Healthy diet delays development, progression of chronic kidney disease in diabetics

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1. Eating a healthy diet with 5 or more servings of fruit per week led to lower risk of development or progression of chronic kidney disease and death in type 2 diabetics. 

2. Neither sodium nor protein intake were associated with an increased risk of development or progression of chronic kidney disease. 

Evidence Rating Level: 1 (Excellent)     

Study Rundown:  As Type II Diabetes (DM2) has become increasingly prevalent understanding modifiable risk factors to prevent the development or progression of chronic kidney disease (CKD) has exceedingly important. In this study, the authors used data from a large prospective study to examine the effects of diet on CKD in patients with DM2. Participants were followed for 5.5 years for any of the three following primary outcomes: no incidence or progression of CKD, incidence or progression of CKD, and death. They found that a healthy diet high in fruits and moderate alcohol intake led to decreases in CKD outcomes and all-cause mortality. Interestingly, the previous dogma that a diet low in sodium and protein was beneficial in CKD was not supported by the data, and in fact led to worse outcomes.

The limitations include the exclusion of patients with pre-existing macroalbuminuria, and the reliance on subject questionnaires for characterization of diet.  Furthermore, study subjects were part of the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) cohort, and therefore it is unclear what, if any, impact the study interventions had on outcomes in this subgroup.  Nonetheless, this large prospective trial allows physicians to make new dietary recommendations for patients with DM2 without macroalbuminuria in order to decrease their risk of CKD incidence or progression.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Evaluation and Management of Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice Guideline

In-Depth [prospective observational study]: This study selected 6213 participants from the ONTARGET study with diabetes and without macroalbuminuria . Outcomes included new microalbuminuria(15.8%), GFR decline of >5% per year (20.4%), and death (8.3%). Participants with modified Alternate Healthy Eating Index (mAHEI) in higher tertiles (indicating a healthier diet) had significantly lower renal risk (OR_renal2nd vs 1st tertiles 0.88 [95% CI, 0.82-0.94], OR 3vs1, 0.74 [95% CI, 0.64-0.84]), and risk of death (ORdeath3vs1, 0.61 [95% CI, 0.48-0.78]).  Unexpectedly, an increased consumption of animal protein lead to better renal outcomes (OR 3vs1, 0.86, 95% CI, 0.77-0.95).  Consumption of leafy green vegetables was similarly associated with improved renal outcomes (OR 3vs1, 0.90, 95% CI, 0.83-0.98). Sodium intake,was not associated with CKD, but showed a U-shaped association with mortality, with increased mortality at both low and high levels of sodium intake. Also, moderate alcohol intake (5 drinks/week) was associated with a lower risk of CKD (OR 3vs1 0.75 95% CI, 0.65-0.87).

By Evan Shalen and Brittany Hasty

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