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Cochrane Database of Systematic Reviews

Dietary interventions for adults with chronic kidney disease

Information

DOI:
https://doi.org/10.1002/14651858.CD011998.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 23 April 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Kidney and Transplant Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Suetonia C Palmer

    Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand

  • Jasjot K Maggo

    Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand

  • Katrina L Campbell

    Faculty of Health Science and Medicine, Bond University, Robina, Australia

  • Jonathan C Craig

    Sydney School of Public Health, The University of Sydney, Sydney, Australia

    Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia

  • David W Johnson

    Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia

  • Bernadet Sutanto

    Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia

  • Marinella Ruospo

    Medical Scientific Office, Diaverum, Lund, Sweden

    Division of Nephrology and Transplantation, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy

  • Allison Tong

    Sydney School of Public Health, The University of Sydney, Sydney, Australia

    Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia

  • Giovanni FM Strippoli

    Correspondence to: Sydney School of Public Health, The University of Sydney, Sydney, Australia

    [email protected]

    [email protected]

    Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia

    Medical Scientific Office, Diaverum, Lund, Sweden

    Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy

    Diaverum Academy, Bari, Italy

Contributions of authors

  1. Draft the protocol: SP, GS, KC, JC, AT

  2. Study selection: SP, JM

  3. Extract data from studies: SP, JM

  4. Enter data into RevMan: SP, JM

  5. Carry out the analysis: SP, JM

  6. Interpret the analysis: All authors

  7. Draft the final review: All authors

  8. Disagreement resolution: KC

  9. Update the review: SP, GS

Declarations of interest

  • Suetonia C Palmer: none known

  • Jasjot Maggo: none known

  • Allison Tong: none known

  • Katrina L Campbell: none known

  • Jonathan C Craig: none known

  • David W Johnson: none known

  • Bernadet Sutanto: none known

  • Marinella Ruospo: none known

  • Giovanni FM Strippoli: none known

Acknowledgements

We wish to thank Katrina Soroka, research assistant at the University of Otago Christchurch in 2013, for her assistance with our protocol. We also wish to thank the referees for very helpful advice and assistance in the review's scope and content. We thank the personnel at the Cochrane Kidney and Transplant Group editorial office for tireless work including with this review. We thank Elaine Beller (Deputy Co‐ordinating Editor) and Elisabeth Hodson (Cochrane editor) for overseeing the review process. Suetonia Palmer wishes to acknowledge generous funding from the Royal Society of New Zealand Rutherford Discovery Fellowship programme for salary and research support during the preparation of the protocol and full review.

Version history

Published

Title

Stage

Authors

Version

2017 Apr 23

Dietary interventions for adults with chronic kidney disease

Review

Suetonia C Palmer, Jasjot K Maggo, Katrina L Campbell, Jonathan C Craig, David W Johnson, Bernadet Sutanto, Marinella Ruospo, Allison Tong, Giovanni FM Strippoli

https://doi.org/10.1002/14651858.CD011998.pub2

2015 Dec 16

Dietary patterns for adults with chronic kidney disease

Protocol

Suetonia C Palmer, Jasjot K Maggo, Katrina L Campbell, Jonathan C Craig, David W Johnson, Bernadet Sutanto, Marinella Ruospo, Allison Tong, Giovanni FM Strippoli

https://doi.org/10.1002/14651858.CD011998

Differences between protocol and review

None.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Flow diagram of study selection
Figures and Tables -
Figure 1

Flow diagram of study selection

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Dietary intervention versus control, Outcome 1 All‐cause mortality.
Figures and Tables -
Analysis 1.1

Comparison 1 Dietary intervention versus control, Outcome 1 All‐cause mortality.

Comparison 1 Dietary intervention versus control, Outcome 2 Cardiovascular mortality.
Figures and Tables -
Analysis 1.2

Comparison 1 Dietary intervention versus control, Outcome 2 Cardiovascular mortality.

Comparison 1 Dietary intervention versus control, Outcome 3 Health‐related quality of life (SF‐36) score.
Figures and Tables -
Analysis 1.3

Comparison 1 Dietary intervention versus control, Outcome 3 Health‐related quality of life (SF‐36) score.

Comparison 1 Dietary intervention versus control, Outcome 4 End‐stage kidney disease.
Figures and Tables -
Analysis 1.4

Comparison 1 Dietary intervention versus control, Outcome 4 End‐stage kidney disease.

Comparison 1 Dietary intervention versus control, Outcome 5 Doubling of serum creatinine.
Figures and Tables -
Analysis 1.5

Comparison 1 Dietary intervention versus control, Outcome 5 Doubling of serum creatinine.

Comparison 1 Dietary intervention versus control, Outcome 6 Employment.
Figures and Tables -
Analysis 1.6

Comparison 1 Dietary intervention versus control, Outcome 6 Employment.

Comparison 1 Dietary intervention versus control, Outcome 7 Dietary adherence.
Figures and Tables -
Analysis 1.7

Comparison 1 Dietary intervention versus control, Outcome 7 Dietary adherence.

Comparison 1 Dietary intervention versus control, Outcome 8 Worsening nutrition.
Figures and Tables -
Analysis 1.8

Comparison 1 Dietary intervention versus control, Outcome 8 Worsening nutrition.

Comparison 1 Dietary intervention versus control, Outcome 9 eGFR [mL/min/1.73 m2].
Figures and Tables -
Analysis 1.9

Comparison 1 Dietary intervention versus control, Outcome 9 eGFR [mL/min/1.73 m2].

Comparison 1 Dietary intervention versus control, Outcome 10 Serum creatinine.
Figures and Tables -
Analysis 1.10

Comparison 1 Dietary intervention versus control, Outcome 10 Serum creatinine.

Comparison 1 Dietary intervention versus control, Outcome 11 Systolic blood pressure.
Figures and Tables -
Analysis 1.11

Comparison 1 Dietary intervention versus control, Outcome 11 Systolic blood pressure.

