Question 3
In the article, Dietary protein restriction as a treatment for slowing chronic kidney disease progression: the case against, do you think the reasons outlined are sufficient enough to do away with recommending protein restrictions for patients with CKD? Why or why not?
Blogger Update (4/16)--Posts so far have indicated that research from one article is not sufficient enough to change years of experience and practice--I agree. However, there are many more articles in addition to this one with similar arguments against the feasibility of the clinical practice of protein restriction. I think we need to aim our focus at the arguments for or against protein restriction, rather than the fact that this is only one article showing opposition to the long used practice of protein restriction.
Conclusions
This article brought up many interesting and somewhat conflicting ideas about how to best treat a patient with CKD. Posts to this question and discussions amongst bloggers were varied about this topic. Initially, posts were mainly pointing out that methods other than those that have been established for 70+ years in the medical community cannot be done away with from one contrasting article. However, there is currently a growing body of evidence making claims that protein restrictions may not be warranted or beneficial in the clinical setting. Taking into account the issue of providing protein restrictions or not, many posts shrewdly noted that while this article brings up many interesting counterpoints to the practice of protein restriction, the clinical practice must be on a case by case basis. Excellent point bloggers! For example, some clients may be taking in well over the RDA for protein and may benefit from a restriction, while other patients with CKD who may not be eating as well, may not benefit from protein restriction, as we are also trying to prevent malnutrition. Many posts were on opposite sides as to how much weight we should give to eliminating protein restrictions in practice. Some thought that a tradition withheld for 70+ years should not be changed so easily, and others felt that the length of practice of protein restriction does not necessarily mean that it is the best practice, and that we should continually strive to update and shape our knowledge of suitable methods. Many bloggers agreed that the article raised some interesting points and forced us to "think outside the box". These posts were excellently pointing out that as professionals we need to be flexible in our thinking and education, and continue to update ourselves on research in order to be proactive in our field.
posted by Andrea @ 1:06 PM
50 comments
50 Comments:
Although this article did raise some valid arguments and it is important to note the clinical evidence, it was not enough to convince me to completely change conventional renal diet procedures and completely do away with protein restriction recommendations. There are still many studies with conflicting conclusions and further research (as always) would have to be done before I would make changes in current recommendations.
I also don't think we can overhaul the current protein recommendations with just this one article/literature review. I think by better educating our patients about making wiser choices about things we do know (at this point in time) and stressing that food is their medicine, we will better ensure their health...instead of focusing on the unknown or uncertain.
No, I do not think the reasons outlined are sufficient enough to do away with recommending protein restrictions for patients with CKD. For the longest time, protein restriction has been the dietary recommendation for those with CKD. We know the consequences of ingesting too much protein and the problems that could occur in CKD patients. Although, that article has important points, now we are aware that maybe other recommendations are being studied and talked about, further information and research would have to be done for me to do away with protein restrictions for patients with CKD. In our field, things are always changing and studies and research that are conducted are important for us to review and learn about.
Nisa M., I agree with you when you said, “I think by better educating our patients about making wiser choices about things we do know (at this point in time) and stressing that food is their medicine, we will better ensure their health.” I think at this time we can not do away with protein restrictions for CKD patients, but we can do what we know how to do and properly educate the patients about healthy diets and recommend certain food products. Educating others is important, but I would not feel comfortable at this point saying that CKD patients should not have protein restrictions in their diet.
I also don't think that one article substantiates doing away with current practice of recommending low protein intake. But, I think it pointed out some really strong flaws in the current recommendations. They pointed out that a lot of the research that supported low protein diets were biased and that their is no good clinical evidence to support that low protein diets help prevent progression of CKD. Also it pointed out that a low protein diet may have negative effects in that it sets up the patient for further malnutrition.
I think further research is definitely warranted. Just because the current nutrition recommendation has been around for a long time does not mean it is the best method and may need some redefinition.
