Skip to main content
Log in

An approach to protein restriction in children with renal insufficiency

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Children with mild to moderate renal insufficiency may be at an increased risk for developing glomerulosclerosis and subsequent renal failure. Low protein diets (LPD) have been shown to delay the progression of renal insufficiency in laboratory animals and may be of benefit in adult humans. The nutritional costs of a LPD in adults are reportedly minimal. We review the protein and caloric requirements of growing children and discuss the potential harmful effects and benefits of an LPD in this population. We also discuss dietary adherence and the difficulty of designing an LPD for children. We conclude that the protein content of a typical American diet can safely be reduced to, but not below, the recommended daily allowance for protein if diets are carefully planned, patients and their parents extensively counseled, and if dietary supplements are given to help meet the caloric and vitamin-mineral nutrient needs of growing children. In addition, ongoing nutritional assessment, counseling, and frequent monitoring of growth, diet and biochemical indicators of protein status are essential for maintaining the health of these children.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hostetter TH, Olson JL, Rennke HT, Ven Katachalam MA, Brenner BM (1981) Hyperfiltration in remnant nephrons: a potentially adverse response to renal ablation. Am J Physiol 241:F85-F93

    Google Scholar 

  2. Brenner BM, Meyer TW, Hostetter TH, (1982) Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically-mediated glomerular injury in the pathogenesis of progressive glomerulosclerosis in aging, renal ablation and intrinsic renal disease. N Engl J Med 307:652–659

    Google Scholar 

  3. Pullman TN, Alving AS, Dein RJ, Landowne M (1954) The influence of dietary protein intake on specific renal function in normal man. J Lab Clin Med 44:320–332

    Google Scholar 

  4. Paulson DF, Fraley EE (1973) Compensatory renal growth after unilateral ureteral obstruction. Kidney Int 4:22–27

    Google Scholar 

  5. Segaul RM, Lytton B, Schiff M (1972) Functional aspects of compensatory renal growth after ischemic injury. Invest Urol 10: 235–238

    Google Scholar 

  6. Toback FG, Smith PD, Lowenstein LM (1974) Phospholipid metabolism in the initiation of renal compensatory growth after reduction of renal mass. J Clin Invest 54:91–97

    Google Scholar 

  7. Threlfall G, Taylor DM, Beck AT (1967) Studies of the changes in growth and DNA synthesis in the rat kidney during experimentally induced renal hypertrophy. Am J Pathol 50:1–14

    Google Scholar 

  8. Aperia A, Broberger O, Wikstad I, Wilton P (1977) Renal growth and function in patients nephrectomized in childhood. Acta Paediatr Scand 66:185–192

    Google Scholar 

  9. Walker RD, Reid CF, Richard GA, Talbert JL, Rogers BM (1982) Compensatory renal growth and function in postnephrectomized patients with Wilms tumor. Urology 19:127–130

    Google Scholar 

  10. Dean WM, Maddox DA, Robertson CR, Brenner BM (1974) Dynamics of glomerular ultrafiltration in the rat. VII. Response to reduced renal mass. Am J Physiol 227:556–562

    Google Scholar 

  11. Jones MG, Lee K, Swaminathin R (1987) The effect of dietary protein on GFR in normal subjects. Clin Nephrol 27:71–75

    Google Scholar 

  12. Addis T, Barrett E, Poo LJ, Ureen HJ, Lippman RW (1951) The relationship between protein consumption and diurnal variations of the endogenous creatinine clearance in normal individuals. J Clin Invest 30:206–209

    Google Scholar 

  13. Johannesen J, Lu M, Kiil F (1977) Effect of glycine and glucagon on glomerular filtration and renal metabolic rates. Am J Physiol 233: F61-F66

    Google Scholar 

  14. Bosch JP, Saccaggi A, Lauer A, Ronco C, Belledonne M, Glabman S (1983) Renal functional reserve in humans: effect of protein intake on glomerular filtration rate. Am J Med 75:943–950

    Google Scholar 

  15. Parving HH, Noer J, Kehler H, Mogensen CE, Svensen PA, Heding L (1977) The effect of short term glucagon infusion on kidney function in normal man. Diabetologia 13:323–325

