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The impact of low-protein diet on residual renal function in dialysis patients: a systematic review and metaanalysis

BMC Nephrology volume 26, Article number: 122 (2025) Cite this article

Abstract

Objective

A low-protein diet is essential for the nutritional management of chronic kidney diseases as it can reduce renal burden. However, the effect of low-protein diets on dialysis patients compared to pre-dialysis patients remains unclear. This study aims to compare residual renal function among dialysis patients following a low-protein diet versus a normal diet, offering valuable insights into the optimal nutritional strategy for preserving residual renal function.

Methods

This meta-analysis has been registered on PROSPERO, an international registry of prospective systematic reviews. We conducted a comprehensive and systematic literature search using PubMed, Cochrane Library and Web of Science (WOS). Our search strategy was designed to discover all relevant studies investigating the influence of low-protein diets on residual renal function among dialysis patients. Four studies met the inclusion criteria. Heterogeneity was discussed through subgroup analysis of dialysis method, the addition of ketoacid and other relevant factors.

Results

We included four prospective studies of low-protein diets among dialysis patients, each of which included at least 40 participants. Individuals receiving a 12-months low-protein diet had a higher GFR (MD = 1.37 ml/min; 95% CI:0.18 to 2.55), while daily urine volume decreasing more slowly (MD = 660 ml; 95% CI: 110 to 1210). In addition, dialysis patients undergoing a low-protein diet for 4 or 12 months had reduced serum phosphorus (MD=-0.74 g/dl; 95% CI: -1.04 to -0.45). Their serum albumin was higher than dialysis patients received a free-choice diet (MD = 4.00 g/dl; 95% CI: 2.46 to 5.54).

Conclusion

Dialysis patients who adhere to a long-term low-protein diet may have a positive effect on residual kidney function. In addition, dialysis patients receiving a low-protein diet increased serum albumin, reduced serum phosphorus levels, and maintained a better nutritional status and electrolyte balance.

Peer Review reports

Introduction

As a significant global public health issue, chronic kidney disease (CKD) affects millions of people worldwide [1, 2]. The progression of CKD can result in a gradual deterioration of renal function and ultimately come to end-stage renal disease (ESKD), requiring life-sustaining peritoneal dialysis or hemodialysis [3]. While these methods effectively remove waste and excess water from the body, they also present various complications and reduce quality of life [4].

Residual renal function, the portion that remains functional during dialysis, plays a crucial role in fluid and electrolyte balance control, reducing dialysis-related complications, improving quality of life, and increasing survival rates [5, 6]. Therefore, preserving residual renal function has become a key objective in treating CKD patients.

In the nutritional management of kidney disease, low-protein diets have always been an important consideration [7]. These diets are designed to alleviate strain on the kidneys and slow down further decline in renal function. For dialysis patients specifically [8], appropriate protein intake is essential for maintaining nutritional status, enhancing treatment outcomes, and safeguarding residual renal function. However, in published meta-analyses, it is controversial whether a low-protein diet has an impact on residual renal function among CKD patients [9, 10]. At the same time, studies among dialysis patients on the influence of low-protein diets on residual renal function have produced inconsistent results [11,12,13] due to factors such as study design, patient characteristics, and dialysis mode. The safety of low-protein diets also needs to be further explored due to possible malnutrition and other problems [14,15,16].

As such, this meta-analysis aims to comprehensively assess the influence of low-protein diets on dialysis patients’ residual renal function and potential safety issues. By rigorously screening existing literature for data extraction and quality assessment purposes, this study will further delve into the mechanism by which low-protein diets affect residual renal function in this specific population as well as their potential clinical value so as to provide a more robust evidence base for nutritional treatment strategies targeting the progression of kidney diseases.

Materials and methods

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) group [17, 18]. We registered the protocol on PROSPERO (CRD42024507043).

