Dietary Protein Sources and Risk for Incident Chronic Kidney Disease: Results From the Atherosclerosis Risk in Communities (ARIC) Study

Abstract

Objective: Dietary protein restriction is recommended for patients with moderate to severe renal insufficiency. Long-term data on the relationship between dietary protein sources and risk for incident kidney disease in individuals with normal kidney function are largely missing. This study aimed to assess the association between dietary protein sources and incident chronic kidney disease (CKD).

Design: Prospective cohort.

Setting: Atherosclerosis Risk in Communities study participants from 4 US communities.

Subjects: A total of 11,952 adults aged 44-66 years in 1987-1989 who were free of diabetes mellitus, cardiovascular disease, and had an estimated glomerular filtration rate (eGFR) ≥ 60 mL/minute/1.73 m².

Main outcome measure: A 66-item food frequency questionnaire was used to assess food intake. CKD stage 3 was defined as a decrease in eGFR of ≥25% from baseline resulting in an eGFR of less than 60 mL/minute/1.73 m²; CKD-related hospitalization; CKD-related death; or end-stage renal disease. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression.

Results: During a median follow-up of 23 years, there were 2,632 incident CKD cases. Red and processed meat consumption was associated with increased CKD risk (HR_{Q5 vs. Q1}: 1.23, 95% CI: 1.06-1.42, p_trend = 0.01). In contrast, higher dietary intake of nuts, legumes, and low-fat dairy products was associated with lower CKD risk (nuts: HR_{Q5 vs. Q1}: 0.81, 95% CI: 0.72-0.92, p_trend <0.001; low-fat dairy products: HR_{Q5 vs. Q1}: 0.75, 95% CI: 0.65-0.85, p_trend <0.001; legumes: HR_{Q5 vs. Q1}: 0.83, 95% CI: 0.72-0.95, p_trend = 0.03).

Conclusion: There were varied associations of specific dietary protein sources with risk of incident CKD; with red and processed meat being adversely associated with CKD risk; and nuts, low-fat dairy products, and legumes being protective against the development of CKD.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.

Figure 1. Frequency histograms and adjusted hazard ratios^a for the association between dietary intake of (A) total protein, (B) legumes, (C) red and processed meat, (D) fish and seafood, (E) nuts, and (F) low-fat dairy products and incident chronic kidney disease

^a Dietary intake of total protein and sources of protein are modeled using linear spline terms with knots at the 20^th, 40^th, 60^th, and 80^th percentiles. The 10^th percentile of dietary intake of protein was used as the reference point, and data were truncated at the 99^th percentile. The solid lines represent hazard ratios adjusted for age, race-center, sex, education level, total caloric intake, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, lipid-lowering medication, systolic blood pressure, anti-hypertensive medication use, alcohol intake, current smoker, physical activity index, leisure-related physical activity, total carbohydrate, body mass index, and waist-to-hip ratio.