Authors: Vladimír Teplan 1-5; Ondřej Gojiš 3 Authors‘ workplace: Interní a kardiologická klinika Fakultní nemocnice Ostrava a Lékařská fakulta Ostravské univerzity, Ostrava 1; Katedra interních oborů Lékařské fakulty Ostravské univerzity 2; Klinika Ambicare, Praha 3; Subkatedra nefrologie, Institut postgraduálního vzdělávání ve zdravotnictví, Praha 4; Codum s. r. o., Praha 5 Published in: Geriatrie a Gerontologie 2026, 15, č. 1: 11-21 Category: Review Article doi: https://doi.org/10.61568/geri/50-6703/20260311/143072
Increased life expectancy includes a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In seniors with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities.
These issues were repeatedly addressed by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) and are very important clinical problems in management of conservative treatment in seniors with CKD.
Based on our long-term experience there is a need for careful assessment to identify the presence of malnutrition-protein-energy wasting (PEW) just before reduction of protein intake, regular control of the metabolic and nutritional status and frequently also the use of nutritional supplements such as keto amino acids or renal enteral nutritional products for sipping.
The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient’s preferences and quality of life.
chronic kidney disease – seniors – keto amino acids – protein-energy wasting – low-protein diet
1. Teplan V, et al. Nefrologie vyššího věku. Praha: Mladá fronta; 2015. Edice Aesculap.
2. United States Renal Data System. USRDS Annual Data Report: epidemiology of kidney disease in the United States. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2022.
3. Koppe L, Fouque D, Kalantar-Zadeh K. Kidney cachexia or protein-energy wasting in chronic kidney disease: facts and numbers. J Cachexia Sarcopenia Muscle 2019; 10 : 479–484.
4. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017; 36 : 49–64.
5. Donini LM, Busetto L, Bischoff SC, et al. Definition and diagnostic criteria for sarcopenic obesity: ESPEN and EASO consensus statement. Obes Facts 2022; 15 : 321–335.
6. Volkert D, Beck AM, Cederholm T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 2019; 38 : 10–47.
7. Ikizler TA, Burrowes JD, Byham-Gray JD, et al. KDOQI clinical practice guidelines for nutrition in CKD: 2020 update. Am J Kidney Dis 2020; 76(Suppl 1): S1–S107.
8. Fiaccadori E, Sabatino A, Barazzoni R, et al. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40 : 1644–1668.
9. Piccoli GB, Cederholm T, Avesani CM, et al. Nutritional status and the risk of malnutrition in older adults with chronic kidney disease – implication for low protein intake and nutritional care: a critical review endorsed by ERN-ERA and ESPEN. Clin Nutr 2023; 42(4): 443–457.
10. Teplan V, Topinková E. Konzervativní léčení seniorů s chronickým onemocněním ledvin ve stadiu CKD 3b a vyšším. Geriatr Gerontol 2017; 6(1): 16–22.
11. Druml W, Cano N, Fiaccadori E, Teplan V. Nutritional support in renal disease. In: Sobotka L, ed. Basics in clinical nutrition. 5th ed. Praha: Galen; 2019 : 422–435.
12. Teplan V. Suplementované restriktivní diety u nemocných vyššího věku s onemocněním ledvin. Vnitř Lék 2016; 62(Suppl 6): 88–96.
13. Oliveira EA, Zheng R, Carter CE, Mak RH. Cachexia/protein energy wasting syndrome in CKD: causation and treatment. Semin Dial 2019; 32 : 493–499.
14. MacLaughlin HL, Friedman AN, Ikizler TA. Nutrition in kidney disease: core curriculum 2022. Am J Kidney Dis 2022; 79 : 437–449.
15. Cederholm T, Jensen GL, Correia M, et al. GLIM criteria for the diagnosis of malnutrition – a consensus report from the global clinical nutrition community. Clin Nutr 2019; 38 : 1–9.
16. Karavetian M, Salhab N, Rizk R, Poulia KA. Malnutrition-inflammation score vs phase angle in the era of GLIM criteria: a cross-sectional study among hemodialysis patients in UAE. Nutrients 2019; 11.
17. Davenport A. Comparison of frailty, sarcopenia and protein energy wasting in a contemporary peritoneal dialysis cohort. Perit Dial Int 2022; 42 : 571–577.
18. Gungor O, Ulu S, Hasbal NB, Anker SD, et al. Effects of hormonal changes on sarcopenia in chronic kidney disease: where are we now and what can we do? J Cachexia Sarcopenia Muscle 2021; 12 : 1380–1392.
19. Sabatino A, Cuppari L, Stenvinkel P, et al. Sarcopenia in chronic kidney disease: what have we learned so far? J Nephrol 2021; 34 : 1347–1372.
20. Roshanravan B, Gamboa J, Wilund K. Exercise and CKD: skeletal muscle dysfunction and practical application of exercise to prevent and treat physical impairments in CKD. Am J Kidney Dis 2017; 69 : 837–852.
21. Donini LM, Busetto L, Bischoff SC, et al. Definition and diagnostic criteria for sarcopenic obesity: ESPEN and EASO consensus statement. Clin Nutr 2022; 41 : 990–1000.
22. Barreto Silva MI, Picard K, Klein M. Sarcopenia and sarcopenic obesity in chronic kidney disease: update on prevalence, outcomes, risk factors and nutrition treatment. Curr Opin Clin Nutr Metab Care 2022; 25 : 371–377.
23. Androga L, Sharma D, Amodu A, Abramowitz MK. Sarcopenia, obesity, and mortality in US adults with and without chronic kidney disease. Kidney Int Rep 2017; 2 : 201–211.
