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In the Vegetarian & Vegan News...
   Bill Harris, M.D. | Q&A

Diet & Dialysis
Q&A with Bill Harris, M.D.

Q. I have a dear friend who is starting Peritoneal Dialysis in a couple weeks. She has been a vegtartian for quite some years now. She is desperately looking for help with nutrition advice. Her doctors are telling her she needs high protein from meats mostly; some beans but very limited quantity; dairy products; egg whites; some nuts but limited quantity; fruit for potassium (that's a good thing). There are minerals/electrolytes being given to her in the Dialysis fluids.

 



A. I think the animal protein dear to nephrologists is based on some fairly sloppy thinking done in the 60s. Their idea was that since injured kidneys don't handle protein very well, whatever protein is allowed has to be of "high biological value" (i.e. meat). The idea that properly complemented plant protein is of low biological value has long been overthrown and there is increasing evidence that the amino acid sequence in animal proteins may be what caused the autoimmune reaction that damaged the kidneys in the first place. Continuing dietary animal protein in my opinion is like trying to put out a fire by throwing gasoline on it.

She consumes very little dairy in her diet, mostly an ocassional cottage cheese and butter when at someone's house. As a rule, she eats an almost vegan diet and is VERY concerned about the requirements the doctors are placing on her to eat meat and dairy.

Since I'm not the physician in charge and only have your report to go on I can make no substantive recommendations. However if she's " VERY concerned about the requirements the doctors are placing on her to eat meat and dairy" why is she only on an "almost vegan diet"?

Being that she is in kidney failure, has had a three-way heart bypass three years ago, she needs to be careful what she eats so as not to bring toxins in to further harm her kidney and heart.

Dr. Harris, can you advise what she can eat to get good quality protein, without eating animal products, that would not cause further stress on her kidney while using the Peritoneal Dialysis; and also foods that contain low phosphorus and magnesium. She will be getting lab tests done next week that will show exactly how her body is reacting to the dialysis and details on where her levels of nutrition are.

The rub here is that the leafy vegetables that should have always been the source of her protein and the fruits that should have been the source of many other nutrients are now the very foods that will get her into trouble with calcium, potassium, and magnesium.

If you could help us with the protein question now, that would solve her immediate urgency in trying to avoid eating the animal products the doctors are telling her she has to consume.

There is no trouble getting enough protein from almost any plant food save fruit and the entire protein question is a very over-ripe red herring. The problem now is that her electrolytes have to be micro-managed by her physicians. I can only append for their benefit the few references that may bear slightly on her problem.

Sincerely,

-William Harris, M.D.

************

A low-nitrogen low-phosphorus Vegan diet for patients with chronic renal failure.

Barsotti G, Morelli E, Cupisti A, Meola M, Dani L, Giovannetti S

Clinica Medica I, Universita di Pisa, Italia.

The nutritional treatment of chronic renal failure with a low-protein low-phosphorus diet (conventional low-protein diet, CLPD) is effective in reducing uremic intoxication, slowing the progression of renal failure and preventing secondary hyperparathyroidism. Unfortunately, in some patients, the poor palatability and the high cost of the protein-free substitutes, together with difficulties in following the diet away from home, can make good compliance difficult, possibly causing low energy intake and malnutrition. Here the results are reported of an attempt we made to overcome these drawbacks, using a diet supplying only natural foods of plant origin in definite proportions to give an essential amino acid supply satisfying the recommended dietary allowance. This is possible thanks to an appropriate cereal-legume mixture, supplying proteins complementary for essential amino acids. Additional positive features of this special vegan diet (SVD) are the high ratio of unsaturated to saturated fatty acids, the absence of cholesterol, and the lower net acid production in comparison with a mixed diet. This study indicates that the results obtained with the SVD are similar to those obtained with the CLPD. Therefore the SVD can be a substitute for the CLPD in the management of patients with mild chronic renal failure. The SVD is the diet of choice when products made of starch are not available or poorly tolerated.