I do not think that the well-established renal diet procedures of protein restriction can be done away with. This has been the procedure for 70 years, and many studies have shown that protein restriction is beneficial in renal patients. Again, most symptoms of CKD are caused by protein intolerance, and further, a well-balanced, low-protein diet maintains body weight, another issue today, as well as protein stores. Research has proven that there are problems when the kidneys cannot excrete ions and other metabolic waste products. Why would we make changes to this based on one study versus many years of evidence?
Samantha,
You make a good point that the study does have some valid arguments, and that if anything, it raises our awareness of new research that could be looked further into. It is vital to be up on the current research in our field, and this is just one example of how important it is.
The results of the study showing that low protein diets are not necessary for CKD patients are not sufficient enough. One study is not sufficient enough to make a change in something that has been around for many years. The study could have been flawed or performed with a limited population. There needs to be plenty more studies to successfully say that a low protein diet is not necessary for CKD patients. -Pam Moore (I am having trouble logging in)
As I’ve said in response to the previous two questions, I believe a patient will do what works for him/her. For that reason, I don’t think clinical evidence will encourage a patient to follow or disregard a specific diet. Most likely, the patient will follow a diet that yields improvement.
I completely agree with everyone else that one single article doesn’t substantiate changing the nutrition recommendations for renal patients. If further research were to come up with the same conclusions, then maybe the diet should be re-evaluated, but a lot more research would be required for that type of major change to be made. I also feel like the protein restriction may not directly help with improving renal function, but it likely does help with controlling symptoms from waste build-up in the blood, that should definitely be taken into consideration as well before abandoning the low-protein recommendation.
The dietitian needs to approach each incidence of CKD on a case to case basis. For one individual who is highly motivated and has a quality of life that is very good, the dietitian should use all means at his or her disposal to aid this patient in his fight against CKD. If the patient is advanced in years, severely depressed, and suffers throughout his her day, it is probably not appropriate severely restrict dietary protein, especially when this data shows that a protein restriction may not be as helpful as initial thought. Though lowering dietary protein may have conflicting results for alleviating CKD complications, the alternative of retaining the high protein diet is without question harmful. The patient and dietitian must weigh the options for treatment when considering the patient quality of life and life state.
Although I agree with the article stating that other factors such as reducing blood pressure need to be examined, I do not believe that protein restrictions should be abandoned. One of the reasons that the article listed was that there is poor compliance among patients. My issue is that if all restrictions are eliminated then patients may fall completely back into their old habits of excessive protein intake. I believe that by at least explaining to patients that they need to be aware of their daily protein intake, health professionals are informing patients that this may be a serious factor in their health and recovery from CKD.
Nicholas-
I think that it is so critical that you brought up the point of quality of life. I think that too often individuals read studies or memorize facts to a fault. I think that dietitians need to remember that we are dealing with human lives. At the same point I agree with Samantha who stated how important it is to stay current on new information that is being released in our field. This is to ensure that we are capable of providing the best possible care to each and every individual.
For many years it has been recommended to react to CKD with a protein restriction. I agree with everyone else that there are valid points, however one article should not change the way this disease is managed. More research needs to be conducted on this topic to change this recommendation. It is something that should be looked into, because there are changes that are warrented due to new technology and research.
Protein restriction has been the dietary recommendation for CKD pateints for 70 years and has shown to be beneficial. We know that too high of a protein intake can harm the kidney as well as the patient with CKD. Having many years of evidence proving that a low-protein diet is beneficial for these patients versus little evidence of doing away with recommending protein restrictions, I would not change the traditional procedures. Although I say this, I would definitely take doing away with protein restrictions into consideration especially considering each and every patient may do well with different approaches.
