CoChat
Sign Up
Cited by 2,328Chronic Kidney Disease and DiabetesDialysis and Renal Disease ManagementAcute Kidney Injury Research

The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease

Open access
Klahr, Saulo, Levey, Andrew S., Beck, Gerald J., Caggiula, Arlene W., Hunsicker, Lawrence, Kusek, John W., Striker, Gary·1994·New England Journal of Medicine
DOI 10.1056/nejm199403313301301
Open this paper in CoChat — free accountOpen PDF

Abstract

BACKGROUND: Restricting protein intake and controlling hypertension delay the progression of renal disease in animals. We tested these interventions in 840 patients with various chronic renal diseases. METHODS: In study 1, 585 patients with glomerular filtration rates of 25 to 55 ml per minute per 1.73 m2 of body-surface area were randomly assigned to a usual-protein diet or a low-protein diet (1.3 or 0.58 g of protein per kilogram of body weight per day) and to a usual- or a low-blood-pressure group (mean arterial pressure, 107 or 92 mm Hg). In study 2, 255 patients with glomerular filtration rates of 13 to 24 ml per minute per 1.73 m2 were randomly assigned to the low-protein diet (0.58 g per kilogram per day) or a very-low-protein diet (0.28 g per kilogram per day) with a keto acid-amino acid supplement, and a usual- or a low-blood-pressure group (same values as those in study 1). An 18-to-45-month follow-up was planned, with monthly evaluations of the patients. RESULTS: The mean follow-up was 2.2 years. In study 1, the projected mean decline in the glomerular filtration rate at three years did not differ significantly between the diet groups or between the blood-pressure groups. As compared with the usual-protein group and the usual-blood-pressure group, the low-protein group and the low-blood-pressure group had a more rapid decline in the glomerular filtration rate during the first four months after randomization and a slower decline thereafter. In study 2, the very-low-protein group had a marginally slower decline in the glomerular filtration rate than did the low-protein group (P = 0.07). There was no delay in the time to the occurrence of end-stage renal disease or death. In both studies, patients in the low-blood-pressure group who had more pronounced proteinuria at base line had a significantly slower rate of decline in the glomerular filtration rate. CONCLUSIONS: Among patients with moderate renal insufficiency, the slower decline in renal function that started four months after the introduction of a low-protein diet suggests a small benefit of this dietary intervention. Among patients with more severe renal insufficiency, a very-low-protein diet, as compared with a low-protein diet, did not significantly slow the progression of renal disease.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1056/nejm199403313301301

Cites

30 of 30 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Compared with a non-protein-limited diet, a low-protein diet of 0.6 g/kg BW/d can prevent a decline in GFR of approximately 1 mL/min per year per 1.73 m2 and is associated with a 30% decrease in reaching a dialysis-dependent stage.

    “Compared with a noneproteinlimited diet, a low-protein diet of 0.6 g/kg BW/d can prevent a decline in GFR of approximately 1 mL/min per year per 1.73 m 2 and is associated with a 30% decrease in reaching a dialysisdependent stage.114,115”

    From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [115]

    In Study 1 (p. 3), the approximately 0.6 g/kg/day diet was associated with a slower GFR decline than the usual-protein diet after four months, supporting the direction and approximate size of the GFR claim. But GFR declined faster in the low-protein group during the first four months, and the Discussion (p. 7) describes only a possible small benefit. The paper reports no significant difference in time to end-stage renal disease or death; it does not support a 30% decrease in reaching a dialysis-dependent stage. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Reducing dietary protein below the recommended daily allowance of 0.8 g/kg/day does not alter blood glucose levels, cardiovascular risk measures, or the course of GFR decline.

    “Reducing the amount of dietary protein below the recommended daily allowance of 0.8 g/kg/day is not recommended because it does not alter blood glucose levels, cardiovascular risk measures, or the course of GFR decline (46).”