Search strategy

A search was performed by two reviewers (XJY and LXQ) using three databases from the establishment (PubMed 1879, Cochrane Library 1993, Web of Science 1997) until January 9, 2024. The search terms included dialysis [Mesh], peritoneal dialysis [Mesh], hemodialysis [Mesh], renal function, renal function, protein-restricted, dietary proteins, low-protein diet and protein restriction. EndNote X9 was utilized to manage these retrieved studies.

Selection criteria

We defined dietary protein intake (DPI) of 0.6–0.8 g/kg/day as low protein diet. The inclusion criteria for the studies were as follows: (i) participants were aged ≥ 18 years; (ii) randomized controlled trial (RCT) and prospective study; (iii) patients undergoing peritoneal dialysis (PD) or hemodialysis (HD); (iv) English articles.

Studies were excluded based on these exclusion criteria: (i) patients with evidence of infection or inflammation; vomiting, persistent anorexia or diarrhea; concurrent wasting disease like tuberculosis. (ii) participants received dialysis because of acute kidney injury (AKI) or AKI; (iii) publications were reviews, case reports, commentary, conference articles and animal studies; (iv) publications without abstracts or full texts.

Data extraction and quality assessment

By two reviewers (XJY and LXQ), the characteristics were extracted independently. The primary outcome was residual renal function which measured by daily urine volume and glomerular filtration rate (GFR). GFR is defined as the average of creatinine and urea clearances measured over a 24-hour urine collection. And the secondary outcomes were KT/V, the number of adverse events (infection, cardiovascular event or hospitalization for other reasons), patients dropped for declining of residual renal function, all-cause mortality, and nutritive index (serum phosphorus, serum calcium serum albumin).

We extracted data from included studies: author name, publication year, region, study design, inclusion criteria, sample size, gender, average age, follow-up time, treatment, and data pertaining to outcome variables.

For randomized controlled trials, we used the Cochrane Collaboration tool [19] to evaluate the quality. It includes allocation concealment, random sequence generation, blinding of outcome assessment, and other biases, assigning low risk, high risk, or unclear risk. And we used the Newcastle-Ottawa (NCO) scale for non-RCTs and prospective observational study [20, 21]. It includes selection, comparability and outcome.

Statistical analyses

We used Review Manager (RevMan) for the meta-analysis. Calculate the standard deviation (SD) and 95% confidence intervals (95% CIs) for continuous variables. Among the included studies’ results, heterogeneity was quantified with the Q statistic and quantified by the I2index. Based on the outcomes of these statistical tests, we adopted different models for data synthesis. When studies exhibited low heterogeneity, indicated by a P-value for the Q statistic of ≥ 0.1 and an I² index ≤ 50%, we utilized a fixed effects model. This model assumes that the studies included in the meta-analysis are estimating the same true effect size, and it provides a single summary estimate. Conversely, for studies demonstrating substantial heterogeneity, we adopted a random effects model. This model acknowledges that the true effect size may vary across studies and thus provides a more conservative estimate, incorporating this variability into the final summary effect. To delve deeper into the sources of heterogeneity observed among the studies, we conducted subgroup analyses. By comparing the results within and between subgroups, we aimed to identify potential factors contributing to the observed heterogeneity. P-value > 0.05 in these tests suggested that there was no significant evidence of bias.

Results

Search results

Flowchart illustrating the selection process is showed in Fig. 1. A total of 210 studies were initially screened across 3 academic research databases. After removing duplicates and inconsistent literature, 4 studies ultimately met the inclusion criteria for the meta-analysis [11,12,13, 22].

Fig. 1
figure 1

Flow diagram of articles considered for inclusion

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The publication years of the included studies ranged from 2009 to 2018. Three studies (75%) included HD patients and two studies (50%) had keto acids added to a low-protein diet. Most of them were in small sample sizes, ranging from 40 to 142 patients, and follow-up times varied from 4 to 12 + months. Additional details can be found in Table 1.

