A consensus document, formulated in collaboration of the Italian Society of Nephrology (SIN), the Italian Society of Dietitians (ANDID) and representatives from Italian Association of Patients with Renal Failure (ANED) in 2018, outlines nutritional therapies for patients with advanced chronic renal failure.
According to consensus, dialysis should start if uremic symptoms are no longer manageable independent of the glomerular filtration rate (GFR). Fortunately, uremic symptoms can be controlled with Dietetic-Nutritional Therapy (DNT) among pre-dialysis patients (CKD3-5). DNT, which includes adequate energy intake, can postpone renal replacement therapy to a more advanced stage at no increased risk for protein-energy malnutrition for the patient. DNT is based on limitations of protein intake (below 0.8g/kg/day), phosphorus (below 700 mg/day), sodium (if hypertensive, 5-6g/day), control of potassium (reduced if hyperkalemia is >5.5 mmol/l), a reduced acid load (reducing animal-based protein consumption while increasing vegetable intake) and fulfilling the energy requirement (35 kcal/kg/day for subjects <60 years and 30kcal/kg/day in subjects >60 years). Consumption of low protein medical foods can increase caloric intake, and minimize nitrogenous waste-products with negligible phosphorus, sodium, and potassium content. Considering maintenance of caloric intake, low protein diets do not cause malnutrition. Low protein diets (LPD) are limited to 0.6g/kg/day, whereas a very low protein diet (VLPD) consists of less than 0.3g of plant-based protein/kg/day must be supplemented with essential amino acid (EAA) and ketoacid (KA) mixtures (supplemented VLPD, sVLPD). Implementation of DNT can allow an integrated incremental dialysis regimen in selected patients. For optimal results, diets should be personalized to improve adherence alongside pharmacological therapies.
Cupisti, A., Brunori, G., Raffaele Di Iorio, B., et al. Nutritional treatment of advanced CKD: twenty consensus statements. Journal of Nephrology, 2018; https://doi/org/10.1007/s40620-018-0497-z.