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REVIEW ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 105-111

Lifestyle Modification and Nutrition: Halt the Progression to End-Stage Renal Disease


Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission08-Jun-2022
Date of Decision12-Jul-2022
Date of Acceptance15-Jul-2022
Date of Web Publication3-Oct-2022

Correspondence Address:
Sunil Kumar
Senior Professor, Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha 442001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnpnd.ijnpnd_36_22

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   Abstract 


Introduction Chronic kidney disease (CKD) is quickly becoming a global epidemic. There is an estimated annual increase of 8%, with a corresponding economic and clinical burden. Recent research into lifestyle factors has confirmed that certain dietary characteristics can help slow the progression of chronic nephropathies. Methods: This narrative review had focus on historical and emerging data on the role of nutrition in the course of CKD, with a particular focus on dietary patterns that have been shown to reduce the risk of ESRD. In this article, obesity, lipids, protein, diabetes, and blood pressure are all discussed in order to demonstrate how the current literature reflects the way to modify the dietary aspects of these. Results: Evidence strongly supports a balanced diet, good glycemic control, lipid control, modest protein reduction, and salt reduction halts the progression of CKD . The importance of these dietary strategies is not solely the role of the dietitian, but of the entire multidisciplinary team like general physician, nephrologist, exercise instructor specially yoga in providing a consistent message. Discussion: The mechanisms underlying causes are unknown, but the message remains consistent: there is an increased need for dietary advice in the predialysis population. This has significant implications and could be a cost-effective way to help slow the progression of the disease.

Keywords: Chronic kidney disease, diet, diabetes, end-stage renal disease, hypertension


How to cite this article:
Verma P, Mahajan J, Kumar S, Acharya S. Lifestyle Modification and Nutrition: Halt the Progression to End-Stage Renal Disease. Int J Nutr Pharmacol Neurol Dis 2022;12:105-11

How to cite this URL:
Verma P, Mahajan J, Kumar S, Acharya S. Lifestyle Modification and Nutrition: Halt the Progression to End-Stage Renal Disease. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 Nov 29];12:105-11. Available from: https://www.ijnpnd.com/text.asp?2022/12/3/105/357222




   Introduction Top


Chronic kidney disease (CKD) is spreading quickly over the world. Renal replacement therapy was used to treat 1.8 million patients worldwide in 2004.[1] These figures are expected to skyrocket, with a projected yearly growth of 8%, posing a significant economic and clinical burden. The causes of kidney failure have been found to be both genetic and partly environmental, while more research is needed to determine the relative importance of each.[2] Type 2 diabetes and hypertension (HT), both of which are influenced by lifestyle and nutritional variables, are the two primary causes of kidney failure in all populations. Diet is one of the modifiable risk factors that can help slow the progression of the disease.[3]

Many risk factors for CKD are similar to those for cardiovascular disease, including some that cannot be changed, including age, gender, and genetic ancestry. Patients with CKD and their clinicians are looking for ways to alter the course of their disease in order to lower the chance of developing end-stage renal disease (ESRD), death, and other CKD consequences. Adopting dietary changes is one of the options available. Understanding CKD patients’ food consumption and the challenges to improving it could lead to the development of successful CKD-reduction treatments. In this systematic review, we focus on historical and emerging data on the role of nutrition in the course of CKD, with a particular focus on dietary patterns that have been shown to reduce the risk of ESRD.


   Methods Top


The following goals are being pursued with this review: nutrition in CKD and its role to halt the progression of ESRD.

A literature search in English was conducted using the electronic databases PubMed, MEDLINE, Embase, and Google. The search terms were “nutrition” OR “CKD” OR “renal disease” OR “protein” OR “diet” OR “lifestyle modifications.” The archiving of relevant papers was supported by the writers’ personal knowledge and experience in the field. Articles that match the following criteria are included in this review: studies in English are included, studies from the previous 10 years are included as well, and studies devoted entirely to CKD, nutrition, and lifestyle modification are included. Research methodology by PRISMA method is shown in [Figure 1].
Figure 1 PRISMA method for search strategy.

