Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients.

OBJECTIVES: The nutritional adequacy of both animal-based and plant-based low protein diets (LPDs) and moderate protein diets that are recommended for patients with chronic kidney disease have not been well examined. We therefore analyzed the nutrient content of three representative LPDs and moderate protein diets (lacto-ovo vegetarian, omnivorous, and vegan) containing foods that are likely to be prescribed for nondialyzed chronic kidney disease or chronic dialysis patients in the United States to determine the nutritional adequacy at different levels of protein intake. METHODS: Theoretical 3-day menus were developed as per current renal dietary guidelines to model each diet at 7 different levels of protein intake (0.5-1.2 g/kilograms body weight/day [g/kg/d]). The diets were analyzed for their content of essential amino acids (EAAs) and other essential nutrients. RESULTS: At an a priori recognized inadequate dietary protein level of 0.5 g/kg/d, all 3 diets failed to meet the Recommended Dietary Allowances (RDAs) for the following EAAs: histidine, leucine, lysine, and threonine. The omnivorous LPD met both the RDA and Estimated Average Requirement at levels of 0.6 g protein/kg/d or more. The lacto-ovo and vegan diets at 0.6 and 0.8 g protein/kg/d, respectively, were below the RDA for lysine. The amounts of several other vitamins and minerals were not uncommonly reduced below the RDA or Adequate Intake with all 3 LPDs. CONCLUSION: In comparison to omnivorous LPDs, both vegan and lacto-ovo LPDs are more likely to be deficient in several EAAs and other essential nutrients. To provide sufficient amounts of all EAA, vegan and lacto-ovo LPDs must be carefully planned to include adequate amounts of appropriate dietary sources. Supplements of some other essential nutrients may be necessary with all three LPDs.

Effects of low protein diet with a balanced amino acid pattern on growth performance, meat quality and cecal microflora of finishing pigs.

BACKGROUND: The present study aimed to investigate the effects of low protein diets balanced with four amino acids on growth performance, meat quality and cecal microflora of finishing pigs. Fifty-four healthy hybrid barrows (Duroc × Landrace × Yorkshire) with an average body weight of 70.12 ± 4.03 kg were randomly assigned to one of the three dietary treatments with six replicate pens per treatment (three barrows per pen). The three dietary treatments included a normal protein diet (NP), a low protein diet (LP) and a very low protein diet (VLP). RESULTS: The average daily gain, average daily feed intake and feed conversion ratio of pigs were not significantly changed with the LP and VLP diets compared to the NP diet (P > 0.05). The water holding capacity and shear force of longissimus dorsi muscle were decreased, whereas the intramuscular fat content of the longissimus dorsi muscle was increased (P < 0.05) in pigs fed with the LP and VLP diets compared to the NP diet. The contents of saturated fatty acids in muscle were decreased (P < 0.05), whereas the content of polyunsaturated fatty acids in muscle was increased (P < 0.01) with the VLP diet compared to the NP diet. The contents of histamine, spermidine, spermine and tyramine of muscle were decreased with the VLP diet compared to the NP diet (P < 0.05). The relative abundance of Turicibacter, Terrisporobacter, Clostridium_sensu_stricto_1 and UCG-005 was higher (P < 0.05), whereas the relative abundance of Lactobacillus and Streptococcus was lower (P < 0.05) in pigs fed with the LP and VLP diets compared to the NP diet. Based on the correlation of cecal microbiota and cecal biogenic amine, the contents of tyramine, spermidine and histamine were negatively correlated with the abundance of Terrisporobacter (P < 0.01) and the content of histamine was positively correlated with the abundance of Lactobacillus (P < 0.01). CONCLUSION: Balanced with four essential amino acids, the VLP diet with crude protein levels decreased by > 4% increased the intramuscular fat content, changed the fatty acid and amino acid composition of longissimus dorsi muscle and the profile of cecum microbiota, and reduced the content of cecum bioamine, with no negative effect on the growth performance of pigs. © 2022 Society of Chemical Industry.

Effect of Isoleucine and Added Valine on Performance, Nutrients Digestibility and Gut Microbiota Composition of Pigs Fed with Very Low Protein Diets.