24. Jagadeswaran D, Indhumathi E, Hemamalini AJ, et al. Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients. Clin Nutr 2019; 38 : 341–347.
25. Hanna RM, Ghobry L, Wassef O, et al. A practical approach to nutrition, protein-energy wasting, sarcopenia, and cachexia in patients with chronic kidney disease. Blood Purif 2020; 49 : 202–211.
26. Verberne WR, van den Wittenboer ID, Voorend CGN, et al. Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review. Nephrol Dial Transplant 2021; 36 : 1418–1433.
27. Voorend CGN, van Oevelen M, Verberne WR, et al. Survival of patients who opt for dialysis versus conservative care: a systematic review and meta-analysis. Nephrol Dial Transplant 2022; 37 : 1529–1544.
28. Kalantar-Zadeh K, Fouque D. Nutritional management of chronic kidney disease. N Engl J Med 2018; 378 : 584–585.
29. Carrero JJ, Gonzalez-Ortiz A, Avesani CM, et al. Plant-based diets to manage the risks and complications of chronic kidney disease. Nat Rev Nephrol 2020; 16 : 525–542.
30. Koppe L, Fouque D. The role for protein restriction in addition to renin-angiotensin-aldosterone system inhibitors in the management of CKD. Am J Kidney Dis 2019; 73 : 248–257.
31. Lee SW, Kim YS, Kim YH, et al. Dietary protein intake, protein energy wasting, and the progression of chronic kidney disease: analysis from the KNOW-CKD study. Nutrients 2019; 11.
32. Windahl K, Faxen Irving G, Almquist T, et al. Prevalence and risk of protein-energy wasting assessed by subjective global assessment in older adults with advanced chronic kidney disease: results from the EQUAL study. J Ren Nutr 2018; 28 : 165–174.
33. Krok-Schoen JL, Archdeacon Price A, et al. Low dietary protein intakes and associated dietary patterns and functional limitations in an aging population: a NHANES analysis. J Nutr Health Aging 2019; 23 : 338–347.
34. Bellizzi V, Signoriello S, Minutolo R, et al. 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 : 1404–1417.
35. Torreggiani M, Fois A, Moio MR, et al. Spontaneously low protein intake in elderly CKD patients: myth or reality? Analysis of baseline protein intake in a large cohort of patients with advanced CKD. Nutrients 2021; 13.
36. Garneata L, Stancu A, Dragomir D, et al. Ketoanalogue-supplemented vegetarian very low-protein diet and CKD progression. J Am Soc Nephrol 2016; 27 : 2164– 2176.
37. Bellizzi V, Chiodini P, Cupisti A, et al. Very low-protein diet plus ketoacids in chronic kidney disease and risk of death during end-stage renal disease: a historical cohort controlled study. Nephrol Dial Transplant 2015; 30 : 71–77.
38. Koppe L, Cassani de Oliveira M, Fouque D. Ketoacid analogues supplementation in chronic kidney disease and future perspectives. Nutrients 2019; 11 : 2071.
39. Teplan V. Ketoanaloga esenciálních aminokyselin v konzervativní léčbě chronického onemocnění ledvin (CKD) u seniorů vysoké věkové kategorie (80–95 let). Aktual Nefrol 2023; 29(1): 6–17.
40. Ikizler TA. Very low-protein diets in advanced kidney disease: safe, effective, but not practical. Am J Clin Nutr 2022; 115 : 1266–1267.
41. Piccoli GB, Di Iorio BR, Chatrenet A, et al. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (Torino-Pisa study). Nephrol Dial Transplant 2020; 35 : 790–802.
42. Fois A, Torreggiani M, Trabace T, et al. Quality of life in CKD patients on low-protein diets in a multiple-choice diet system. Comparison between a French and an Italian experience. Nutrients 2021; 13.
43. Piccoli GB, Nazha M, Capizzi I, et al. Diet as a system: an observational study investigating a multi-choice system of moderately restricted low-protein diets. BMC Nephrol 2016; 17 : 197.
44. Longhitano E, Trabace T, Fois A, et al. Ready to change: attitudes of an elderly CKD stage 3–5 population towards testing protein-free food. Nutrients 2020; 12.
45. Cupisti A, Morelli E, Meola M, et al. Vegetarian diet alternated with conventional low-protein diet for patients with chronic renal failure. J Ren Nutr 2002; 12 : 32– 37.
46. Hamidianshirazi M, Shafiee M, Ekramzadeh M, et al Diet therapy along with nutrition education can improve renal function in people with stages 3–4 chronic kidney disease who do not have diabetes (a randomized controlled trial). Br J Nutr 2022; 128 : 1– 36.
47. Mocanu CA, Cuiban E, Paul Ret al. 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 : 836–837.
48. Teplan V, Petejová N, Valkovský I. Duální efekt ketoanalog esenciálních aminokyselin a inhibitorů SGLT2 receptorů u seniorů s chronickým onemocněním ledvin: tříleté klinické sledování. Vnitř Lék 2025; 71(7): 376–385.
49. Teplan V, Mengerová O. Dieta a nutriční opatření u chorob ledvin a močových cest. Praha: Mladá fronta; 2010. Edice Aesculap.
50. Teplan V, et al. Metabolismus a ledviny. Praha: Grada Publishing; 2000.
51. Teplan V. Klinická výživa u pacientů s onemocněním ledvin. In: Kohout P, ed. Klinická výživa. Praha: Galén; 2021 : 663–684.
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