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Role of diet

For decades, researchers have been fascinated by the impact of nutrition in the advancement of renal disease. There are multiple dietary guidelines for people with CKD, as well as numerous researches that look at the association between dietary components and patterns and clinical outcomes in people with CKD. Protein restriction is by far the most researched dietary intervention. Dietary protein restriction, according to the Brenner hyperfiltration theory, minimizes progressive glomerular damage by lowering glomerular hyperfiltration.[4] Despite the fact that protein restriction has been found to be successful in animal models, results in human trials have been inconsistent. A 2018 meta-analysis of low-protein diets in persons with nondiabetic CKD found that low protein intake (0.5–0.6 g/kg/day) had no influence on the risk of ESKD compared to normal protein intake (0.8 g/kg/day).[4],[5] Although there were limited data on adverse effects and no data on quality of life, a very low protein consumption (0.3–0.4 g/kg/d) probably reduced the risk of ESKD (Relative risk (RR): 0.65, 95% Confidence interval (CI): 0.49–0.85) compared to a low or normal protein intake.[5] As a result, the Kidney Disease Outcomes Quality Initiative (KDOQI) Nutrition 2020 guidelines propose protein restriction with or without keto acid analogues under intensive clinical monitoring to lower the risk of ESKD/death.[6] The Kidney Disease improving Global Outcome (KDIGO) Diabetes guidelines put forwards protein restriction in individual’s metabolic status and stage of chronic kidney disease.[7] Animal-based protein appears to elicit more glomerular hyperfiltration than vegetable-based protein, and a vegetarian diet with equal nutrition has been demonstrated to result in lower blood phosphorus, urine phosphorus excretion, and fibroblast growth factor-23 levels.[8] However, there is little evidence that current phosphorus intake in humans contributes to CKD progression or that lowering phosphorus intake improves renal injury.[9]

Individual nutrient studies may not capture the relationship between diet and chronic disease as well as dietary patterns. Furthermore, by focusing on a combination of healthful food groups rather than restricting specific nutrients, dietary patterns may make it easier to provide nutritional advice to patients.[10] A systematic review and meta-analysis discovered that healthy dietary patterns were associated with a 27% reduction in mortality (n = 7 studies; 13,930 participants), but not with ESKD (RR: 1.04, 95% CI: 0.68–1.40; n = 3 studies; 10,071 participants).[11]

In CKD patients, too much phosphorus lowers calcium levels, weakening the bones and making them more prone to fractures. High levels of phosphorus can cause itching and bone and joint pain.

Phosphorus is added in many packaged foods that have “PHOS” on the ingredient labels.[12]

Foods lacking phosphorus are: fresh fruits and vegetables, breads, rice, rice milk, corn and rice grains, and light carbonated beverages such as lemonade and homemade iced tea. Foods rich in phosphorus are: meat, poultry, fish, bran cereals and oatmeal, dairy products, beans, lentils, nuts, dark soda, and phosphorus added bottled or iced tea.

It is also advisable to take a phosphorus adsorbent to reduce the amount of phosphorus in the blood. Phosphorus adsorbents bind to phosphorus in the stomach. Phosphorus does not enter the blood, because it is bound. Instead, it is removed by defecation. Kidney damage can increase potassium levels, causing weakness and paralysis, life-threatening cardiac arrhythmias, and cardiac arrest. It is also associated with reduced renal ion excretion. Therefore, controlling the rise in potassium is essential to reduce the mortality rate of CKD patients.[11]

Foods low in potassium are: apples, peaches, carrots, green beans, white bread, white rice, rice milk (nonfortified), rice and wheat cereals, and gourds, apple, grapes, or cranberry juice. Foods high in potassium are: orange, banana, coconut water, potatoes, tomatoes, brown rice, wild rice, and dairy products.

Role of proteins

High protein intake increases glomerular pressure and its over filtration. This can lead to glomerular damage that exacerbates CKD. Therefore, a low-protein diet of 0.6 to 0.8 g/kg/day is recommended for the treatment of CKD. We investigated the effect of low protein intake on progression and CKD.

This review explains why high dietary protein intake may cause harm to the kidney, may extend kidney longevity, and why dietary protein restriction should be considered and how it works in the management of CKD.[13]

Higher protein intake inflects by augmenting renal blood flow and elevating intraglomerular pressure leading to higher glomerular filtration rate (GFR). “Glomerular hyperfiltration” that is induced by high-protein diet together with resultant increase in urinary albumin excretion, may have detrimental unwelcome consequences on kidney and other organs.[14] Glomerular injury by an elevation in intraglomerular pressure and renal blood flow can lead to continuous glomerular damage and sclerosis.

