Efficacy and Safety of a Very-Low-Protein Diet in the Elderly: What are the Options?
Article Outline
To the Editor:
The study by Brunori et al1 makes some interesting observations. Elderly renal patients constitute a rapidly growing segment of the end-stage renal disease population. However, the proof for short- and long-term nutritional safety of low and/or very low protein diets in elderly patients (>70 y) with advanced renal failure is lacking.2
There were 31 deaths of dialysis patients and 28 deaths of patients that “started” on diet. However, the total deaths in the diet group also include those who died after they started dialysis (10 deaths on diet, 18 on dialysis). Also, 40 of the 56 diet patients (71%) had to start dialysis mainly because of “hyperkalemia and/or fluid overload” after a median of 9.8 months. The total number of treatment failures on diet (including deaths on diet and all those who failed diet and had to start dialysis) included all but 6 of the diet group (56-[10+40]). If death on diet as well as transfer from diet had been considered as a diet treatment failure and had been considered as an end point, then diet did not do very well. Of patients that switched from diet to dialysis, the median time delay was 9.8 months (range, 6-20 months); thus, many did not last a year on diet.
Furthermore, the diet group had intensive dietary management by skilled dieticians. The Modification of Diet in Renal Disease Study requirement for dietician input was several hours per visit, and even then adherence was a problem. We showed3 that US dieticians do not and cannot spend much time in predialysis dietary counseling because of inadequate numbers and lack of pay for dietician input in predialysis patients via Medicare. Thus, we worry about the nutritional status of patients placed on extremely low protein intakes with little dietician input and inability to ensure adherence with the mandated supplements.
Finally, one has to wonder if the delay of dialysis for a few months was worth the recurring episodes of fluid overload and/or hyperkalemia that the diet group experienced. Our treatment plans should be to prevent such things and not allow such events to dictate dialysis initiation. Dialysis should be used to prevent the complications of end-stage renal disease and not to simply treat them once they are present. In our opinion, the argument for delaying dialysis with dietary management is unacceptable if the indications for dialysis initiation require that a patient must suffer first.
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Acknowledgements
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Financial Disclosure: None.
References
- Efficacy and safety of a very low protein diet when postponing dialysis in the elderly: A prospective randomized multicenter controlled study. Am J Kidney Dis. 2007;49:569–580
- . Treatment of advanced renal failure: Low protein diets or timely initiation of dialysis?. Kidney Int. 2000;58:1381–1388
- National Kidney Foundation Council on renal nutrition survey: past-present clinical practices and future strategic planning. J Ren Nutr. 2003;13:233–240
PII: S0272-6386(08)00055-3
doi:10.1053/j.ajkd.2007.11.034
© 2008 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved.
Refers to article:
- Efficacy and Safety of a Very-Low-Protein Diet When Postponing Dialysis in the Elderly: A Prospective Randomized Multicenter Controlled Study
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