Table 1 Characteristics of the included studies
Full size table

Quality assessment

Among the two RCTs, only random sequence generation showed a low risk of bias (Fig. 2). Majority exhibited low or unclear risk of bias. We assessed the remaining studies using the NCO scale, with a score of 7.5 for the non-randomized controlled trial and 5 for the prospective observational study. Of the two, Stefania’s research on selection of the non-exposed cohort, comparability of cohorts on the basis of the design or the analysis and comparability of cohorts on the basis of the measurement options received higher scores.

Fig. 2
figure 2

Risk of bias summary: review authors’ judgements about each risk of bias item for RCTs

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Fig. 3
figure 3

Forest plots of residual renal function in dialysis patients. (A) GFR for all durations; (B) GFR for patients following a 12-month low-protein diet; (C) daily urine volume for all durations; (D) daily urine volume for patients following a 12-month low-protein diet. *: low protein diet with keto acids added

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Fig. 4
figure 4

Forest plots of nutritive index in dialysis patients. (A) serum albumin; (B) serum calcium; (C) serum phosphorus. *: low protein diet with keto acids added

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Fig. 5
figure 5

Forest plots of other outcomes in dialysis patients. (A) all-cause mortality; (B) KT/V; (C) the number of adverse events; (D) the number of patients dropped for declining of residual renal function. *: low protein diet with keto acids added

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Effects of interventions

Residual renal function

Three studies involving a total of 270 patients reported data on residual renal function (RRF) with follow-up at least 12 months.

If data of all durations was combined, a significant difference in GFR was presented within the subgroup of patients following a 12-month low-protein diet (three studies; 270 patients; MD = 1.37 ml/min; 95% CI, 0.18 to 2.55; I2 = 84%) (Fig. 3A). Subsequently, to address the high heterogeneity, we conducted a subgroup analysis. The subgroup of the ‘baseline GFR < 4 ml/min’ showed no heterogeneity (I2 = 0%, P < 0.00001), and the subgroup of the ‘baseline GFR ≥ 4 ml/min’ demonstrated high heterogeneity (I2 = 94%, P = 0.39) (Fig. 3B). Consequently, dialysis patients who adhered to a long-term low-protein diet, especially those with a lower baseline GFR, experienced a slower decline in GFR.

Similarly, for daily urine volume, three studies of 270 patients were reported, while follow-up at least 12 months. There was a significant difference in GFR within the subgroup of patients following the 12-month low-protein diet (three studies; 270 patients; MD = 660 ml; 95% CI, 110 to 1210; I2 = 97%) (Fig. 3C). To address the high heterogeneity, we conducted a subgroup analysis. The subgroup of the ‘peritoneal dialysis’ presented low heterogeneity (I2 = 36%, P = 0.07), while the subgroup of the ‘hemodialysis’ demonstrated high heterogeneity (I2 = 97%, P = 0.006) (Fig. 3D). Consequently, dialysis patients who adhered to a long-term low-protein diet better retain daily urine volume, especially those undergoing hemodialysis. This suggests that a long-term low-protein diet shows positive influence on dialysis patients’ residual renal function.

Nutritive index

The nutritive index was assessed in four studies involving 310 patients, with the follow-up periods ranging from 4 to 12 + months.

Overall, no significant difference in serum albumin levels was observed (MD = 0.40 g/dl; 95% CI, -2.43 to 3.24; I2 = 90%, P = 0.78). However, subgroup analysis revealed significant differences and low heterogeneity in the ‘Control DPI 1.0-1.2 g/kg/d’ (I2 = 21%, P = 0.04) and ‘Control free-choice diet’ (I2 = 0%, P < 0.00001) (Fig. 4A).

Serum calcium showed no significant difference (MD = 1.08 g/dl; 95% CI, -1.02 to 3.19; I2 = 99%, P = 0.31) (Fig. 4B), while a significant difference in serum phosphorus was observed (MD=-0.74 g/dl; 95% CI, -1.04 to -0.45; I2 = 90%, P = 0.78) (Fig. 4C). By subgroup analysis, both the subgroup of the ‘keto acids’ (I2 = 68%, P < 0.0001) and ‘no keto acids’ (I2 = 0%, P = 0.001) demonstrated significant difference.

