characterized by high consumption of egg, cheese, and legumes and low consumption of sweets, white meat, and commercially prepared dishes. In men, eGFR-DP were characterized by high consumption of cheese, bread, milk, fruits, vegetables, and beer and low consumption of white and red meat. A higher eGFR-DP score was associated with a lower risk of a ≥20% eGFR decline (OR 4th vs. 1st quartile, women: 0.79 [95% CI: 0.73–0.87]; men: 0.67 [0.59–0.76]). The association between the eGFR-DP score and CKD incidence was lost upon adjustment for baseline eGFR. Our results provide support for dietary interventions to prevent kidney function decline in the general population. Full article
(This article belongs to the Special Issue Renal Nutrition and Metabolism)
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Review

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Open AccessFeature PaperReview
Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease
Nutrients 2020, 12(7), 1931; https://doi.org/10.3390/nu12071931 - 29 Jun 2020
Cited by 5
Abstract
Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the [...] Read more.
Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the first year. Recent declarations by the World Kidney Day and the U.S. Government Executive Order seek to implement strategies that reduce the burden of kidney failure by slowing CKD progression and controlling uremia without dialysis. Pragmatic dietary interventions may have a role in improving CKD outcomes and preventing or delaying dialysis initiation. Evidence suggests that a patient-centered plant-dominant low-protein diet (PLADO) of 0.6–0.8 g/kg/day composed of >50% plant-based sources, administered by dietitians trained in non-dialysis CKD care, is promising and consistent with the precision nutrition. The scientific premise of the PLADO stems from the observations that high protein diets with high meat intake not only result in higher cardiovascular disease risk but also higher CKD incidence and faster CKD progression due to increased intraglomerular pressure and glomerular hyperfiltration. Meat intake increases production of nitrogenous end-products, worsens uremia, and may increase the risk of constipation with resulting hyperkalemia from the typical low fiber intake. A plant-dominant, fiber-rich, low-protein diet may lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation and slow CKD progression, along with reducing cardiovascular risk. PLADO is a heart-healthy, safe, flexible, and feasible diet that could be the centerpiece of a conservative and preservative CKD-management strategy that challenges the prevailing dialysis-centered paradigm. Full article
(This article belongs to the Special Issue Renal Nutrition and Metabolism)
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Planned Papers

The below list represents only planned manuscripts. Some of these manuscripts have not been received by the Editorial Office yet. Papers submitted to MDPI journals are subject to peer-review.

Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease

Professor Kamyar Kalantar-Zadeh

University of California Irvine (UCI), Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, Orange, CA, USA

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