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Review
, 4 (4), CD011998

Dietary Interventions for Adults With Chronic Kidney Disease

Affiliations
Review

Dietary Interventions for Adults With Chronic Kidney Disease

Suetonia C Palmer et al. Cochrane Database Syst Rev.

Abstract

Background: Dietary changes are routinely recommended in people with chronic kidney disease (CKD) on the basis of randomised evidence in the general population and non-randomised studies in CKD that suggest certain healthy eating patterns may prevent cardiovascular events and lower mortality. People who have kidney disease have prioritised dietary modifications as an important treatment uncertainty.

Objectives: This review evaluated the benefits and harms of dietary interventions among adults with CKD including people with end-stage kidney disease (ESKD) treated with dialysis or kidney transplantation.

Search methods: We searched the Cochrane Kidney and Transplant Specialised Register (up to 31 January 2017) through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

Selection criteria: Randomised controlled trials (RCTs) or quasi-randomised RCTs of dietary interventions versus other dietary interventions, lifestyle advice, or standard care assessing mortality, cardiovascular events, health-related quality of life, and biochemical, anthropomorphic, and nutritional outcomes among people with CKD.

Data collection and analysis: Two authors independently screened studies for inclusion and extracted data. Results were summarised as risk ratios (RR) for dichotomous outcomes or mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI) or in descriptive format when meta-analysis was not possible. Confidence in the evidence was assessed using GRADE.

Main results: We included 17 studies involving 1639 people with CKD. Three studies enrolled 341 people treated with dialysis, four studies enrolled 168 kidney transplant recipients, and 10 studies enrolled 1130 people with CKD stages 1 to 5. Eleven studies (900 people) evaluated dietary counselling with or without lifestyle advice and six evaluated dietary patterns (739 people), including one study (191 people) of a carbohydrate-restricted low-iron, polyphenol enriched diet, two studies (181 people) of increased fruit and vegetable intake, two studies (355 people) of a Mediterranean diet and one study (12 people) of a high protein/low carbohydrate diet. Risks of bias in the included studies were generally high or unclear, lowering confidence in the results. Participants were followed up for a median of 12 months (range 1 to 46.8 months).Studies were not designed to examine all-cause mortality or cardiovascular events. In very-low quality evidence, dietary interventions had uncertain effects on all-cause mortality or ESKD. In absolute terms, dietary interventions may prevent one person in every 3000 treated for one year avoiding ESKD, although the certainty in this effect was very low. Across all 17 studies, outcome data for cardiovascular events were sparse. Dietary interventions in low quality evidence were associated with a higher health-related quality of life (2 studies, 119 people: MD in SF-36 score 11.46, 95% CI 7.73 to 15.18; I2 = 0%). Adverse events were generally not reported.Dietary interventions lowered systolic blood pressure (3 studies, 167 people: MD -9.26 mm Hg, 95% CI -13.48 to -5.04; I2 = 80%) and diastolic blood pressure (2 studies, 95 people: MD -8.95, 95% CI -10.69 to -7.21; I2 = 0%) compared to a control diet. Dietary interventions were associated with a higher estimated glomerular filtration rate (eGFR) (5 studies, 219 people: SMD 1.08; 95% CI 0.26 to 1.97; I2 = 88%) and serum albumin levels (6 studies, 541 people: MD 0.16 g/dL, 95% CI 0.07 to 0.24; I2 = 26%). A Mediterranean diet lowered serum LDL cholesterol levels (1 study, 40 people: MD -1.00 mmol/L, 95% CI -1.56 to -0.44).

Authors' conclusions: Dietary interventions have uncertain effects on mortality, cardiovascular events and ESKD among people with CKD as these outcomes were rarely measured or reported. Dietary interventions may increase health-related quality of life, eGFR, and serum albumin, and lower blood pressure and serum cholesterol levels.Based on stakeholder prioritisation of dietary research in the setting of CKD and preliminary evidence of beneficial effects on risks factors for clinical outcomes, large-scale pragmatic RCTs to test the effects of dietary interventions on patient outcomes are required.

Conflict of interest statement

Suetonia C Palmer: none known

Jasjot Maggo: none known

Allison Tong: none known

Katrina L Campbell: none known

Jonathan C Craig: none known

David W Johnson: none known

Bernadet Sutanto: none known

Marinella Ruospo: none known

Giovanni FM Strippoli: none known

Figures

Figure 1
Figure 1
Flow diagram of study selection
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Dietary intervention versus control, Outcome 1 All‐cause mortality.
Analysis 1.2
Analysis 1.2
Comparison 1 Dietary intervention versus control, Outcome 2 Cardiovascular mortality.
Analysis 1.3
Analysis 1.3
Comparison 1 Dietary intervention versus control, Outcome 3 Health‐related quality of life (SF‐36) score.
Analysis 1.4
Analysis 1.4
Comparison 1 Dietary intervention versus control, Outcome 4 End‐stage kidney disease.
Analysis 1.5
Analysis 1.5
Comparison 1 Dietary intervention versus control, Outcome 5 Doubling of serum creatinine.
Analysis 1.6
Analysis 1.6
Comparison 1 Dietary intervention versus control, Outcome 6 Employment.
Analysis 1.7
Analysis 1.7
Comparison 1 Dietary intervention versus control, Outcome 7 Dietary adherence.
Analysis 1.8
Analysis 1.8
Comparison 1 Dietary intervention versus control, Outcome 8 Worsening nutrition.
Analysis 1.9
Analysis 1.9
Comparison 1 Dietary intervention versus control, Outcome 9 eGFR [mL/min/1.73 m2].
Analysis 1.10
Analysis 1.10
Comparison 1 Dietary intervention versus control, Outcome 10 Serum creatinine.
Analysis 1.11
Analysis 1.11
Comparison 1 Dietary intervention versus control, Outcome 11 Systolic blood pressure.
Analysis 1.12
Analysis 1.12
Comparison 1 Dietary intervention versus control, Outcome 12 Diastolic blood pressure.
Analysis 1.13
Analysis 1.13
Comparison 1 Dietary intervention versus control, Outcome 13 Energy intake.
Analysis 1.14
Analysis 1.14
Comparison 1 Dietary intervention versus control, Outcome 14 Body weight.
Analysis 1.15
Analysis 1.15
Comparison 1 Dietary intervention versus control, Outcome 15 BMI.
Analysis 1.16
Analysis 1.16
Comparison 1 Dietary intervention versus control, Outcome 16 Waist‐hip ratio.
Analysis 1.17
Analysis 1.17
Comparison 1 Dietary intervention versus control, Outcome 17 Waist circumference, cm.
Analysis 1.18
Analysis 1.18
Comparison 1 Dietary intervention versus control, Outcome 18 Arm circumference.
Analysis 1.19
Analysis 1.19
Comparison 1 Dietary intervention versus control, Outcome 19 Serum albumin.
Analysis 1.20
Analysis 1.20
Comparison 1 Dietary intervention versus control, Outcome 20 Serum LDL cholesterol.
Analysis 2.1
Analysis 2.1
Comparison 2 Mediterranean diet versus low fat, Outcome 1 Serum LDL cholesterol.
Analysis 3.1
Analysis 3.1
Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 1 eGFR [mL/min/1.73 m2].
Analysis 3.2
Analysis 3.2
Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 2 Serum creatinine.
Analysis 3.3
Analysis 3.3
Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 3 Systolic blood pressure.
Analysis 3.4
Analysis 3.4
Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 4 Body weight.

Update of

  • Cochrane Database Syst Rev. doi: 10.1002/14651858.CD011998

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