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Meta-Analysis
. 2015 Sep 16;2015(9):CD010350.
doi: 10.1002/14651858.CD010350.pub2.

Dietary interventions for mineral and bone disorder in people with chronic kidney disease

Zhuangzhu Liu  1 , Guobin Su, Xinfeng Guo, Yifan Wu, Xusheng Liu, Chuan Zou, Lei Zhang, Qianchun Yang, Yuan Xu, Weizhong Ma
Affiliations
Meta-Analysis

Dietary interventions for mineral and bone disorder in people with chronic kidney disease

Zhuangzhu Liu et al. Cochrane Database Syst Rev. .

Abstract

Background: Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a systemic dysfunction of mineral and bone metabolism in people with CKD. Recent research shows that phosphate retention plays a significant role in the development of CKD-MBD. Compared with drug therapies, dietary interventions may be simple, inexpensive and feasible for phosphate retention. However, there is little evidence to support these interventions.

Objectives: Our objective was to assess the benefits and harms of any dietary intervention for preventing and treating CKD-MBD.

Search methods: We searched Cochrane Kidney and Transplant's Specialised Register to 27 August 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched the Chinese Biomedicine Database (CBM) (1976 to August 2015), China Knowledge Resource Integrated Database (CNKI) (1979 to August 2015), and VIP (1989 to August 2015).

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs looking at dietary interventions for prevention or treatment of CKD-MBD were eligible for inclusion.

Data collection and analysis: Two authors independently assessed the eligibility, methodological quality, and extracted data. Continuous outcomes (serum calcium level, serum phosphorus level, calcium × phosphate product, parathyroid hormone (PTH), fibroblast growth factor 23 (FGF-23) and alkaline phosphatase) were expressed as mean difference (MD) with 95% confidence interval (CI). Dichotomous outcomes (mortality) were expressed as risk ratio (RR) with 95% CI. We used a random-effects model to meta-analyse studies.

Main results: Nine studies were included in this review which analysed 634 participants. Study duration ranged from 4 to 24 weeks. The interventions included calcium-enriched bread, low phosphorus intake, low protein intake, very low protein intake, post haemodialysis supplements and hypolipaemic diet. Only one study reported death; none of the included studies reported cardiovascular events or fractures. There was insufficient reporting of design and methodological aspects among the included studies to enable robust assessment of risk of bias.There was limited and low-quality evidence to indicate that calcium-enriched bread increased serum calcium (1 study, 53 participants: MD -0.16 mmol/L, 95% CI -0.51 to -0.31), decreased serum phosphorus (53 participants: MD -0.41 mmol/L, 95% CI -0.51 to -0.31) and decreased the calcium × phosphate product (53 participants: MD -0.62 mmol²/L², 95% CI -0.77 to -0.47).Very low protein intake was not superior to conventional low protein intake in terms of effect on serum phosphorus (2 studies, 41 participants: MD -0.12 mmol/L, 95% CI -0.50 to 0.25), serum calcium (MD 0.00 mmol/L, 95% CI -0.17 to 0.17), or alkaline phosphatase (MD -22.00 U/L, 95% CI -78.25 to 34.25). PTH was significantly lower in the very low protein intake group (2 studies, 41 participants: MD -69.64 pmol/L, 95% CI -139.83 to 0.54).One study reported no significant difference in the number of deaths between low phosphorus intake and normal diet (279 participants: RR 0.18, 95% CI 0.01 to 3.82). Low phosphorus intake decreased serum phosphorus (2 studies, 359 participants: MD -0.18 mmol/L, 95% CI -0.29 to -0.07; I(2) = 0%).One study reported post-haemodialysis supplements did not increase serum phosphorus compared to normal diet (40 participants: MD 0.12 mmol/L, 95% CI -0.24 to 0.49).One study reported low phosphorus intake plus lanthanum carbonate significantly decreased FGF-23 (19 participants: MD -333.80 RU/mL, 95% CI -526.60 to -141.00), but did not decrease serum phosphorus (19 participants: MD -0.10 mg/dL, 95% CI -0.38 to 0.58) or PTH (19 participants: MD 31.60 pg/mL, 95% CI -29.82 to 93.02).

Authors' conclusions: There was limited low quality evidence to indicate that dietary interventions (calcium-enriched bread or low phosphorus/protein intake) may positively affect CKD-MBD by increasing serum calcium, decreasing serum phosphorus, the calcium × phosphate product and FGF-23. Large and well-designed RCTs are needed to evaluate the effects of various interventions for people with CKD-MBD.

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Conflict of interest statement

None known.

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Calcium‐enriched bread versus calcium acetate, Outcome 1 Serum phosphorus.
1.2
1.2. Analysis
Comparison 1 Calcium‐enriched bread versus calcium acetate, Outcome 2 Serum calcium.
1.3
1.3. Analysis
Comparison 1 Calcium‐enriched bread versus calcium acetate, Outcome 3 Calcium × phosphate product.
1.4
1.4. Analysis
Comparison 1 Calcium‐enriched bread versus calcium acetate, Outcome 4 Alkaline phosphatase activity.
2.1
2.1. Analysis
Comparison 2 Very low versus low protein intake, Outcome 1 Serum phosphorus.
2.2
2.2. Analysis
Comparison 2 Very low versus low protein intake, Outcome 2 Serum calcium.
2.3
2.3. Analysis
Comparison 2 Very low versus low protein intake, Outcome 3 Alkaline phosphatase.
2.4
2.4. Analysis
Comparison 2 Very low versus low protein intake, Outcome 4 PTH.
3.1
3.1. Analysis
Comparison 3 Low phosphorus intake versus normal diet, Outcome 1 Mortality.
3.2
3.2. Analysis
Comparison 3 Low phosphorus intake versus normal diet, Outcome 2 Serum phosphorus.
4.1
4.1. Analysis
Comparison 4 Post‐haemodialysis dietary supplement versus normal diet, Outcome 1 Serum phosphorus.
5.1
5.1. Analysis
Comparison 5 Low phosphorus intake plus drug/placebo versus ad libitum diet plus drug/placebo, Outcome 1 Serum phosphorus.
5.2
5.2. Analysis
Comparison 5 Low phosphorus intake plus drug/placebo versus ad libitum diet plus drug/placebo, Outcome 2 PTH.
5.3
5.3. Analysis
Comparison 5 Low phosphorus intake plus drug/placebo versus ad libitum diet plus drug/placebo, Outcome 3 FGF‐23.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010350

References

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References to other published versions of this review

Liu 2013
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