Vegetarian Diets and Chronic Kidney Disease Complications: History
View Latest Version
Please note this is an old version of this entry, which may differ significantly from the current revision.
Contributor:
Yoko Narasaki
,
Kamyar Kalantar-Zadeh
,
Connie M. Rhee
,
Giuliano Brunori
,
Diana Zarantonello

A growing body of evidence has demonstrated that higher consumption of plant-based foods and the nutrients found in vegetarian and plant-based diets are associated with numerous health benefits, including improved blood pressure, glycemic control, lipid levels, body mass index, and acid–base parameters. Furthermore, there has been increasing recognition that vegetarian and plant-based diets may have potential salutary benefits in preventing the development and progression of chronic kidney disease (CKD). While increasing evidence shows that vegetarian and plant-based diets have nephroprotective effects, there remains some degree of uncertainty about their nutritional adequacy and safety in CKD (with respect to protein-energy wasting, hyperkalemia, etc.). 

  • nutrition
  • vegetarian diet
  • plant-based diet
  • chronic kidney disease

1. Introduction

There is rising interest worldwide regarding the health implications of vegetarian or plant-based diets, including reductions in animal-based food intake and/or fully excluding animal-based products from the diet [1]. A growing body of evidence has demonstrated that higher consumption of plant-based foods and the nutrients found within plant-based diets are associated with numerous health benefits, including improved blood pressure, glycemic control, lipid levels, body mass index (BMI), and acid–base parameters, as well as lower risk of complications such as diabetes [2], cardiovascular disease [3], and death [4]. Furthermore, there has been increasing recognition that plant-based diets have a potential salutary role in the management of chronic kidney disease (CKD). For example, the low-protein vegan diet (0.7 g/kg of body weight/day of protein), the low-protein supplemented vegan diet (0.6 g/kg of body weight/day of protein supplemented with essential amino acids (EAAs) and keto acids (KAs), i.e., one tablet per 10 kg of body weight), and the very-low-protein diet (0.3 g/kg of body weight/day of protein supplemented with EAAs and KAs, i.e., one tablet for every 5 kg of body weight) are vegan/vegetarian diets that have been proposed as possible kidney-conservative treatments [5]. A tablet of Ketosteril®, which is used globally, contains L-lysine (105 mg), L-threonine (53 mg), L-histidine (38 mg), L-tyrosine (30 mg), L-tryptophan (23 mg), hydroxy-methionine (59 mg), calcium-keto-valine (86 mg), calcium-keto-phenylalanine (68 mg), calcium-keto-leucine (101 mg), and calcium-keto-isoleucine (67 mg) [6]. Moreover the “Plant-Dominant Low-Protein Diet” (PLADO) [7] and “Plant-Focused Nutrition in Patients With Diabetes and CKD Diet” (PLAFOND) [8] are two subtypes of plant-based diets that have been established for people with CKD as a means to reduce the progression of kidney disease (Table 1). A sizeable body of research has shown that vegetarian diets have nephroprotective effects, although there remains some degree of uncertainty about safety with respect to the high contents of minerals such as phosphorus and potassium, along with the potential risks of hyperphosphatemia and/or hyperkalemia that may ensue with greater plant-based food consumption.
Table 1. Different types of plant-based low-protein diets.

Diet

CKD Stage

Protein

Carbohydrates

LPD vegan

3–4

0.7 g/kg/day (100% from grain and legumes)

From cereals

LPDs vegan

3–4

Indicated in pregnant women with advanced CKD [9], in people at high risk of malnutrition, or in people who do not tolerate legumes [10]

0.6 g/kg/day (100% from cereals and legumes) + EAAs/KAs (1 tablet every 10 kg of body weight)

From cereals

PLADO diet

3–5

0.6 g/kg/day (with >50% plant-based sources)

From whole cereals

PLAFOND diet

3–5

Diabetic nephropathy

0.6 to <0.8 g/kg/day (with >50% plant-based sources)

From whole cereals

VLPDs

4–5

0.3–0.4 g/kg/day + EAAs/KAs (1 tablet every 5 kg of body weight)

Especially from low-protein substitutes

LPD: low-protein diet; LPDs: low-protein diet supplemented; PLADO: Plant-Dominant Low-Protein Diet; PLAFOND: patient-centered plant-focused LPD for the nutritional management of CKD/DM; VLPDs: very-low-protein diet supplemented. EAAs/KAs: essential amino acids/keto acids.

