Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan; Asia Pacific Clinical Nutrition Society (APCNS), Department of Food Science and Nutrition, Zhejiang University, 866 Yu-Hang-Tang Road, Hangzhou 310058, ChinaChina
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Chronic kidney disease (CKD) is pervasive into aging society, affecting permanent implications on patients’ life. Approximately 10% of the global population has CKD, and millions die each year. The prevalence of CKD was high in Latin America, Europe, East Asia and the Middle East, where approximately 12% of the population has CKD.1 Diabetic kidney disease (DKD) or diabetic nephropathy (DN) is a part of CKD when the patients have diabetes.2 Both CKD and DKD may progressively fall from a normal estimated glomerular filtration rate (eGFR >90 ml/min/1.73 m2) to less than 15, at which point the patient becomes end-stage kidney disease (ESKD). The status of DKD could be estimated by measuring the amount of urinary protein and the serum creatinine, which can be used to calculate the eGFR. Progression rate of CKD/DKD is recently reported by Warren et al3 who classified 15,517 participants in the communitybased Atherosclerosis Risk in Communities (ARIC) study by diabetes status. They quantified eGFR trajectories at four visits over 26 years. Adjusted mean eGFR decline over the full study period among participants without diabetes was − 1.4 ml/min/1.73 m2/ year, with undiagnosed diabetes was − 1.8 ml/min/year, and with diagnosed diabetes was − 2.5 ml/min/year.
Open Journal PUBLISHERS Editorial Low Protein Brown Rice for Preventing Progression of CKD and DKD to End Stage Renal Failure 1,2* Shaw Watanabe, MD, PhD1,2* 1Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan 2Asia Pacific Clinical Nutrition Society (APCNS), Department of Food Science and Nutrition, Zhejiang University, 866 Yu-Hang-Tang Road, Hangzhou 310058, China * *Corresponding author Shaw Watanabe, MD, PhD Lifescience Promoting Association, Daikyo-cho 25-3-1004, Shinjuku-ku, Tokyo 160-0015, Japan; Fax: +81-3-5379-7786; E-mail: watashaw@lifescience.or.jp Article information th th th Received: August 10 , 2018; Accepted: August 16 , 2018; Published: August 16 , 2018 Cite this article Watanabe S. Low protein brown rice for preventing progression of CKD and DKD to end stage renal failure. Diabetes Res Open J. 2018; 4(1): e5-e7. doi: 10.17140/DROJ-4-e012 hronic kidney disease (CKD) is pervasive into aging society, However, relatively little is known about the optimal affecting permanent implications on patients’ life. Approxi- way to coordinate, finance and regulate the care for people with C mately 10% of the global population has CKD, and millions die CKD, especially the patients living in inequality present low-and- each year. The prevalence of CKD was high in Latin America, Eu- middle income countries. Furthermore, high cost intervention did rope, East Asia and the Middle East, where approximately 12% of not yield expected results. In Japan, J-Doit-3 study, in which 2,542 the population has CKD.1 Diabetic kidney disease (DKD) or dia- patients were randomly assigned either to ordinary therapy or in- betic nephropathy (DN) is a part of CKD when the patients have tensive therapy with multiple targeting of HbA1c, blood pressure, diabetes.2 Both CKD and DKD may progressively fall from a nor- LDL cholesterol, HDL cholesterol, triacylglycerol, and BMI pur- mal estimated glomerular filtration rate (eGFR >90 ml/min/1.73 posed to suppress these values within the normal range.6 A pri- m2) to less than 15, at which point the patient becomes end-stage mary outcome occurred in 109 patients in the intensive therapy kidney disease (ESKD). The status of DKD could be estimated by group and in 133 patients in the conventional therapy group (haz- measuring the amount of urinary protein and the serum creatinine, ard ratio [HR] 0.81, p=0.094). Only cerebrovascular events were which can be used to calculate the eGFR.
significantly less frequent in the intensive therapy group (HR 0.42, p=0.02), but hypoglycemia occurred in 41.1% patients in the inten- Progression rate of CKD/DKD is recently reported by sive treatment vs. 22.3% in the control group.7 Cost- effectiveness Warren et al3 who classified 15,517 participants in the community- would be a problem.
based Atherosclerosis Risk in Communities (ARIC) study by dia- betes status. They quantified eGFR trajectories at four visits over According to the survey conducted by the Japan Society 26 years. Adjusted mean eGFR decline over the full study period of Dialysis Medicine, the hemodialysis patients was 324,48, an in- among participants without diabetes was − 1.4 ml/min/1.73 m2/ crease of 6,010 from the previous year in 2013. DKD was the most year, with undiagnosed diabetes was − 1.8 ml/min/year, and with common, with 118,081 patients, accounting for 38.1% of dialysis diagnosed diabetes was − 2.5 ml/min/year.
