Protein restriction for diabetic renal disease

Lynn M Robertson; Norman Waugh; Aileen Robertson

doi:10.1002/14651858.CD002181.pub2

Restricción proteica para la nefropatía diabética

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Referencias

Referencias de los estudios incluidos en esta revisión

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estudios excluidos
otras referencias

Barsotti G, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Nutritional treatment of renal failure in type 1 diabetic nephropathy. Clinical Nephrology 1988;29:280‐287.

Barsotti G, Navalesi R, Giampietro O, Cioardella F, Morelli E, Cupisti A, Mantovanelli A, Giovanetti S. Effects of a vegetarian, supplemented diet on renal function, proteinuria and glucose metabolism in patients with 'overt' diabetic nephropathy and renal insufficency. Contributions to Nephrology 1988;65:87‐94.

Barsotti G, Cupisti A, Barsotti M, Sposini S, Palmieri D, Meola M, Lenti C, Morelli E. Dietary treatment of diabetic nephropathy with chronic renal failure. Nephrology Dialysis Transplantation 1998;13 (Suppl 8):49‐52.

Brouhard BH, LaGrone L. Effect of dietary protein restriction on renal function reserve in diabetic nephropathy. The American Journal of Medicine 1990;89:427‐31.

Ciavarella A, Gianfranco MI, Stefoni S, Borgnino LC, Bannini P. Reduced albuminuria after dietary protein restrictions in insulin dependent diabetic patients with clinical nephropathy. Diabetes Care 1987;10:407‐13.

Dullart RP, Beusenkamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long term effects of protein‐restricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and hypertension. Diabetes Care 1993;16:483‐92.

Hansen HP, Tauber‐Lassen E, Jensen BR, Parving H‐H. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney International 2002;62:220‐228.

Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone‐Gallucci M, Casciani CU. Severe dietary protein restriction in overt diabetic nephropathy: benefits or risks?. Journal of Renal Nutrition 2002;12:96‐101.

Meloni C, Tatangelo P, Cipriani S, Rossi V, Suraci C, Tozzo C, Rossini B, Cecilia A, Di Franco D, Straccialano E, Casciani CU. Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure. Journal of Renal Nutrition 2004;14:208‐13.

Pijls LTJ, de Vries H, Donker AJM, Van Eijk T. The effect of protein restriction on albuminuria in patients with type 2 diabetes mellitus: a randomized trial. Nephrology Dialysis Transplantation 1999;14:1445‐1453.

Pijls LTJ, de Vries H, van Eijk JT, Donker AJM. Protein restriction, glomerular filtration rate and albuminuria in patients with type 2 diabetes mellitus: A randomized trial. European Journal of Clinical Nutrition 2002;56:1200‐1207.

Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L. Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6‐month prospective study. American Journal of Clinical Nutrition 1994;60:579‐85.

Walker JF, Bending JJ, Dodds RA, Mattock MB, Murrells TJ, Keen H. Restriction of dietary protein and progression of renal failure in diabetic nephropathy. Lancet 1989;December:1411‐5.

Zeller K, Whittaker E, Sullivan L, Raskin P, Jacobson HR. Effect of restricting dietary protein on the progression of renal failure in patients with insulin‐dependent diabetes mellitus. New England Journal of Medicine 1991;324:78‐84.

Referencias de los estudios excluidos de esta revisión

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estudios incluidos
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Attman PO, Bucht H, Larsson O, Uddebom G. Protein restricted diet in diabetic renal failure. Clinical Nephrology 1983;19:217‐20.

Azadbakht L, Shakerhosseini R, Atabak S, Jamshidian M, Mehrabi Y, Esmaill‐Zadeh A. Beneficiary effect of dietary soy protein on lowering plasma levels of lipid and improving kidney function in type II diabetes with nephropathy. European Journal of Clinical Nutrition 2003;57:1292‐4.

Bending JJ, Dodds RA, Keen H, Viberti G. Renal response to restricted protein intake in diabetic nephropathy. Diabetes 1988;27:1641‐6.

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Brodsky IG, Robbins DC, Hiser E, Fuller SP, Fillyaw M, Devlin JT. Effects of low protein diets on protein metabolism in insulin‐dependent diabetes mellitus patients with early nephropathy. Journal of Clinical Endocrinologgy Metabolism 1992;75:351‐7.

