Does Protein Restriction Cause Malnutrition

One of the most tenacious misconceptions about kidney disease is the idea that increasing protein intake will improve protein nutrition. Logical though this seems, the opposite is more commonly the case.

Most patients with chronic kidney disease receive no dietary counseling and therefore make no change to their diets. For most Americans, this means a relatively high-protein diet. (We eat about twice as much protein as we need, on the average.) As the kidneys fail, products of protein breakdown progressively accumulate in the blood. Appetite falls off, and nausea and vomiting may occur. People consume fewer calories than they need, and malnutrition rears its head. Indeed, when dietary treatment is omitted, wasting develops sooner or later.

But any number of reports have documented that wasting is not a feature of properly treated kidney failure. In a paradox that has not been generally recognized, protein restriction improves protein nutrition.

When essential amino acids (or their keto-analogues) are given, protein intake can be severely restricted without inducing protein malnutrition. Indeed, this is exactly what Dr. Rose and his colleagues showed in normal college students many decades ago. Far from wasting, with the optimal mixture of amino acid supplements, but zero dietary protein, protein nutrition actually improved.

The largest study of protein nutrition in patients with kidney failure prescribed a very-low-protein diet was the Modification of Diet in Renal Disease (MDRD) study. As noted earlier, patients on such diets tend to reduce caloric intake at first, but as they get used to the diet, caloric intake recovers, and in the long term, nutrition is well maintained or even improves. Sophisticated markers of body composition may show significant declines during the first three months, but stabilize or improve thereafter.

I sincerely hope that as a patient with kidney failure, you give the very-low-protein diet supplemented with amino acids a try. I and many other researchers and doctors think that this diet will give you a fighting chance of slowing the course of your disease and delaying the need for you to go on dialysis.

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