2. Overview of Vegetarian and Plant-Based Diets

Vegetarian or plant-based diets are types of diets composed of a larger proportion of foods from plant-based sources as opposed to animal-based sources. There are various forms of vegetarian diets, such that some types fully exclude all animal products (i.e., vegan diets), whereas other types include dairy products such as milk and cheese, eggs, and honey (i.e., lacto-ovo vegetarian diets) or may even include small amounts of fish and seafood (i.e., pescatarian), as well as meat and poultry (i.e., semi-vegetarian or flexitarian) [11]. The phrases “vegetarian” and “plant-based diet” are often used without differentiation, but the terminology “vegetarian” is commonly used to refer to lacto-ovo vegetarians, while the terminology “plant-based diet” is used to refer to dietary patterns with a greater proportion of foods derived from plant-based sources but may not mean that they are devoid of animal-based foods. In other words, a plant-based diet is a hybrid form of a diet rich in plant-based foods. A person who consumes a plant-based diet eats healthy plant-based foods (i.e., fresh/whole/unprocessed/unrefined foods and beverages) and avoids unhealthy plant-based foods (i.e., processed/refined/sugar-sweetened foods and beverages) [12]. Two types of plant-based diets that have specifically been designed for the non-dialysis-dependent CKD (NDD-CKD) population include the (1) Plant-Dominant Low-Protein Diet (PLADO), consisting of a dietary protein intake of 0.6–0.8 g/kg/day, with >50% from plant-based sources [7], and the (2) Plant-Focused Nutrition in CKD and Diabetes Diet (PLAFOND), consisting of a dietary protein intake of 0.6–0.8 g/kg/day from >50% plant-based sources [8]. Low-protein diets are supported by clinical practice guidelines to ameliorate the progression of CKD, and they are considered to be the centerpiece of conservative and preservative kidney disease management strategies as a means to delay or avert the need for dialysis [7][8]. Irrespective of the specific type of plant-based diet, such diets typically consist of a greater proportion of healthy plant-based foods (i.e., whole grains, cereals, nuts, fruits, and vegetables) and favorable nutrient profiles (i.e., dietary fiber, unsaturated fatty acids, folate, magnesium, vitamin C, vitamin E, carotenoids, phytochemicals, and low bioavailability of phosphorus and potassium) (Figure 1) [11]. Dietary phosphorus and potassium from unprocessed plant-based foods have lower bioavailability and, therefore, confer lower loads of phosphorus and potassium, respectively, compared to animal-based foods and processed foods, which is in part due to concomitantly higher glucose and dietary fiber contents. Additionally, phosphorus in plant-based foods is present in the form of phytate, which generally has limited bioavailability in the human digestive system. There is more discussion on this topic in the latter part of this research.
Figure 1. Characteristics of nutrients and components in plant-based vs. animal-based diets. Abbreviations: ALA, α-linolenic acid; B1, vitamin B1; B6, vitamin B6; B12, vitamin B12, Ca, calcium; D, vitamin D; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; Fe, iron; K, potassium; Mg, magnesium; MUFAs, monounsaturated fatty acids; phytochem, phytochemicals; Pi, phosphorus; PUFAs, total polyunsaturated fatty acids; SFAs, saturated fatty acids; Zn, zinc.
In the general population, the popularity of plant-based diets is in part due to their perceived health benefits related to the control of diabetes, obesity, hypertension, and hyperlipidemia. More recently, there has been interest in the role of plant-based diets in preventing the development of de novo CKD, attenuating CKD progression, and mitigating CKD-related complications (Figure 2).
Figure 2. Plant-based diets and health benefits in chronic kidney disease. Abbreviations: ALA, α-linolenic acid; CKD, chronic kidney disease; CVD, cardiovascular disease; ESKD, end-stage kidney disease; MUFAs, monounsaturated fatty acids; PUFAs, total polyunsaturated fatty acids; SFAs, saturated fatty acids.

3. Vegetarian Diets and Risk Factors for Incident CKD

3.1. Hypertension in Non-CKD Populations

Hypertension and CKD are closely interrelated, such that sustained hypertension can lead to incident CKD and CKD progression, which can in turn result in worse blood pressure (BP) control [13]. Randomized controlled trials have shown the benefits of plant-based diets for BP control. In a study of 59 normotensive participants without underlying CKD, consumption of a vegetarian diet for a six-week period lowered their mean systolic BP by 6.8 mmHg when measured at the laboratory, and by 4.9 mmHg when measured at home [14]. Another study in 58 participants with mild untreated hypertension, comparing ovo-lacto-vegetarian vs. omnivorous diets, showed that the ovo-lacto-vegetarian diet resulted in a reduction in BP by an average of 5.5 mmHg [15]. The Dietary Approach to Stop Hypertension (DASH) trial, a landmark randomized controlled trial examining the effects of a largely plant-based diet on BP control, showed that the DASH diet reduced BP by an average of 5.5 mmHg compared to the control diet [16]. A meta-analysis of seven clinical trials with an aggregate of 313 participants, which excluded the DASH diet trials, also confirmed the benefits of plant-based diets for BP, such that consumption of vegetarian diets reduced systolic BP by a mean of 4.8 mmHg compared to omnivorous diets [17].

