American Journal of Kidney Diseases

Adherence to Healthy Dietary Patterns and Risk of CKD Progression and All-Cause Mortality: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study

Published:August 05, 2020DOI:

      Rationale & Objective

      Current dietary guidelines recommend that patients with chronic kidney disease (CKD) restrict individual nutrients, such as sodium, potassium, phosphorus, and protein. This approach can be difficult for patients to implement and ignores important nutrient interactions. Dietary patterns are an alternative method to intervene on diet. Our objective was to define the associations of 4 healthy dietary patterns with risk for CKD progression and all-cause mortality among people with CKD.

      Study Design

      Prospective cohort study.

      Setting & Participants

      2,403 participants aged 21 to 74 years with estimated glomerular filtration rates of 20 to 70 mL/min/1.73 m2 and dietary data in the Chronic Renal Insufficiency Cohort (CRIC) Study.


      Healthy Eating Index-2015, Alternative Healthy Eating Index-2010, alternate Mediterranean diet (aMed), and Dietary Approaches to Stop Hypertension (DASH) diet scores were calculated from food frequency questionnaires.


      (1) CKD progression defined as ≥50% estimated glomerular filtration rate decline, kidney transplantation, or dialysis and (2) all-cause mortality.

      Analytical Approach

      Cox proportional hazards regression models adjusted for demographic, lifestyle, and clinical covariates to estimate hazard ratios (HRs) and 95% CIs.


      There were 855 cases of CKD progression and 773 deaths during a maximum of 14 years. Compared with participants with the lowest adherence, the most highly adherent tertile of Alternative Healthy Eating Index-2010, aMed, and DASH had lower adjusted risk for CKD progression, with the strongest results for aMed (HR, 0.75; 95% CI, 0.62-0.90). Compared with participants with the lowest adherence, the highest adherence tertiles for all scores had lower adjusted risk for all-cause mortality for each index (24%-31% lower risk).


      Self-reported dietary intake.


      Greater adherence to several healthy dietary patterns is associated with lower risk for CKD progression and all-cause mortality among people with CKD. Guidance to adopt healthy dietary patterns can be considered as a strategy for managing CKD.