Dialysis patients adhering to a low-protein diet exhibited lower serum albumin levels compared to those adhering to a DPI of 1.0–1.2 g/kg/d diet, but demonstrated higher serum albumin comparing to those adhered to free-choice diet. Besides, whether or not keto acids were added, dialysis patients who adhered to a low-protein diet had lower serum phosphorus levels than others.

Other outcomes

No significant difference was observed among these results: all-cause mortality (RR = 0.55; 95% CI, 0.26 to 1.18; I2 = 0%, P = 0.13) (Fig. 5A), KT/V (MD = 0.05; 95% CI, -0.06 to 0.17; I2 = 0%, P = 0.37) (Fig. 5B), the number of adverse events (infection, cardiovascular event or hospitalization for other reasons) (RR = 0.42; 95% CI, 0.17 to 1.04; I2 = 55%, P = 0.06) (Fig. 5C), and the number of patients who dropped for declining of residual renal function (RR = 0.64; 95% CI, 0.19 to 2.13; I2 = 5%, P = 0.47) (Fig. 5D).

Discussion

This systematic review and meta-analysis showed that long-term adherence to a low-protein diet has a positive impact on dialysis patients’ residual renal function.

We observed improvements in both GFR and daily urine volume in dialysis patients after 12 months of adherence to a low-protein diet, which is particularly significant for patients with low baseline GFR and those undergoing hemodialysis. With the intervention of low-protein diet, the renal function of these patients has been protected and improved to a certain extent. By restricting protein intake [8, 23], DPI 0.6–0.8 g/kg/day effectively minimizes the production of nitrogen waste, thus alleviating the metabolic stress on the kidneys. It diminishes the likelihood of glomerular sclerosis and fibrosis to slow down the deterioration of renal function. Moreover, low-protein diet potentially exerts a positive impact on the kidneys by modulating inflammatory factors and rectifying acid-base imbalances as well as electrolyte disturbances [7, 24]. Its benefits collectively contribute to the preservation of kidney health and slow the progression of any existing kidney ailments.

In addition, our findings indicate that the addition of keto acids had not significant effect on dialysis patients’ residual renal function, who following a low-protein diet through heterogeneity analysis. But in studies of CKD patients, ketone analogues of essential amino acids can trap excess nitrogen residues for essential amino acid production to reduce the formation of endogenous urea [25]. For CKD patients, supplementation with the low-protein diet and ketoacids can effectively ameliorate metabolic disorders, reduce the rate of kidney function decline, and delay the initiation of dialysis without any negative impact on nutritional status [26,27,28,29,30,31]. Supplemented with keto acids has no additional benefit may be related to dietary adherence [31]. More relevant clinical studies on dialysis patients are needed to explain this phenomenon.

While a low-protein diet exhibits a positive impact on dialysis patients’ residual renal function, prolonged adherence to such a diet may pose certain risks like the change of serum electrolytes, malnutrition and compromised immunity [14,15,16]. Our comprehensive study revealed dialysis patients adhering to a low-protein diet exhibited lower serum phosphorus levels and relatively high serum albumin concentrations, indicating a favorable nutritional status. We observed no alterations in serum calcium levels, which aligns with the findings of a meta-analysis involving patients with kidney disease [32] and warrants further interpretation in additional studies. High levels of phosphoric acid associated with increased mortality and cardiovascular disease pose a risk to dialysis patients [33]. Phosphorus intake is closely related to protein [12] and a low-protein diet can slow down serum phosphoric acid levels. While a high serum albumin concentration indicates good nutritional status [34]. This underscores the necessity of meticulously monitoring these patients’ nutritional status and promptly adjusting their dietary regimens. It ensures that dialysis patients with a low-protein diet receive adequate nutritional support and minimizes the potential risks associated with long-term dietary restrictions while maximizing the protective benefits for their residual renal function [26, 35, 36]. A low protein diet of 0.6 g/kg/day can reduce the accumulation of nitrogenous waste products [37] and may also prevent negative nitrogen balance, which is reflected in the improvement of albumin and phosphorus levels. At present, it appears that low-protein diets have a certain level of safety, and with personalized diets and long-term monitoring [38], malnutrition may not occur.