It is important to look at each patient to determine if protein restriction is necessary. For CKD patients, a low-protein diet does seem to ease symptoms although it does not prevent the disease from progressing. So for patients who are not malnourished, protein restriction may be a good idea just to help their symptoms. However, if patients are malnourished, the situation should be looked at to see if protein restriction is appropriate. It may be necessary to increase their protein until they are nourished and then decrease protein. Overall, protein restriction seems to be beneficial for CKD patients
Nick-
You bring up a good point at examining the quality of life the patient has. Each patient is different and some are going to be more willing to make changes. If it is a patient is set in their ways, it is important to make small changes so that there is a chance that they will stick to them. If a CKD patient is ready to make significant changes in their diets, then a more aggressive approach can be taken.
I don't think it is a good idea to completely abandon the idea of protein restriction until it is proven to be non beneficial. It is true that it is unhelpful with malnutrition, but it is still possible that protein restriction could slow the effects of CKD. I think it is important to keep the research going but maintain the procedures that are in place until some conclusive evidence is found.
I think the best thing that we can get out of this article has to do with having an open mind when in this field. Medicine is an ever changing field! New research and findings are consistently changing current treatments and upgrading these techniques to what is thought to be the "better" way. It is still a good idea to be wary of new findings but you should never completely rule them out. In the case of using higher protein diets with renal patients, this is something that needs to be researched more before an objective conclusion can be reached, but it is the same on the other end of the spectrum as well. The article mentioned that the long term effects of low protein diets in renal patients has also not been substantially researched and is still poorly understood. Yet because it is already in practice it will more than likely stay in practice until conclusive evidence tells professionals otherwise.
Since the dietary protein restriction has been around for 70 years and has been helping people with CKD live healthier lives for that same amount of time I would not change that approach. Until more research has been done and we are more confident about withdrawing protein restrictions we should continue to use them. As for the pt, it is up to them on weather they feel this protein restriction is helping them or not. Ultimately, each pt is going to have a different set of circumstances and will need slightly different nutritional support based off their situation.
Nick,
I agree when you say that we need to approach each individual on a case by case basis. Also, like you mentioned, taking their quality of life into consideration is important. Since only the pt really knows how they feel when on different diets and medications it is important to listen and ask questions on how they feel.
I completely agree with Brittney's comment on how vital it is for professional's to stay up on current research. It is always good to know what is being researched in fields that affect the treatment of your patients whether or not you choose to practice these guidelines. We as dietitians are in a field that will always be bettering its treatment techniques according to new research that is always piling in. In order to not be caught off guard with new practices, professionals should keep seeking out current research throughout their practice.
Jamie said...
Protein restriction for CKD patients should remain an option for dietary recommendations. High protein intake has been proven to be stenuous on the kidneys; therefore, restriction may be a better route in the long run.
I think this article had very valid point, but I will need to have more evidence before I can make a definitive conclusion on this subject. Treating CKD patients with a low protein intake still shows evidence of correct treatment. One article on any argued point will never make me change my view on one certain subject because I simply need more than one article as evidence. As stated before, this study had several flaws and unanswered questions, which makes me question the pertinence of this article.
I do not think that there is sufficient evidence to do away with protein restrictions. Also if you give someone an inch they'll take a mile. While me may liberalize diets in the short term for some not all patients would do well with liberalization. Our country goes over board on many things and Americans definitely goes well over the protein recommendation to begin with. Care needs to be taken with CKD patients and just because one article alludes to something doesn't mean we need to take it into practice.
I do feel that protein restrictions are needed for CKD patients. But I do think that it should be on a case by case decision. Some patients who are malnourished should not be placed on such a strict protien restriction. I do think that a healthy individual will benefit in the long run by following a protein restriction. But like it was mentioned recommendations do change and we have to have an open mind if the evidence is there to back up the facts.
The point made in the article made me think of a different way to treat CKD. I feel a low protein diet on a patient to patient basses can be helpful to treat CKD. Each patient needs to be monitored solely of their protein needs. Some patients may need more protein or less protein when they have CKD.
this is dana
Well I think that this article did make me think about the protein choices between amimal and plant. I think plant protein would be safer for now, but maybe incorporate a little animal protein because it is a complete protein.