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Brouhard BH, LaGrone LF, Richards GE, Travis LB. Short‐term protein loading in diabetics with a ten‐year duration of disease. American Journal of Disease in Childhood 1986;140:473‐6.

Cianciaruso B, Capuano A, D' Amaro E, Ferrara N, Nastasi A, Conte G, Bellizzi V, Andreucci VE. Dietary compliance to a low protein and phosphate diet in patients with chronic renal failure. Kidney International 1989;36:173‐6.

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Cohen D, Dodds R, Viberti G. Effect of protein restriction in insulin dependent diabetics at risk of nephropathy. British Medical Journal 1987;294:795‐8.

Evanoff G, Thompson C, Brown J, Weinman E. Prolonged dietary protein restriction in diabetic nephrology. Archives of Internal Medicine 1989;149:1129‐33.

Evanoff GV, Thompson CS, Brown J, Weinman EJ. The Effect of Dietary Protein Restriction on the progression of Diabetic Nephropathy. Archives of Internal Medicine 1987;147:492‐495.

Facchini FS, Saylor KL. A low‐iron‐available, polyphenol‐enriched, carbohydrate‐restricted diet to slow progression of diabetic nephropathy.. Diabetes 2003;52:1204‐9.

Gin H, Aparicio M, Potaux L, Merville P, Combe Ch, de Precigout V, Bouchet J‐L, Aubertin J. Low ‐protein, low‐phosphorous diet and tissue insulin sensitivity in insulin‐dependent diabetic patients with chronic renal failure. Nephron 1991;57:411‐5.

Gross JL, Zelmanovitz T, Moulin CC, De M, V, Perassolo M, Leitao C, Hoefel A, Paggi A, Azevedo MJ. Effect of a chicken‐based diet on renal function and lipid profile in patients with type 2 diabetes: a randomized crossover trial. Diabetes Care 2002;25:645‐51.

Hansen HP, Christensen PK, Tauber‐Lassen E, Klausen A, Jensen BR, Parving H‐H. Low‐protein diet and kidney function in insulin‐dependent diabetic patients with diabetic nephropathy. Kidney International 1999;55:621‐628.

Jibani MM, Bloodworth LL, Foden E, Griffiths KD, Galpin OP. Predominantly vegetarian diet in patinets with incipient and early clinical diabetic nephropathy: effects on albumin excretion rate and nutritional status. Diabetic Medicine 1991;8:949‐53.

Kupin WL, Cortes P, Dumler F, Feldkamp CS, Kilates MC, Levin NW. Effect on renal function of change from high to moderate protein intake in type 1 diabetic patients. Diabetes 1987;36:73‐9.

Levine SE, S'Elia JA, Bistrian B, Smith‐Ossman S, Gleason R, Mitche WE, Miller GG. Protein restricted diets in diabetic nephropathy. Nephron 1989;52:55‐61.

Mollsten AV, Dahlquist GG, Stattin EL, Rudberg S. Higher intakes of fish protein are related to a lower risk of microalbuminuria in young Swedish type 1 diabetic patients. Diabetes Care 2001;24:805‐10.

Parrilo M, Riccardi G, Pacioni D, Iovine C, Contaldo F, Isernia C, Marco F, Perrotti N, Rivellese A. Metabolic consequences of feeding a high carbohydrate, high fibre diet to diabetic patients with chronic kidney failure. American Journal of Clinical Nutrition 1988;48:255‐9.

Pecis M, de Azevedo MJ, Gross JL. Chicken and fish diet reduced glomerular hyperfiltration in IDDM patients. Diabetes Care 1994;17:665‐72.

Pedersen M, Mogensen CE, Schonau JF, Moller B, Lykke G, Pedersen O. Renal effects from limitation of high dietary protein in normoallbuminuric diabetic patients. Kidney International 1989;36:115‐21.

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Rudberg S, Dahlquist G, Aperia A, Persson B. Reduction of protein intake decreases glomerular filtration rate in young Type 1 (insulin‐dependent) diabetic patients mainly in hyperfiltering patients. Diabetologia 1988;31:878‐83.

Stephenson TJ, Setchell KD, Kendall CW, Jenkins DJ, Anderson JW, Fanti P. Effect of soy protein‐rich diet on renal function in young adults with insulin‐dependent diabetes mellitus. Clinical Nephrology 2005;64:1‐11.