Low protein diet (LPD) lessens nitrogen waste products and reduces load on the kidneys by lowering the glomerular pressure, which may protect the kidneys, especially in patients with decreased nephron capital and renal function. It leads to favorable metabolic effects that can preserve kidney function and control of uremic symptoms. However, the Modification of Diet in Renal Disease (MDRD) study in renal disease, the largest controlled trial of dietary protein management in CKD till date, failed to demonstrate the clear efficacy of LPD on slowing CKD progression.[15] It was brought in to help form the notion that diet plays a minor but significant role in the management of CKD. However, a secondary analysis of the MDRD study showed that for every 0.2 g/kg/day reduction, the decrease in GFR over time was slightly improved, that is, 1.15 mL/minute/1.73 m2/year, and the risk of renal failure and death is halved.

LPD is also beneficial in improving the metabolic acidosis in CKD. Acid is produced during metabolism of proteins and sulfur-containing amino acids, and predialysis serum bicarbonate concentration was lower in patients with higher protein consumption. Acid tends to be retained with decreased renal function resulting in chronic metabolic acidosis impairing protein metabolism, increasing muscle catabolism and wasting, and exacerbation of the uremic manifestations.[16]

Numerous foods of plant and animal origin are rich source of protein. Animal proteins include chicken, fish, meat, eggs, and dairy products. Foods that contain vegetable protein are: nuts, seeds, beans, pea beans, legumes, and grains. Food in cans, boxes, jars, or bags is processed and tends to be high in sugar and salt and should be avoided. High intakes of vegetable protein reduce the risk of CKD, while high intakes of animal protein increase the risk of developing CKD. Therefore, we need a balanced combination of both. A cooked serving of chicken, fish, or meat is about 2 to 3 ounces, or about the same size as a deck of playing cards. Serving for dairy products is a half cup of milk or yogurt, or a slice of cheese. Cooked beans serve about half cup and nuts serve one-quarter cup. Bread serving is a slice and rice is one-half cup.[17]

Role of lipids

Hyperlipidemia is defined as an abnormally high level of lipids (cholesterol and/or triglycerides) in the blood or the lipoproteins that transport them.[18] A 10% reduction in cholesterol (equivalent to 0.6 mmol/L) equates to a 54% reduction in Coronary heart disease (CHD) at 40 years of age, but drops to 19% at 80 years.[19] A growing body of evidence suggests that elevated lipids may contribute to renal function decline. Given that cardiac events are the leading cause of death in renal patients, it is critical to keep lipid levels under control. The evidence that it may hasten the progression of kidney failure strengthens the case for treatment, both dietary and pharmaceutical. Explanatory mechanisms linking an abnormal lipid profile to the progression of renal failure include mesangial cell proliferation stimulation, cytokine expression, oxidative stress, and insulin resistance.[20] Regardless of traditional risk factors, the increased risk of cardiovascular disease is associated with mild renal dysfunction and is highest in patients with ESRD who require dialysis. Patients with advanced CKD or ESRD have characteristic lipid patterns of hypertriglyceridemia and low high density lipids (HDL) cholesterol levels, but low density lipids (LDL) cholesterol levels are normal. For good total cholesterol, the target is <200 mg/dL, and LDL < 70 mg/dL in CKD with diabetes and <100 mg/dL in CKD without diabetes are condemned. Triglyceride level < 150 mg/dL is most desirable.[21] Foods that are very high in omega-3 fatty acids, mono-unsaturated and poly-unsaturated fatty acids, such as two servings of fish or salmon twice a week, Canola, olives, peanuts, safflower, soybeans, and sunflower oil are recommended. Foods containing hydrogenated oils, margarines, and trans fats found in many commercial snack foods should be restricted.[22]

Lifestyle modifications

Obesity is the most common nutritional disorder in the world, defined as a body mass index (BMI) greater than 30 kg/m2.[23] Obesity is known to be a risk factor for disease progression in immunoglobulin A (IgA) nephropathy but it is currently unknown whether obesity is an independent risk factor for developing end-stage renal failure (ESRF) after blood pressure and diabetes mellitus have been adjusted. A cohort study of 320,252 people found that having a higher baseline BMI was an independent predictor of ESRF.[24] Participants with BMI > 40 had a relative risk score of 7.07, indicating a strong positive correlation between increasing BMI and increased risk of developing CKD.

