Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis.

An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.

Prevalence Rate of Proteinuria and Metabolic Acidosis Among Kidney Transplant Recipients in a Tertiary Teaching Hospital and Its Relationship to Dietary Intake.

BACKGROUND: Proteinuria and metabolic acidosis adversely affect long term renal allograft outcome and are highly prevalent in reported studies. The role of dietary intake in influencing proteinuria and metabolic acidosis remained uncertain. This study aims to determine the prevalence rate of proteinuria and metabolic acidosis among kidney transplant recipients (KTRs) and to study their relationship with dietary intake. METHODS: We performed a cross-sectional study on KTRs with functioning renal allograft and at least 3 months post transplant. Dietary protein, salt, and dietary acid load were estimated using 24-hour urine collection. Demographic characteristics, concomitant medications, medical history, and laboratory results were obtained from electronic medical records. RESULTS: A total of 204 KTRs were recruited with median age of 48 years (interquartile range [IQR], 18 years); male to female ratio was 61:39. A total of 79.9% (n = 163) were living related kidney transplants. The median duration after transplant was 71 months (IQR, 131 months), and median eGFR was 65 mL/min/1.73 m2 (IQR, 25 mL/min/1.73 m2). The prevalence rates of proteinuria (defined as ≥ 0.5 g/d) and metabolic acidosis (defined as at least 2 readings of serum bicarbonate ≤ 22 mmol/L in the past 6 months) were 17.7 % and 6.2%, respectively. High dietary protein of > 1.2 g/kg ideal body weight (adjusted odds ratio, 3.13; 95% CI, 1.35-7.28; P = .008) was significantly associated with proteinuria. Dietary protein, salt, and acid load did not correlate with chronic metabolic acidosis. CONCLUSIONS: The prevalence rate of proteinuria is consistent with published literature, but metabolic acidosis rate is extremely low in our cohort. High protein intake (> 1.2 g/kg ideal body weight) is a risk factor of proteinuria and may have negative impact on KTR outcome.

Utility of Estimated Glomerular Filtration Rate Equations in Assessing Renal Allograft Function: Are They Accurate?

Creatinine clearance (CrCl) is more accurate than other methods when assessing renal allograft function, but it is inconvenient for patients. In clinical practice, renal allograft function is often estimated using estimated glomerular filtration rate (GFR) equations. This cross-sectional study compared agreement between CrCl and serum creatinine-based equations among renal transplant recipients (RTRs) attending a transplant clinic in a tertiary center. Six equations (Cockcroft-Gault, Walser's, Nankivell, abbreviated Modification of Diet in Renal Disease [MDRD], Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI], and European Kidney Function Consortium[EKFC]) were included in the analysis. The bias, precision, and accuracy of each equation were determined. Correlation analysis was performed by determining the correlation coefficient and plotting Bland-Altmann plots. A total of 165 subjects were included in this study. Mean serum creatinine was 112.03 ± 38.67 µmol/L, and mean CrCl was 58.44 ± 21.24 mL/min/1.73 m2. Walser's equation showed strongest correlation, lowest bias, and highest accuracy of the proportion of estimated GFR falling within ±30% of CrCl, followed by the 4-variable MDRD equation. All 6 equations systematically underestimated GFR among RTRs. Walser's equation showed the best estimation of GFR, suggesting that it may be the formula of choice to estimate GFR among RTRs.