Comparison 1 Dietary intervention versus control, Outcome 12 Diastolic blood pressure.
Figures and Tables -
Analysis 1.12

Comparison 1 Dietary intervention versus control, Outcome 12 Diastolic blood pressure.

Comparison 1 Dietary intervention versus control, Outcome 13 Energy intake.
Figures and Tables -
Analysis 1.13

Comparison 1 Dietary intervention versus control, Outcome 13 Energy intake.

Comparison 1 Dietary intervention versus control, Outcome 14 Body weight.
Figures and Tables -
Analysis 1.14

Comparison 1 Dietary intervention versus control, Outcome 14 Body weight.

Comparison 1 Dietary intervention versus control, Outcome 15 BMI.
Figures and Tables -
Analysis 1.15

Comparison 1 Dietary intervention versus control, Outcome 15 BMI.

Comparison 1 Dietary intervention versus control, Outcome 16 Waist‐hip ratio.
Figures and Tables -
Analysis 1.16

Comparison 1 Dietary intervention versus control, Outcome 16 Waist‐hip ratio.

Comparison 1 Dietary intervention versus control, Outcome 17 Waist circumference, cm.
Figures and Tables -
Analysis 1.17

Comparison 1 Dietary intervention versus control, Outcome 17 Waist circumference, cm.

Comparison 1 Dietary intervention versus control, Outcome 18 Arm circumference.
Figures and Tables -
Analysis 1.18

Comparison 1 Dietary intervention versus control, Outcome 18 Arm circumference.

Comparison 1 Dietary intervention versus control, Outcome 19 Serum albumin.
Figures and Tables -
Analysis 1.19

Comparison 1 Dietary intervention versus control, Outcome 19 Serum albumin.

Comparison 1 Dietary intervention versus control, Outcome 20 Serum LDL cholesterol.
Figures and Tables -
Analysis 1.20

Comparison 1 Dietary intervention versus control, Outcome 20 Serum LDL cholesterol.

Comparison 2 Mediterranean diet versus low fat, Outcome 1 Serum LDL cholesterol.
Figures and Tables -
Analysis 2.1

Comparison 2 Mediterranean diet versus low fat, Outcome 1 Serum LDL cholesterol.

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 1 eGFR [mL/min/1.73 m2].
Figures and Tables -
Analysis 3.1

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 1 eGFR [mL/min/1.73 m2].

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 2 Serum creatinine.
Figures and Tables -
Analysis 3.2

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 2 Serum creatinine.

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 3 Systolic blood pressure.
Figures and Tables -
Analysis 3.3

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 3 Systolic blood pressure.

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 4 Body weight.
Figures and Tables -
Analysis 3.4

Comparison 3 Fruits and vegetables versus bicarbonate, Outcome 4 Body weight.

Summary of findings for the main comparison. Dietary modifications (counselling or dietary change) versus control for chronic kidney disease (CKD)

Dietary modifications (counselling or dietary change) versus control for CKD

Patient or population: people with CKD

Intervention: dietary modifications

Comparison: control

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard care

Dietary intervention

Death

High risk population

Not estimable

539 (5)

⊕⊖⊖⊖
very low1,2,3

Studies were not designed to measure effects of dietary interventions on mortality

150 per 1000

Not estimable

Medium risk population

25 per 1000

Not estimable

Major cardiovascular event

High risk population

Not estimable

Insufficient data observations

No studies were available for this outcome

Studies were not designed to measure effects of dietary interventions on cardiovascular events. 0 studies reported major cardiovascular events

150 per 1000

Not estimable

Medium risk population

45 per 1000

Not estimable

Progression to ESKD

Measured as requiring dialysis treatment in people with CKD

0.6 per 1000

0.3 per 1000

RR 0.53

(0.26 to 1.07)

242 (2)

⊕⊖⊖⊖
very low1,2,3,4

29 participants developed ESKD in these studies. No studies included recipients of a kidney transplant

Health‐related quality of life

Measured using the Short Form‐36 scale from 0 to 100

The mean SF‐36 score ranged across control groups from 43.6 to 48.8

The mean SF‐36 score in the intervention groups was 11.46 higher (95% CI 7.73 to 15.18)

119 (2)

⊕⊕⊖⊖
low1,3

0 studies included recipients of a kidney transplant. None of the studies were blinded

*The basis for the assumed risk of mortality (e.g. the median control group risk across studies) was obtained from the absolute population risk estimated from previously published cohort studies or data registries (Johnson 2011; Weiner 2006). The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Study limitations were due to high or unclear risks of bias

2 Confidence interval includes range of plausible values that include substantial benefit or harm

3 Based on few events and/or participants across all studies

4 Data not available for recipients of a kidney transplant

Figures and Tables -
Summary of findings for the main comparison. Dietary modifications (counselling or dietary change) versus control for chronic kidney disease (CKD)
Table 1. Summary of included studies

Study ID

Treatment

Control

CKD stage

GFR (mL/min)

Mean age

% men

Mean GFR (mL/min)

Mean BMI (kg/m2)

Detailed inclusion criteria

Counselling

Campbell 2008

Dietary counselling

Written material

4‐5

≤ 30

69.5 (11.7)

70.9 (11.6)

61

23.1 (7.2)

21.6 (6.1)

26.8 (4.7)

27.6 (5.2)

> 18 years; eGFR < 30 mL/min/1.73 m2; CKD not previously seen by a dietitian for stage 4 CKD; absence of communication or intellectual impairment; absence of malnutrition from a cause other than CKD; not expected to require RRT within 6 months

Chanwikrai 2012

Dietary counselling

Standard care

3‐5

‐‐

‐‐

‐‐

‐‐

‐‐

CKD stage 3‐5

Flesher 2011

Dietary counselling + exercise

Standard care

3‐4

20‐60

63.4 (12.1)

63.4 (11.8)

53

37.2 (3.2)

38.4 (3.0)

‐‐

eGFR 20 to 60 mL/min for ≥3 months; presence of urinary protein; adult (≥ 19 years); hypertension or taking at least 1 antihypertensive medication; physician approval to exercise

