Greater adherence to the dietary approaches to stop hypertension dietary pattern is associated with preserved muscle strength in patients with autosomal dominant polycystic kidney disease: a single-center cross-sectional study
Introduction
Autosomal dominant polycystic kidney disease (ADPKD) is a common inherited kidney disease typically caused by mutations in the polycystin-1 and -2 genes [1]. ADPKD is characterized by the presence of large cysts in the kidney and/or liver, which may cause organomegaly, ischemia, or organ dysfunction [1]. ADPKD is the fourth leading cause of end-stage renal disease (ESRD), and the most common genetic cause of that disease [2].
Protein-energy wasting (PEW) and malnutrition are common in advanced chronic kidney disease (CKD) [3]. The protein and energy intake are significantly below the body's requirements in patients with PEW, and PEW may result from reduced protein and energy intake, hypercatabolism, decreased anabolism, and increased levels of uremic toxins and inflammation [4]. Muscle wasting, due to increased muscle protein catabolism, contributes to the reduced muscle strength and performance observed in PEW patients [4,5]. Sarcopenia was previously defined as a state of low muscle mass, strength, or performance by the European Working Group on Sarcopenia in Older People (EWGSOP) 1 [6]. The EWGSOP 2 subsequently modified the definition of sarcopenia to low muscle strength, quantity, or quality [7]. Sarcopenia is correlated with reduced kidney function [8,9], and the prevalence of sarcopenia is relatively high in CKD patients [10], [11], [12], [13]. CKD patients with PEW have a higher risk of sarcopenia [14], which in turn increases the risk of progression to ESRD and mortality [15]. Therefore, prevention or improvement of sarcopenia through dietary modifications may reduce the risk of CKD progression and mortality.
In patients with CKD, especially those with advanced disease and ADPKD, a low-protein diet and close monitoring of the levels of minerals (potassium, sodium, phosphorus, and calcium) are recommended [16], [17], [18]. However, strict protein restriction can increase the risk of sarcopenia. Increased rates of protein catabolism and protein loss in uremic conditions also increase the likelihood of reduced muscle mass and strength [19]. In addition to the characteristics of CKD, increased kidney and liver volumes are risk factors for malnutrition in ADPKD patients [20], leading to further reductions in muscle mass and strength. In a previous study of ADPKD patients, 30% were either malnourished or at increased risk of malnutrition [20]. Malnutrition should be treated to delay ADPKD progression and prevent moderate-to-severe PEW or sarcopenia. Therefore, regular nutritional assessments and timely interventions are recommended for ADPKD patients.
There are few studies on dietary interventions for ADPKD patients, although a recent review summarized the data on the effects of dietary interventions on ADPKD progression [18]. The review also summarized the current recommendations regarding food components (including protein, water, sodium, and phosphate) for ADPKD, and newly introduced dietary strategies with limited evidence (such as ketogenic diet, time-restricted feeding, and certain dietary patterns) [18]. Recently, the effects of various dietary patterns on health and disease have been studied [21,22]. Because protein intake is difficult to increase in CKD and ADPKD patients, adopting dietary patterns may be useful to prevent PEW and improve outcomes. In particular, Dietary Approaches to Stop Hypertension (DASH), Mediterranean (MED), and anti-inflammatory diets have been reported to be beneficial for CKD patients [23], [24], [25], [26], [27], [28], although evidence of their efficacy for sarcopenia is limited. Given the importance of nutrition in ADPKD patients, and limited evidence of the effects of diet and nutritional status on sarcopenia, the relationship between dietary patterns and sarcopenia in ADPKD patients needs to be investigated.
In this study, we hypothesized that certain dietary patterns would lower the risk for low muscle strength in ADPKD patients. To test this hypothesis, we analyzed the dietary intakes and nutritional status of ADPKD patients, and investigated whether dietary patterns were associated with reduced muscle strength. We also identified food groups associated with reduced muscle strength. The current findings could aid the development of dietary guidelines for ADPKD patients.
Section snippets
Study population and design
Study participants were enrolled between January, 2019 and January, 2020 from the ADPKD clinic at Seoul National University Hospital, Seoul, Republic of Korea. Pre-dialysis ADPKD patients aged ≥ 18 years were included in this study if they provided written informed consent. Participants with unreliable responses to a semi-quantitative food frequency questionnaire (SQ-FFQ) or implausible energy intake (< 500 kcal or > 4,000 kcal) were excluded. We included 68 (27 men and 41 women) of the 72
General characteristics of study participants according to the presence of low HGS
Table 2 summarizes the general characteristics of the study population. Of the 68 participants, 19 had low HGS (men, n = 6; women, n = 13). Body weights were lower in the low HGS groups in all patients (P = 0.006) and women (P = 0.007). However, the BMI and SGA score were not different between the groups. The proportions of patients reporting hypertension or diabetes, body weight changes over the past 6 months, physical activity, and the use of dietary supplements were not statistically
Discussion
The current study investigated the association between dietary patterns and muscle strength in ADPKD patients. More than a quarter of the ADPKD patients had low muscle strength, and the DASH diet was negatively associated with low muscle strength. These findings suggest that the DASH diet may reduce the risk of low muscle strength in ADPKD patients.