3.2. Diabetes Mellitus in Non-CKD Populations

Vegetarian diets have been reported as an effective intervention for the prevention and treatment of diabetes mellitus, the dominant etiology of CKD globally. It has been shown that the prevalence of type 2 diabetes in people consuming vegetarian diets is lower than that among non-vegetarians, even after adjusting for BMI [18]. A meta-analysis of nine large prospective studies with a total of 307,099 participants reported an inverse association between higher adherence to a plant-based dietary pattern and the risk of type 2 diabetes [19]. This association was strengthened in healthy plant-based diet patterns, i.e., consumption of more healthy plant-based foods (e.g., whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea, and coffee) vs. unhealthy foods (e.g., fruit juices, refined grains, fried potatoes or potato chips, desserts, and sweetened beverages).
Several potential mechanisms explain the relationship between plant-based diets and lower risk of diabetes mellitus. For example, the foods in healthy plant-based diets individually and jointly reduce the risk of diabetes by improving insulin sensitivity and BP [17][20], mitigating long-term weight gain, and ameliorating systemic inflammation [21]. Moreover, plant-based diets may reduce the risk of type 2 diabetes by ameliorating excessive weight gain. Multiple interventional and observational studies have shown that plant-based diets provide favorable weight control and/or weight loss in the short term and weight loss and/or prevention of weight gain in the long term [22][23][24]. Plant-based diets may also improve circulating levels of adiposity-related biomarkers, including leptin, adiponectin, high-sensitivity C-reactive protein, and interleukin-6 [25][26].

4. Vegetarian Diets and CKD Complications

4.1. Hypertension in CKD Populations

Different components of vegetarian diets contribute to directly or indirectly lowering BP levels in people with CKD, through various pathways. First, lower consumption of sodium in plant-based vs. animal-based diets can prevent and control hypertension. Unprocessed plant-based foods generally have less sodium than animal-based foods and processed foods. Indeed, data from the National Health and Nutrition Examination Survey (NHANES) showed that vegetarians ate less sodium, as ascertained using 24 h dietary recall, compared to non-vegetarians (2347 ± 80 mg vs. 3621 ± 27 mg) [27]. A meta-analysis that included 21 studies among people with earlier stages of CKD, dialysis patients, and kidney transplant recipients reported that salt reduction reduced systolic and diastolic BP in the short term (i.e., 1 to 36 weeks) [28]. This study also reported that salt reduction resulted in lower albuminuria levels. Another meta-analysis also showed that salt restriction was associated with lower systolic BP, diastolic BP, and proteinuria levels among 738 people with stages 1–4 CKD [29], and another pooled analysis showed that reduction of salt intake resulted in lower systolic and diastolic BP among 101,077 people with CKD [30].
Second, higher potassium intake from plant-based diets may help reduce BP. It is well established that higher dietary potassium intake lowers BP in the general population. While studies examining the effects of dietary potassium on BP in people with CKD are sparse, limited data suggest potential benefits. In an animal study of rats with CKD, it was demonstrated that potassium supplementation lowered BP among rats with slightly higher serum potassium levels compared to rats on a low-potassium diet [31].
Third, all plant-based foods contain dietary fiber, a carbohydrate that is indigestible by digestive tract enzymes (Table 2) [32]. Dietary fiber intake improves BP by modifying arterial contraction due to its effect on arterial smooth muscle, influencing the activity of the angiotensin-converting enzyme (ACE) or retaining minerals such as potassium and magnesium in its matrix [33][34]. In addition to BP control, there are a variety of health benefits of dietary fiber that affect CKD outcomes. For example, dietary fiber intake can improve glycemic control by delaying gastric emptying, reducing postprandial glucose absorption, providing a lower glycemic response, producing greater satiety, and improving insulin sensitivity [8][35]. Moreover, dietary fiber intake also contributes to improving dyslipidemia. Dietary soluble fiber with high viscosity decreases cholesterol absorption, binds to bile acids, and increases their fecal excretion. Bacterial fermentation in the colon can inhibit cholesterol production in the liver by producing short-chain fatty acids (SCFAs) [36]. SCFAs also exert trophic action on the mucosa and strengthen the defense function of the intestinal barrier by counteracting bacterial translocation and low-grade chronic inflammation [37]. Moreover, fiber intake reduces serum urea levels by promoting a fecal route of excretion for nitrogenous waste, and it can reduce serum levels of AGEs (advanced glycation end products) [32]. Lastly, greater dietary fiber intake may lead to improvements in constipation, increased satiety, reduced energy intake, weight control, and slower absorption of some nutrients in the intestine, leading to reduced inflammation [33].
Table 2. Importance of dietary fiber in human health.