Leon 2006

Dietary counselling and targeting nutritional barriers

Standard care

5 (HD)

Dialysis

62

60

42

‐‐

29.0

27.9

18 to 85 years; receiving dialysis for at least 9 months; mean serum albumin level for previous 3 months < 3.70 g/dL (bromcresol green method) or < 3.40 g/dL (bromcresol purple method)

Orazio 2011

Dietary counselling

Standard care

Transplant

Transplant

54.9 (9.9)

54.7 (11.8)

61

54 (20)

48 (17)

29 (5)

29 (6)

Kidney transplant > 6 months

Riccio 2014

Dietary counselling

Low protein diet

‐‐

‐‐

‐‐

‐‐

‐‐

‐‐

CKD not requiring dialysis

Sutton 2007

Dietary counselling + physical activity

Standard care

5 (PD)

Dialysis

60.7 (15.5)

58.5 (15.4)

55

‐‐

25.4 (3.8)

25.7 (3.4)

Treatment with CAPD for 3 months or longer; not diabetic

Teng 2013

Dietary counselling + exercise

Standard care

1‐3

‐‐

62.1 (14.0)

65.7 (11.2)

71

53.7 (18.3)

49.5 (13.3)

24.4 (3.9)

25.3 (3.1)

20 years or older; communicate in Mandarin or Taiwanese; aware of CKD diagnosis; GFR range 30 to 106.7 mL/min/1.73 m2

Tzvetanov 2014

Dietary counselling + exercise

Standard care

Transplant

Transplant

46 (6.9)

45 (19)

47

‐‐

‐‐

Kidney transplant; obese

Zhou 2011b

Dietary counselling

Standard care

5 (PD)

Dialysis

57.8 (12.8)

59.9 (13.6)

71

‐‐

23.3 (4.5)

22.8 (6.2)

18 to 70 years; receiving long‐term dialysis > 3 months

Mediterranean diet

DIRECT Study 2013

Mediterranean diet (restricted calorie)

Low‐fat (restricted calorie) diet

Low‐carbohydrate (unrestricted calorie) diet

3

30‐60

52.5 (6.2)

99

52.6 (5.9)

30.9 (3.4)

40 to 65 years with BMI ≥ 27 kg/m2; individuals with type 2 diabetes or coronary heart disease were eligible regardless of age. Post‐hoc analysis among participants with eGFR 30 to 60 mL/min/1.73 m2

Mekki 2010

Mediterranean diet

Standard care

2‐3

60‐89

60 (10)

59 (12)

53

70 (10)

75 (15)

26.9 (3.9)

25.1 (4.2)

eGFR 60 to 89 mL/min/1.73 m2; dyslipidaemia

Stachowska 2005

Modified Mediterranean diet

Low fat diet

Transplant

Transplant

41 (12.5)

46

(9.5)

68

‐‐

25.0 (4.1)

26.2 (4.2)

Stable transplant function

Increased fruit and vegetables

Goraya 2013

Increased fruit and vegetable intake

Oral bicarbonate

4

15‐29

53.9 (6.9)

54.2 (5.3)

54

22.8 (4.9)

23.0 (3.5)

‐‐

Non‐malignant hypertension; eGFR 15 to 29 mL/min/1.73 m2; plasma TCO2< 22 mM; no diabetes or cardiovascular disease; two or more primary care physician visits in previous year; age ≥ 18 years

Goraya 2014

Increased fruit and vegetable intake

Oral bicarbonate

Standard care

3

30‐59

53.5 (5.2)

53.9 (4.8)

44

42.3 (7.1)

42.6 (7.6)

‐‐

Non‐malignant hypertension, eGFR 30 to 59 mL/min/1.73 m2; plasma TCO2< 25 mM; macroalbuminuria; able to tolerate angiotensin‐converting inhibition; non‐smoking for ≥ 1 year; no diabetes or cardiovascular disease; 2 or more primary care physician visits in previous year; ≥ 18 years

Carbohydrate‐restricted, low‐iron, polyphenol enriched (CR‐LIPE) diet

Facchini 2003

CR‐LIPE diet

Protein restriction

2‐5

15‐75

59 (10)

60 (12)

51

64 (28)

62 (32)

28 (5)

28 (5)

Type 2 diabetes; referred to nephrology clinic for kidney failure (15 ± 75 mL/min); otherwise unexplained proteinuria (350 ± 12,000 mg/d); kidney disease attributed to diabetes

High‐nitrogen, low‐carbohydrate diet

Whittier 1985

High‐nitrogen, low carbohydrate diet

Standard care

Transplant

Transplant

33

32

75

‐‐

‐‐

Kidney transplant; no diabetes

BMI ‐ body mass index; CAPD ‐ continuous ambulatory peritoneal dialysis; CKD ‐ chronic kidney disease; eGFR ‐ estimated glomerular filtration rate; HD ‐ haemodialysis; PD ‐ peritoneal dialysis; RRT ‐ renal replacement therapy; TCO2 ‐ total carbon dioxide

Figures and Tables -
Table 1. Summary of included studies
Table 2. TIDieR framework of intervention descriptions for included studies

Study ID

Materials

Dietary intervention

Adherence

Why

What

Who

How

Where

When and how much

Tailoring

Modification

Planned

Actual

Counselling

Campbell 2008

To determine whether individual nutrition counselling improves body composition, energy intake, and nutritional status

Individualised dietary prescription (including energy (125 to 146 kJ/kg/d) and protein (0.75 to 1.0 g/kg/d)) incorporating KDOQI recommendations to provide intensive nutritional counselling with regular monitoring

Dietitian

Face‐to‐face, telephone, individualised

‐‐

Baseline for 60 min; then biweekly for 1st month (15 to 30 min); then weekly till end of study period

Depending on dietary requirements, diet was tailored following clinical data and initial interview. Delivery was guided by the medical nutrition therapy framework from the American Dietetic Association

Self‐management principles: goal‐setting, menu planning, label reading, and identification of foods containing protein, sodium, and so on, depending on requirements

Dietary intake assessed using 3‐day food record, verified by the dietitian. Strategies to improve adherence or fidelity not reported

No patient voluntarily withdrew from the study

Chanwikrai 2012

Changes of diet and lifestyle can slow progression of CKD

Dietary modification with or without exercise by an empowerment approach (including low protein 0.6 to 0.8 g/kg/d) and low salt (5 g/d).