Although the protective impact of a low-protein diet on dialysis patients’ residual renal function has been demonstrated, there are differences in the tolerance of low-protein diets among dialysis patients. We observed no significant difference in this meta-analysis, but in a study which was not included for lack of a control group [13], 27 of 112 hemodialysis patients dropped out of a low-protein diet due to decreased renal function in 12 months. It may be that the mode of dialysis affects the tolerance of patients following a low-protein diet. For peritoneal dialysis [3, 39], peritoneum serves as a semi-permeable membrane, facilitating solute exchange and water clearance between blood and peritoneal permeable fluid within the peritoneal capillaries. As peritoneal dialysis patients exhibit a relatively lower reliance on residual renal function [40], they often maintain a good tolerance to a low-protein diet even as renal function diminishes [41]. Contrastingly, hemodialysis involves the artificial establishment of a cardiopulmonary bypass system, where blood is circulated through a dialysate for the purpose of substance exchange [42]. This process aims to eliminate waste products and excess water from the body, making hemodialysis patients more dependent on residual renal function [41]. As a result, when renal function deteriorates, hemodialysis patients may encounter greater challenges in maintaining a low-protein diet.

Since patients differ in renal function, dialysis methods, and nutritional status, it’s particularly essential to develop a personalized diet plan [43]. Strengthening patient education and nutritional counseling can help reduce complications and adverse consequences due to improper diet [36]. Furthermore, studying the optimal protein intake level to balance kidney protection and nutritional adequacy is also an important research direction. This will help us to develop a more scientific and rational diet management program for dialysis patients.

Although our study has achieved these results, there are still some limitations. First, the number of included studies was limited, which may affect the stability and reliability of the results. Some studies were excluded due to copyright restrictions, paywalls, absence of control group and insufficient data on kidney function. Besides, there has been a greater focus on conducting clinical trials involving patients with predialysis CKD, while fewer have been conducted on those undergoing dialysis. Second, potential publication bias may also have an impact on the results. In addition, the high degree of heterogeneity observed in some analyses may also pose difficulties in the interpretation of the results. These limitations suggest that when interpreting and using the results of this study, we should be cautious and conduct a comprehensive analysis in conjunction with other relevant studies. Larger randomized controlled trials are in need to further verify the protective impact of a low-protein diet on dialysis patients’ residual renal function, explore the long-term influence, and investigate the variations in effects among patients using different dialysis modalities.

Conclusion

In summary, this study evaluated the influence of a low-protein diet on dialysis patients’ residual renal function through a systematic review and meta-analysis. The results showed that adherence to a low-protein diet for 12 months had positive effects on residual renal function and nutritional status of dialysis patients. Future research should delve deeper into the optimal practices for low-protein diets and their long-term effects on managing dialysis patients. Through further research with larger sample and the implementation of a personalized diet plan, it may be possible to balance the need for kidney protection with adequate nutrition and improve patients’ quality of life.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Li Y, Ning Y, Shen B, Shi Y, Song N, Fang Y, Ding X. Temporal trends in prevalence and mortality for chronic kidney disease in China from 1990 to 2019: an analysis of the global burden of disease study 2019. Clin Kidney J. 2023;16(2):312–21.

