Targeting CKD Patients’ Quality of Life – Organised by FRESENIUS KABI

Symposium Summary

Written by Jasna Trbojevic-Stankovic
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Welcome and introduction

Giorgina Piccoli, France

Quality of life is closely linked to nutrition – “because we are, what we eat”, explained symposium chairwoman Prof. Giorgina Piccoli. Being on a diet is not necessarily painful, she was keen to emphasize – it is about changing lifestyle and can also be fun! There is more to quality of life (QoL) than just nutrition, however.

Living well with kidney disease – the importance of patient empowerment

Kamyar Kalantar-Zadeh, United States of America

Prof. Kalantar-Zadeh focused on patients’ empowerment as another important aspect of QoL, which was also the theme of World Kidney Day 2021. Living with chronic kidney disease (CKD) is not always easy, however CKD is associated with unpleasant symptoms which affect patients and their families. It is therefore important to address patients’ priorities, values and goals to enable them to decide on the appropriate choices for their health, including diet. One important question is: when to start renal replacement therapy? The process can be arduous and burdensome; therefore, many patients opt instead for supportive treatment and conventional care without dialysis. “We have tools for conservative and preventive management and can offer a gradual transition to dialysis.” Prof. Kalantar-Zadeh pointed out that empowering patients, brings them hope. “The key word here is choice. If I give my patients more than one option, my patient will be more hopeful.” Furthermore, the approach of making a gradual transition to dialysis prolongs dialysis-free time and thus achieves better survival and quality of life by effective management of renal and non-renal comorbidities, such as cardiovascular events.

Diet is an important factor in this context: A low dietary protein intake decreases intracapillary pressure and thus preserves kidney function. The MDRD study showed that people who were randomized to a lower protein intake initially had a loss of Glomerular Filtration Rate (GFR), but in the long term the decrease was very slow. On the other hand, there are concerns about malnutrition, of course. Prof. Kalantar-Zadeh pointed out that 0.46 g of protein per kilogram body weight per day is really all a normal healthy adult requires if essential amino acids are provided, whereas the current recommended dietary allowance is 0.8 g. He emphasized that 50% of the protein intake should be plant-based, “vegan proteins have an adequate biological value – and potassium should not be a problem, especially since potassium binders can be used”. Prof. Kalantar-Zadeh´s plea was to fight the dogma of avoiding fruits and vegetables in CKD.

He also recommended that adding keto-analogues of amino acids (AA) should be considered. “These allow us to go as low as 0.3-0.4 g/kg/day and ensure that the patients have an adequate supply of all nine essential amino acids.” In one study, 56 elderly uremic patients were randomized to a low protein diet plus keto-analogues of AA versus dialysis initiation. The result showed that the diet group had slightly better survival, although the study failed to show superiority.

Prof. Kalantar-Zadeh noted that, when dialysis is needed, incremental dialysis transition (once to twice per week) is the goal, which can be reached with continued restricted protein diet on dialysis-free days, potentially supplemented with keto-analogues, in order to preserve residual kidney function longer. “This expands patients’ choices, empowers the patients and brings hope”, he concluded.

Tailored nutritional approach to improve adherence and QoL in CKD patients

Giorgina Piccoli, France

One conclusion drawn in Prof. Giorgina Piccoli’s talk was that low-protein diets are feasible in many patients, including the elderly and those with comorbidities. However, there is no ‘one diet for all’, and experience from practice shows that the success rate of ‘prescribing a diet’ is rather low. Prof. Piccoli explained the concepts of compliance, adherence and concordance, and remarked that this last one is about offering choices and setting up the right goals. Its guiding principle is that patient and healthcare providers must work together to find the best possible solution for the patient’s condition.

The MDRD trial produced some conflicting results and was unable to prove the effect of a low-protein diet. As Prof. Piccoli pointed out, this might have been due to a lack of compliance. When the results were analyzed on the basis of the amount of protein actually consumed, one benefit became obvious: Each 0.2 g less protein/kg/day was associated with a 29% slower rate of GFR loss (<0.001). But how can more patients adhere to a lower protein intake? Deferring dialysis initiation might be a powerful incentive, but in one study, only 15% of the patients could be randomized, because they were able to adapt to the diet. The rest could not, and they also knew about the possible benefits. [/av_textblock] [av_textblock size='16' font_color='' color='' av-medium-font-size='' av-small-font-size='' av-mini-font-size='' av_uid='av-kr3n6nfq' custom_class='' admin_preview_bg=''] What lessons can be learned? First, the right target must be set, and the patient needs motivation. It is then important to adapt to local habits and rediscover traditions, because the quantity of protein in our normal diets has increased only in the two last generations. Individual habits and preferences must also be reflected. “Diet is a system, and we have to offer different choices – the key is an individual approach, because different patients follow different diets”, said Prof. Piccoli. She highlighted a multiple step approach: (1) assess the habit, (2) normalize the protein intake, (3) then reduce the protein intake further, (4) implement keto-analogues of AA, if needed, and (5) reduce further, if possible. The results of this flexible and stepwise approach aiming at progressive reduction were shown to be very good in terms of compliance. Furthermore, new studies have shown that patients on a protein-restricted diet report a good QoL.