‐‐

‐‐

‐‐

‐‐

‐‐

‐‐

81 (96%) completed the study program

Flesher 2011

To determine whether additional of cooking and exercise classes would slow progression of CKD

Individual nutrition counselling on moderate protein and low sodium, with individualised modification of potassium and/or phosphate plus a group nutrition class, cooking classes with a dietitian and cook education, CKD cookbook, shopping tour, and 12‐week exercise program led by a Certified Exercise Physiologist and nurse. Exercise program started after 6 months

Cooking class ‐ dietitian and cook educator; Exercise ‐ exercise physiologist and nurse

Face‐to‐face; individual and group sessions

Exercise class took place in well‐equipped gym at Garatt Wellness Centre: details regarding cooking class not provided

Cooking classes over 4 weeks for 2 hour session, shopping tour; Exercise class at Garratt Wellness centre, 3 x 1 hour session/week with strength training, flexibility components, resistance training

Skills for tailoring and modifying diet and lifestyle were provided. Diet history was discussed in detail at the individual appointments

Self‐management focus in using goal‐setting and building confidence in the management of disease

Adherence to exercise was assessed by physical activity readiness questionnaire and 6 minute submaximal walk test; biochemical and clinical parameters related to cardiovascular health; monitored at baseline, 6 months and 12 months

Overall, the experimental group showed ‘improvement’’
in their exercise frequency, concern over health condition, and frequency of visits to health providers or hospitalisation; also 20 versus 83 improved endpoints in control group

Leon 2006

Whether targeting specific nutritional barriers will improve albumin levels

Study coordinators abstracted medical records and interviewed participants to determine the presence of 10 specific nutritional barriers (nutritional knowledge, appetite, help needed with cooking and shopping, low fluid intake, dialysis dose, depression, difficulty chewing, difficulty swallowing, gastrointestinal symptoms, acidosis). Study coordinators educated all intervention patients about
the meaning and importance of good nutritional status. They then provided feedback and recommendations to intervention patients. The information was provided during a dialysis treatment and tailored to the specific barriers present. Study coordinators also communicated information about barriers to facility dietitians and modified recommendations based on feedback from these dietitians. Facility dietitians were asked to reinforce study coordinator recommendations when they met with their study patients

Study coordinators; dietitians

Face‐to‐face; individualised

During dialysis sessions

During the next 12 months, study coordinators met monthly with patients to reinforce recommendations,
monitor progress, and answer questions. Study coordinators
also updated patients’ dietitians monthly

Tailored to specific nutritional barriers identified during interviews

Specific to nutritional barriers

‐‐

‐‐

Orazio 2011

To investigate the effect of dietitian involvement in a multidisciplinary lifestyle intervention comparing risk factor modification for cardiovascular disease with standard post‐transplant care in kidney transplant recipients with abnormal glucose tolerance

Individualised dietary advice was provided to participants for the duration of the study. Achievement and/or maintenance of a healthy weight (BMI), 20 to 25 kg/m2) was the primary goal of nutrition therapy using a Mediterranean‐style (< 30% total energy from
fat), low GI diet. A moderate energy deficit of 500 kcal/d (2,000 kJ/d) to promote 0.5 kg of weight loss/week was used. Study materials used to teach participants included a study manual with dietary and lifestyle information, food models, and pictures.

The long‐term goal of physical activity advice was to achieve 150 min of accumulated physical activity/week, in accordance with current National Physical Activity Recommendations. To help achieve this, goals
were individualised for each patient according to
mobility, fitness, personal preference, and self‐efficacy
for activities. Moderate physical activity, such as walking,
was encouraged, both as structured activity
and activity of daily living.

The Transtheoretical Model of Health Behavior Change or Stage of Change Model underpinned the lifestyle intervention to provide a framework for goal‐setting throughout the study

Multidisciplinary team (nephrologist, dietitian, nurse, endocrinologist)

Individualised advice from nephrologist, dietitian, nurse and endocrinologist (individual or group)

Multiple locations and settings including during routine transplant care, outpatient dietetic and nursing care, and routine diabetes management

Bimonthly reviews for 2 years by nephrologist; 4‐week initial program from dietitian with bimonthly reviews for 2 years and 6 monthly group meetings; bimonthly reviews by nurse and endocrinologist

Dietitian delivery of individual diet initially and then individualist dietetic reviews including weight, waist circumference and hip circumference measurements

Specific to patient and anthropomorphic measurements during follow‐up

‐‐

8/96 participants chose to withdraw

Riccio 2014

To determine if a simplified dietary approach self‐managed by patients had beneficial impact on nutritional and metabolic control of CKD, to be acceptable and safe

List of recommendations to modify dietary habits (do not add salt at table or for cooking; foods to avoid; replacing noodles or bread; meat, fish and egg intake; 4‐5 servings of fruit or vegetables; replacement of noodles with legumes

Nephrologist

Face‐to‐face; individualised

‐‐

‐‐

The goal of the study was to tailor and modify diet for participants in intervention group (not otherwise specified)

‐‐

Adherence to diet was assessed at regular intervals (1, 3 and 6th), method for assessing adherence was not reported

19/27 in intervention group were adherent with protein prescription whereas 12/27 in control group were adherent with protein prescription

Sutton 2007

To determine whether offering dietary advice was effective in supporting patients in adjusting energy intake

The intervention group was offered follow‐up dietary advice that would encourage them to match energy intake with their estimated energy expenditure allowing for dialysate calories and with a protein intake of not < 0.8 to 1.0 g/kg IBW

