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Observational Study
. 2024 Oct 30;39(11):1867-1875.
doi: 10.1093/ndt/gfae077.

The safety of a low-protein diet in older adults with advanced chronic kidney disease

Karin Windahl  1   2 , Nicholas C Chesnaye  3   4 , Gerd Faxén Irving  5 , Peter Stenvinkel  1 , Tora Almquist  6 , Maarit Korkeila Lidén  1 , Christiane Drechsler  7 , Maciej Szymczak  8 , Magdalena Krajewska  8 , Esther de Rooij  9 , Claudia Torino  10 , Gaetana Porto  11 , Fergus J Caskey  12   13 , Christoph Wanner  14 , Kitty J Jager  3   4 , Friedo W Dekker  9 , Marie Evans  1 ; EQUAL study investigators
Collaborators, Affiliations
Observational Study

The safety of a low-protein diet in older adults with advanced chronic kidney disease

Karin Windahl et al. Nephrol Dial Transplant. .

Abstract

Background: A low-protein diet (LPD) is recommended to patients with advanced chronic kidney disease (CKD), whereas geriatric guidelines recommend a higher amount of protein. The aim of this study was to evaluate the safety of LPD treatment in older adults with advanced CKD.

Methods: The EQUAL study is a prospective, observational study including patients ≥65 years of age with an incident estimated glomerular filtration rate <20 ml/min/1.73 m2 in six European countries with follow-up through 6 years. Nutritional status was assessed by a 7-point subjective global assessment (SGA) every 3-6 months. Prescribed diet (g protein/kg of bodyweight) was recorded on every study visit; measured protein intake was available in three countries. Time to death and decline in nutritional status (SGA decrease of ≥2 points) were analysed using marginal structural models with dynamic inverse probability of treatment and censoring weights.

Results: Of 1738 adults (631 prescribed LPD at any point during follow-up), there were 1319 with repeated SGA measurements, of which 267 (20%) decreased in SGA ≥2 points and 565 (32.5%) who died. There was no difference in survival or decrease in nutritional status for patients prescribed a LPD ≤0.8 g/kg ideal bodyweight {odds ratio [OR] for mortality 1.15 [95% confidence interval (CI) 0.86-1.55)] and OR for decrease in SGA 1.11 [95% CI 0.74-1.66]} in the adjusted models. In patients prescribed a LPD <0.6 g/kg ideal bodyweight, the results were similar. There was a significant interaction with LPD and older age >75 years, lower SGA and higher comorbidity burden for both mortality and nutritional status decline.

Conclusions: In older adults with CKD approaching end-stage kidney disease, a traditional LPD prescribed and monitored according to routine clinical practice in Europe appears to be safe.

Keywords: CKD; age; malnutrition; nutrition; survival analysis.

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Conflict of interest statement

None declared.

Figures

Graphical Abstract
Graphical Abstract
Figure 1:
Figure 1:
Description of the exposure, prescribed diet.
Figure 2:
Figure 2:
Cumulative incidence for decrease in the 7-point SGA in patients with spontaneously low protein intake (prescribed standard diet, but low protein intake <0.8 g/kg/day) and a standard diet with standard intake of protein (>0.8 g/kg/day).
See this image and copyright information in PMC

References

    1. Ikizler TA, Burrowes JD, Byham-Gray LDet al. . KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis 2020;76(3 Suppl 1):S1–107. 10.1053/j.ajkd.2020.05.006 - DOI - PubMed
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    1. Windahl K, Faxén Irving G, Almquist Tet al. . Prevalence and risk of protein-energy wasting assessed by subjective global assessment in older adults with advanced chronic kidney disease: results from the EQUAL study. J Ren Nutr 2018;28:165–74. 10.1053/j.jrn.2017.11.002 - DOI - PubMed
    1. Chesnaye NC, Dekker FW, Evans Met al. . Renal function decline in older men and women with advanced chronic kidney disease-results from the EQUAL study. Nephrol Dial Transplant 2021;36:1656–63. 10.1093/ndt/gfaa140.MO074 - DOI - PMC - PubMed
    1. Windahl K, Irving GF, Almquist Tet al. . Patient-reported measures and lifestyle are associated with deterioration in nutritional status in CKD stage 4-5: the EQUAL cohort study. J Ren Nutr 2022;32:161–9. - PubMed

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