Little is known whether a combination Ile and added Val improves the growth of pigs offered very low protein (VLP) diets through changes in nutrients digestibility and gut microbiota. The objective of this study was to investigate the effect of a mixture of Val above and Ile at NRC levels on growth, nutrient digestibility and gut microbiota in pigs fed with VLP diets. Forty, weaned piglets were assigned to: positive control: normal-protein-diet; negative control (NC): VLP diet supplemented with first four limiting amino acids; VA: NC with Val above NRC; IL: NC with Ile at NRC level; VAIL: NC with Val above and Ile at NRC levels. While both VAIL and VA groups completely recovered the inhibitory effects of VLP diets on feed intake, only VAIL partially recovered the negative effects of VLP diets on growth performance. VAIL and VA increased the thermal radiation and decreased the digestibility of nitrogen. NC increased the relative abundance of Pasteurellaceae and Enterobacteriaceae in the colon. VAIL had a higher abundance of colonic Actinobacteria, Enterococcus, and Brevibacillus and the colon content of VA was more enriched with Mogibacterium. Overall, VAIL partially improved the growth performance which is likely linked with alterations in gut microbiota composition.

Muscle protein turnover and low-protein diets in patients with chronic kidney disease.

Adaptation to a low-protein diet (LPD) involves a reduction in the rate of amino acid (AA) flux and oxidation, leading to more efficient use of dietary AA and reduced ureagenesis. Of note, the concept of 'adaptation' to low-protein intakes has been separated from the concept of 'accommodation', the latter term implying a decrease in protein synthesis, with development of wasting, when dietary protein intake becomes inadequate, i.e. beyond the limits of the adaptive mechanisms. Acidosis, insulin resistance and inflammation are recognized mechanisms that can increase protein degradation and can impair the ability to activate an adaptive response when an LPD is prescribed in a chronic kidney disease (CKD) patient. Current evidence shows that, in the short term, clinically stable patients with CKD Stages 3-5 can efficiently adapt their muscle protein turnover to an LPD containing 0.55-0.6 g protein/kg or a supplemented very-low-protein diet (VLPD) by decreasing muscle protein degradation and increasing the efficiency of muscle protein turnover. Recent long-term randomized clinical trials on supplemented VLPDs in patients with CKD have shown a very good safety profile, suggesting that observations shown by short-term studies on muscle protein turnover can be extrapolated to the long-term period.

Dietary Protein Intake and Bone Across Stages of Chronic Kidney Disease.

PURPOSE OF REVIEW: This review aims to summarize the current evidence on the effect of very-low-, low-, and high-protein diets on outcomes related to chronic kidney disease-mineral and bone disorder (CKD-MBD) and bone health in patients with CKD. RECENT FINDINGS: Dietary protein restriction in the form of low- and very-low-protein diets have been used to slow down the progression of CKD. These diets can be supplemented with alpha-keto acid (KA) analogues of amino acids. Observational and randomized controlled trials have shown improvements in biochemical markers of CKD-MBD, including reductions in phosphorus, parathyroid hormone, and fibroblast growth factor-23. However, few studies have assessed changes in bone quantity and quality. Furthermore, studies assessing the effects of high-protein diets on CKD-MBD are scarce. Importantly, very-low- and low-protein diets supplemented with KA provide supplemental calcium in amounts that surpass current dietary recommendations, but to date there are no studies on calcium balance with KA. Current evidence suggests that dietary protein restriction in CKD may slow disease progression, which may subsequently benefit CKD-MBD and bone health outcomes. However, prospective randomized controlled trials assessing the effects of modulating dietary protein and supplementing with KA on all aspects of CKD-MBD and particularly bone health are needed.

[Nutritional support for patients with chronic kidney disease at pre-dialysis stages].

Chronic kidney disease (CKD) is characterized by poor outcomes, an increasing frequency of new cases, the need for expensive method of renal replacement therapy at the terminal stage. The main task facing the doctor is slowing the progression of CKD and delay the start of dialysis by applying the nephroprotective strategy, of which diet therapy is an essential part. The key components of the diet for CKD patients are reducing sodium intake to 2.3 g per day in order to improve control of blood pressure (BP), dietary protein restriction adequate to renal function from 0.8 to 0.3 g/kg of body weight per day combined with the prescribing of ketoanalogues of essential amino acids, hyperglycemia control. With the progression of CKD, the main objectives of the diet therapy are the prevention/correction of complications: protein-energy waisting, metabolic acidosis, ensuring sufficient calories, corresponding to the bodys energy expenditures (3035 kcal/kg of body weight per day), limiting phosphate intake to 0.81 g a day, restriction of food potassium. Low-protein diet in combination with ketoanalogues of amino acids, regular monitoring and correction of the nutritional status of patients at the pre-dialysis stages of CKD is an effective and safe method of nephroprotection, which allows delaying the start of dialysis.