Dietitian

Face‐to‐face

‐‐

Face‐to‐face contact at baseline and 4 months. Suggested snack ideas, alterations in food preparation, or modification of portion sizes

‐‐

‐‐

49/59 participants completed the study

Teng 2013

To examine effects of a targeted Lifestyle Modification Program on lifestyle behaviours, knowledge, and physical indicators of CKD

The Trans Theoretical model using the stage‐of‐change construct was used to assess the patient's readiness stage to promote behaviour change. Targeted interventions were given according to the stage of change about diet and exercise. Patients were encouraged to find individual methods of overcoming barriers to regular exercise. Written materials were provided to encourage adherence to a CKD diet. An information booklet on protecting kidney function was provided and reviewed with patient. Discussion provided information about kidney function and disease, and dietary and lifestyle management

Registered nurse research assistants

Face‐to‐face; individualised

Clinic

Counselling provided with each clinic visit

The goal of the study to tailor and modify diet for participants in intervention group

‐‐

To ensure the fidelity of the Lifestyle Modification Program, all provided counselling and information were recorded, and the interventions were reviewed by the investigators at random

There was a 64.4% retention rate at 12 months

Tzvetanov 2014

Examine the effectiveness of a physical exercise program including behaviour modification interventions and nutritional training for obese recipients of a kidney transplant

Individual physical training (one‐to‐one sessions with a coach) using low‐impact, low‐repetition, resistance‐based weight training with 2 x 1‐hour sessions each week in
a private environment. The objective of the exercise protocol was to maximize adherence, improve medical health, reduce pain, improve energy, and enhance emotional wellness and quality of life. Each session had a clearly defined protocol incorporating physical, educational, and psychological aspects

Coach

Individual training

Private environment

2 x 1‐hour sessions each week for 12 months

Standardised process
and curriculum customised to each individual patients’ energy level, medical wellness, physical status/limitations, and emotional life

Response to participants muscle strength, empowerment, and identifying most impactful behaviour/lifestyle changes for each patient

Only 4/8 people allocated to the control returned to the 6 month follow up appointment and 2 for the 12 month appointment. Adherence with the supervised rehabilitation program and follow up was 100% in people allocated to the intervention

Zhou 2011b

To investigate the effects of nutrition intervention and individualised nursing care on nutritional status and quality of life in people with ESKD receiving peritoneal dialysis

An individualised nutrition intervention developed by dietitian with regard to the patient's nutritional status, clinical condition, and characteristics. The study group received the following intervention: energy 125 kJ/kg/d, protein 1.2 to 1.3 g/kg/d, and 70% to 75% proportion of protein as of high biological value. Oral enteral nutrition supplements were used for patients who did not receive enough nutrients from food. The volume of water intake was equivalent to the urine volume plus 500 mL/d and sodium was 3 g/d. In addition, nurse practitioners provided psychological care, an individualised exercise program, and blood pressure treatment

Dietitian and nurses

Individual face‐to‐face

‐‐

Psychological support was given for 30 min once‐monthly over 6 months

Individualised according to nutritional and clinical status

‐‐

‐‐

Not reported

Mediterranean diet

DIRECT Study 2013

To investigate the long‐term effect of Mediterranean diet on kidney function

Mediterranean diet: moderate‐fat, restricted calorie, rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb. Energy intake was restricted to 1500 kcal/d for women and 1800 kcal/d for men, with a goal of no more than 35% of calories from fat; the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (5 to 7 nuts, < 20 g)/d.

Low carbohydrate diet: low‐carbohydrate, non‐restricted‐calorie diet aimed to provide 20 g of carbohydrates/d for the 2‐month induction phase and immediately after religious holidays, with a gradual increase to a maximum of 120 g/d to maintain weight loss.

Low fat diet: Low‐fat calorie restricted diet based on American Heart Association guidelines, with an energy intake of 1500 kcal/d for women and 1800 kcal/d for men with 30% of calories from fat, 10% of calories from saturated fat, and an intake of 300 mg of cholesterol/d. Patients were counselled to consume low‐fat grains, vegetables, fruits, and legumes and to limit consumption of additional fats, sweets, and high‐fat snacks.

This study was included as a post‐hoc analysis of the main study including people with CKD (eGFR < 60 mL/min/1.73 m2)

Dietitian

Members of each treatment group were assigned to subgroups of between 17 and 19 participants, with 6 groups for each dietary treatment group. Each group was assigned to a registered dietitian who led all 6 subgroups of that dietary group. Self‐service cafeterias in workplaces worked closely with dietitians to adjust specific food items to specific diet groups. Each food item was provided with a label showing the number of calories and the number of grams of carbohydrates, fat and saturated fat

‐‐

Dietitians met with groups in weeks 1, 3, 5, and 7, and thereafter at 6‐week intervals, for a total of 18 sessions of 90 min each. The Israeli version of the diabetes prevention program was adapted including additional themes for each dietary change. In addition, a group of spouses received education.

6 times during the 2‐year intervention, another dietitian conducted 10 to 15 min motivational telephone calls with patients who were having difficulty adhering to the diet.

‐‐

Adherence with the diets was evaluated by a validated food‐frequency questionnaire that included 127 food items and three portion‐size pictures for 17 items. A subgroup of participants completed two repeated 24‐hour dietary recalls to verify absolute intake. We used a validated questionnaire to assess physical activity. At baseline, and at 6, 12, and 24 months of follow‐up, the questionnaires were self‐administered electronically through the workplace intranet. The 15% of patients who request aid in completing the questionnaires were assisted by the study nurse

Adherence with study intervention was 95.4% at first year and 84.6% at second year

Mekki 2010

To evaluate effect of nutritional advice on dyslipidaemia and biomarkers

Nutritional advice based on the National Kidney Foundation—Kidney Disease Outcomes Quality Initiative guideline (energy intake 0.12 MJ/kg BW/d, protein 0.75 g/kg BW/d, lipid intake 35%, and carbohydrates 55% of total energy intake). Dietary recommendations were modified and adapted to a Mediterranean diet with increased intake of mono‐unsaturated fatty acids (MUFA), poly‐unsaturated fatty acids (PUFA), and fibres. Patients were asked to consume olive oil and nuts for seasonings, whole grains (50 g bread at each meal, 250 g cereal or starch once a day), fruits (once a day), vegetables (200 g twice a day) and fish (twice a week). A list of foods rich in salt, potassium and phosphorus was provided. In addition, patients received advice about cooking methods best suited to adherence