      Index Words

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        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2019; 73: A7-A8
        • Go A.S.
        • Chertow G.M.
        • Fan D.
        • McCulloch C.E.
        • Hsu C.Y.
        Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.
        N Engl J Med. 2004; 351: 1296-1305
        • Hu E.A.
        • Steffen L.M.
        • Grams M.E.
        • et al.
        Dietary patterns and risk of incident chronic kidney disease: the Atherosclerosis Risk in Communities study.
        Am J Clin Nutr. 2019; 110: 713-721
        • Khatri M.
        • Moon Y.P.
        • Scarmeas N.
        • et al.
        The association between a Mediterranean-style diet and kidney function in the Northern Manhattan Study cohort.
        Clin J Am Soc Nephrol. 2014; 9: 1868-1875
        • Rebholz C.M.
        • Crews D.C.
        • Grams M.E.
        • et al.
        DASH (Dietary Approaches to Stop Hypertension) diet and risk of subsequent kidney disease.
        Am J Kidney Dis. 2016; 68: 853-861
        • Lin J.
        • Fung T.T.
        • Hu F.B.
        • Curhan G.C.
        Association of dietary patterns with albuminuria and kidney function decline in older white women: a subgroup analysis from the Nurses’ Health Study.
        Am J Kidney Dis. 2011; 57: 245-254
        • Bach K.E.
        • Kelly J.T.
        • Palmer S.C.
        • Khalesi S.
        • Strippoli G.F.M.
        • Campbell K.L.
        Healthy dietary patterns and incidence of CKD: a meta-analysis of cohort studies.
        Clin J Am Soc Nephrol. 2019; 14: 1441-1449
        • Hu E.A.
        • Rebholz C.M.
        Can dietary patterns modify risk for CKD?.
        Clin J Am Soc Nephrol. 2019; 14: 1419-1420
        • Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
        KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 1-150
        • St-Jules D.E.
        • Goldfarb D.S.
        • Sevick M.A.
        Nutrient non-equivalence: does restricting high-potassium plant foods help to prevent hyperkalemia in hemodialysis patients?.
        J Ren Nutr. 2016; 26: 282-287
        • Kalantar-Zadeh K.
        • Fouque D.
        Nutritional management of chronic kidney disease.
        N Engl J Med. 2017; 377: 1765-1776
        • Elliott J.O.
        • Ortman C.
        • Almaani S.
        • Lee Y.H.
        • Jordan K.
        Understanding the associations between modifying factors, individual health beliefs, and hemodialysis patients’ adherence to a low-phosphorus diet.
        J Ren Nutr. 2015; 25: 111-120
        • Thomas L.K.
        • Sargent R.G.
        • Michels P.C.
        • Richter D.L.
        • Valois R.F.
        • Moore C.G.
        Identification of the factors associated with compliance to therapeutic diets in older adults with end stage renal disease.
        J Ren Nutr. 2001; 11: 80-89
        • Ikizler T.A.
        • Burrowes J.D.
        • Byham-Gray L.D.
        • et al.
        • KDOQI Nutrition in CKD Guideline Work Group
        KDOQI clinical practice guideline for nutrition in CKD: 2020 update.
        Am J Kidney Dis. 2020; 76: S1-S107
        • Feldman H.I.
        • Appel L.J.
        • Chertow G.M.
        • et al.
        The Chronic Renal Insufficiency Cohort (CRIC) Study: design and methods.
        J Am Soc Nephrol. 2003; 14: S148-S153
        • Lash J.P.
        • Go A.S.
        • Appel L.J.
        • et al.
        Chronic Renal Insufficiency Cohort (CRIC) Study: baseline characteristics and associations with kidney function.
        Clin J Am Soc Nephrol. 2009; 4: 1302-1311
        • Subar A.F.
        • Thompson F.E.
        • Kipnis V.
        • et al.
        Comparative validation of the Block, Willett, and National Cancer Institute food frequency questionnaires: the Eating at America’s Table Study.
        Am J Epidemiol. 2001; 154: 1089-1099
        • Hu F.B.
        • Stampfer M.J.
        • Rimm E.
        • et al.
        Dietary fat and coronary heart disease: a comparison of approaches for adjusting for total energy intake and modeling repeated dietary measurements.
        Am J Epidemiol. 1999; 149: 531-540
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Chiuve S.E.
        • Fung T.T.
        • Rimm E.B.
        • et al.
        Alternative dietary indices both strongly predict risk of chronic disease.
        J Nutr. 2012; 142: 1009-1018
        • Fung T.T.
        • McCullough M.L.
        • Newby P.K.
        • et al.
        Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction.
        Am J Clin Nutr. 2005; 82: 163-173
        • Fung T.T.
        • Chiuve S.E.
        • McCullough M.L.
        • Rexrode K.M.
        • Logroscino G.
        • Hu F.B.
        Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
        Arch Intern Med. 2008; 168: 713-720
        • Appel L.J.
        • Moore T.J.
        • Obarzanek E.
        • et al.
        A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group.
        N Engl J Med. 1997; 336: 1117-1124
        • Sacks F.M.
        • Svetkey L.P.
        • Vollmer W.M.
        • et al.
        Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group.