patients overall, but DKD in newly started dialysis in the past one year was 15,809, accounting for 43.5% of the new hemodialysis.8 Over the past 90 years, a protein-restricted diet has been successfully used to treat chronic renal failure. Recently, the treat- Prevention of hemodialysis is very important, both for ment of CKD uses an angiotensin converting enzyme inhibitor reducing medical costs and for improving patients’ quality of life or angiotensin receptor blocker to dilates the glomerular arteriole (QOL). Prevention of hypertension and low protein diet are two for reducing hyperfiltration within the glomerular capillaries. Other major strategies against CKD progression. We have reported in the classes of diabetes medications, such as GLP-1 agonists, DPP-4 Saku population-based cohort study, in which the decline of eGFR inhibitors, and SGLT2 inhibitors, are also thought to slow the pro- was 1 ml/min/1.73 m0/year by ordinary lifestyle of aging, while it 2,4,5 gression of diabetic nephropathy.
was nearly 5 ml among people whose daily meat consumption was large (2.0 g/kg body weight).9 cc Copyright 2018 by Watanabe S. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows to copy, redistribute, remix, transform, and reproduce in any medium or format, even commercially, provided the original work is properly cited. Diabetes Res Open J. 2018; 4(1): e5-e7. doi: 10.17140/DROJ-4-e012 However, the critical dose of protein restriction is still WFBR, but vitamin E, niacin, folic acid and pantothenic acid were in debate. We define the definition of a low protein diet to be lost 30 to 40%. The antioxidant activity of both brown rice and less than 0.5 g/kg body weight from the clinical case study.10 Our WFBR remained 3-4 unit in the boiled rice, mostly water-soluble clinical review on 241 CKD patients, with a serum creatinine level AOU-L. Polished white rice did not show antioxidant activity at all. greater than 5 mg/dL, eGFR kept to decline within 1.0 ml/min/yr by every 0.2 g/kg body weight reduction of daily protein intake. At Newly-made protein extracted wax free brown rice serum creatinine level lower than 5 mg/dL, a daily protein intake (LPBR) could be expected to have wide usage in clinical nutri- of 0.5 g/kg body weight could decrease urinary protein approxi- tion.19 CKD patients have a necessity to reduce phosphorus and mately 1.1 g/day in a relatively short time span. The survival until potassium intake in addition to decrease protein intake. At the ESKD was better by a daily protein intake of 0.3-0.5 g/kg body same time, there is a need to ensure the patient takes in enough weight with enough energy source intake, while more than 0.6 g/ energy source. LPBR meets all these requirements as a staple food kg body weight showed the same poor prognosis as control.11 for CKD patients. Additional benefits should be obtained for the disease by dietary fiber, vitamins, gamma oryzanol, ferulic acid and Effect of low protein diet on CKD patients are denied antioxidant activity. Almost no potassium and low phosphate in by many clinicians based upon the Modification of Diet in Renal LPBR were also beneficial for the patients to prevent hyperkale- Disease (MDRD) study.12 In that study, 585 patients in group A mia and hyperphosphatemia. Dietary fiber intake stimulated the (GFR 22-55 ml/min/l.73 m2) were divided into two sets, one set growth of intestinal bacteria which produce short-chain fatty acids, 20,21 prescribed a normal protein intake (l.3 g/kg/day) and the other a which are beneficial for gut environment.
low protein diet (LPD, 0.6 g/kg/day); the 255 patients in group B (GFR 13-24 ml/min/l.73 m2) were divided into an LPD set (0.6 g/ Primary, secondary and tertiary prevention measures kg/day) and very low protein diet (VLPD, 0.28 g/kg/day) set. The exist for CKD, DKD and ESKD. Such measures include public VLPD set were prescribed a daily 0.28 g/kg amino acid-keto acid education on healthy dieting, exercise, proper body weight, self- supplement and multivitamin tablet. Energy intake was set at 30 awareness of serum creatinine, urinary albumin and blood pres- 22 23 kcal/kg body weight. Follow-up period of 2.2 years on an average sure levels.22 A low protein brown rice is a hope of medical rice.23 and an additional 9-month follow-up showed poor prognosis in A new low protein diet could be developed by using this rice, and it the VLPD group. However, the actual protein intake was found to becomes easier to make a recipe more tasteful for the patients with be above the set level, and the energy intake had been low (22-20 renal failure.
kcal/kg), so that the malnutrition would be the cause of death. In our opinion, failure of the MDRD study to demonstrate efficacy