‐‐

Face‐to‐face

Nephrology ward

‐‐

‐‐

‐‐

Recall and record every 4 days, patients interviewed by trained interviewers using adapted and structures questionnaire regarding 24 hour dietary intake. Serving sizes were estimated by the use of the food portion model handbook. Dimensions of dishes, utensils and
foods were measured, and the portion sizes were estimated accurately. The consumed foods were converted into various
nutrients using the software GENI

By 90 days, the qualitative distribution of nutrients had a tendency to be closer to the recommended diet

Stachowska 2005

To verify the effect of the Mediterranean diet on risk factors of atherosclerosis in people with a kidney transplant

This diet featured carbohydrates with a low GI (poor in glucose, simple carbohydrates, and amylose, rich in cellulose). Approved diet constituents included cereals, pulse, whole‐rye bread, vegetables (cooked or fresh), oat flakes (cooked), and noodles prepared al dente. Amylose‐rich foods, sweets, and sweet drinks were prohibited. Breakfast was the main meal, providing 39% 2% of daily calorie intake, whereas supper provided the least (16% 3%). In the study group, daily energy intake was attributed as follows: 47% carbohydrates, 38% fatty acids (including 10% saturated, 22% monounsaturated, and 6% polyunsaturated species), and 15% protein. Cholesterol and fibre supply was 165 ± 17 mg/d and 47 ± 9 g/d, respectively. The significant content of fibre in the diet was attributed to the use of fresh, unprocessed food, elimination of semi processed products, and daily intake of pulse/cereal (e.g. buckwheat, barley)/vegetables/whole‐meal rye bread. The dominating fatty acid was oleic acid from olive oil and erucic acid‐poor rapeseed oil. Patients consumed 30 mL cold‐pressed
olive oil/d (fresh salads) and prepared their cooked meals exclusively with rapeseed oil. All other oils were totally eliminated from the diet. Patients consumed approximately 30 g daily of products rich in alpha‐tocopherol and alpha‐linolenic acid C 18:3 n‐3 (grains, flaxseed, nuts). The patients were advised to consume fresh vegetables with every meal. The daily animal protein consumption was 25 to 50 g for men and 23 to 46 g for women, representing one third of the total protein. No additional vitamin supplementation was offered

‐‐

‐‐

‐‐

‐‐

‐‐

‐‐

Dietary adherence was ascertained every 4 weeks using questionnaires (24‐h food diaries) and monitoring oleic acid content in plasma triglycerides

The content of oleic acid in triglycerides
continued to increase in the study group and remained unchanged in controls (Table 2)

Increased fruit and vegetables

Goraya 2013

To evaluate increased intake of base‐producing fruits and vegetables on kidney function and metabolic acidosis

Patients received fruits and vegetables free of charge, distributed from the food bank in amounts to reduce potential renal acid load by half. Prescriptions emphasised base‐producing fruits and vegetables such as apples, apricots, oranges, peaches, pears, raisins, strawberries, carrots, cauliflower, eggplant, lettuce, potatoes, spinach, tomatoes, and zucchini

Dietitian prescribed

Individuals were not given specific dietary instructions and they integrated the prescribed fruits and vegetables into their diets as they wished. To better assure that each patient ate all the prescribed fruits and vegetables, the prescribed amount was given for each household person

‐‐

‐‐

‐‐

‐‐

Formal assessment methods was not employed; however to ensure participants consumed required amount of fruit and vegetables, fruit and vegetables were distributed for whole family/household

‐‐

Goraya 2014

To evaluate increased intake of base‐producing fruits and vegetables on kidney function and metabolic acidosis

Patients received fruits and vegetables free of charge, distributed from the food bank in amounts to reduce potential renal acid load by half. Prescriptions emphasised base‐producing fruits and vegetables such as apples, apricots, oranges, peaches, pears, raisins, strawberries, carrots, cauliflower, eggplant, lettuce, potatoes, spinach, tomatoes, and zucchini

Dietitian prescribed

Individuals were not given specific dietary instructions and they integrated the prescribed fruits and vegetables into their diets as they wished. To better assure that each patient ate all the prescribed fruits and vegetables, the prescribed amount was given for each household person

‐‐

‐‐

‐‐

‐‐

Formal assessment methods was not employed; however to ensure participants consumed required amount of fruit and vegetables, fruit and vegetables were distributed for whole family/household

‐‐

Carbohydrate‐restricted, low‐iron, polyphenol enriched (CR‐LIPE) diet

Facchini 2003

To evaluate whether dietary modification had effect on progression of CKD

CR‐LIPE diet; 50% reduction in carbohydrate intake; substitution of iron‐enriched meats (beef and pork) with iron‐poor white meats (poultry and fish) and with protein‐enriched food items known to inhibit iron absorption (dairy; eggs; soy); elimination of all beverages other than tea, water and red wine; exclusive use of polyphenol‐enriched extra‐virgin olive oil

‐‐

‐‐

‐‐

‐‐

‐‐

‐‐

Serum ferritin level; to assess adherence with low iron diet

Serum ferritin level decreased in group on CR‐LIPE diet

High‐nitrogen, low carbohydrate diet

Whittier 1985

Whether a high‐nitrogen, low carbohydrate diet could result in a positive nitrogen balance and fewer cushingoid side effects in the immediate post‐transplant period

On the morning of the 4th postoperative day, the patients were randomly assigned to receive either the control or the experimental diet. A general daily diet order was prescribed for all patients; it consisted of 800 mL fluid restriction plus an amount equal to the urine volume/d, 2 g sodium, 80 mEq potassium, 800 to 1200 mg of calcium, and 30 calories/kg. Total calories and content of the diet, in identical proportions, were adjusted up or down per kilogram to the nearest 10 kg for patients who weighed more or less than 70 kg since the ideal body weight of these patients varied from 50 to 90 kg prior to transplantation

Dietitian

Diets were prepared in batches in the metabolic kitchen by a research dietician. One meal from each batch was slurried and analysed for nitrogen and electrolyte
content. The remainder of the diet trays from the batch were frozen and microwaved prior to serving to the patient. Uneaten food from each tray was weighed and subtracted from the daily total intake

Inpatient General Clinical Research Centre for 4‐week duration of study.