Effects of low-protein diet on the intestinal morphology, digestive enzyme activity, blood urea nitrogen, and gut microbiota and metabolites in weaned pigs.

This study investigated the effects of low-protein diet supplemented with Lysine (Lys), Methionine (Met), Threonine (Thr), and Tryptophan (Trp) on small intestine morphology, enzyme activity, blood urea nitrogen, and gut microbiota and metabolites in weaned piglets. Eighteen weaned pigs weighing an average of 9.57 kg received one of three treatments: a normal protein diet with 20% crude protein (CP, diet [NP]), a moderately reduced protein diet with 17% CP (MP), or a low-protein diet with 14% CP (LP). All three diets were supplemented with Lys, Met, Thr and Trp to meet essential amino acid requirements for post-weaned piglets according to the NRC (2012). Following a 45 d study period, piglets on the LP and MP diets demonstrated atrophic small intestinal morphology, with decreased villus heights and lower ratios of villus height to crypt depth (p < 0.05); pepsin activity in the stomach was also reduced in these two groups (p < 0.05). Increased plasma cholesterol and decreased blood urea nitrogen presented in the MP and LP groups compared with the NP group (p < 0.05). Overall, gastrointestinal hormones were not affected by dietary protein levels with the exception of reduced somatostatin levels in the MP and LP groups. Jejunum and colon microbiota were not affected at either the phyla or genera level in any of the diets. Colonic ammonia nitrogen concentration was reduced in MP and LP groups. Dietary protein level had no effect on short chain fatty acids or biogenic amines. Our data suggest that reducing dietary protein levels by 3% (MP) or 6% (LP) in weaned pigs has the potential to decrease nitrogen emissions and impaired digestive capacity. Therefore, dietary protein level cannot be reduced by more than 3% in consideration of maladaptive changes to small intestinal morphology and pepsin activity in weaned piglets.

Dose response of rumen-protected conjugated linoleic acid supplementation to fattening bulls and heifers on growth, and carcass and meat quality.

We investigated the influence of rumen-protected conjugated linoleic acid (rpCLA) on growth performances, and carcass and meat quality traits in beef. Twenty-four young bulls and 30 heifers obtained from double-muscled beef sires and dairy cows were fed a low-protein ration (110 g/kg DM of crude protein) supplemented with 0, 8 or 80 g/d of a commercial rpCLA product. The animals were monthly weighed and scored for body muscularity and fatness. Blood samples were collected after 140 days on feed. Animals were slaughtered when they reached average in vivo fatness scores of around 2.5 (heifers) and 2.0 (bulls) points respectively. At slaughter, carcasses, various organs and parts of the gastrointestinal tract were weighed; the 5th rib was dissected and its tissue and muscle chemical composition was determined. The rpCLA had little influence on growth performance but decreased the blood urea content by 28% (p < 0.01). The rpCLA × sex interactions for daily gain (p < 0.05), conformation scores (p < 0.01), and blood creatinine content (p < 0.05) suggest that males were more responsive to rpCLA than females when fed a low-protein ration, probably because of the metabolic protein-sparing effect of CLA. Only slight differences were observed in carcass weight and quality at slaughter. The results indicate that the response of beef cattle to rpCLA is dependent on sex or on their propensity for lean and fat accretion. It is also possible that counteracting feedback mechanisms compensate for the influence of rpCLA administration over the course of growth.

Supplementation with α-ketoglutarate to a low-protein diet enhances amino acid synthesis in tissues and improves protein metabolism in the skeletal muscle of growing pigs.