A special, supplemented 'vegan' diet for nephrotic patients.
Barsotti G; Morelli E; Cupisti A; Bertoncini P; Giovannetti S Istituto di Clinica Medica 1, Universita di Pisa, Italy.
Am J Nephrol 1991, 11 (5) p380-5, ISSN 0250-8095 Journal Code: 3MB
Languages: ENGLISH
Document type: JOURNAL ARTICLE
JOURNAL ANNOUNCEMENT: 9207
Subfile: INDEX MEDICUS

High dietary protein intake, in the past recommended for nephrotic syndrome, does not improve hypoproteinemia and may accelerate progressive renal damage. In contrast, low-protein diets reduce proteinuria and preserve renal function in experimental renal models of nephrotic syndrome. In this study, 20 steroid-resistant, nephrotic patients were treated with a pure vegetarian, low-protein diet, supplemented with essential amino acids and ketoanalogues (supplemented vegan diet, SVD) for 4.6 +/- 3.1 months. Before the study, these patients followed an unrestricted protein, low-sodium diet (LSD). Proteinuria, daily urea nitrogen excretion and creatinine clearance decreased significantly on SVD. A similar lowering effect of SVD was observed on serum total cholesterol. Seven of the 20 patients changed from LSD to SVD and vice-versa on 3 occasions, and in all cases, we found an increase of proteinuria during the LSD period. Serum albumin, HDL cholesterol, triglycerides and anthropometric measurements did not change on SVD. Our data suggest that SVD exerts a favorable effect on proteinuria and hypercholesterolemia in nephrotic patients, without inducing clinical or laboratory signs of malnutrition.

Vegan supplemented diet in nephrotic syndrome.
Barsotti G; Cupisti A; Morelli E; Ciardella F; Giovannetti S Clinica Medica I, Universita degli Studi, Pisa, Italy.
Nephrol Dial Transplant 1990, 5 Suppl 1 p75-7, ISSN 0931-0509
Journal Code: N7J
Languages: ENGLISH
Document type: JOURNAL ARTICLE
JOURNAL ANNOUNCEMENT: 9112
Subfile: INDEX MEDICUS

Thirteen patients (7 males, 6 females, aged 17-68 years) affected by primary, steroid-resistant, nephrotic syndrome and normal renal function were treated with a vegan, low-protein (0.7 g/kg per day) diet supplemented with essential amino acids and Ketoanalogues (VSD) for 3.9 +/- 2.9 months. These patients were studied at the beginning (following an unrestricted protein diet (UPD) supplying about 1 g/kg per day of mixed proteins) and at the end of VSD period. Urinary protein excretion decreased from 8.7 +/- 2.6 to 5.6 +/- 2.4 g/day (P less than 0.01), serum total cholesterol from 334.6 +/- 97.1 to 275.6 +/- 49.4 mg/dl (P less than 0.05). Serum albumin, HDL-cholesterol, triglycerides, and anthropometric measurements (triceps skinfold thickness and middle arm muscle circumference) did not change. Urinary urea nitrogen decreased from 7.5 +/- 1.8 to 3.8 +/- 1.2 g/day (P less than 0.005), according to dietary prescriptions. Creatinine clearance changed from 104.4 +/- 28.7 to 89.3 +/- 16.7 ml/min (n.s.) and no correlation was found with the changes in urinary protein excretion. This data suggest that VSD reduces proteinuria and exerts favourable effects on hypercholesterolaemia. Protein malnutrition was absent in these patients, probably because of the essential amino acids and ketoanalogues supplementation.