    Google Scholar 

  16. Sandahl Christrianssen J, Gumelgard J, Orskov H, Adersen R, Telmer S, Parving HH (1981) Kidney function and size in normal subjects before and after growth hormone administration for one week. Eur J Clin Invest 11:487–490

    Google Scholar 

  17. Corvilain J, Abramow MJ, Bergans H (1962) Some effects of human growth hormone on renal hemodynamics and on tubular phosphate transport in man. J Clin Invest 41:1230–1235

    Google Scholar 

  18. Hirschberg R, Rabb H, Bergamo R, Kopple J (1989) The delayed effect of growth hormone on renal function in humans. Kidney Int 35:865–870

    Google Scholar 

  19. Hirschberg R, Kopple JD (1988) Increase in renal plasma flow and GFR during growth hormone treatment may be mediated by insulin-like growth factor I. Am J Nephrol 8:249–253

    Google Scholar 

  20. Alvestrand A, Bergstrom J (1984) Glomerular hyperfiltration after protein ingestion, during glucagon infusion, and in insulin-dependent diabetes is by a liver hormone. Lancet I:195–197

    Google Scholar 

  21. Brouhard BH, LaGrone LF, Richards GE, Travis LB (1987) Somatostatin limits rise in glomerular filtration rate after a protein meal. J Pediatr 110:729–734

    Google Scholar 

  22. Koprov DD, Colvin RB, McCluskey RT (1982) Focal and segmental glomerulosclerosis and proteinuria associated with unilateral renal agenesis. Lab Invest 46:275–281

    Google Scholar 

  23. Emmanuel B, Nachman R, Aronson N, Weiss H (1974) Congenital solitary kidney. A review of 74 cases. Am J Dis Child 127:17–19

    Google Scholar 

  24. Hakim RM, Goldszer RC, Brenner BM (1984) Hypertension and proteinuria: Long-term sequelae of uninephrectomy in humans. Kidney Int 25:930–936

    Google Scholar 

  25. Thorner PS, Arbus GS, Celermajer DS, Baumal R (1984) Focal segmental glomerulosclerosis and progressive renal failure associated with a unilateral kidney. Pediatrics 73:806–810

    Google Scholar 

  26. Giordano C, Esposito R, Pascale C (1966) Dietary treatment in renal failure. In: Giordano C, Esposito R, Pascale C (eds) Proceedings of the Third International Congress on Nephrology, vol 3. Karger, New York, pp 214–229

    Google Scholar 

  27. Giovannetti S, Maggiore Q (1964) A low-nitrogen diet with protein of high biological value for severe chronic uremia. Lancet I:1000–1003

    Google Scholar 

  28. Maschio G, Oldrizzi L, Tessitore N, D'Angelo A, Valvo E, Lupo A, Loschiavo C, Fabris A, Gammaro L, Rugio C, Panzetta G (1982) Effects of dietary protein and phosphorous restriction on the progression of early renal failure. Kidney Int 22:371–376

    Google Scholar 

  29. Alvestrand A, Ahlberg M, Bergstrom J (1983) Retardation of the progression of renal insufficiency in patients treated with low-protein diets. Kidney Int 24 [Suppl 16]:268–272

    Google Scholar 

  30. Rosman JB, TerWee PM, Meijer S, Sluitter WJ, Piers-Becht TP, Donker AJM (1984) Prospective randomized trial of early dietary protein restriction in chronic renal failure. Lancet II:1291–1295

    Google Scholar 

  31. Holliday MA (1986) Protein intake, renal function and growth in chronic renal failure. In: Mitch WE, Brenner BM, Stein JH (eds) The progressive nature of renal disease. Churchill Livingstone, New York, pp 245–261

    Google Scholar 

  32. Nath KA, Kaufman D, Hostetter TH (1985) Effect of low protein diet after renal injury is established. Kidney Int 27:248

    Google Scholar 

  33. Brenner BM (1985) Nephron adaptation to renal injury or ablation. Am J Physiol 249 (Renal Fluid Electrolyte Physiol 18):F324-F337