Property

Function

Health Benefits

Bulk

  • Adds bulk to diet

    ○

    Satiety effect

  • Adds bulk to stool

    ○

    Improves GI motility

    ▪

    Increases bowel movement

    ▪

    Reduces intestinal transit time

    ○

    Increases fecal bulk

    ○

    Increases stool frequency

  • Regulates energy intake

  • Lowers blood pressure

  • Promotes weight loss

  • Alleviates constipation

Viscosity

  • Inhibits intestinal digestion and absorption

    ○

    Inhibits glucose absorption

    ▪

    Traps carbohydrates

    ▪

    Slows glucose absorption

    ○

    Inhibits cholesterol absorption

    ▪

    Traps bile acids and extracts to feces

    ▪

    Increases the synthesis of bile acids from cholesterol

    ○

    Traps carcinogenic substances

  • Improves glycemic control

    ○

    Lowers postprandial serum glucose levels

  • Improves cholesterol control

    ○

    Lowers serum total and LDL cholesterol

  • Contributes to cancer prevention

Fermentability

  • Alters intestinal microbiota composition and function

    ○

    Increases gut-microbiome-induced production of SCFAs

  • Anti-inflammation

  • Anti-obesity

  • Anti-diabetes

  • Anticancer

  • Hepatoprotection

  • Cardiovascular protection

  • Neuroprotection

  • Constipation treatment

  • Inflammatory bowel disease treatment

  • Immunoregulation
Abbreviations: GI, gastrointestinal; LDL, low-density lipoprotein; SCFAs, short-chain fatty acids.
Fourth, more balanced intake of macronutrients (including dietary protein, fat, and carbohydrates) conferred by a plant-based diet can contribute to better BP control. Results from observational studies indicate an inverse association between dietary plant protein intake and BP [38], and both prospective studies and randomized controlled trials have shown similar relationships between plant and animal protein intake with respect to BP [39]. The effects of plant vs. animal protein on BP control remain to be established. Additionally, vegetarian diets usually provide low intake of saturated fatty acids and omega-3 polyunsaturated fatty acids (PUFAs). In a cross-sectional study of 26 vegetarians vs. 26 non-vegetarians, matched according to age, sex, and BMI, the vegetarians had higher plant-based fat consumption than the non-vegetarians, which may lead to higher resting energy expenditure (REE) in vegetarians and potentially contribute to better body weight and BP control [40].

4.2. Hyperphosphatemia in CKD Populations

In people with advanced CKD, decreased phosphorus excretion by the kidneys, coupled with disordered mineral metabolism, engenders hyperphosphatemia, leading to vascular calcification and stiffness, altered cardiac structure and function, kidney osteodystrophy, and increased mortality [41]. Therefore, in the traditional dietary management of advanced CKD patients, dietary phosphorous has been restricted and plant-based foods have been avoided due to concerns regarding high contents of minerals such as phosphorus. However, increasing evidence suggests that greater intake of plant-based foods may lead to better phosphorus control. The amount of phosphorus contained in food vs. phosphorus absorbed by the body is not always consistent. Given that phosphorus in plant-based foods is often in the form of phytate (which humans have limited ability to digest, given the absence of the phytase enzyme), phosphorus found in plant-based foods usually has lower absorbability and/or bioavailability (20 to 40% bioavailability) compared with animal foods, which often have phosphorus in the form of caseins (40 to 60% bioavailability), and processed foods, in which phosphorus is usually present as food additives (~100% bioavailability) [42][43]. Indeed, both animal and human studies show reduced phosphorus loads when consuming plant-based vs. animal-based diets, despite both diets having the same amounts of phosphorus. In a rat model of CKD–mineral bone disease (CKD–MBD), administration of a plant-based diet led to a reduced phosphorus load, such that rats fed grain-based diets showed similar serum phosphorus levels, calcium levels, and intact parathyroid hormone (PTH) levels, yet lower urinary phosphorus excretion and serum fibroblast growth factor 23 (FGF-23) levels vs. rats fed the same amount of phosphorous from casein-based diets [44]. In a crossover trial of people with stage 3–4 CKD, receipt of a vegetarian diet for one week led to lower serum phosphorus, phosphaturia, and FGF-23 levels compared to a meat-based diet with the same phosphorus content [45]. A randomized controlled trial in which participants underwent partial replacement of animal protein with plant protein also led to reduced serum phosphorus levels [46].