Stojceva‐Taneva O, Polenakovic M, Grozdanovski R, Sikole A. Lipids, protein intake, and progression of diabetic nephropathy. Nephrology Dialysis Transplantation 2001;16 (Suppl. 6):90‐91.

Wheeler ML, Fineberg SE, Fineberg NS, Gibson RG, Hackward LL. Animal versus plant protein meals in individuals with type 2 diabetes and microalbuminuria: effects on renal, glycemic, and lipid parameters.[see comment]. Diabetes Care 2002;25:1277‐82.

Wiseman MJ, Bognetti E, Dodds R, Keen H, Viberti G. Changes in renal function in response to protein restricted diet in type 1 (insulin‐dependent) diabetic patients. Diabetologia 1987;30:154‐5.

Referencias adicionales

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estudios incluidos
estudios excluidos

Bilous RW. The kidney in systemic disease. In: Warrell DA, Cox TM, Firth JD, Benz EJ editor(s). Oxford Textbook of Medicine. 4th Edition. Vol. 3, Oxford: Oxford University Press, 2005.

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El Nahas AM, Masters‐Thomas A, Brady SA. Selective effect of low protein diets in chronic renal diseases. British Medical Journal 1984;289:1337‐41.

Finne P, Reunanen A, Stenman S, Groop PH, Gronhagen‐Riska C. Incidence of end‐stage renal disease in patients with type 1 diabetes. JAMA 2005;295:1782‐1787.

Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care 2005;28:164‐176.

Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Statistics in medicine 2002;21:1539‐58.

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analysis. BMJ 2003;327:557‐60.

Ikizler TA, Greene JH, Wingard RL. Spontaneous dietary protein intake during progression of chronic renal failure. Journal of the American Society of Nephrology 1995;6:1386‐1391.

Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary?. Controlled Clinical Trials 1996;17:1‐12.

Klahr S, Levey AS, Beck GJ. The effects of dietary protein restriction and blood pressure control on the progression of chronic renal diseases. New England Journal of Medicine 1994;330:884.

Levey AS, Beck GJ, Caggiula AW. Trends towards a beneficial effect of a low protein diet during additional follow‐up in the Modification of Diet in Renal Disease Study. Journal of the American Society of Nephrology 1994;5:336A.

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Mogensen CE. Progression of nephropathy in long‐term diabetes with proteinuria and effect of initial anti‐hypertensive therapy. Scandinavian Journal of Clinical Investigations 1976;36:383‐8.

Parving H‐H, Smidt UM, Friisberg B, Bonnevie‐Nielsen V, Andersen AR. A prospective study of glomerular filtration rate and arterial blood pressure in insulin‐dependent diabetics with diabetic nephropathy. Diabetologia 1981;20:457‐461.

Pedrini MT, Levey AS, Lau J, Chalmers TC, Wang PH. The Effect of Dietary Protein Restriction on the Progression of Diabetic and Nondiabetic Renal diseases: A Meta‐analysis. Annals of Internal Medicine 1996;124(7):627‐632.

Raine AEG. The rising tide of diabetic nephropathy ‐ the warning before the flood?. Nephrology Dialysis and Transplantation 1995;10:460‐1.

Rosman JB, Meijer S, Sluiter WJ, Wee PMT, Piers‐Becht TPM, Donker AJM. Prospective randomised trial of early protein restriction in chronic renal failure. Lancet 1984;December:1291‐6.

Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408‐12.

Sitprija V, Suvanpha R. Low protein diet and chronic renal failure in Buddist monks. British Medical Journal 1983;287:469‐71.

Sterne JAC, Egger M, Davey Smith G. Investigating and dealing with publication and other biases. In: Egger M, Davey Smith G, Altman DG editor(s). Systematic Reviews in Health Care; Meta‐analysis in Context. London: BMJ Publishing Group, 2001:189‐208.

Toeller M, Klischan A, Heitkamp G, Schumacher W, Milne R, Buyken A, Karamanos B, Gries FA. Nutrutional intake of 2868 IDDM patients from 30 centres in Europe. Diabetologia 1996;39:929‐939.

Viberti GC, Bilous RW, Mackintosh D, Keen H. Monitoring Glomerular Function in Diabetic Nephropathy. The American Journal of Medicine 1983;74:256‐64.