    Google Scholar 

  34. Welch TR, McAdams AJ (1986) Focal glomerulosclerosis as a late sequela of Wilms tumor. J Pediatr 108:105–109

    Google Scholar 

  35. Neugarden J, Feiner H, Schacht RG, Balewin O (1982) Ameliorative effect of dietary protein restriction on the course of nephrotoxic serum nephritis. Clin Res 30:541A

    Google Scholar 

  36. Dworkin LD, Hostetter TH, Rennke MG, Brenner BM (1982) Evidence for a hemodynamic basis for glomerular injury in hypertension. Kidney Int 21:229–234

    Google Scholar 

  37. Friend PS, Fernandes G, Good RA, Michael AS, Yunis EJ (1978) Dietary restrictions early and late: effects on the nephropathy of the NZB/NZW mouse. Lab Invest 38:629–632

    Google Scholar 

  38. Farr LE, Smadel JE (1939) The effect of dietary protein on the course of nephrotoxic nephritis in rats. J Exp Med 70:615–627

    Google Scholar 

  39. Jones R, Dalton N, Turner C, Start K, Haycock G, Chantler C (1983) Oral essential amino acid and ketoacid supplements in children with chronic renal failure. Kidney Int 24:95–103

    Google Scholar 

  40. Rizzoni G, Basso T, Setari M (1984) Growth in children with chronic renal failure on conservative treatment. Kidney Int 26:52–58

    Google Scholar 

  41. Polito C, Greco L, Totino SF (1987) Statural growth of children with chronic renal failure on conservative treatment. Acta Paediatr Scand 76:97–102

    Google Scholar 

  42. Friedman AL, Pityer R (1986) Beneficial effect of moderate protein restriction on growth, renal function and survival in young rats with chronic renal failure. J Nutr 116:2466–2477

    Google Scholar 

  43. Kleinknecht C, Salusky I, Broyer M (1979) Effects of various protein diets on growth, renal function and survival of uremic rats. Kidney Int 15:534–541

    Google Scholar 

  44. Salusky I, Kleinknecht C, Broyer M (1981) Prolonged renal survival and stunting with protein-deficient diets in experimental uremia. J Lab Clin Med 97:21–30

    Google Scholar 

  45. Holliday M, Chantler C, MacDonnell R (1977) Effect of uremia on nutritionally induced variations in protein metabolism. Kidney Int 11:236–241

    Google Scholar 

  46. Li JB, Wassner SJ (1981) Muscle degradation in uremia: 3-methyl histidine release in fed and fasted rats. Kidney Int 20:321–325

    Google Scholar 

  47. Chantler C, El Bishti M, Counahan R (1980) Nutritional therapy in children with chronic renal failure. Am J Clin Nutr 33:1682–1688

    Google Scholar 

  48. Scrimshaw NS (1976) Strengths and weaknesses of the committee approach. N Engl J Med 294:136–142, 198–203

    Google Scholar 

  49. Garza C, Scrimshaw NS, Young VR (1977) Human protein requirements: a long-term metabolic nitrogen balance study in young men to evaluate the 1973 FAO/WHO safe level of egg protein inkate. J Nutr 107:335–352

    Google Scholar 

  50. Food and Agriculture Organization/World Health Organization (1985) Energy and protein requirements. Report of a joint FAO/WHO Expert Committee.WHO Technical Report Series No. 724. WHO, Geneva

    Google Scholar 

  51. Committee on Dietary Allowances. Food and Nutrition Board (1980) Recommended dietary allowances, 9th edn. National Academy of Sciences, Washington, D. C.

    Google Scholar 

  52. United States Department of Health and Human Services, United States Public Health Service. Dietary intake findings, United States (1976–1980) In: Vital health statistics, series 11, no 231. National Center for Health Statistics, Hyattsville, MD

    Google Scholar 

  53. Waterlow JC (1986) Adaptation to low protein intakes. In: Olson RO (ed) Annual review of nutrition, vol 6. Annual Reviews, Palo Alto, pp 495–526

    Google Scholar 

  54. Kurtin PS, Shapiro AC (1988) Energy expenditure in children with renal disease. Clin Res 36:357A

    Google Scholar 

  55. Alvestrand A, Ahlberg M, Furst P, Bergstrom J (1983) Clinical results of long term treatment with a low protein diet and a new amino acid preparation in patients with chronic uremia. Clin Nephrol 19:67