4.3. Uremic Toxins, Inflammation, and Oxidative Stress in CKD

Given the concomitant rich consumption of dietary fiber, along with their lower contents of carnitine, choline, phosphatidylcholine, tyrosine, and tryptophan, plant-based diets lead to less generation of uremic toxins (i.e., trimethylamine n-oxide (TMAO), indoxyl sulfate, and p-cresyl sulfate), as well as reducing inflammation and oxidative stress [47][48]. In a randomized controlled study of 32 non-dialysis-dependent CKD patients, one week of a supplemented very-low-protein diet of plant-based origin (0.3 g/kg body weight/day) led to reduced indoxyl sulfate levels [49]. In a randomized controlled study of 40 hemodialysis patients who received higher vs. lower dietary fiber intake for six weeks, those who received higher dietary fiber intake had reduced free plasma levels of indoxyl sulfate and p-cresyl sulfate [50]. Data from the NHANES III cohort included 14,543 participants, in whom it was observed that dietary fiber intake was negatively associated with serum C-reactive protein (CRP) levels, such that each 10 g/day increase in total fiber intake was associated with an 11% and 38% decline in the odds of elevated serum CRP levels in the CKD and non-CKD groups, respectively [51]. In a rat model of CKD, consumption of high-amylose maize resistant starch for three weeks also ameliorated inflammation and oxidative stress [52].
Dietary fiber confers a number of advantages for sustainable human health [53]. The bulking effect from the food is important to control the events in the digestive tract, including improved gastrointestinal motility (i.e., increased bowel movements and reduced intestinal transit time), increased fecal bulk, and greater stool frequency. Dietary fiber adds bulk not only to stool, but also to the overall diet, which provides a satiety effect and regulates energy intake. This bulking property of dietary fiber can also reduce BP, promote weight loss, and alleviate constipation [54]. The viscosity effect of dietary fiber can also improve glycemic and cholesterol control, and it may additionally contribute to cancer prevention. Increasing viscosity during digestion due to soluble dietary fiber results in the trapping of carbohydrates, slowing of glucose absorption, and lowering of postprandial blood glucose levels. Soluble fiber also helps to reduce total and LDL cholesterol levels by binding bile acids in the small intestine following extraction from the body through feces, as well as increasing the synthesis of bile acids from cholesterol. Dietary fiber also traps carcinogenic substances and may prevent the development of cancer [54]. Fermentable dietary fiber is the substrate for bacterial metabolism and stimulates the production of short-chain fatty acids (SCFAs) through intestinal fermentation, primarily acetate, propionate, and butyrate, leading to its protective effects against inflammation, obesity, diabetes, cancer, and cardiovascular disease, along with immune regulation and a number of other health benefits [55][56]. The mechanisms underlying the association between dietary fiber intake and lower uremic toxin levels, as well as urea and creatinine concentrations, are interrelated, such that greater dietary fiber intake (1) decreases toxin absorption and increases their fecal excretion by improving intestinal motility, (2) reduces the permeability of toxins by improving the integrity of tight junctions in the colonic epithelium by producing SCFAs, and (3) facilitates the growth of a more favorable microbiome.

4.4. Metabolic Acidosis

A large proportion of people with CKD suffer from metabolic acidosis and its adverse consequences, including muscle wasting, bone loss, impaired insulin sensitivity, chronic inflammation, and progression of kidney disease [57]. While alkali therapy is typically conducted to correct metabolic acidosis in CKD patients by administering sodium bicarbonate, a series of trials have shown that plant-based diets could also be used to treat metabolic acidosis. In a randomized controlled trial of 71 people with stage 4 CKD, people assigned to greater fruit and vegetable intake over the course of one year had higher plasma CO2 levels and lower urinary indices of kidney injury [58]. Another randomized controlled trial of 108 people with stage 3 CKD also confirmed similar effects of fruit and vegetable intake on metabolic acidosis parameters, such that daily administration of two to four cups of fruits and vegetables over a period of three years resulted in higher CO2 levels, lower net acid excretion, lower urinary albumin–creatinine ratios, and preserved kidney function [59]. According to this evidence, the KDOQI guidelines also support prescribing more fruits and vegetables for stage 1–4 CKD patients in order to decrease their body weight, blood pressure, and net acid production [33].