α-Ketoglutarate (AKG) is a crucial intermediate in the tricarboxylic acid (TCA) cycle and can be used for the production of ATP and amino acids in animal tissues. However, the effect of AKG on the expression patterns of genes involved in muscle protein metabolism is largely unknown, and the underlying mechanism remains to be elucidated. Therefore, we used young pigs to investigate the effects of a low crude protein (CP) diet and a low CP diet supplemented with AKG on protein accretion in their skeletal muscle. A total of 27 growing pigs with an initial body weight of 11.96 ± 0.18 kg were assigned randomly to one of the three diets: control (normal recommended 20% CP, NP), low CP (17% CP, LP), or low CP supplemented with 1% AKG (ALP). The pigs were fed their respective diets for 35 days. Free amino acid (AA) profile and hormone levels in the serum, and the expression of genes implicated in protein metabolism in skeletal muscle were examined. Results showed that compared with the control group or LP group, low-protein diets supplemented with AKG enhanced serum and intramuscular free AA concentrations, the mRNA abundances of AA transporters, and serum concentrations of insulin-like growth factor-1 (IGF-1), activated the mammalian target of rapamycin (mTOR) pathway, and decreased serum urea concentration and the mRNA levels for genes related to muscle protein degradation (P < 0.05). In conclusion, these results indicated that addition of AKG to a low-protein diet promotes amino acid synthesis in tissues and improves protein metabolism in skeletal muscle.

Low-protein diet supplemented with ketoacids delays the progression of diabetic nephropathy by inhibiting oxidative stress in the KKAy mice model.

Diabetic nephropathy (DN) is a major cause of chronic kidney disease. We aimed to investigate the effect of the low-protein diets (LPD) supplemented with ketoacids (LPD+KA) in KKAy mice, an early type 2 DN model. KKAy mice were treated with normal protein diet (NPD), LPD or LPD+KA from 12 to 24 weeks of age. A period of 12-week treatment with LPD significantly reduced albuminuria as compared with that observed after NPD treatment. Treatment with LPD+KA further reduced albuminuria as compared with that observed with LPD treatment alone. Moreover, LPD treatment reduced mesangial expansion, thickness of glomerular basement membrane and the severity of the podocyte foot process effacement in KKAy mice; these effects were more pronounced in KKAy mice treated with LPD+KA. Both LPD and LPD+KA treatments slightly reduced total body weight, but had no significant effect on kidney weight and blood glucose concentrations when compared with NPD-treated KKAy mice. LPD treatment slightly attenuated oxidative stress in kidneys as compared with that observed in NPD-treated KKAy mice; however, LPD+KA treatment remarkably ameliorated oxidative stress in diabetic kidneys as shown by decreased malondialdehyde concentrations, protein carbonylation, nitrotyrosine expression and increased superoxide dismutase expression. Nutritional therapy using LPD+KA confers additional renal benefits as compared with those of LPD treatment alone in early type 2 DN through inhibition of oxidative stress.

Relative influence of dietary protein and energy contents on lysine requirements and voluntary feed intake of rainbow trout fry.

The effect of dietary digestible protein (DP) and/or digestible energy (DE) levels on lysine (Lys) requirements, Lys utilisation efficiency and voluntary feed intake (VFI) were studied in rainbow trout fry when Lys was the first limiting indispensable amino acid or in excess in the diet. Two trials were conducted at 11·6°C with eighty-one experimental diets, containing 280 g DP/kg DM (low protein (LP), trial 1), 600 g DP/kg DM (high protein (HP), trial 1) or 440 g DP/kg DM (medium protein (MP), trial 2), 17 MJ DE/kg (low energy (LE)), 19·5 MJ DE/kg (medium energy (ME)) or 22 MJ DE/kg (high energy (HE)), and nine Lys levels from deeply deficient to large excess (2·3-36 g/kg DM). Each diet was given to apparent satiety to one group of fifty fry (initial body weight 0·85 g) for 24 (MP diets, trial 2) or 30 (LP and HP diets, trial 1) feeding days. Based on N gain data fitted with the broken-line model, the relative Lys requirement was significantly different with the dietary DP level, from 13·3-15·7 to 22·9-26·5 g/kg DM for LP and HP diets, respectively, but did not significantly change with the DE level for a same protein level. The Lys utilisation efficiency for protein growth above maintenance was constant across diets, suggesting no effect of either dietary DE or DP levels. In Lys excess, the VFI was markedly decreased by the DP level but not by the extra DE supply. Our results suggest that the relative Lys need is best expressed in terms of percentage of protein content for optimum fish feed formulation, at least in rainbow trout fry.