The current literature is not strong enough to begin eliminating protein restrictions from patients with CKD. That being said, articles with recommendations against the norm can be great for the profession because it forces us think outside our box to examine is conventional actually best? When conventional practices become inferior, it does take time for the medical communities to embrace improved practices. Continue even after school to keep updated with the research based recommendations, which will allow us to be pro-active at work to make necessary changes.
There is research that supports both sides of the arguments, however at this point all the conflicting information can it hard to determine what should be done with pro restrictions. I think that an adequate protein diet is important as protein digestion eventually puts a strain on the kidneys to some degree. I think that today many people eat excess protein so having them follow a lower protein diet may mean they are consuming an adequate/normal amount. It should depend on the patient and what seems to be working for them!
I think that in the fast-paced world of nutrition, you have to be ready for all the continuing research and be open to change. You have to do what is shown to be best for the patient. All cases are different and as a dietitian, you have thr disgression to say, based on experience, what will better your patient.
No I do not feel that the reasons outlined are sufficient enough to do away with recommending protein restrictions for patients with CKD. If a low-protein diet has worked for people in the past why would you do away with it. I do believe that protein restriction may not work for everyone, but that does not mean that it won’t work for anyone. I think that all individuals react differently to different treatments so if protein restriction works for them then they should use it and if it doesn’t then another alternative should be suggested.
Steph,
I agree with your comments about how patients should be consuming the recommended amount of protein instead of the typical American diet that far exceeds those recommendations. Obviously this is a highly controversial topic and should probably be handled on a case by case basis which means protein restriction might not be best for everyone. Especially when we are adding in the quality of life factor as well.
Jamie said…
Lori – I agree that in today’s world, nutrition findings are changing faster than in the past. We are most definitely the “quick-fix/cure” age. This may be a reason why many do not take nutrition seriously. As far as the protein restriction is concerned, it has been given to CKD for many years and has proven to be beneficial. Protein restriction should not be “done away with,” however, it may not be suitable for every CKD patient.
I would make the currents recommendations. They have been used for 70 years and I think they have shown to be the most successful in most cases. If I were to increase the protein recommendation for a patient with CKD, it would probably depend on the severity of the case and if they had a problem with protein malnutrition. If the patient did have protein malnutrition then I might try increasing their protein intake, but still monitor them closely. If the patient did not have a malnutrition problem then I would definitely stick with the current recommendations.
This is a topic that we as dietitians need to keep an eye on. As mentioned our society typically consumes more protein than is recommended. So eventually it may be more important to educate everyone on protein requirements and portion sizes to help lower the risk for renal complications.
Andrea does bring up a valid point that there are more articles that are leaning toward ending the protein restrictions in CKD patients, but if this is the case, why have the protein restricted diets worked to control CKD so well in the past? I believe that even though this study says that protein restrictions are not "important" anymore, it is still important to individualize the diet for each person's tolerance. Obviously, if an individual is showing signs of poorly managed CKD, it is either from protein wasting or too much protein being delivered. I think this is the main reason that protein should neither be restricted nor overloaded. In order to debate both sides of the argument, you could start a patient off with the average recommendations for protein, not restricted or providing large amounts. It should be recommended then that the patient start with the RDA for protein of .8-1.0 g/kgIBW and then adjust according to their tolerance. The way that the patient handles this amount of protein would then determine whether or not I restrict their calories!