        N Engl J Med. 2001; 344: 3-10
        • Anderson A.H.
        • Yang W.
        • Hsu C.Y.
        • et al.
        Estimating GFR among participants in the Chronic Renal Insufficiency Cohort (CRIC) Study.
        Am J Kidney Dis. 2012; 60: 250-261
        • Yang W.
        • Xie D.
        • Anderson A.H.
        • et al.
        Association of kidney disease outcomes with risk factors for CKD: findings from the Chronic Renal Insufficiency Cohort (CRIC) study.
        Am J Kidney Dis. 2014; 63: 236-243
        • Bertoni A.G.
        • Whitt-Glover M.C.
        • Chung H.
        • et al.
        The association between physical activity and subclinical atherosclerosis: the Multi-Ethnic Study of Atherosclerosis.
        Am J Epidemiol. 2009; 169: 444-454
        • Diaz-Lopez A.
        • Bullo M.
        • Martinez-Gonzalez M.A.
        • et al.
        Effects of Mediterranean diets on kidney function: a report from the PREDIMED trial.
        Am J Kidney Dis. 2012; 60: 380-389
        • Banerjee T.
        • Crews D.C.
        • Tuot D.S.
        • et al.
        Poor accordance to a DASH dietary pattern is associated with higher risk of ESRD among adults with moderate chronic kidney disease and hypertension.
        Kidney Int. 2019; 95: 1433-1442
        • Kelly J.T.
        • Palmer S.C.
        • Wai S.N.
        • et al.
        Healthy dietary patterns and risk of mortality and ESRD in CKD: a meta-analysis of cohort studies.
        Clin J Am Soc Nephrol. 2017; 12: 272-279
        • Palmer S.C.
        • Maggo J.K.
        • Campbell K.L.
        • et al.
        Dietary interventions for adults with chronic kidney disease.
        Cochrane Database Syst Rev. 2017; 4: CD011998
        • Goraya N.
        • Simoni J.
        • Jo C.H.
        • Wesson D.E.
        A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate.
        Clin J Am Soc Nephrol. 2013; 8: 371-381
        • Goraya N.
        • Simoni J.
        • Jo C.
        • Wesson D.E.
        Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy.
        Kidney Int. 2012; 81: 86-93
        • Banerjee T.
        • Crews D.C.
        • Wesson D.E.
        • et al.
        High dietary acid load predicts ESRD among adults with CKD.
        J Am Soc Nephrol. 2015; 26: 1693-1700
        • Scialla J.J.
        • Appel L.J.
        • Astor B.C.
        • et al.
        Net endogenous acid production is associated with a faster decline in GFR in African Americans.
        Kidney Int. 2012; 82: 106-112
        • Kanda E.
        • Ai M.
        • Kuriyama R.
        • Yoshida M.
        • Shiigai T.
        Dietary acid intake and kidney disease progression in the elderly.
        Am J Nephrol. 2014; 39: 145-152
        • Scialla J.J.
        • Anderson C.A.
        Dietary acid load: a novel nutritional target in chronic kidney disease?.
        Adv Chronic Kidney Dis. 2013; 20: 141-149
        • Zhu F.
        • Du B.
        • Xu B.
        Anti-inflammatory effects of phytochemicals from fruits, vegetables, and food legumes: a review.
        Crit Rev Food Sci Nutr. 2018; 58: 1260-1270
        • Claesson M.J.
        • Jeffery I.B.
        • Conde S.
        • et al.
        Gut microbiota composition correlates with diet and health in the elderly.
        Nature. 2012; 488: 178-184
        • Aron-Wisnewsky J.
        • Clement K.
        The gut microbiome, diet, and links to cardiometabolic and chronic disorders.
        Nat Rev Nephrol. 2016; 12: 169-181
        • Garcia-Mantrana I.
        • Selma-Royo M.
        • Alcantara C.
        • Collado M.C.
        Shifts on gut microbiota associated to Mediterranean diet adherence and specific dietary intakes on general adult population.
        Front Microbiol. 2018; 9: 890
        • Mafra D.
        • Borges N.
        • Alvarenga L.
        • et al.
        Dietary components that may influence the disturbed gut microbiota in chronic kidney disease.
        Nutrients. 2019; 11: 496
        • Rebholz C.M.
        • Coresh J.
        • Grams M.E.
        • et al.
        Dietary acid load and incident chronic kidney disease: results from the ARIC Study.
        Am J Nephrol. 2015; 42: 427-435
        • Boudonck K.J.
        • Mitchell M.W.
        • Nemet L.
        • et al.
        Discovery of metabolomics biomarkers for early detection of nephrotoxicity.
        Toxicol Pathol. 2009; 37: 280-292
        • Scialla J.J.
        • Appel L.J.
        • Wolf M.
        • et al.
        Plant protein intake is associated with fibroblast growth factor 23 and serum bicarbonate levels in patients with chronic kidney disease: the Chronic Renal Insufficiency Cohort study.
        J Ren Nutr. 2012; 22: 379-388 e1
        • Kalantar-Zadeh K.
        • Gutekunst L.
        • Mehrotra R.
        • et al.
        Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease.
        Clin J Am Soc Nephrol. 2010; 5: 519-530
        • Paul D.R.
        • Rhodes D.G.
        • Kramer M.
        • Baer D.J.
        • Rumpler W.V.
        Validation of a food frequency questionnaire by direct measurement of habitual ad libitum food intake.
        Am J Epidemiol. 2005; 162: 806-814