[Modern approaches to dietary support for patients with diabetic nephropathy].

The article presents modern approaches to dietary support of patients with diabetic nephropathy (DN) characterized by gradual sclerosis of the renal tissue, leading to a loss of filtration and nitrogen excretory function of the kidneys. An analysis of publications of domestic and foreign authors indicates a slowdown in the progression of chronic kidney disease against the background of low-protein diets. However, the role of protein restriction and its qualitative composition in the diet of patients with DN is the subject of comprehensive discussion. KDOQI (2007) Clinical Practice Guidelines and Clinical Practice Guidelines for Kidney Disease determine the target level of protein intake in individuals with diabetes and chronic kidney disease 1-4 stages at the level of 0.8 g/kg of body weight per day. In the recommendations on nutrition for patients with DN, along with a controlled reduction in protein content, great importance is attached to reducing sodium intake from food to 1.5-2.3 g per day. In recent years, close attention has been paid to the use of highly active natural antioxidants for the treatment and prevention of type 2 diabetes, including DN, which was determined by the results of studies demonstrating their beneficial effects on DN patterns. It has been shown that one of the ways to optimize the nutrition of patients with DN is the use of specialized foods modified by protein, fat and carbohydrate composition, including food ingredients with hypoglycemic, hypolipidemic and antioxidant effects.

Effect of endurance training and branched-chain amino acids on the signaling for muscle protein synthesis in CKD model rats fed a low-protein diet.

A low-protein diet (LPD) protects against the progression of renal injury in patients with chronic kidney disease (CKD). However, LPD may accelerate muscle wasting in these patients. Both exercise and branched-chain amino acids (BCAA) are known to increase muscle protein synthesis by activating the mammalian target of rapamycin (mTOR) pathway. The aim of this study was to investigate whether endurance exercise and BCAA play a role for increasing muscle protein synthesis in LPD-fed CKD (5/6 nephrectomized) rats. Both CKD and sham rats were pair-fed on LPD or LPD fortified with a BCAA diet (BD), and approximately one-half of the animals in each group was subjected to treadmill exercise (15 m/min, 1 h/day, 5 days/wk). After 7 wk, renal function was measured, and soleus muscles were collected to evaluate muscle protein synthesis. Renal function did not differ between LPD- and BD-fed CKD rats, and the treadmill exercise did not accelerate renal damage in either group. The treadmill exercise slightly increased the phosphorylation of p70s6 kinase, a marker of mTOR activity, in the soleus muscle of LPD-fed CKD rats compared with the sham group. Furthermore, BCAA supplementation of the LPD-fed, exercise-trained CKD rats restored the phosphorylation of p70s6 kinase to the same level observed in the sham group; however, the corresponding induced increase in muscle protein synthesis and muscle mass was marginal. These results indicate that the combination of treadmill exercise and BCAA stimulates cell signaling to promote muscle protein synthesis; however, the implications of this effect for muscle growth remain to be clarified.

Progressive response of large intestinal bacterial community and fermentation to the stepwise decrease of dietary crude protein level in growing pigs.

The study aimed to determine the effects of reduction of dietary crude protein (CP) level with balanced essential amino acids (EAA) on intestinal bacteria and their metabolites of growing pigs. Forty pigs (initial BW 13.50 ± 0.50 kg, 45 ± 2 days of age) were randomly assigned to four dietary treatments containing CP levels at 20.00% (normal crude protein, NP); 17.16% (medium crude protein, MP); 15.30% (low crude protein, LP); and 13.90% (extremely low crude protein, ELP), respectively. Crystalline AAs were added to meet the EAA requirement of pigs. After 4-week feeding, eight pigs per treatment (n = 8) were randomly selected and slaughtered for sampling of ileal, cecal, and colonic digesta and mucosa. Pigs with moderately reduced CP level had increased bacterial diversity, with the Shannon diversity indices for the colon digesta in the LP group and mucosa in the MP and LP groups significantly (P < 0.05) higher than those in the NP and ELP groups. As the CP level reduces, the Bifidobacterium population were linearly decreased (P < 0.05) both in ileum, cecum, and colon, and the ELP group had the lowest Bifidobacterium population in the cecum and colon, with its value significantly lower than NP and MP groups (P < 0.05). However, the ELP group had the highest population of Escherichia coli in the colon, with its value significantly higher than the LP group (P < 0.05). For bacterial metabolites, as CP level decreased, total short-chain fatty acid (T-SCFA), acetate, and butyrate were linearly increased (linear, P < 0.05) in the ileum, while all SCFAs except formate in the cecum and T-SCFA and acetate in the colon, were linearly decreased (P < 0.05). Reducing CP level led to a linear decrease of microbial crude protein (MCP) in the ileum (P < 0.05) and ammonia in all intestine segments (P < 0.05). The spermidine in cecum and total amines, cadaverine, methylamine, and spermidine in colon were shown a quadratic change (P < 0.05) as dietary CP decreases, with the highest concentration in LP group. These findings suggest that moderate reduction of dietary CP level may benefit large intestinal bacterial community and its fermentation, which was negatively affected by extremely low CP diet.