According to research, extra pressure from weight gain causes increased tubular sodium absorption, and excess adipose tissue accumulation causes compression and sluggish flow.[25] Furthermore, obesity is a pro-inflammatory state that increases the risk of developing CKD. Obesity is a component of metabolic syndrome, a condition associated with atherogenic diabetes, high blood pressure, glucose intolerance, and abdominal obesity.[26] Patients with metabolic syndrome are significantly more likely to develop microalbuminuria and/or CKD, and the level of risk is related to the components themselves.[27] There are very little data in this area, and more long-term prospective research is needed to determine whether obesity alone is a risk factor for CKD progression.[28]

Hypertension is defined by the World Health Organization as having a systolic blood pressure of ≥140 mm Hg and a diastolic blood pressure of ≥90 mm Hg.[29] A meta-analysis of 22 trials in the general population found that lowering salt intake from 9.5 g/day to 4.6 g/day reduced systolic blood pressure by 5.06 mm Hg and diastolic blood pressure by 2.70 mm Hg. This is expected to result in a 14% reduction in deaths caused by stroke and a 9% reduction in deaths from ischemic heart disease.[30]

Sodium handling by the kidney is altered in CKD, and sodium retention plays a significant role in HT via extracellular fluid volume expansion.[31] The multiple risk factor intervention trial found that high blood pressure was a significant and independent risk factor for the development of ESRF.[32] The UK Prospective Diabetes Study (UKPDS) trial adds to this evidence by demonstrating that strict blood pressure control in type 2 diabetes patients significantly lowers urinary albumin concentration.[33] This, in turn, may slow the decline in renal function. It has been demonstrated that lifestyle factors can help control HT in renal patients.

Diabetes-related nephropathy affects up to 40% of people with type 1 and type 2 diabetes.[34] Dialysis patients with ESRF have a worse outcome. As a result, strict control must be instituted from the time diabetes is diagnosed. Diabetes damages the kidney, causing a progressive leak of large molecules (particularly protein) into the urine. Plasma creatinine is normal at this stage of persistent proteinuria, but the average patient is only 5 to 10 years away from ESRF. The Diabetes Control and Complications Trial (DCCT), a multicenter randomized trial in type 1 diabetes, found that tight blood sugar control caused kidney disease in only half of the subjects compared to standard treatment.[35]

Despite a lack of efficacy evidence from large trials, maintaining a healthy lifestyle remains a cornerstone of CKD management because healthy lifestyle behaviors are largely modifiable, have been shown to improve cardiovascular health and blood pressure control, and are thought to influence CKD progression indirectly or directly. All adults with CKD should be counseled on the benefits of a healthy lifestyle, including diet, physical activity, smoking cessation, weight management, and alcohol moderation, and it is equally important to address suboptimal lifestyle behavior adherence during routine clinic visits, despite competing issues. Patients with CKD can be referred to medical nutrition therapy-trained dieticians who specialize in behavioral change plans that include exercise, nutrition, and stress management, and this service is covered by most health insurance plans. Lifestyle recommendations are relevant in all countries, have little to no public health costs, and have the potential to have a large impact on public health. The international CKD management guidelines emphasize the importance of lifestyle behaviors in CKD with the following statement: for the practicing clinician, ideally working with a team of healthcare professionals, it is important to institute general lifestyle modifications practices in people with CKD so that they may benefit from these in addition to more kidney-specific strategies.

Patients with CKD are frequently encouraged to eat a “healthy” diet. Such a diet may be especially difficult to follow if the recommended foods are difficult to obtain − a situation that many people in poverty face. Food insecurity is frequently associated with poverty and is linked to a number of diet-related conditions, including CKD and progression to ESRD.[36] Individuals who are food insecure tend to consume more energy-dense foods, as well as relatively inexpensive processed and fast foods enriched with highly absorbable phosphorus additives. Furthermore, people who are food insecure frequently live in areas where there are no grocery stores that sell healthy foods. Limited access to nutritious food may be linked to poor dietary quality and ultimately to diet-related diseases.