Continuous assessment

The composition of the diet was determined according
to inclusion into either the treatment or control group

‐‐

Uneaten food from each tray was weighed and subtracted from the daily
total intake. The patients were encouraged to report any non‐tray items (e.g. candy, fruit, snacks) to the dietician so that the totals could reflect actual intake

Both groups ingested a similar amount of total calories, and when factored by weight, intakes per kg of body weight were very close to the objective of 28 to 30
calories/kg of body weight. As prescribed, the control group's intake of carbohydrate was significantly greater and the protein intake was significantly less than that of the experimental diet group. In the control group there was little variation in protein or caloric intake from patient to patient with the exception of patient 9, whereas in the experimental group, the protein intake varied from 1.4 g/kg/d up to the goal of 3.0 g/kg/d

BMI ‐ body mass index; (I)BW ‐ (individual) body weight‐ CKD ‐ chronic kidney disease; eGFR ‐ estimated glomerular filtration rate; GI ‐ glycaemic index

Figures and Tables -
Table 2. TIDieR framework of intervention descriptions for included studies
Table 3. Narrative description of health‐related quality of life outcomes

Study ID

Tool

Description

Dietary counselling

Campbell 2008

Kidney Disease Quality of Life Short Form Version 1.3 (combining the SF‐36 with a kidney‐disease specific module)

"There was a clear trend for a mean increase in ratings from the intervention group with a clinically significant mean improvement in 13 of the 18 sub‐scales from baseline to week 12, indicated by an effect size of 0.2 or greater...". There was a statistically significant difference in mean change for scores of symptoms of kidney disease (7.1 (0.1‐14.1) P = 0.047); cognitive functioning (14.6 (5.4‐23.7) P = 0.003); and vitality (12.0 (4.6‐19.5) P = 0.002) in favour of the intervention."

Chanwikrai 2012

‐‐

Not reported

Flesher 2011

Self‐Management Questionnaire

"Overall, the experimental group showed 'improvement' in exercise frequency, concern over health condition, and frequency of visits to health providers or hospitalisation. Overall the control group answers indicated an improvement in their communication with health providers in asking question and discussing personal issues."

Leon 2006

Kidney Disease Quality of Life questionnaire (combining the SF‐36 with a kidney‐disease specific module)

"There were no differences between intervention and control patients in quality‐of‐life subscales, including general health, physical functioning, emotional well‐being, social function, pain, and dialysis‐related symptoms."

Orazio 2011

‐‐

Not reported

Riccio 2014

‐‐

Not reported

Sutton 2007

‐‐

Not reported

Teng 2013

52‐item HPLP‐IIC questionnaire

Intervention had a significant effect on health responsibility and physical activity, but not stress management, interpersonal relations, spiritual growth or nutrition

Tzvetanov 2014

SF‐36

"The mean SF‐36 score at 6 months was significantly higher in the intervention group compared with the control group (583±13 vs 436±22, P = 0.008), reflecting an improved perception of health status. ... The intervention group had improvements compared with the control group in the domains of vitality and general health."

Zhou 2011b

Kidney Disease Quality of Life Short Form Version 1.3 (combining the SF‐36 with a kidney‐disease specific module)

"Prior to intervention, the differences in KDTA and SF‐36 scores were not statistically significant in both groups (P >0.05 for all). After intervention, both KDTA and SF‐36 scores were improved in the study group, but decreased in the control group. The difference in KDTA (P = 0.001) and SF‐36 scores (P = 0.001) before and after intervention were statistically significant in both groups (Table 2)."

Mediterranean diet

DIRECT Study 2013

‐‐

Not reported

Mekki 2010

‐‐

Not reported

Stachowska 2005

‐‐

Not reported

Increased fruit and vegetables

Goraya 2013

‐‐

Not reported

Goraya 2014

‐‐

Not reported

Carbohydrate‐restricted, low‐iron‐available, polyphenol‐enriched diet

Facchini 2003

‐‐

Not reported

High‐protein, low carbohydrate diet

Whittier 1985

‐‐

Not reported

Figures and Tables -
Table 3. Narrative description of health‐related quality of life outcomes
Table 4. Adverse events

Study

Adverse events reported in study

Campbell 2008a

Mortality; need for dialysis

Chanwikrai 2012

Not reported

DIRECT Study 2013

Not reported

Facchini 2003

Not reported

Flesher 2011

Not reported

Goraya 2013

No participants meeting eGFR and plasma potassium criteria developed plasma potassium concentration >5.0 mEq/L

Goraya 2014

Not reported

Leon 2006

Not reported

Mekki 2010

Not reported

Orazio 2011

Not reported

Riccio 2014

Not reported

Stachowska 2005

Not reported

Sutton 2007

Mortality; transfer from PD to HD

Teng 2013

Not reported

Tzvetanov 2014

Not reported

Whittier 1985

Dialysis due to elevated blood urea and potassium concentrations

Zhou 2011b

Not reported

eGFR ‐ estimated glomerular filtration rate; HD ‐ haemodialysis; PD ‐ peritoneal dialysis

Figures and Tables -
Table 4. Adverse events
Comparison 1. Dietary intervention versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All‐cause mortality Show forest plot

5

Risk Ratio (IV, Random, 95% CI)

Subtotals only

1.1 Dietary counselling

4

371

Risk Ratio (IV, Random, 95% CI)

1.59 [0.60, 4.21]