'Let food be thy medicine ': lessons from low-protein diets from around the world.

In this editorial we present the special issue dedicated to low-protein diets (LPDs) in chronic kidney disease, from a global perspective.The experiences gathered from several countries across all continents have created an issue which we hope you will find insightful, and lead to further discussion on this interesting topic.We discover that LPDs are feasible in both developed and low income countries, in patients where literacy is an issue, and are also safe, including during pregnancy and in old age.Patients prescribed a low protein diet are more inclined to follow and adhere to this change in lifestyle, provided the diet has been adapted to meet their own individual needs. With an increasing list of different menu options and better medical advice being offered we no longer need to identify low protein diets with a specific menu, ingredient or supplement, or with a specific level of protein restriction. Evidence shows how the best diet is often the one chosen by the patients, which doesn't drastically affect their day-to-day life, and delays the start of dialysis for as long as is safe under careful clinical control. The colourful menus gathered from all over the world remind us that a low protein diet does not necessarily mean that the pleasure of preparing a delicious meal is lost. The final comment is therefore dedicated to our patients: low protein diets can be beautiful.

Effects of isoleucine on glucose uptake through the enhancement of muscular membrane concentrations of GLUT1 and GLUT4 and intestinal membrane concentrations of Na+/glucose co-transporter 1 (SGLT-1) and GLUT2.

Knowledge of regulation of glucose transport contributes to our understanding of whole-body glucose homoeostasis and human metabolic diseases. Isoleucine has been reported to participate in regulation of glucose levels in many studies; therefore, this study was designed to examine the effect of isoleucine on intestinal and muscular GLUT expressions. In an animal experiment, muscular GLUT and intestinal GLUT were determined in weaning pigs fed control or isoleucine-supplemented diets. Supplementation of isoleucine in the diet significantly increased piglet average daily gain, enhanced GLUT1 expression in red muscle and GLUT4 expression in red muscle, white muscle and intermediate muscle (P<0·05). In additional, expressions of Na+/glucose co-transporter 1 and GLUT2 were up-regulated in the small intestine when pigs were fed isoleucine-supplemented diets (P<0·05). C2C12 cells were used to examine the expressions of muscular GLUT and glucose uptake in vitro. In C2C12 cells supplemented with isoleucine in the medium, cellular 2-deoxyglucose uptake was increased (P<0·05) through enhancement of the expressions of GLUT4 and GLUT1 (P<0·05). The effect of isoleucine was greater than that of leucine on glucose uptake (P<0·05). Compared with newborn piglets, 35-d-old piglets have comparatively higher GLUT4, GLUT2 and GLUT5 expressions. The results of this study demonstrated that isoleucine supplementation enhanced the intestinal and muscular GLUT expressions, which have important implications that suggest that isoleucine could potentially increase muscle growth and intestinal development by enhancing local glucose uptake in animals and human beings.

A practical approach to low protein diets for patients with chronic kidney disease in Cameroon.