Waugh N, Robertson A. Treatment of diabetic nephropathy: low protein diet. Management of Diabetic Nephropathy. London: Martin Dunitz Ltd, 2003.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Barsotti 1988

Methods	Before and after study. Mean duration on UPD 15.9 months. Mean duration on LPD 17.4 months.
Participants	8 type 1 patients with severe renal failure. Mean age 44.7. Mean duration of diabetes 20.5 years.
Interventions	LPD was a low protein vegetarian diet. Low phosphorous. Supplemented with EAA and ketoanalogs. 4 patients were permitted to eat normal wheat flour products. 4 used protein‐free substitutes. UPD = 1.2‐1.4 g/kg/day.
Outcomes	Creatinine clearance. Nutritional status assessed by TST & MAMC, serum albumin, serum transferrin and serum complement. Compliance assessed by urinary urea. Actual protein intake in LPD not reported.
Notes	4 out of the 8 patients changed to maintenance hemodialysis after a period of 11 to 29 months. In 2 patients there was a spontaneous decision to abandon the LPD due to compliance difficulties. In 2, dialysis was started as they were not responding to diuretic therapy. No sign of protein or caloric malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Barsotti 1998

Methods	Before and after study. Mean duration 3.7 years.
Participants	22 type 1 and 10 type 2 patients with overt diabetic nephropathy. Mean age 44. Duration of diabetes not stated.
Interventions	UPD = Free diet. LPD: Diet A (n=19) 0.3 g/kg/day (patients with creatinine clearance ranging from 19 to 6.5 ml/min) Diet B (n=13) 0.7 g/kg/day (patients with creatinine clearance ranging from 60 to 22 ml/min) Both diets vegetarian.
Outcomes	Creatinine clearance. Malnutrition assessed by anthropometric indices (Wt, TST, MAMC). Compliance assessed by urinary urea. Diet A 45% good, Diet B 69% good.
Notes	No evidence of malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Brouhard 1990

Methods	RCT. 12 months duration. A 3 month trial period to assess compliance.
Participants	15 type 1 patients with microalbuminuria 30 ug/min. LPD mean age 36. UPD mean age 30. Mean duration of diabetes 19 years.
Interventions	LPD = 0.6 g/kg/day (n=8). UPD = 1.0 g/kg/day (n=7).
Outcomes	GFR. Compliance by uU. Actual protein intake 0.6 g/kg/day.
Notes	After trial period, 1 patient requested normal diet, reinstated. No significant differences in baseline measurements between groups but UPD had worse factors. No mention of malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Ciavarella 1987

Methods	RCT. Mean duration 4.5 months.
Participants	16 type 1 patients with proteinuria > 0.5g/24 hours; creatinine < 1.9mg/dl. Mean age 37. Duration of diabetes 10‐30 years.
Interventions	LPD = 0.71 g/kg/day (n=7). UPD = 1.44 g/kg/day (n=9).
Outcomes	Creatinine clearance. Compliance verified by dietary interview, blood nitrogen and urea nitrogen excretion. Actual protein intake 0.71 g/kg/day.
Notes	Small numbers. No information on number with follow‐up under 4.5 months. No mention of malnutrition
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Dullart 1993

Methods	RCT. Duration 2 years.
Participants	31 type 1 patients with microalbuminuria (10‐200 ug/min overnight). UPD mean age 39 LPD mean age 43 Duration of diabetes > 5 years.
Interventions	LPD = 0.6 g/kg/day (n=14). UPD = 1.09 g/kg/day (n=16). Diet supplement with methionine if necessary.
Outcomes	GFR. Compliance assessed by uU. Actual protein intake 0.79 g/kg/day. Malnutrition assessed by calorie intake, BMI and serum albumin.
Notes	No evidence of malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Hansen 2002

Methods	RCT. Duration 4 years.
Participants	82 type 1 patients (18‐60 yrs) with diabetic retinopathy, albuminuria >= 300 mg/24 hr. GFR above 20ml/min/1.73 m2 and a pre‐study decline in GFR >=2 ml/min/year (progressive diabetic nephropathy). Mean duration of diabetes LPD 28 years, UPD 27 years.
Interventions	LPD = 0.6 g/kg/day. Supplementation of calcium of 500 mg/day (n=38). UPD = patients' pre‐study diet (n=34).
Outcomes	GFR. RR of ESRD or death. Malnutrition assessed by mid‐arm circumference, serum albumin and body weight. Compliance monitored by dietary interview and uU. Actual protein intake 0.89 g/kg/day.
Notes	Comparable number in both groups received antihypertensives and ACE but +4 at follow‐up on antihypertensive and +4 on ACE. Malnutrition indicators comparable in 2 groups, but data not shown.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Meloni 2002