Prospective, randomised, multicentre trial of effect of protein restriction on progression of chronic renal insufficiency. Northern Italian Cooperative Study Group [see comments]
Locatelli F; Alberti D; Graziani G; Buccianti G; Redaelli B; Giangrande A
Division of Nephrology, Ospedale di Lecco, Italy.
Lancet Jun 1 1991, 337 (8753) p1299-304, ISSN 0023-7507
Journal Code: L0S
Comment in Lancet 1991 Aug 17;338(8764):442-4
Languages: ENGLISH
Document type: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY;
RANDOMIZED CONTROLLED TRIAL
JOURNAL ANNOUNCEMENT: 9108
Subfile: AIM; INDEX MEDICUS

A multicentre, prospective trial was organised to clarify the role of protein restriction in the progression of chronic renal insufficiency (CRI). 456 adult patients were assigned either a low-protein diet (0.6 g/kg body weight daily; n = 226) or a "normal" controlled-protein diet (1.0 g/kg daily; n = 230) and were stratified into three groups (A-C) with increasing baseline plasma creatinine concentrations. Each patient was followed up for 2 years or until an endpoint (a doubling of the baseline plasma creatinine or a need for dialysis) was reached. The difference between the diet groups in cumulative renal survival defined by these endpoints (27 low-protein, 42 controlled-protein) was of borderline significance (p less than 0.06). The difference in renal survival between the low-protein and controlled-protein diet groups was of borderline significance in group A (0 vs 4 endpoints), significant in group B (10 vs 21 endpoints; p less than 0.025), and not significant in group C. There were no differences among the diet groups or subgroups in mean plasma creatinine concentrations, creatinine clearance, the slope of the plasma creatinine reciprocal, or mean blood pressures. Compliance was good in the controlled-protein group but poor for the low-protein diet: the difference in protein intake between the groups was substantially less than that required by the protocol. However, there was no correlation between the progression of renal failure and protein catabolic rate. These findings offer little, if any, support to the hypothesis that protein restriction retards CRI progression: careful medical care and a "normal" controlled protein intake also allow very slow progression of CRI.

Amino acid supplemented diet vs. selective low protein diet in chronic renal failure.
Vujic D; Djukanovic L
Institute for Kidney Diseases and Metabolic Disorders, Zvezdara
University Hospital Centre, Beograd.
Acta Med Iugosl 1990, 44 (4) p377-87, ISSN 0375-8338 Journal Code: 10S
Languages: ENGLISH
Document type: JOURNAL ARTICLE
JOURNAL ANNOUNCEMENT: 9108
Subfile: INDEX MEDICUS

Two groups of patients with chronic renal failure (creatinine clearance 13 ml/min) were treated with two different low protein diets: unselected protein diet with 0.35 g of protein/kg/day supplemented with amino acids (first group; 10 patients) and selective protein restricted diet with 0.6 g/kg/day of high biologically valuable proteins (second group; 9 patients). Both diets showed a good patient compliance. The serum urea level decreased significantly only in the first group of patients with a simultaneous disappearance of uremic gastrointestinal side effects. Progression of renal failure, shown by plotting the reciprocal of the serum creatinine concentration against the time, was significantly slower in the first group of patients and therefore their survival without dialysis was longer than that in the second group. The nutritional state was well maintained in both groups. Comparison of two low protein diets showed that the unselected protein diet supplemented with amino acids is more effective in delaying the progression of renal failure. The clinical state of patients is improved and their protein nutrition maintained.


William Harris MD received a degree in physics from the University of California Berkeley, where he earned Phi Beta Kappa honors. He received his degree in medicine from the University of California at San Francisco, and received his postgraduate training at San Diego County Hospital. He holds a Medical License in the State of Hawaii. He has been an Emergency Department physican since 1963, and the Director of the Kaiser Permanente Vegan Lifestyle Clinic on Oahu until his retirement in 1998. Dr. Harris is the author of The Scientific Basis of Vegetarianism.

In addition, he was the 1950 Big Ten Trampoline Champion, is an accomplished hangglider and commercial pilot, and at age 70 became a skydiver with 108 jumps to date. Dr. Harris has been vegetarian since 1950, and vegan since 1963.

 
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