Cameroon is a low-middle income country with a rich diversity of culture and cuisine. Chronic kidney disease (CKD) is common in Cameroon and over 80 % of patients present late for care, precluding the use of therapies such as low protein diets (LPDs) that slow its progression. Moreover, the prescription of LPDs is challenging in Cameroon because dieticians are scarce, there are no renal dieticians, and people often have to fund their own healthcare. The few nephrologists that provide care for CKD patients have limited expertise in LPD design. Therefore, only moderate LPDs of 0.6 g protein per kg bodyweight per day, or relatively mild LPDs of 0.7-0.8 g protein per kg bodyweight per day are prescribed. The moderate LPD is prescribed to patients with stage 3 or 4 CKD with non-nephrotic proteinuria, no evidence of malnutrition and no interrcurrent acute illnesses. The mild LPD is prescribed to patients with stage 3 or 4 CKD with nephrotic proteinuria, non-symptomatic stage 5 CKD patients or stage 5 CKD patients on non-dialysis treatment. In the absence of local sources of amino and keto acid supplements, traditional mixed LPDs are used. For patients with limited and sporadic access to animal proteins, the prescribed LPDs do not restrict vegetable proteins, but limit intake of animal proteins (when available) to 70 % of total daily protein intake. For those with better access to animal proteins, the prescribed LPDs limit intake of animal proteins to 50-70 % of total daily protein intake, depending on their meal plan. Images of 100 g portions of meat, fish and readily available composite meals serve as visual guides of quantities for patients. Nutritional status is assessed before LPD prescription and during follow up using a subjective global assessment and serum albumin. In conclusion, LPDs are underutilised and challenging to prescribe in Cameroon because of weakness in the health system, the rarity of dieticians, a wide diversity of dietary habits, the limited nutritional expertise of nephrologists and the unavailability of amino and keto acid supplements.

Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: fifteen years of experience.

BACKGROUND: Pregnancy in women with advanced CKD becoming increasingly common. However, experience with low-protein diets in CKD patients in pregnancy is still limited. Aim of this study is to review the results obtained over the last 15 years with moderately restricted low-protein diets in pregnant CKD women (combining: CKD stages 3-5, proteinuria: nephrotic at any time, or > =1 g/24 at start or referral; nephrotic in previous pregnancy). CKD patients on unrestricted diets were employed for comparison. STUDY PERIOD: January, 2000 to September, 2015: 36 on-diet pregnancies (31 singleton deliveries, 3 twin deliveries, 1 pregnancy termination, 1 miscarriage); 47 controls (42 singleton deliveries, 5 miscarriages). The diet is basically vegan; since occasional milk and yoghurt are allowed, we defined it vegan-vegetarian; protein intake (0.6-0.8 g/Kg/day), keto-acid supplementation, protein-unrestricted meals (1-3/week) are prescribed according to CKD stage and nutritional status. Statistical analysis was performed as implemented on SPSS. RESULTS: Patients and controls were similar (p: ns) at baseline with regard to age (33 vs 33.5), referral week (7 vs 9), kidney function (CKD 3-5: 48.4 % vs 64.3 %); prevalence of hypertension (51.6 % vs 40.5 %) and proteinuria >3 g/24 h (16.1 % vs 12.2 %). There were more diabetic nephropathies in on-diet patients (on diet: 31.0 % vs controls 5.3 %; p 0.007 (Fisher)) while lupus nephropathies were non-significantly higher in controls (on diet: 10.3 % vs controls 23.7 %; p 0.28 (Fisher)). The incidence of preterm delivery was similar (<37 weeks: on-diet singletons 77.4 %; controls: 71.4 %). The incidence of other adverse pregnancy related outcomes was non-significantly lower in on-diet patients (early preterm delivery: on diet: 32.3 % vs controls 35.7 %; birth-weight = <1.500 g: on diet: 9.7 % vs controls 23.8 %). None of the singletons in the on-diet series died, while two perinatal deaths occurred among the controls (p = 0.505). The incidence of small for gestational age (SGA <10th centile) and/or extremely preterm babies (<28th week) was significantly lower in singletons from on-diet mothers than in controls (on diet: 12.9 % vs controls: 33.3 %; p: 0.04 (Fisher)). CONCLUSION: Moderate protein restriction in the context of a vegan-vegetarian supplemented diet is confirmed as a safe option in the management of pregnant CKD patients.

Performance of Broiler Chickens Fed Low Protein, Limiting Amino Acid Supplemented Diets Formulated Either on Total or Standardized Ileal Digestible Amino Acid Basis.

