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Cited by 128Chronic Kidney Disease and DiabetesDialysis and Renal Disease ManagementDiet and metabolism studies

Low protein diets for non-diabetic adults with chronic kidney disease

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Hahn, Deirdre, Hodson, Elisabeth M, Fouque, Denis·2018·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd001892.pub4PMC PMC6517211
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Abstract

BACKGROUND: Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006 and 2009. OBJECTIVES: To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 2 March 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi RCTs in which adults with non-diabetic chronic kidney disease (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/d) compared with a low protein intake (0.5 to 0.6 g/kg/d) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/d) for 12 months or more. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE. MAIN RESULTS: We identified an additional six studies to include 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months.Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding.Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence).Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence).Final body w

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  • In clinical studies predominantly enrolling people with nondiabetic and especially advanced CKD, low-protein intake compared with normal protein intake of 0.8 g/kg/d has been demonstrated to slow the decline in kidney function.

    “In few clinical studies, predominantly enrolling those with nondiabetic and especially advanced CKD, a low-protein intake (compared to those with normalprotein intake of 0.8 g/kg/d) has been demonstrated to slow down the decline in kidney function. 264”

    From KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (2022) · cites this paper as [264]

    The Discussion’s summary of main results says it is uncertain whether low-protein intake, compared with normal intake, affects the change in GFR; it does not establish a slower decline in kidney function. The review also says these comparisons mainly enrolled people with CKD categories 3a and 3b, rather than especially advanced CKD. (LLM, conf=0.89)

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  • A Cochrane systematic review on a very low-protein diet (0.3-0.4 g/kg/d) compared to a low-protein diet (0.5-0.6 g/kg/d) or normal-protein diet (≥0.8 g/kg/d) for 12 months found that it likely had little or no effect on death and/or kidney failure (moderate-quality evidence).

    “A Cochrane systematic review on a very low -protein diet (0.3 -0.4 g/kg/d) compared to a low-protein diet (0.5 -0.6 g/kg/d) or normal-protein diet ( $ 0.8 g/kg/d) for 12 months found that it likely had little or no effect on death and/or kidney failure (moderate-quality evidence).”

    From KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (2022) · cites this paper as [264]

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References 154 · Cited by 128

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Authors
Hahn, D., Hodson, E. M., & Fouque, D.
Affiliations
  • The Children's Hospital at Westmead; Department of Nephrology; Locked Bag 4001 Westmead NSW Australia 2145
  • Children's Hospital at Westmead (AU)
  • Lyon 1 Université (FR)
ORCID
Fouque, Denis
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2018-10-04
Volume
10
Pages
CD001892-CD001892
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd001892.pub4
PMC
PMC6517211
OpenAlex
W3131017658
Cited by
128
References
154
Citations by year
2026: 5 · 2025: 12 · 2024: 11 · 2023: 22 · 2022: 18 · 2021: 20 · 2020: 23 · 2019: 17
FWCI
2.58
Type
journal article
Language
en
Update notices
new_version (2020-10-29)
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
  • Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
  • Health Sciences › Medicine › Physiology › Diet and metabolism studies
Keywords
low-protein diet, chronic kidney disease, non-diabetic adults, protein restriction, end-stage renal disease, dialysis initiation, glomerular filtration rate, proteinuria, serum albumin, mortality, adverse effects, renal replacement therapy, CKD stages 3-5
MeSH terms
Adult, Cause of Death, Chronic Disease, Humans, Kidney Diseases, Kidney Failure, Chronic, Protein-Energy Malnutrition, Randomized Controlled Trials as Topic, Disease Progression, Diet, Protein-Restricted

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