Methods	RCT. Duration 12 months.
Participants	32 type 1 patients (14‐32 yrs), duration of diabetes 20.9 years. 37 type 2 patients (15‐34 yrs), duration of diabetes 24.9 years. Overt nephropathy and hypertension.
Interventions	LPD = 0.6 g/kg/day (n=20). UPD = 1.39 g/kg/day (n=17).
Outcomes	GFR. Malnutrition measured by serum albumin, serum pre‐albumin and anthropometric parameters. Compliance monitored by uU. Actual protein intake 0.68 g/kg/day.
Notes	Malnutrition noted in LPD.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Meloni 2004

Methods	RCT. Duration 12 months.
Participants	24 type 1 patients (mean age 47), duration of diabetes 20.9 years. 56 type 2 patients (mean age 63), duration of diabetes 24.9 years.
Interventions	LPD = 0.8 g/kg/day (n=40). UPD = 1.24 g/kg/day (n=40).
Outcomes	GFR. Malnutrition measured by serum albumin and pre‐albumin. Compliance assessed by uU. Actual protein intake 0.86 g/kg/day.
Notes	No sign of malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Pijls 2002

Methods	RCT. Duration 28 months. Data for 12 months.
Participants	160 type 2 patients. Duration >5yrs. UPD mean age 65, duration of diabetes 7.2 years. LPD mean age 63, duration of diabetes 6.7 years.
Interventions	LPD = 0.8 g/kg/day (n=63). UPD = 1.14 g/kg/day (n=68).
Outcomes	Estimated GFR measured with cimetidine‐influenced creatinine clearance. Compliance assessed by uU. Actual protein intake 1.1 g/kg/day.
Notes	No mention of malnutrition.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Raal 1994

Methods	RCT. Mean duration 6 months.
Participants	26 type 1 patients. UPD mean age 30 years. LPD mean age 29 years. Duration of diabetes >= 10 years.
Interventions	LPD = 0.8 g/kg/day (n=11). UPD = 2 g/kg/day (n=11).
Outcomes	GFR was measured by Cr EDTA. Malnutrition assessed by body weights, serum total protein, and serum albumin. Compliance assessed by dietary history carried out by a dietitian and by measurement of 24 hour uU nitrogen excretion. Actual protein intake 0.87 g/kg/day.
Notes	Body weight, serum total protein, and serum albumin concentrations did not decrease in patients consuming the protein‐restricted diet.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Walker 1989

Methods	Before and after study. Mean duration on UPD was 29 months. Mean duration on LPD was 33 months.
Participants	19 type 1 patients with proteinuria and GFR>20ml/min. Mean age 42 years. Mean duration of diabetes 24 years.
Interventions	LPD = 40g/day, half and half animal and vegetable sources. Patients whose urinary protein excretion rate exceeded 3g/24h were allowed an additional 1.6g of dietary protein per extra gram of urinary protein. UPD = patients' normal diet.
Outcomes	GFR was assessed by clearance of Cr‐labelled edetic acid. Malnutrition assessed by MAMC and plasma albumin. Compliance assessed by uU, dietary history and weighed food record. Actual protain intake 0.67 g/kg/day.
Notes	4 patients were started on ACE inhibitors while on LPD. Data on these patients have been excluded from the analysis. LPD had no untoward nutritional effect.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Zeller 1991

Methods	RCT . Mean duration 35 months , minimum 12 months.
Participants	47 type 1 patients with proteinuria over 500mg/24 hours , with diabetic retinopathy and no other cause of renal failure . LPD mean age 33. Mean duration of diabetes 21 years. UPD mean age 35. Mean duration of diabetes 22.4 years.
Interventions	LPD = 0.6g / kg / ideal body weight/day (n=20). UPD = at least 1 g/kg/day (n=15).
Outcomes	GFR by iothalamate and creatinine. Malnutrition measured by weight, mid‐arm circumference, and serum albumin. Compliance assessed by uU and dietary history. Actual protein intake 0.72 g/kg/day.
Notes	Malnutrition measures showed no significant change.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

