Very Low Protein Diet Allows Delay of Dialysis in Elderly

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NEW YORK (Reuters Health) May 23 - A very low protein diet can be safely used to postpone the start of dialysis in elderly uremic patients without diabetes, according to a report in the May issue of the American Journal of Kidney Diseases.

"It is possible to postpone in a safe way the start of dialysis," Dr. Giuliano Brunori, from Spedali Civili Brescia in Italy, told Reuters Health. "Imagining that 25% of elderly patients (and at the present, more than 60% of patients starting dialysis in US or Europe are older than 65) could be treated with this diet, a tremendous amount of money can be saved."

Dr. Brunori and colleagues investigated the safety and efficacy of a very low protein diet, supplemented with essential amino acids, keto-analogues, and vitamins, in decreasing uremic symptoms, metabolic disturbances and postponing the start of dialysis in 56 patients with stage 5 chronic kidney disease who were 70 years of age or older.

Nearly three quarters (71%) of the very-low-protein diet-treated patients began dialysis therapy a median of 9.8 months after beginning the diet, the authors report. By the time this report was published, six patients (11%) had been on the very-low-protein diet a median of 16.6 months (range, 14.7 to 41.8 months).

One-year survival rates did not differ significantly between the dialysis (83.7%) and diet (87.3%) groups, the results indicate. The very-low-protein-diet group had significantly fewer hospitalizations and days of hospitalization than did the dialysis group, the researchers note, even after adjustment for differences in age and cerebral vasculopathy.

"In a normal elderly uremic population (in other words, not very compromised patients) the diet does not induce malnutrition and is not life-threatening," Dr. Brunori said. "Hospitalization is lower and patients' and families' burdens can be reduced."

Based on these study findings, Dr. Brunori's group concludes that nephrologists need to rethink some axioms about dialysis. "In fact, guidelines are based on the total population on dialysis, but elderly patients may require a different approach," Dr. Brunori said. "In the next years we should re-discuss guidelines with the aim of revising guidelines more oriented to elderly patients."

"We are doing a cost-benefit study on the patients randomized in our protocol," Dr. Brunori added. "Furthermore, we want to verify the feasibility of this diet in patients younger than 70 (for example, patients not suitable for kidney transplant or diabetic patients)."

"Brunori et al. have performed a useful service to nephrologists everywhere by providing preliminary evidence that selected elderly patients can survive for a median interval of 10 months without dialysis by adhering to a nearly protein-free diet," writes Dr. Allon N. Friedman from Indiana University School of Medicine, Indianapolis, in a related editorial.

"However," the editorial concludes, "it remains to be seen whether these results can be reproduced in patients with outcome rates and quality of life issues similar to those of the US population."

If the data are confirmed in future trials, Dr. Friedman adds, this approach may "offer a temporary but valuable alternative to renal replacement therapy that could benefit both patients and our already overburdened health care systems."

Am J Kidney Dis 2007;49:563-565

Source: http://www.medscape.com/viewarticle/557122?src=mp