    From 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [46]

    Study 2 (p. 5) found no statistically significant difference in GFR decline between the low- and very-low-protein groups, but the Discussion (p. 7) notes a nonsignificant trend toward slower decline with very low protein intake. The paper does not report that protein restriction leaves blood glucose unchanged; Adverse Events (p. 5) instead reports significant differences in serum cholesterol changes between diet groups. It does not establish the broad recommendation against intake below 0.8 g/kg/day. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • In people with CKD and diabetes, consuming protein below the recommended daily allowance of 0.8 g/kg/day does not alter blood glucose levels, cardiovascular risk measures, or the course of GFR decline.

    “In people with CKD and diabetes, consuming protein below the recommended daily allowance of 0.8 g/kg/day is not recommended, because it does not alter blood glucose levels, cardiovascular risk measures, or the course of GFR decline (48).”

    From 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [48]

    The Methods (p. 1) compare protein diets below 0.8 g/kg/day, and Study 2 (p. 5) reports no statistically significant difference in average GFR decline between its diet groups. But this was not a finding specific to people with diabetes: only 3% of participants had non-insulin-dependent diabetes (Base-Line Characteristics, p. 2). The paper does not establish the claimed lack of effects on blood glucose or cardiovascular risk measures, and its Discussion (p. 7) describes a possible small benefit for renal progression rather than showing no effect. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Under conditions of nutritional counseling and regular follow-up, the development of malnutrition during a low-protein diet is an extremely rare event.

    “Under those conditions, the development of malnutrition during a low-protein diet is an extremely rare event.115”

    From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [115]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. [13]13. Beck GJ, Berg RL, Coggins CH, et al. Design and statistical issues of the Mo o it D Dt tn Renal Disease Study Group. Controlled Clin Trials 1991;12:566-86.
  2. [18]18. Kusek J, Caggiula A, Williams G, Klahr S. Modification of Diet in Renal Disease Study. In: Albertazzi A, Cappelli P, Del Rosso G, Di Paolo B, Evangelista M, Palmieri PF, eds. Nutritional and pharmacological strategies in chronic renal failure. Vol. 81 of Contributions in nephrology. Basel, Switzerland: S. Karger, 1991:50-60.
  3. [19]19. Levey AS, Greene T, Schluchter MD, et al. GFR measurements in clinical trials. J Am Soc Nephrol 1993;4:1159-71.

Cited by

Sorted by citations

Related

Authors
Klahr, S., Levey, A. S., Beck, G. J., Caggiula, A. W., Hunsicker, L., Kusek, J. W., & Striker, G.
Affiliations
  • National Institutes of Health (US)
  • Tufts Medical Center (US)
  • Cleveland Clinic (US)
  • University of Pittsburgh (US)
  • University of Iowa Hospitals and Clinics (US)
ORCID
Venue
New England Journal of Medicine
Publisher
Massachusetts Medical Society
Published
1994-03-31
Volume
330
Issue
13
Pages
877-884
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
DOI
10.1056/nejm199403313301301
OpenAlex
W2321986725
Semantic Scholar
01e2c22d0073b85c7e2ba3a9327f2c898329d6af
Cited by
2,328
References
30
Citations by year
2026: 25 · 2025: 53 · 2024: 56 · 2023: 66 · 2022: 64 · 2021: 74 · 2020: 73 · 2019: 82 · 2018: 81 · 2017: 98 · 2016: 82 · 2015: 84 · 2014: 100 · 2013: 92 · 2012: 92
FWCI
51.46
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (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 › Nephrology › Acute Kidney Injury Research
Keywords
chronic kidney disease, protein restriction, very low protein diet, low-protein diet, blood pressure control, hypertension, glomerular filtration rate decline, end-stage renal disease, proteinuria, renal failure, disease progression, mortality, renal function decline, end-stage renal disease prevention, mortality prevention
MeSH terms
Blood Pressure, Chronic Disease, Dietary Proteins, Female, Follow-Up Studies, Glomerular Filtration Rate, Humans, Hypertension, Kidney Diseases, Kidney Failure, Chronic, Polycystic Kidney Diseases, Male, Middle Aged, Linear Models

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review