The aim of present experiment was to investigate the effect of protein reduction in commercial broiler chicken rations with incorporation of de-oiled rice bran (DORB) and supplementation of limiting amino acids (valine, isoleucine, and/or tryptophan) with ration formulation either on total amino acid (TAA) or standardized ileal digestible amino acids (SIDAA). The experimental design consisted of T1, TAA control; T2 and T3, 0.75% and 1.5% protein reduction by 3% and 6% DORB incorporation, respectively by replacing soybean meal with supplemental limiting amino acids to meet TAA requirement; T4, SIDAA control, T5 and T6, 0.75% and 1.5% protein reduction by DORB incorporation (3% and 6%) with supplemental limiting amino acids on SIDAA basis. A total of 360 d-old fast growing broiler chicks (Vencobb-400) were divided into 36 homogenous groups of ten chicks each, and six dietary treatments described were allocated randomly with six replications. During 42 days trial, the feed intake was significantly (p<0.05) reduced by TAA factor compared to SIDAA factor and protein factor significantly (p<0.05) reduced the feed intake at 1.5% reduction compared to normal protein group. This was observed only during pre-starter phase but not thereafter. The cumulative body weight gain (BWG) was significantly (p<0.05) reduced in TAA formulations with protein step-down of 1.5% (T3, 1,993 g) compared to control (T1, 2,067 g), while under SIDAA formulations, BWG was not affected with protein reduction of 1.5% (T6, 2,076 g) compared to T4 (2,129 g). The feed conversion ratio (FCR) was significantly (p<0.05) reduced in both TAA and SIDAA formulations with 1.5% protein step-down (T3, 1.741; T6, 1.704) compared to respective controls (T1, 1.696; T4, 1.663). The SIDAA formulation revealed significantly (p<0.05) higher BWG (2,095 g) and better FCR (1.684) compared to TAA formulation (2,028 g; 1.721). Intake of crude protein and all limiting amino acids (SID basis) was higher in SIDAA group than TAA group with resultant higher nitrogen retention (4.438 vs 4.027 g/bird/d). The nitrogen excretion was minimized with 1.5% protein reduction (1.608 g/bird) compared to normal protein group (1.794 g/bird). The serum uric acid concentration was significantly reduced in T3 (9.45 mg/dL) as compared to T4 (10.75 mg/dL). All carcass parameters were significantly (p<0.05) higher in SIDAA formulation over TAA formulation and 1.5% protein reduction significantly reduced carcass, breast and thigh yields. In conclusion, the dietary protein can be reduced by 0.75% with TAA formulation and 1.5% with SIDAA formulation through DORB incorporation and supplementation of limiting amino acids and among formulations, SIDAA formulation was better than TAA formulation.

Is there a role for ketoacid supplements in the management of CKD?

Ketoacid (KA) analogues of essential amino acids (EAAs) provide several potential advantages for people with advanced chronic kidney disease (CKD). Because KAs lack the amino group bound to the α carbon of an amino acid, they can be converted to their respective amino acids without providing additional nitrogen. It has been well established that a diet with 0.3 to 0.4 g of protein per kilogram per day that is supplemented with KAs and EAAs reduces the generation of potentially toxic metabolic products, as well as the burden of potassium, phosphorus, and possibly sodium, while still providing calcium. These KA/EAA-supplemented very-low-protein diets (VLPDs) can maintain good nutrition, but the appropriate dose of the KA/EAA supplement has not been established. Thus, a KA/EAA dose-response study for good nutrition clearly is needed. Similarly, the composition of the KA/EAA supplement needs to be reexamined; for example, some KA/EAA preparations contain neither the EAA phenylalanine nor its analogue. Indications concerning when to inaugurate a KA/EAA-supplemented VLPD therapy also are unclear. Evidence strongly suggests that these diets can delay the need for maintenance dialysis therapy, but whether they slow the loss of glomerular filtration rate in patients with CKD is less clear, particularly in this era of more vigorous blood pressure control and use of angiotensin/aldosterone blockade. Some clinicians prescribe KA/EAA supplements for patients with CKD or treated with maintenance dialysis, but with diets that have much higher protein levels than the VLPDs in which these supplements have been studied. More research is needed to examine the effectiveness of KA/EAA supplements with higher protein intakes.