    Article  PubMed  Google Scholar 

  2. Jha V, Al-Ghamdi SMG, Li G, Wu MS, Stafylas P, Retat L, Card-Gowers J, Barone S, Cabrera C, Garcia Sanchez JJ. Global economic burden associated with chronic kidney disease: A pragmatic review of medical costs for the inside CKD research programme. Adv Therapy. 2023;40(10):4405–20.

    Article  Google Scholar 

  3. Chan CT, Blankestijn PJ, Dember LM, Gallieni M, Harris DCH, Lok CE, Mehrotra R, Stevens PE, Wang AY, Cheung M et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney international 2019, 96(1):37–47.

  4. Mehrotra R, Davison SN, Farrington K, Flythe JE, Foo M, Madero M, Morton RL, Tsukamoto Y, Unruh ML, Cheung M, et al. Managing the symptom burden associated with maintenance dialysis: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. Kidney Int. 2023;104(3):441–54.

    Article  PubMed  Google Scholar 

  5. Brener ZZ, Kotanko P, Thijssen S, Winchester JF, Bergman M. Clinical benefit of preserving residual renal function in dialysis patients: an update for clinicians. Am J Med Sci. 2010;339(5):453–6.

    Article  PubMed  Google Scholar 

  6. Patel N, Hu SL. Preserving residual renal function in dialysis: what we know. Semin Dial. 2015;28(3):250–8.

    Article  PubMed  Google Scholar 

  7. Ko GJ, Obi Y, Tortorici AR, Kalantar-Zadeh K. Dietary protein intake and chronic kidney disease. Curr Opin Clin Nutr Metab Care. 2017;20(1):77–85.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Cupisti A, Bolasco P, D’Alessandro C, Giannese D, Sabatino A, Fiaccadori E. Protection of residual renal function and nutritional treatment: first step strategy for reduction of uremic toxins in End-Stage kidney disease patients. Toxins (Basel) 2021, 13(4).

  9. Aparicio M, Chauveau P, Combe C. Low protein diets and outcome of renal patients. J Nephrol. 2001;14(6):433–9.

    CAS  PubMed  Google Scholar 

  10. Hahn D, Hodson EM, Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2020;10(10):Cd001892.

    PubMed  Google Scholar 

  11. Jiang N, Qian J, Sun W, Lin A, Cao L, Wang Q, Ni Z, Wan Y, Linholm B, Axelsson J, et al. Better preservation of residual renal function in peritoneal dialysis patients treated with a low-protein diet supplemented with Keto acids: a prospective, randomized trial. Nephrol dialysis Transplantation: Official Publication Eur Dialysis Transpl Association - Eur Ren Association. 2009;24(8):2551–8.

    Article  CAS  Google Scholar 

  12. Caria S, Cupisti A, Sau G, Bolasco P. The incremental treatment of ESRD: a low-protein diet combined with weekly Hemodialysis May be beneficial for selected patients. BMC Nephrol. 2014;15:172.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Nakao T, Kanazawa Y, Takahashi T. Once-weekly Hemodialysis combined with low-protein and low-salt dietary treatment as a favorable therapeutic modality for selected patients with end-stage renal failure: a prospective observational study in Japanese patients. BMC Nephrol. 2018;19(1):151.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hara H, Nakamura Y, Hatano M, Iwashita T, Shimizu T, Ogawa T, Kanozawa K, Hasegawa H. Protein energy wasting and sarcopenia in Dialysis patients. Contrib Nephrol. 2018;196:243–9.

    Article  PubMed  Google Scholar 

  15. Piccoli GB, Cederholm T, Avesani CM, Bakker SJL, Bellizzi V, Cuerda C, Cupisti A, Sabatino A, Schneider S, Torreggiani M, et al. Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN. Clin Nutr. 2023;42(4):443–57.

    Article  CAS  PubMed  Google Scholar 

  16. Noce A, Vidiri MF, Marrone G, Moriconi E, Bocedi A, Capria A, Rovella V, Ricci G, De Lorenzo A, Di Daniele N. Is low-protein diet a possible risk factor of malnutrition in chronic kidney disease patients? Cell Death Discovery. 2016;2:16026.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ (Clinical Res ed). 2021;372:n71.

