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Medical nutrition therapy previously focused on limiting fruits, vegetables, legumes, nuts, seeds, and whole grains because they are high in potassium and phosphorus. Research has shown these foods have a lower bioavailability for absorption and offer more nutritional benefits than the items people may use in place of them.
The 2020 Clinical Practice Guidelines for Nutrition in CKD recommend consuming these natural sources of fiber to aid in satiety, reduce acid load, and help control blood pressure.
The National Kidney Foundation recommends the Dietary Approaches to Stop Hypertension (DASH) diet to improve blood pressure, heart disease, and slow the progression of kidney disease. The DASH diet incorporates at least 4 to 5 servings of fruits and vegetables daily; use of whole grains; lean proteins like poultry, fish, and beans; and nuts, seeds, and low-fat dairy.
These advantages range from reducing progression of CKD, improving gut microbiota, blood pressure, lipid panel, glucose control, satiety for weight reduction, bowel regularity, and reducing risk of colon cancer.
Patients with CKD have been noted to only consume up to 12 g of fiber per day and there is a high prevalence of constipation which may be due to a lack of fiber, use of iron supplements, lack of physical activity, decreased intestinal motility, and polypharmacy.
In gut dysbiosis, there are less bacteria that can produce the healthier end products and higher concentration of the bacteria whose fermentation results in toxin precursors. The latter of these yields end products that can promote proinflammatory processes, oxidative stress, and reduced epithelial layer which leads to transit of endotoxins and fibrosis in the kidney.
Patients with CKD have increased urea within their systemic fluids which results in a large flow into the intestine. The urea is converted to ammonia and then to ammonium hydroxide producing an increase in pH resulting in lumen that is less inhabitable for beneficial bacteria and impair the intestinal barrier.
Research has found that CKD-associated gut dysbiosis can decrease intestinal transit likely due to inflammation in the gastrointestinal tract, the increased production of uremic toxins within the gut, and compromised integrity of the intestinal barrier.
One study transplanted fresh fecal microbes from a patient living with end-stage renal disease to mice with CKD and found it resulted in an increased production of uremic toxins, oxidative stress, and fibrosis of the kidney compared to the control group who did not receive fecal transplantation.
Increasing fiber intake provides indigestible starch which can improve growth of helpful bacteria and stimulate motility, maintain integrity of intestinal barrier, increase renal function as noted in histopathology of the kidney, and reduce inflammation and oxidation.
The National Health and Nutrition Examination Survey III observed that participants with CKD who increased their total daily fiber consumption, by 10 g/day, experienced a 38% reduction in the likelihood of C-reactive protein being elevated.
Dietary consumption of complex carbohydrates may also improve fermentation, which can increase acid creation and reduce the intestinal pH, therefore creating an environment more conducive to beneficial bacteria.
Large observational studies have also shown participants with the highest fiber intakes had a 40%-50% reduction in occurrence of CKD. Other research conducted in a population of more than 1,600 subjects noted that for each 5 g/day increase in fiber there was 11% less risk of CKD.
A meta-analysis of several studies including more than 15,000 patients with CKD noted healthy eating consisting of fruits, vegetables, and whole grains was regularly associated with a less risk of all-cause mortality.