Everyone made very good arguments for keeping the low protein restricted diet. I would not recommend completely getting rid of the recommended protein restrictions with CRF pt. However, perhaps for some pt., the normal-high protein diet would be more appropriate for some. Bottom line is that nutritional therapy has to be individually tailored to the pt., taking into consideration the clinical condition the pt is in (i.e BW, body condition, alb status), the degree uremia, and food preferences. If the “presence of such malnutrition is number one strongest prediction of morbidity and mortality” how can we not take into consideration to increase protein intake? I understand that high protein diets do put unwanted stress on the kidneys and what is not metabolized is excreted through the urine and/or potentially cause more waste build up in the blood and increase the progression of the disease. This is why it is crucial to take into account preexisting and current conditions and gradually increase protein intake. Monitor pt very closely and adjust accordingly.
Mary Ellen-
You bring up a great point that Americans typically consume too much protein as it is and if we allow for increased protein intake with this diet, the patients may see it as simply being allowed to eat with no restrictions. The patient may already be consuming more protein than they need (even without taking into account their disease)which is hard on the kidneys regardless of disease state.
In our field, things are always changing. However, a lot of times we just add on to the knowledge that we already know. I don’t think that because of one article we should reconsider what we have been teaching patients for years. There are many studies that do show that protein restriction is beneficial. However, I think it is useful to take into consideration new techniques of dealing with this disease. Overall, I still believe that every patient is different and will follow a diet that suits them.
Steph,
I think it’s interesting that you said that today people seem to over consume protein on a daily basis so by lowering their intake they would be getting an adequate amount. I agree with you. Due to the larger portions and over consumption of food in general we need to consider the amount of protein that is consumed in a patient’s diet. A patient may think they are on a low protein diet when in reality they are lowering their needs to a normal amount.
I do not believe there is suffecient evidence to stop recommending protein restrictions for CKD patients. There are many symptoms that can be relieved or weaked by the modifications. Patients absolutly need proper nutrition, but they we also need to consider the quality of life.
jessie janik...I agree
If we as RD and health professional start to eliminate diet restrictions,then patient might start to get the mind set that they don't have to watch what they eat at all and the "pill cure" will just get worse.
I agree with a number of people that this should be looked into further and more research should be done. This is how new ideas come into play... when we find interesting results from research but before we start makeing recommendations across the board it is important to find more "proof".
Steph-
I agree with you that people may be getting to much protein and lowering it would probably be to the recommended amount. The American diet is based mainly around meat, animal based protein. I also agree we should work with each patient individually!
Lisa,
I agree with you in that a patient will only comply with what works. If clinical evidence supports it, but it is not improving the health of the patient, then why would you use it? You have to realize that everyone reacts differently. You have to make recommendations specific to your patient and their needs.
larusk85 said...
Lori,
Being open to change is definitely important when it comes to continuing research. Staying up to date with conflicting views such at protien recommendations can help you assess and accurately plan a diet for an individual.
I haven't seen a restriction of 0.6 grams of protein used in practice. The dietitans usually would not go below 0.8 for recommendations. I'm not saying that this is wrong or right, it's just what i've seen in practice. Also, at one of the hospitals renal diets were rarely used. The rational behind this is that renal patients do not usually eat well. You always have to consider how the patient is eating and what stage of renal disease they are in (how well their kidneys are functioning). If they are receiving hemodialysis or peritoneal dialysis then obviously a protein restrition is not warranted. I think that a protein restriction can be helpful, but it depends on the individual patient. And I agree that more research needs to be done before we completely do away with protein restriction.
Lauren,
I completely agree with you that the medical field is always changing, so new findings should not be taken lightly just because it is only one study! Plus you have to account for individualized responses from each person because even though it may work for one person, the other person may benefit from the complete opposite recommendation. In the case of protein for renal patients, I believe that this study may be one of those that work for some, but others may not tolerate it well, so I believe that you make a valid point by saying that we should not just dismiss because it is only one finding!
lcflier,
Thanks for the insight of what you have seen in the hospitals. I find it interesting that you said at one hospital renal diets were rarely used and that you have never seen a RD recommend less than 0.8 g of protein. I agree that a restriction would depend on the individual patient and a person on dialysis would not benefit from a restriction.
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