    Google Scholar 

  18. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.

    Article  CAS  PubMed  Google Scholar 

  19. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA. The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical Res ed). 2011;343:d5928.

    Article  Google Scholar 

  20. Lo CK, Mertz D, Loeb M. Newcastle-Ottawa scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol. 2014;14:45.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.

    Article  PubMed  Google Scholar 

  22. Li H, Long Q, Shao C, Fan H, Yuan L, Huang B, Gu Y, Lin S, Hao C, Chen J. Effect of short-term low-protein diet supplemented with Keto acids on hyperphosphatemia in maintenance Hemodialysis patients. Blood Purif. 2011;31(1–3):33–40.

    Article  PubMed  Google Scholar 

  23. Kelly OJ, Huang MC, Liao HY, Lin CC, Tung TY, Cheng RW, Wang MY, Yalawar M, Hwang SJ. A Low-Protein diet with a Renal-Specific oral nutrition supplement helps maintain nutritional status in patients with advanced chronic kidney disease. J Personalized Med 2021, 11(12).

  24. Wang M, Chou J, Chang Y, Lau WL, Reddy U, Rhee CM, Chen J, Hao C, Kalantar-Zadeh K. The role of low protein diet in ameliorating proteinuria and deferring dialysis initiation: what is old and what is new. Panminerva Med. 2017;59(2):157–65.

    Article  PubMed  Google Scholar 

  25. Mitch WE. Dietary therapy in uremia: the impact on nutrition and progressive renal failure. Kidney Int Supplement. 2000;75:S38–43.

    Article  CAS  Google Scholar 

  26. Aparicio M, Chauveau P, Combe C. Are supplemented low-protein diets nutritionally safe? Am J Kidney Diseases: Official J Natl Kidney Foundation. 2001;37(1 Suppl 2):S71–76.

    Article  CAS  Google Scholar 

  27. Zhang J, Xie H, Fang M, Wang K, Chen J, Sun W, Yang L, Lin H. Keto-supplemented low protein diet: A valid therapeutic approach for patients with Steroid-resistant proteinuria during Early-stage chronic kidney disease. J Nutr Health Aging. 2016;20(4):420–7.

    Article  CAS  PubMed  Google Scholar 

  28. Yen CL, Fan PC, Lee CC, Kuo G, Tu KH, Chen JJ, Lee TH, Hsu HH, Tian YC, Chang CH. Advanced chronic kidney disease with low and very low GFR: can a low-Protein diet supplemented with ketoanalogues delay dialysis?? Nutrients 2020, 12(11).

  29. Yen CL, Fan PC, Chen JJ, Kuo G, Hsiao CC, Chen CY, Tu YR, Hsu HH, Chen YC, Chang CH. Ketoanalogues Supplemental Low Protein Diet Safely Decreases Short-Term Risk of Dialysis among CKD Stage 4 Patients. Nutrients 2022, 14(19).

  30. Zhang HW, Ma SJ, Yin YD, Zhao MM. Efficacy and safety of keto-supplemented low-protein diet on nutritional status of peritoneal-dialysis patients: a systematic review and meta-analysis of randomized controlled trials. Eur Rev Med Pharmacol Sci. 2024;28(2):709–20.

    PubMed  Google Scholar 

  31. Bellizzi V, Signoriello S, Minutolo R, Di Iorio B, Nazzaro P, Garofalo C, Calella P, Chiodini P, De Nicola L. No additional benefit of prescribing a very low-protein diet in patients with advanced chronic kidney disease under regular nephrology care: a pragmatic, randomized, controlled trial. Am J Clin Nutr. 2022;115(5):1404–17.