Role of yoga

Yoga is an ancient Indian way of life, which includes changes in mental attitude, diet, and the practice of specific techniques such as yogic postures (asanas) and breathing practices (pranayamas). The anatomical overview of postural exercises in yoga suggests that these exercises are centered toward stretching and strengthening of muscles and increasing blood supply. Studies have shown that Yoga plays crucial role in managing Hypertension and Diabetes. One study found that the corpse pose (Shavasana) lowers blood pressure and reduces the need for antihypertensive drugs. Another study showed that yoga is effective in reducing blood pressure, blood glucose, serum cholesterol, and weight. Kashinath et al. in their hypothetical review article explained how yoga works with CKD.[37] Diabetes and high blood pressure are the main causes of CKD, and yoga plays an important role in controlling them, therefore, it is logical to think that yoga is safe and effective measure and serves as an adjuvant therapy in improving renal function, lessen the need of hemodialysis and ameliorating quality of life in CKD patients.

Patients were encouraged to change their lifestyles based on yoga. They were trained in yoga techniques and asanas (specific body postures) that are beneficial to the kidneys and are motivated to participate in an integrated yoga program.
  1. Body poses/Asanas:
    1. Standing asanas − Tadasana and Urdhva Hastasana (mountain posture with stretched arms), Tadasana and Urdhva Baddha Hastasana (with hands bound), Padahastasana (hand–foot posture), and Ardha Kati Chakrāsana (half–waist rotation).
    2. Sitting asanas − Paschimottanasana (seated forward bend), Adha-asana (sitting half with spinal twist), and Shashankasana (hare pose).
    3. Supine asanas − Setu Bandhasana (bridge pose), Naukasana (boat pose), Dhanurasana (bow posing), Makarasana (crocodile), and Shavasana (corpse).
  2. Effective breathing exercises:
    1. Pranayama, in and out breathing, breathing with alternate nostril; Nadi Shuddhi, with left nostril; Chandra Anuloma Viloma, humming breathing; and Bhramari pranayama, abdominal breathing in lying down position.


In a study, yoga showed a significant reduction in oxidative stress and increase in antioxidant activity (superoxide dismutase and catalase) in patients with CKD who were on hemodialysis. Studies show that increased sympathetic tone can contribute to the progression of CKD, promote high blood pressure, and cause damage to target organs.[38] There is evidence that suggests yoga reduces sympathetic tone and improves parasympathetic tone, thereby reducing pulse rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and metabolic rate. This also reveals the important role that yoga plays in control of renal dysfunction as measured by blood urea and serum creatinine levels. Patients who received a yoga exercise program with conventional treatment showed significant reductions in blood urea and serum creatinine levels over a 6-month period.[39]

Role of physical activity

There is little debate about the benefits of physical activity on overall health, so the Physical Activity Guidelines for Americans recommend that adults move more and sit less throughout the day, and engage in any amount of moderate-to-vigorous physical activity to gain some health benefits. Adults should engage in at least 150 minutes of moderate-intensity activity per week or 75 minutes of vigorous-intensity activity per week to reap significant health benefits. Adults should also engage in moderate to vigorous strengthening activities ≥2 days per week to reap additional health benefits. The term “exercise” refers to moderate to vigorous physical activities.[40]

Randomized control trial (RCTs) of physical activity or exercise training programs are required to directly assess the effects of physical activity on CKD progression in patients with established CKD. Two recent meta-analyses examined the effect of RCTs testing physical activity and exercise interventions on CKD progression in people with CKD, and both meta-analyses found that the interventions were not associated with reduced CKD progression, as evidenced by no difference in estimated glomerular filtration rate (eGFR), serum creatinine, or proteinuria between intervention and control groups.[41],[42] However, the RCTs included in these meta-analyses had small sample sizes, were short in duration, and did not have enough observation time to assess the impact of disease progression risk. Furthermore, serum creatinine correlates with muscle mass, making it difficult to interpret small increases in creatinine during an exercise trial due to increased physical activity and muscle metabolism, resulting in an underestimation of eGFR and thus kidney function.[43]


   Conclusion Top


The mechanisms underlying diet-related CKD risk factors are unknown, but evidence strongly supports a balanced diet, good glycemic control, lipid control, modest protein reduction, and salt reduction. The importance of these dietary strategies is not solely the role of the dietitian, but of the entire multidisciplinary team in providing a consistent message. Patients should be informed about the importance of serial measurements such as blood pressure, glycosylated hemoglobin (Hba1C), and BMI, as well as how lifestyle factors such as exercise and diet can help prolong the life of their kidney.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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