Traditional dietary recommendations for patients with chronic kidney disease (CKD) focus on the quantity of nutrients consumed. Without appropriate dietary counselling, these restrictions can result in a low intake of fruits and vegetables and a lack of diversity in the diet. Plant nutrients and plant-based diets could have beneficial effects in patients with CKD: increased fibre intake shifts the gut microbiota towards reduced production of uraemic toxins; plant fats, particularly olive oil, have anti-atherogenic effects; plant anions might mitigate metabolic acidosis and slow CKD progression; and as plant phosphorus has a lower bioavailability than animal phosphorus, plant-based diets might enable better control of hyperphosphataemia. Current evidence suggests that promoting the adoption of plant-based diets has few risks but potential benefits for the primary prevention of CKD, as well as for delaying progression in patients with CKD G3–5. These diets might also help to manage and prevent some of the symptoms and metabolic complications of CKD. We suggest that restriction of plant foods as a strategy to prevent hyperkalaemia or undernutrition should be individualized to avoid depriving patients with CKD of these potential beneficial effects of plant-based diets. However, research is needed to address knowledge gaps, particularly regarding the relevance and extent of diet-induced hyperkalaemia in patients undergoing dialysis.
The idea that animal protein has ‘high biological value’ is not relevant in the context of a mixed diet and is not an a priori reason to consider plant protein inferior to animal protein for people with or without chronic kidney disease (CKD).
Plants are the only dietary source of fibre, which shifts the gut microbiota profile towards increased production of anti-inflammatory compounds and reduced production of uraemic toxins.
Plant fats, particularly olive oil, are anti-inflammatory and anti-atherogenic.
Plant-based diets have low net endogenous acid load, which could mitigate metabolic acidosis in patients with CKD and potentially slow the progression of kidney disease.
Plant phosphorus is bound to phytate and is less bioavailable than animal phosphorus; consequently, many plant-based foods have a favourable protein to phosphorus ratio.
Restriction of plant foods as a strategy to prevent hyperkalaemia deprives patients with CKD of the potential beneficial effects of these foods; plants with low potassium content provide choice for those who need to restrict their potassium intake.
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The authors are members of the European Renal Nutrition (ERN) Working Group, an initiative of and supported by the European Renal Association–European Dialysis Transplant Association (ERA–EDTA). Further information on this Working Group and its activities can be found at https://www.era-edtaworkinggroups.org/en-US/group/european-renal-nutrition. A.G.O. was supported by The National Council of Science and Technology (CONACYT), CVU 373297, School of Medicine, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud. J.J.C. acknowledges support from the Swedish Research Council (grant number 2019-01059) and the Swedish Heart and Lung Foundation.
J.J.C. has received consultation, speaker fees or research funding from Abbott, Nutricia, Dr Schär, Laboratorios Rubio, Baxter, AstraZeneca, ViforPharma, Astellas, Novartis and MSD, all outside the submitted work. P.C. is advisory board member at Fresenius Kabi. V.B. acknowledges speaker honoraria from Shire and Fresenius Kabi. P.M. acknowledges consultation or speaker honoraria from Abbott Nutrition, Amgen, Nutricia, Palex and ViforPharma, all outside the submitted work. S.S. acknowledges speaker honoraria from Sanofi Aventis and Abbie. D.F. received honoraria from Fresenius Medical Care, Fresenius Kabi, Sanofi and Vifor. A.C. received speaker honoraria from Shire, Fresenius Kabi, Vifor and Dr Shär. A.E.-C. acknowledges speaker honoraria from Abbott Laboratories and AbbVie. C.C. has received consultation honoraria, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Johnson & Johnson, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter outside the submitted work. The other authors report no conflicts of interest.
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- Vegan diet
A diet that excludes meat, fish, seafood, eggs and dairy.
- Vegetarian diets
Diets that exclude meat, fish and seafood, but not eggs or dairy.
- Dietary Approaches to Stop Hypertension
(DASH). A diet that was designed to help treat or prevent hypertension. This diet encourages reduced sodium consumption and increased intake of potassium, calcium and magnesium through the high consumption of fruit, vegetables, legumes and nuts and low consumption of meat, fish, seafood, eggs and dairy.
- Mediterranean diet
A traditional diet from countries surrounding the Mediterranean sea that emphasizes large numbers of servings of fruit, vegetables, legumes, nuts, olive oil and fish, and low numbers of servings of meat, seafood, eggs, dairy and processed food (including bread and pastries).
- Okinawan diet
A traditional diet from the island of Okinawa in Japan, which has a population with exceptional longevity. This diet is low in calories and fat and high in carbohydrates. It emphasizes vegetables and soy products alongside occasional, and small, amounts of noodles, rice, pork and fish.
- Healthy eating diet
A diet that exemplifies the US recommended dietary targets 2015–2020. This diet emphasizes fruits, vegetables, whole grains and fat-free or low-fat milk and milk products. It includes lean meats, poultry, fish, beans, eggs and nuts. It is low in saturated fats, trans fats, cholesterol, salt (sodium) and added sugars, and stays within daily calorie needs.
- Essential amino acids
Amino acids that cannot be synthesized by an organism from other nitrogen sources.
- Interdialytic weight gain
Change in body weight between two dialysis sessions. It is routinely assessed and used together with clinical symptoms and signs and predialysis blood pressure readings to make decisions regarding the amount of fluid removal during a dialysis session. It is also used as a basis for fluid and salt intake recommendations.
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Carrero, J.J., González-Ortiz, A., Avesani, C.M. et al. Plant-based diets to manage the risks and complications of chronic kidney disease. Nat Rev Nephrol (2020). https://doi.org/10.1038/s41581-020-0297-2