This entry is adapted from the peer-reviewed paper 10.3390/nu16010066

References

  1. Medawar, E.; Huhn, S.; Villringer, A.; Veronica Witte, A. The effects of plant-based diets on the body and the brain: A systematic review. Transl. Psychiatry 2019, 9, 226.
  2. Satija, A.; Bhupathiraju, S.N.; Rimm, E.B.; Spiegelman, D.; Chiuve, S.E.; Borgi, L.; Willett, W.C.; Manson, J.E.; Sun, Q.; Hu, F.B. Plant-Based Dietary Patterns and Incidence of Type 2 Diabetes in US Men and Women: Results from Three Prospective Cohort Studies. PLoS Med. 2016, 13, e1002039.
  3. Satija, A.; Bhupathiraju, S.N.; Spiegelman, D.; Chiuve, S.E.; Manson, J.E.; Willett, W.; Rexrode, K.M.; Rimm, E.B.; Hu, F.B. Healthful and Unhealthful Plant-Based Diets and the Risk of Coronary Heart Disease in U.S. Adults. J. Am. Coll. Cardiol. 2017, 70, 411–422.
  4. Baden, M.Y.; Liu, G.; Satija, A.; Li, Y.; Sun, Q.; Fung, T.T.; Rimm, E.B.; Willett, W.C.; Hu, F.B.; Bhupathiraju, S.N. Changes in Plant-Based Diet Quality and Total and Cause-Specific Mortality. Circulation 2019, 140, 979–991.
  5. Bellizzi, V.; Cupisti, A.; Locatelli, F.; Bolasco, P.; Brunori, G.; Cancarini, G.; Caria, S.; De Nicola, L.; Di Iorio, B.R.; Di Micco, L.; et al. Low-protein diets for chronic kidney disease patients: The Italian experience. BMC Nephrol. 2016, 17, 77.
  6. Garneata, L.; Stancu, A.; Dragomir, D.; Stefan, G.; Mircescu, G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. J. Am. Soc. Nephrol. 2016, 27, 2164–2176.
  7. Kalantar-Zadeh, K.; Joshi, S.; Schlueter, R.; Cooke, J.; Brown-Tortorici, A.; Donnelly, M.; Schulman, S.; Lau, W.L.; Rhee, C.M.; Streja, E.; et al. Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease. Nutrients 2020, 12, 1931.
  8. Kalantar-Zadeh, K.; Rhee, C.M.; Joshi, S.; Brown-Tortorici, A.; Kramer, H.M. Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes. Curr. Opin. Nephrol. Hypertens. 2022, 31, 26–35.
  9. Reyes-López, M.A.; Piccoli, G.B.; Leone, F.; Orozco-Guillén, A.; Perichart-Perera, O. Nutrition care for chronic kidney disease during pregnancy: An updated review. Eur. J. Clin. Nutr. 2020, 74, 983–990.
  10. Piccoli, G.B.; Vigotti, F.N.; Leone, F.; Capizzi, I.; Daidola, G.; Cabiddu, G.; Avagnina, P. Low-protein diets in CKD: How can we achieve them? A narrative, pragmatic review. Clin. Kidney J. 2015, 8, 61–70.
  11. Gluba-Brzózka, A.; Franczyk, B.; Rysz, J. Vegetarian Diet in Chronic Kidney Disease-A Friend or Foe. Nutrients 2017, 9, 374.
  12. Foundation, N.K. Plant-Based Diet or Vegetarian Diet—What is the Difference? Available online: https://www.kidney.org/atoz/content/plant-based-diet-or-vegetarian-diet-difference (accessed on 13 December 2023).
  13. Ku, E.; Lee, B.J.; Wei, J.; Weir, M.R. Hypertension in CKD: Core Curriculum 2019. Am. J. Kidney Dis. 2019, 74, 120–131.
  14. Rouse, I.L.; Beilin, L.J.; Armstrong, B.K.; Vandongen, R. Blood-pressure-lowering effect of a vegetarian diet: Controlled trial in normotensive subjects. Lancet 1983, 1, 5–10.
  15. Margetts, B.M.; Beilin, L.J.; Vandongen, R.; Armstrong, B.K. Vegetarian diet in mild hypertension: A randomised controlled trial. Br. Med. J. (Clin. Res. Ed.) 1986, 293, 1468–1471.
  16. 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. DASH Collaborative Research Group. N. Engl. J. Med. 1997, 336, 1117–1124.
  17. Yokoyama, Y.; Nishimura, K.; Barnard, N.D.; Takegami, M.; Watanabe, M.; Sekikawa, A.; Okamura, T.; Miyamoto, Y. Vegetarian diets and blood pressure: A meta-analysis. JAMA Intern. Med. 2014, 174, 577–587.
  18. Tonstad, S.; Butler, T.; Yan, R.; Fraser, G.E. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care 2009, 32, 791–796.
  19. Qian, F.; Liu, G.; Hu, F.B.; Bhupathiraju, S.N.; Sun, Q. Association Between Plant-Based Dietary Patterns and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA Intern. Med. 2019, 179, 1335–1344.
  20. Kahleova, H.; Tura, A.; Hill, M.; Holubkov, R.; Barnard, N.D. A Plant-Based Dietary Intervention Improves Beta-Cell Function and Insulin Resistance in Overweight Adults: A 16-Week Randomized Clinical Trial. Nutrients 2018, 10, 189.