1.2 CR‐LIPE

1

170

Risk Ratio (IV, Random, 95% CI)

0.50 [0.22, 1.12]

2 Cardiovascular mortality Show forest plot

1

Risk Ratio (IV, Random, 95% CI)

Totals not selected

2.1 Dietary counselling

1

Risk Ratio (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Health‐related quality of life (SF‐36) score Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Dietary counselling

2

119

Mean Difference (IV, Random, 95% CI)

11.46 [7.73, 15.18]

4 End‐stage kidney disease Show forest plot

2

232

Risk Ratio (M‐H, Random, 95% CI)

0.53 [0.26, 1.07]

4.1 Dietary counselling

1

62

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.06, 14.33]

4.2 CR‐LIPE

1

170

Risk Ratio (M‐H, Random, 95% CI)

0.51 [0.25, 1.05]

5 Doubling of serum creatinine Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

5.1 CR‐LIPE

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

6 Employment Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

6.1 Dietary counselling

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

7 Dietary adherence Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

7.1 Dietary counselling

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

8 Worsening nutrition Show forest plot

2

Risk Ratio (IV, Random, 95% CI)

Subtotals only

8.1 Dietary counselling

2

230

Risk Ratio (IV, Random, 95% CI)

0.40 [0.05, 3.37]

9 eGFR [mL/min/1.73 m2] Show forest plot

5

219

Std. Mean Difference (IV, Random, 95% CI)

1.08 [0.20, 1.97]

9.1 Dietary counselling

3

107

Std. Mean Difference (IV, Random, 95% CI)

1.41 [‐0.40, 3.23]

9.2 Mediterranean

1

40

Std. Mean Difference (IV, Random, 95% CI)

0.23 [‐0.39, 0.85]

9.3 Fruits and vegetables

1

72

Std. Mean Difference (IV, Random, 95% CI)

1.14 [0.64, 1.64]

10 Serum creatinine Show forest plot

3

112

Mean Difference (IV, Random, 95% CI)

0.83 [‐16.57, 18.23]

10.1 Dietary counselling

2

72

Mean Difference (IV, Random, 95% CI)

1.79 [‐24.47, 28.05]

10.2 Mediterranean

1

40

Mean Difference (IV, Random, 95% CI)

‐1.0 [‐26.17, 24.17]

11 Systolic blood pressure Show forest plot

3

167

Mean Difference (IV, Random, 95% CI)

‐9.26 [‐13.48, ‐5.04]

11.1 Dietary counselling

2

95

Mean Difference (IV, Random, 95% CI)

‐11.83 [‐13.67, ‐9.98]

11.2 Fruits and vegetables

1

72

Mean Difference (IV, Random, 95% CI)

‐7.10 [‐9.60, ‐4.60]

12 Diastolic blood pressure Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

12.1 Dietary counselling

2

95

Mean Difference (IV, Random, 95% CI)

‐8.95 [‐10.69, ‐7.21]

13 Energy intake Show forest plot

6

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

13.1 Dietary counselling

4

340

Std. Mean Difference (IV, Random, 95% CI)

1.54 [‐0.87, 3.95]

13.2 Mediterranean diet

1

40

Std. Mean Difference (IV, Random, 95% CI)

1.86 [1.11, 2.61]

13.3 High nitrogen/low carbohydrate

1

12

Std. Mean Difference (IV, Random, 95% CI)

‐0.65 [‐1.82, 0.53]

14 Body weight Show forest plot

6

454

Mean Difference (IV, Random, 95% CI)

‐0.44 [‐1.46, 0.58]

14.1 Dietary counselling

3

200

Mean Difference (IV, Random, 95% CI)

‐0.20 [‐1.93, 1.53]

14.2 Fruits and vegetables

1

72

Mean Difference (IV, Random, 95% CI)

‐1.0 [‐3.57, 1.57]

14.3 CR‐LIPE

1

170

Mean Difference (IV, Random, 95% CI)

‐2.0 [‐6.22, 2.22]

14.4 High nitrogen/low carbohydrate

1

12

Mean Difference (IV, Random, 95% CI)

3.0 [‐2.66, 8.66]

15 BMI Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

15.1 Dietary counselling

2

119

Mean Difference (IV, Random, 95% CI)

‐1.70 [‐5.23, 1.82]

16 Waist‐hip ratio Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

16.1 Dietary counselling

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

17 Waist circumference, cm Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

17.1 Dietary counselling

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

18 Arm circumference Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

18.1 Dietary counselling

2

149

Mean Difference (IV, Random, 95% CI)

0.37 [‐0.39, 1.12]

19 Serum albumin Show forest plot

6

541

Mean Difference (IV, Random, 95% CI)

0.16 [0.07, 0.24]

19.1 Dietary counselling

4

331

Mean Difference (IV, Random, 95% CI)

0.15 [0.14, 0.16]

19.2 Mediterranean

1

40

Mean Difference (IV, Random, 95% CI)

0.60 [0.11, 1.09]

19.3 CR‐LIPE

1

170

Mean Difference (IV, Random, 95% CI)

0.0 [‐0.20, 0.20]

20 Serum LDL cholesterol Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

20.1 Mediterranean diet

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

20.2 CR‐LIPE

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Dietary intervention versus control
Comparison 2. Mediterranean diet versus low fat

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Serum LDL cholesterol Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

Figures and Tables -
Comparison 2. Mediterranean diet versus low fat
Comparison 3. Fruits and vegetables versus bicarbonate

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 eGFR [mL/min/1.73 m2] Show forest plot

2

143

Mean Difference (IV, Random, 95% CI)

0.84 [‐0.84, 2.53]

2 Serum creatinine Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3 Systolic blood pressure Show forest plot

2

143

Mean Difference (IV, Random, 95% CI)

‐5.81 [‐8.84, ‐2.77]

4 Body weight Show forest plot

2

143

Mean Difference (IV, Random, 95% CI)

‐5.09 [‐7.73, ‐2.44]

Figures and Tables -
Comparison 3. Fruits and vegetables versus bicarbonate