KDOQI guideline 2020 recommendations for nutrition in CKD – Practical considerations

Denis Fouque, France

Prof. Denis Fouque summarized the key aspects of the 2020 update of the KDOQI Clinical Practice Guideline on Nutrition in CKD, concentrating thereby on protein and energy recommendations and some practical considerations.

He pointed out that, in adults with CKD, who are metabolically stable, an energy intake of 25-35 kcal/kg ideal body weight is recommended. Whether intake should be 25 or 35 is dependent on many factors, among them age, gender, level of physical activity, body composition, and CKD status. One should be aware that a frail elderly patient needs less energy than a young active person. However, all patients should be routinely monitored if dietary energy intake is adequate or the diet should be modified accordingly if it is not. It is important to educate patients and motivate them.

Counselling is also an important factor with regard to protein intake. In non-diabetic, non-dialysis CKD patients, the guidelines recommend protein restriction with or without keto-analogues of AA under clinical supervision in order to reduce risk of end stage renal disease and death – and improve QoL. The protein intake should be 0.55 to 0.6 g dietary protein per kg ideal body weight per day. Alternatively, the guidelines recommend a very low-protein diet providing 0.28 to 0.43 g dietary protein per kg ideal body weight per day, provided that keto-analogues of AA are given to meet protein requirements. This recommendation is based on a high level of evidence, as Prof. Fouque pointed out. For diabetics, the guideline recommends an intake of 0.6 to 0.8 dietary protein per kg ideal body weight per day to maintain a stable nutritional status and optimize glycemic control. This recommendation mirrors expert opinion, as some data are missing.

Like Prof. Piccoli before, Prof. Fouque pointed out that a stepwise approach to reduced protein intake (from an omnivorous to a mainly vegan diet) has proven more successful, but this requires progressive personal care – and more renal dieticians are needed. He emphasized that the key to success is individualization.

2020 award-winning research project presentation: Effects of Keto-Analogues Supplementation on Quality of Life in Palliative Care of ESKD Patients

Paramat Thimachai, Thailand

Dr. Paramat Thimachai briefly summarized his study project on the effects of keto-analogues supplementation on QoL in palliative care of end-stage kidney disease patients, which won the 2020 Keto-Analogues Research Award.

It is known that keto-analogues of AA in combination with a reduced protein diet can improve uremic symptoms, slow down the decline in GFR and delay time to dialysis and consequently, improve the QoL. This was the basic hypothesis of the study project that Dr. Thimachai and colleagues from Phramongkutklao Hospital and College of Medicine in Bangkok, Thailand will initiate.

The plan is to include CKD stage 5 patients who are not on dialysis, and to compare the effect of a very low-protein diet plus keto analogues with the effects of a low-protein diet in terms of QoL (primary endpoint). Further endpoints are changes of metabolic profile, nutritional status, time to initiate dialysis and mortality. After a four-week run-in phase under standard care, the patients will be randomized (n=72 in each group). After six months, QoL will be assessed with the ‘KDQOL-36’ questionnaire, which has been proved to have good validity and reliability in Thai CKD patients.

Further reading

Levey AS, Greene T, Beck GJ et al. Dietary protein restriction and the progression of chronic renal disease: what have all of the results of the MDRD study shown? Modification of Diet in Renal Disease Study group. J Am Soc Nephrol 1999; 10 (11): 2426-39

Kalantar-Zadeh K, Wightman A, Liao S et al. Ensuring Choice for People with Kidney Failure — Dialysis, Supportive Care, and Hope.  N Engl J Med 2020; 383:99-101

Brunori G, Viola BF, Parrinello G et al. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis 2007; 49 (5): 569-80

Garneata L, Stancu A, Dragomir D et al. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. J Am Soc Nephrol 2016; 27 (7): 2164-76

Fois A, Chatrenet A, Cataldo E et al. Moderate Protein Restriction in Advanced CKD: A Feasible Option in An Elderly, High-Comorbidity Population. A Stepwise Multiple-Choice System Approach. Nutrients 2018; 11 (1): 36

Piccoli GB, Di Iorio BR, Chatrenet A et al. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (TOrino-Pisa study). Nephrol Dial Transplant 2020; 35 (5): 790-802

Fois A, Torreggiani M, Trabace T et al. Quality of Life in CKD Patients on Low-Protein Diets in a Multiple-Choice Diet System. Comparison between a French and an Italian Experience. Nutrients 2021; 13(4): 1354

Ikizler TA, Burrowes JD, Byham-Gray LD et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020;76 (3 Suppl 1): S1-S107