    Article  CAS  PubMed  Google Scholar 

  32. Yue H, Zhou P, Xu Z, Liu L, Zong A, Qiu B, Liu W, Jia M, Du F, Xu T. Effect of low-protein diet on kidney function and nutrition in nephropathy: A systematic review and meta-analysis of randomized controlled trials. Clin Nutr. 2020;39(9):2675–85.

    Article  PubMed  Google Scholar 

  33. Kuhlmann MK. Phosphate elimination in modalities of Hemodialysis and peritoneal dialysis. Blood Purif. 2010;29(2):137–44.

    Article  CAS  PubMed  Google Scholar 

  34. Gama-Axelsson T, Heimbürger O, Stenvinkel P, Bárány P, Lindholm B, Qureshi AR. Serum albumin as predictor of nutritional status in patients with ESRD. Clin J Am Soc Nephrology: CJASN. 2012;7(9):1446–53.

    Article  CAS  Google Scholar 

  35. Mocanu CA, Cuiban E, Paul R, Radulescu D, Garneata L. A supplemented very low-protein diet could be effective, safe, and feasible in closely monitored patients with advanced CKD. Am J Clin Nutr. 2022;116(3):836–7.

    Article  CAS  PubMed  Google Scholar 

  36. De Mauri A, Carrera D, Vidali M, Bagnati M, Rolla R, Riso S, Torreggiani M, Chiarinotti D. Compliance, adherence and concordance differently predict the improvement of uremic and microbial toxins in chronic kidney disease on low protein diet. Nutrients 2022, 14(3).

  37. Molina P, Gavela E, Vizcaíno B, Huarte E, Carrero JJ. Optimizing diet to slow CKD progression. Front Med. 2021;8:654250.

    Article  Google Scholar 

  38. Pereira CD, Guimarães C, Ribeiro VS, Vaz DC, Martins MJ. Low-Protein Diets, Malnutrition, and Bone Metabolism in Chronic Kidney Disease. Nutrients 2024, 16(18).

  39. Gokal R, Mallick NP. Peritoneal dialysis. Lancet (London England). 1999;353(9155):823–8.

    Article  CAS  PubMed  Google Scholar 

  40. Alloatti S, Manes M, Paternoster G, Gaiter AM, Molino A, Rosati C. Peritoneal dialysis compared with Hemodialysis in the treatment of end-stage renal disease. J Nephrol. 2000;13(5):331–42.

    CAS  PubMed  Google Scholar 

  41. Horinek A. M Misra 2004 Does residual renal function decline more rapidly in Hemodialysis than in peritoneal dialysis? How good is the evidence? Adv Perit dialysis Conf Perit Dialysis 20 137–40.

    Google Scholar 

  42. Ibrahim A, Chan CT. Managing kidney failure with home Hemodialysis. Clin J Am Soc Nephrology: CJASN. 2019;14(8):1268–73.

    Article  Google Scholar 

  43. Torreggiani M, Wang AY, Fois A, Piccoli GB. Personalized Low-Protein diet prescription in CKD population: merging evidence from randomized trials with observational data. Semin Nephrol. 2023;43(2):151402.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors thank Tongji Hospital for its support of medical work.

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Author notes

  1. Jingyi Xie and Xiaoqin Liu contributed equally to this work.

  2. Shuwang Ge and Ying Yao contributed equally to this work.

Authors and Affiliations

  1. Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

    Jingyi Xie, Xiaoqin Liu, Yue Ling, Shuwang Ge & Ying Yao

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  1. Jingyi Xie
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  2. Xiaoqin Liu
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  3. Yue Ling
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Contributions

Jingyi Xie and Xiaoqin Liu analyzed data and wrote the manuscript. Shuwang Ge and Ying Yao substantively revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Shuwang Ge or Ying Yao.

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Xie, J., Liu, X., Ling, Y. et al. The impact of low-protein diet on residual renal function in dialysis patients: a systematic review and metaanalysis. BMC Nephrol 26, 122 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-04042-1

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-04042-1

Keywords

BMC Nephrology

ISSN: 1471-2369

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