    Google Scholar 

  56. Mitch WE, Abras E, Walser M (1982) Long-term effects of a new ketoacid-amino acid supplement in patients with chronic renal failure. Kidney Int 22:48

    Google Scholar 

  57. Brouhard BH (1986) The role of protein in progressive renal disease. Am J Dis Child 140:630–637

    Google Scholar 

  58. Munro HN (1978) Energy and protein intakes as determinants of nitrogen balance. Kidney Int 14:313

    Google Scholar 

  59. Berger M (1977) Dietary management of children with uremia. J Am Diet Assoc 70:498–504

    Google Scholar 

  60. Nationwide Food Consumption Survey, 1977–1978, Preliminary Report no. 2 (1980) Food and nutrient intakes of individuals one day in the US, Spring, 1977. USDA, Science and Education Administration, Washington, D. C.

    Google Scholar 

  61. Keane WF, Kasiske BL, O'Donnell MP (1988) Hyperlipidemia and the progression of renal disease. Am J Clin Nutr 47:157–160

    Google Scholar 

  62. Nelson P (1987) The role of the dietitian in the management of children undergoing CAPD/CCPD. In: Fine RN (ed) Chronic ambulatory peritoneal dialysis (CAPD) and chronic cycling peritoneal dialysis (CAPD) in children. Martinus-Nijhoff, Boston, pp 245–260

    Google Scholar 

  63. Kurtin PS, Shapiro AC (1989) The effect of caloric supplementation on growth in children with renal disease. Am J Kidney Dis 14:434

    Google Scholar 

  64. Kindt E, Motzfeldt K, Halvorsen S, Lie SO (1983) Protein requirements in infants and children: a longitudinal study of children treated for phenylketonuria. Am J Clin Nutr 37:778–785

    Google Scholar 

  65. Ibels LS, Alfrey AC, Haut L (1978) Preservation of function in experimental renal disease by dietary restriction of phosphate. N Engl J Med 298:122–126

    Google Scholar 

  66. Dallman PR (1981) Iron deficiency: diagnosis and treatment. West J Med 134:496–505

    Google Scholar 

  67. Berg U, Bohlin AB, Aperia A (1987) Short-term effect of low and high protein intake of renal function in children with renal disease. Acta Paediatr Scand 76:288

    Google Scholar 

  68. Hellerstein S, Holliday MA, Grupe WE (1987) Nutritional management of children with chronic renal failure. Pediatr Nephrol 1:195–211

    Google Scholar 

  69. Holliday MA, Chantler C (1978) Metabolic and nutritional factors in children with renal insufficiency. Kidney Int 14:306–312

    Google Scholar 

  70. Blumenkrantz MJ, Kopple JD, Gutman RA, Chan YK, Barbour GL, Roberts C, Shen FH, Gandhi VC, Tucker CT, Curtis FK, Coburn JW (1980) Methods of assessing nutritional status of patients with renal failure. Am J Clin Nutr 33:1567–1585

    Google Scholar 

  71. Potter DE, Broyer M, Chantler C (1978) Measurement of growth in children with renal insufficiency. Kidney Int 14:378–382

    Google Scholar 

  72. Roche AF (1978) Growth assessment in abnormal children. Kidney Int 14:369–377

    Google Scholar 

  73. Barrett TM, Broyer M, Chantler C (1986) Assessment of growth. Am J Kidney Dis 7:340–346

    Google Scholar 

  74. Holliday MA (1987) Requirements and recommendations In: Holliday MA (ed) Pediatric Nephrology, 2nd edn. Williams and Wilkins, Baltimore, pp 160–167

    Google Scholar 

  75. Wassner SJ (1982) The role of nutrition in the care of children with renal insufficiency. Pediatr Clin North Am 29:973–988

    Google Scholar 

  76. Giovannetti S (1986) Answers to ten questions on the dietary treatment of chronic renal failure. Lancet II:1140–1142

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Raymond, N.G., Dwyer, J.T., Nevins, P. et al. An approach to protein restriction in children with renal insufficiency. Pediatr Nephrol 4, 145–151 (1990). https://doi.org/10.1007/BF00858826

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF00858826

Key words

Navigation