  21. Kahleova, H.; Matoulek, M.; Malinska, H.; Oliyarnik, O.; Kazdova, L.; Neskudla, T.; Skoch, A.; Hajek, M.; Hill, M.; Kahle, M.; et al. Vegetarian diet improves insulin resistance and oxidative stress markers more than conventional diet in subjects with Type 2 diabetes. Diabet. Med. A J. Br. Diabet. Assoc. 2011, 28, 549–559.
  22. Huang, R.Y.; Huang, C.C.; Hu, F.B.; Chavarro, J.E. Vegetarian Diets and Weight Reduction: A Meta-Analysis of Randomized Controlled Trials. J. Gen. Intern. Med. 2016, 31, 109–116.
  23. Mozaffarian, D.; Hao, T.; Rimm, E.B.; Willett, W.C.; Hu, F.B. Changes in diet and lifestyle and long-term weight gain in women and men. N. Engl. J. Med. 2011, 364, 2392–2404.
  24. Smith, J.D.; Hou, T.; Ludwig, D.S.; Rimm, E.B.; Willett, W.; Hu, F.B.; Mozaffarian, D. Changes in intake of protein foods, carbohydrate amount and quality, and long-term weight change: Results from 3 prospective cohorts. Am. J. Clin. Nutr. 2015, 101, 1216–1224.
  25. Baden, M.Y.; Satija, A.; Hu, F.B.; Huang, T. Change in Plant-Based Diet Quality Is Associated with Changes in Plasma Adiposity-Associated Biomarker Concentrations in Women. J. Nutr. 2019, 149, 676–686.
  26. Eichelmann, F.; Schwingshackl, L.; Fedirko, V.; Aleksandrova, K. Effect of plant-based diets on obesity-related inflammatory profiles: A systematic review and meta-analysis of intervention trials. Obes. Rev. 2016, 17, 1067–1079.
  27. Bowman, S.A. A Vegetarian-Style Dietary Pattern Is Associated with Lower Energy, Saturated Fat, and Sodium Intakes; and Higher Whole Grains, Legumes, Nuts, and Soy Intakes by Adults: National Health and Nutrition Examination Surveys 2013-2016. Nutrients 2020, 12, 2668.
  28. McMahon, E.J.; Campbell, K.L.; Bauer, J.D.; Mudge, D.W.; Kelly, J.T. Altered dietary salt intake for people with chronic kidney disease. Cochrane Database Syst. Rev. 2021, 6, Cd010070.
  29. Garofalo, C.; Borrelli, S.; Provenzano, M.; De Stefano, T.; Vita, C.; Chiodini, P.; Minutolo, R.; De Nicola, L.; Conte, G. Dietary Salt Restriction in Chronic Kidney Disease: A Meta-Analysis of Randomized Clinical Trials. Nutrients 2018, 10, 732.
  30. Shi, H.; Su, X.; Li, C.; Guo, W.; Wang, L. Effect of a low-salt diet on chronic kidney disease outcomes: A systematic review and meta-analysis. BMJ Open 2022, 12, e050843.
  31. Wang, W.; Soltero, L.; Zhang, P.; Huang, X.R.; Lan, H.Y.; Adrogue, H.J. Renal inflammation is modulated by potassium in chronic kidney disease: Possible role of Smad7. Am. J. Physiol. Ren. Physiol. 2007, 293, F1123–F1130.
  32. Turban, S.; Juraschek, S.P.; Miller, E.R., 3rd; Anderson, C.A.M.; White, K.; Charleston, J.; Appel, L.J. Randomized Trial on the Effects of Dietary Potassium on Blood Pressure and Serum Potassium Levels in Adults with Chronic Kidney Disease. Nutrients 2021, 13, 2678.
  33. Ikizler, T.A.; Burrowes, J.D.; Byham-Gray, L.D.; Campbell, K.L.; Carrero, J.J.; Chan, W.; Fouque, D.; Friedman, A.N.; Ghaddar, S.; Goldstein-Fuchs, D.J.; et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am. J. Kidney Dis. 2020, 76, S1–S107.
  34. Sánchez-Muniz, F.J. Dietary fibre and cardiovascular health. Nutr. Hosp. 2012, 27, 31–45.
  35. Tuttle, K.R.; Bakris, G.L.; Bilous, R.W.; Chiang, J.L.; de Boer, I.H.; Goldstein-Fuchs, J.; Hirsch, I.B.; Kalantar-Zadeh, K.; Narva, A.S.; Navaneethan, S.D.; et al. Diabetic kidney disease: A report from an ADA Consensus Conference. Diabetes Care 2014, 37, 2864–2883.
  36. Trautwein, E.A.; McKay, S. The Role of Specific Components of a Plant-Based Diet in Management of Dyslipidemia and the Impact on Cardiovascular Risk. Nutrients 2020, 12, 2671.
  37. Montemurno, E.; Cosola, C.; Dalfino, G.; Daidone, G.; De Angelis, M.; Gobbetti, M.; Gesualdo, L. What would you like to eat, Mr CKD Microbiota? A Mediterranean Diet, please! Kidney Blood Press. Res. 2014, 39, 114–123.
  38. Altorf-van der Kuil, W.; Engberink, M.F.; Brink, E.J.; van Baak, M.A.; Bakker, S.J.; Navis, G.; van’t Veer, P.; Geleijnse, J.M. Dietary protein and blood pressure: A systematic review. PLoS ONE 2010, 5, e12102.
