Low protein diet with personalized support in advanced chronic kidney disease: association with disease progression, dialysis delay and mortality

Background. Despite therapeutic strategies to manage comorbidities and risk factors associated with chronic kidney disease (CKD), a significant number of patients continue to progress toward kidney failure. The role of low protein diets (LPDs) in delaying the need for kidney replacement therapy (KRT) remains a subject of ongoing discussion. Real-world studies offer insights into the risks, implementation and feasibility of LPDs. Methods. We retrospectively evaluated the efficacy of a moderate LPD (0.6–0.7 g/kg/day) proposed to all newly referred patients with advanced CKD. Survival and need for dialysis were compared between patients who choose an LPD and those who did not. Follow-up was otherwise identical in both groups. Results. Between January 2021 and December 2023, 110 of 182 patients chose to follow an LPD, while 72 did not. No baseline difference in age, sex, kidney function and comorbidity were observed between the two groups. The decline in estimated glomerular filtration rate was faster in patients not adhering to a diet compared with those who followed it (−2.65 versus −0.89 ml/min/1.73 m2/year), with an 84% reduction in the need for KRT {hazard ratio [HR] 0.16 [95% confidence interval (CI) 0.07–0.39]}, 78% in all-cause mortality [HR 0.22 (95% CI 0.06–0.72)] and 81% in the composite outcome death or dialysis [HR 0.19 (95% CI 0.09–0.38)]. Conclusion. When offered the option of an LPD, >60% of patients agreed to and followed it. Choosing an LPD was associated with improved patient and renal survival. While this retrospective study cannot establish a causal relationship, our data provide reassurance regarding feasibility and suggest potential advantages of offering LPDs to unselected patients with CKD who choose this dietary approach.