LPD: Low protein diet
UPD: Usual protein diet
EAA: Essential amino acids
TST: Triceps skinfold thickness
MAMC: Middle arm muscle circumference
GFR: Glomerular filtration rate
BMI: Body mass index
RR: Relative risk
ESRD: End‐stage renal disease
ACE: Angiotensin converting enzyme
RCT: Randomised controlled trial
Wt: Weight

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Attman 1983	Late (pre‐dialysis) intervention
Azadbakht 2003	Duration only 7 weeks
Bending 1988	Duration only 3 weeks
Brodsky 1992	Duration only 12 weeks
Brouhard 1986	Control group were non‐diabetic
Cianciaruso 1989	Trial to assess compliance to a low protein diet
Cohen 1987	Duration only 3 weeks
Evanoff 1989	Changes in antihypertensive therapy
Facchini 2003	Comparison diet not usual diet (carbohydrate‐restricted, low‐iron‐available, polyphenol‐enriched diet
Gin 1991	Aim was to assess the effect of the increase in carbohydrate on insulin sensitivity
Gross 2002	Duration only 4 weeks
Hansen 1999	Duration only 8 weeks
Jibani 1991	Duration only 8 weeks
Kupin 1987	Two consecutive dietary periods of one week
Levine 1989	No comparison period, duration only 15 weeks
Mollsten 2001	Case control study
Parillo 1988	Duration only 10 days
Pecis 1994	Duration only 3 weeks
Pedersen 1989	Duration only 4 weeks
Rudberg 1988	Duration only 10 days
Stephenson 2005	Duration only 8 weeks
Stojceva‐Taneva 2001	Observational study
Wheeler 2002	Duration only 6 weeks
Wiseman 1987	Duration only 3 weeks

Data and analyses

Open in table viewer

Comparison 1. Low protein diet versus usual diet

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change in glomerular filtration rate (ml/min) Show forest plot	7	222	Mean Difference (IV, Random, 95% CI)	0.14 [‐0.06, 0.34]
Open in figure viewer Analysis 1.1 Comparison 1 Low protein diet versus usual diet, Outcome 1 Change in glomerular filtration rate (ml/min).

Analysis 1.1

Comparison 1 Low protein diet versus usual diet, Outcome 1 Change in glomerular filtration rate (ml/min).

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Comparison 1. Low protein diet versus usual diet

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change in glomerular filtration rate (ml/min) Show forest plot	7	222	Mean Difference (IV, Random, 95% CI)	0.14 [‐0.06, 0.34]

Comparison 1. Low protein diet versus usual diet

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Referencias

Referencias de los estudios incluidos en esta revisión

Barsotti 1988 {published data only}

Barsotti 1998 {published data only}

Brouhard 1990 {published data only}

Ciavarella 1987 {published data only}

Dullart 1993 {published data only}

Hansen 2002 {published data only}

Meloni 2002 {published data only}

Meloni 2004 {published data only}

Pijls 2002 {published data only}

Raal 1994 {published data only}

Walker 1989 {published data only}

Zeller 1991 {published data only}

Referencias de los estudios excluidos de esta revisión

Attman 1983 {published data only}

Azadbakht 2003 {published data only}

Bending 1988 {published data only}

Brodsky 1992 {published data only}

Brouhard 1986 {published data only}

Cianciaruso 1989 {published data only}

Cohen 1987 {published data only}

Evanoff 1989 {published data only}

Facchini 2003 {published data only}

Gin 1991 {published data only}

Gross 2002 {published data only}

Hansen 1999 {published data only}

Jibani 1991 {published data only}

Kupin 1987 {published data only}

Levine 1989 {published data only}

Mollsten 2001 {published data only}

Parillo 1988 {published data only}

Pecis 1994 {published data only}

Pedersen 1989 {published data only}

Rudberg 1988 {published data only}

Stephenson 2005 {published data only}

Stojceva‐Taneva 2001 {published data only}

Wheeler 2002 {published data only}

Wiseman 1987 {published data only}

Referencias adicionales

Bilous 2005

Brenner 1982

Connor 2003

El Nahas 1984

Finne 2005

Gross 2005

Higgins 2002

Higgins 2003

Ikizler 1995

Jadad 1996

Klahr 1994

Levey 1994

Maschio 1982

MDRD Study Grp 1989

Mogensen 1976

Parving 1981

Pedrini 1996

Raine 1995

Rosman 1984

Schulz 1995

Sitprija 1983

Sterne 2001

Toeller 1996

Viberti 1983

Waugh 2003

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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