In CKD patients, sarcopenia is not an inevitable consequence of aging. Disease-induced protein catabolism, dialysis, and a low-protein diet (< 0.8
Author contributions
The authors’ responsibilities were as follows – Hyunjin Ryu: Conceptualization and study design, Formal analysis and investigation, Writing – original draft, Approval of the final version. Yun Jung Yang: Formal analysis and investigation, Writing – original draft, Approval of the final version. Eunjeong Kang: Writing – review and editing, Approval of the final version. Curie Ahn: Writing – review and editing, Approval of the final version. Soo Jin Yang: Conceptualization and study design,
Author declarations
The authors declare that they have no competing interests.
Sources of support
This research was supported by research grants from the Bio & Medical Technology Development Program of the National Research Foundation (NRF) by the Ministry of Science, ICT & Future Planning (2017M3A9E4044649) (K.H. Oh) and Seoul Women's University (2021-0135) (S.J. Yang). The funder had no role in study design, data collection, analysis and interpretation, decision to publish, or manuscript preparation.
References (55)
- et al.
Autosomal dominant polycystic kidney disease
Lancet
(2019) - et al.
ERA-EDTA working group for inherited kidney diseases. autosomal dominant polycystic kidney disease: the changing face of clinical management
Lancet
(2015) - et al.
Is it Important to Prevent and treat protein-energy wasting in chronic kidney disease and chronic dialysis patients?
J Ren Nutr
(2018) - et al.
Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis
Clin Nutr
(2017) - et al.
Estimating the prevalence of muscle wasting, weakness, and sarcopenia in hemodialysis patients
J Ren Nutr
(2020) - et al.
Sarcopenia and cardiovascular risk indices in patients with chronic kidney disease on conservative and replacement therapy
Nutrition
(2019) - et al.
The impact of dietary factors on indices of chronic disease in older people: a systematic review
J Nutr Health Aging
(2018) - et al.
Dietary inflammatory index and its association with renal function and progression of chronic kidney disease
Clin Nutr ESPEN
(2019) - et al.
Centers for disease control and prevention chronic kidney disease surveillance team. 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) - et al.
Dietary patterns and risk of incident chronic kidney disease: the atherosclerosis risk in communities study
Am J Clin Nutr
(2019)
CRIC Study investigators. adherence to healthy dietary patterns and risk of CKD progression and all-cause mortality: findings from the CRIC (Chronic Renal Insufficiency Cohort) study
Am J Kidney Dis
A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients
Am J Kidney Dis
Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction
Am J Clin Nutr
Cystatin C: a kidney function biomarker
Adv Clin Chem
Disrupted expression of genes essential for skeletal muscle fibre integrity and energy metabolism in Vitamin D deficient rats
J Steroid Biochem Mol Biol
Associations between dietary patterns at age 71 and the prevalence of sarcopenia 16 years later
Clin Nutr
Predictors of skeletal muscle mass in elderly men and women
Mech Ageing Dev
A proinflammatory diet is associated with systemic inflammation and reduced kidney function in elderly adults
J Nutr
DASH (Dietary Approaches to Stop Hypertension) diet and risk of subsequent kidney disease
Am J Kidney Dis
mediterranean diet and musculoskeletal-functional outcomes in community-dwelling older people: a systematic review and meta-analysis
J Nutr Health Aging
The association between sarcopenic obesity (SO) and major dietary patterns in overweight and obese adult women
Diabetes Metab Syndr
Mechanisms of muscle wasting in chronic kidney disease
Nat Rev Nephrol
European working group on sarcopenia in older people. sarcopenia: european consensus on definition and diagnosis: report of the european working group on sarcopenia in older people
Age Ageing
Writing group for the european working group on sarcopenia in older people 2 (EWGSOP2), and the extended group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis
Age Ageing
Sarcopenia is associated with malnutrition but not with systemic inflammation in older persons with advanced CKD
Nutrients
Sarcopenia and relationships between muscle mass, measured glomerular filtration rate and physical function in patients with chronic kidney disease stages 3-5
Nephrol Dial Transplant
Sarcopenia in chronic kidney disease: what have we learned so far?
J Nephrol
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Abbreviations: ADPKD, autosomal dominant polycystic kidney disease; aMED, alternate Mediterranean diet; BMI, body mass index; CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; DASH, Dietary Approaches to Stop Hypertension; DII, dietary inflammatory index; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; EWGSOP, European Working Group on Sarcopenia in Older People; HGS, handgrip strength; MAC, mid-arm circumference; PEW, protein-energy wasting; SGA, subjective global assessment; SMI, skeletal muscle mass index; SMM, skeletal muscle mass; SQ-FFQ, semi-quantitative food frequency questionnaire.
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These authors contributed equally to the writing of this article.