  39. Tielemans, S.M.; Altorf-van der Kuil, W.; Engberink, M.F.; Brink, E.J.; van Baak, M.A.; Bakker, S.J.; Geleijnse, J.M. Intake of total protein, plant protein and animal protein in relation to blood pressure: A meta-analysis of observational and intervention studies. J. Hum. Hypertens. 2013, 27, 564–571.
  40. Montalcini, T.; De Bonis, D.; Ferro, Y.; Carè, I.; Mazza, E.; Accattato, F.; Greco, M.; Foti, D.; Romeo, S.; Gulletta, E.; et al. High Vegetable Fats Intake Is Associated with High Resting Energy Expenditure in Vegetarians. Nutrients 2015, 7, 5933–5947.
  41. Narasaki, Y.; Rhee, C.M. Dietary Therapy for Managing Hyperphosphatemia. Clin. J. Am. Soc. Nephrol. 2020, 16, 9–11.
  42. 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.
  43. Narasaki, Y.; Yamasaki, M.; Matsuura, S.; Morinishi, M.; Nakagawa, T.; Matsuno, M.; Katsumoto, M.; Nii, S.; Fushitani, Y.; Sugihara, K.; et al. Phosphatemic Index Is a Novel Evaluation Tool for Dietary Phosphorus Load: A Whole-Foods Approach. J. Ren. Nutr. 2020, 30, 493–502.
  44. Moe, S.M.; Chen, N.X.; Seifert, M.F.; Sinders, R.M.; Duan, D.; Chen, X.; Liang, Y.; Radcliff, J.S.; White, K.E.; Gattone, V.H., 2nd. A rat model of chronic kidney disease-mineral bone disorder. Kidney Int. 2009, 75, 176–184.
  45. 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.
  46. Azadbakht, L.; Esmaillzadeh, A. Soy-protein consumption and kidney-related biomarkers among type 2 diabetics: A crossover, randomized clinical trial. J. Ren. Nutr. 2009, 19, 479–486.
  47. Cases, A.; Cigarrán-Guldrís, S.; Mas, S.; Gonzalez-Parra, E. Vegetable-Based Diets for Chronic Kidney Disease? It Is Time to Reconsider. Nutrients 2019, 11, 1263.
  48. Koppe, L.; Fouque, D.; Soulage, C.O. The Role of Gut Microbiota and Diet on Uremic Retention Solutes Production in the Context of Chronic Kidney Disease. Toxins 2018, 10, 155.
  49. Marzocco, S.; Dal Piaz, F.; Di Micco, L.; Torraca, S.; Sirico, M.L.; Tartaglia, D.; Autore, G.; Di Iorio, B. Very low protein diet reduces indoxyl sulfate levels in chronic kidney disease. Blood Purif. 2013, 35, 196–201.
  50. Sirich, T.L.; Plummer, N.S.; Gardner, C.D.; Hostetter, T.H.; Meyer, T.W. Effect of increasing dietary fiber on plasma levels of colon-derived solutes in hemodialysis patients. Clin. J. Am. Soc. Nephrol. 2014, 9, 1603–1610.
  51. Krishnamurthy, V.M.R.; Wei, G.; Baird, B.C.; Murtaugh, M.; Chonchol, M.B.; Raphael, K.L.; Greene, T.; Beddhu, S. High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease. Kidney Int. 2012, 81, 300–306.
  52. Vaziri, N.D.; Liu, S.M.; Lau, W.L.; Khazaeli, M.; Nazertehrani, S.; Farzaneh, S.H.; Kieffer, D.A.; Adams, S.H.; Martin, R.J. High amylose resistant starch diet ameliorates oxidative stress, inflammation, and progression of chronic kidney disease. PLoS ONE 2014, 9, e114881.
  53. Dahl, W.J.; Stewart, M.L. Position of the Academy of Nutrition and Dietetics: Health Implications of Dietary Fiber. J. Acad. Nutr. Diet. 2015, 115, 1861–1870.
  54. Dhingra, D.; Michael, M.; Rajput, H.; Patil, R.T. Dietary fibre in foods: A review. J. Food Sci. Technol. 2012, 49, 255–266.
  55. Veronese, N.; Solmi, M.; Caruso, M.G.; Giannelli, G.; Osella, A.R.; Evangelou, E.; Maggi, S.; Fontana, L.; Stubbs, B.; Tzoulaki, I. Dietary fiber and health outcomes: An umbrella review of systematic reviews and meta-analyses. Am. J. Clin. Nutr. 2018, 107, 436–444.
  56. Xiong, R.G.; Zhou, D.D.; Wu, S.X.; Huang, S.Y.; Saimaiti, A.; Yang, Z.J.; Shang, A.; Zhao, C.N.; Gan, R.Y.; Li, H.B. Health Benefits and Side Effects of Short-Chain Fatty Acids. Foods 2022, 11, 2863.
  57. 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.
  58. 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.
  59. 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.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.
This entry is offline, you can click here to edit this entry!
Video Production Service
Feedback