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PubMed1983

Effects of dietary protein and fiber on growth and selected cholesterol responses of rats.

The effect of dietary protein and fiber on growth and metabolic parameters in blood serum, liver and kidney were determined in a 2 X 5 factorial experiment involving 40 Sprague-Dawley rats. Treatment variables were two dietary protein levels (16 and 24%) and five acid detergent fiber levels (6, 10, 16, 24 and 34%). No difference in growth rate of rats was found due to varying levels of either protein or fiber in the diet. Increasing the dietary protein level from 16 to 24% resulted in an 18.5% reduction in blood cholesterol. The dietary treatment containing 16% fiber influenced most metabolic parameters examined, including blood serum cholesterol, liver cholesterol and total lipid content in liver and kidney. Rats receiving the diet containing 16% fiber had the highest serum cholesterol (88.9 mg/dl) and the lowest liver cholesterol (4.4 mg/g) as compared with other fiber groups.

Animal Feed↗

PubMed1987

Growth and adipose tissue metabolism in young pigs fed cimaterol with adequate or low dietary protein.

The beta-adrenergic agonist, cimaterol, was fed to young growing pigs to determine whether the carcass compositional changes observed in finishing pigs fed a beta-adrenergic agonist would be manifest in young animals. Furthermore, because cimaterol increased the deposition of lean mass in finishing pigs, it could have a protein sparing effect in young pigs that are rapidly accreting muscle mass and have a high dietary protein requirement. Pigs were fed cimaterol (at 0, .25 and .50 mg X kg-1 diet) and either an adequate (18%) or restricted (14%) protein diet from about 10 to 60 kg body weight. Pigs that were fed the 14 compared with 18% protein diet grew slower and ate less but had the same gain-to-feed ratio. These pigs also had shorter carcasses, less lean muscle and more fat deposition (assessed by carcass measurements and carcass chemical composition) than pigs that received adequate protein. Plasma protein and albumin concentrations were greater and plasma cholesterol, triglyceride and fatty acid concentrations were lower in pigs fed high compared with low dietary protein. Dietary cimaterol had no effect on any of the growth or carcass variables or on adipose tissue metabolism. When fed the high protein diet, cimaterol-supplemented pigs had smaller livers and stomachs. Dietary cimaterol did not have any major detectable effects on these young pigs, nor was there any evidence for a protein sparing effect.

Adipose Tissue↗

PubMed1996

The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis.

BACKGROUND: Dietary protein has long been thought to play a role in the progression of chronic renal disease, but clinical trials to date have not consistently shown that dietary protein restriction is beneficial. PURPOSE: To use meta-analysis to assess the efficacy of dietary protein restriction in previously published studies of diabetic and nondiabetic renal diseases, including the recently completed Modification of Diet in Renal Disease Study. DATA SOURCES: The English-language medical literature published from January 1966 through December 1994 was searched for studies examining the effect of low-protein diets in humans with chronic renal disease. A total of 1413 patients in five studies on nondiabetic renal disease (mean length of follow-up, 18 to 36 months) and 108 patients in five studies of type I diabetes mellitus (mean length of follow-up, 9 to 35 months) were included. STUDY SELECTION: Randomized, controlled studies were selected for nondiabetic renal disease; randomized, controlled studies or time-controlled studies with nonrandomized crossover design were selected for diabetic nephropathy. DATA EXTRACTION: Data in tables, figures, or text were independently extracted by two of the authors. DATA SYNTHESIS: The relative risk for progression of renal disease in patients receiving a low-protein diet compared with patients receiving a usual-protein diet was calculated by using a random-effects model. In five studies of nondiabetic renal disease, a low-protein diet significantly reduced the risk for renal failure or death (relative risk, 0.67 [95% Cl, 0.50 to 0.89]). In five studies of insulin-dependent diabetes mellitus, a low-protein diet significantly slowed the increase in urinary albumin level or the decline in glomerular filtration rate or creatinine clearance (relative risk, 0.56 [Cl, 0.40 to 0.77]). Tests for heterogeneity showed no significant differences in relative risk among studies of either diabetic or nondiabetic renal disease. No significant differences were seen between diet groups in pooled mean arterial blood pressure (diabetic and nondiabetic patients) or glycosylated hemoglobin level (diabetic patients only). CONCLUSION: Dietary protein restriction effectively slows the progression of both diabetic and nondiabetic renal diseases.

Adult↗

PubMed2005

Dietary protein: an essential nutrient for bone health.

Nutrition plays a major role in the development and maintenance of bone structures resistant to usual mechanical loadings. In addition to calcium in the presence of an adequate vitamin D supply, proteins represent a key nutrient for bone health, and thereby in the prevention of osteoporosis. In sharp opposition to experimental and clinical evidence, it has been alleged that proteins, particularly those from animal sources, might be deleterious for bone health by inducing chronic metabolic acidosis which in turn would be responsible for increased calciuria and accelerated mineral dissolution. This claim is based on an hypothesis that artificially assembles various notions, including in vitro observations on the physical-chemical property of apatite crystal, short term human studies on the calciuric response to increased protein intakes, as well as retrospective inter-ethnic comparisons on the prevalence of hip fractures. The main purpose of this review is to analyze the evidence that refutes a relation of causality between the elements of this putative patho-physiological "cascade" that purports that animal proteins are causally associated with an increased incidence of osteoporotic fractures. In contrast, many experimental and clinical published data concur to indicate that low protein intake negatively affects bone health. Thus, selective deficiency in dietary proteins causes marked deterioration in bone mass, micro architecture and strength, the hallmark of osteoporosis. In the elderly, low protein intakes are often observed in patients with hip fracture. In these patients intervention study after orthopedic management demonstrates that protein supplementation as given in the form of casein, attenuates post-fracture bone loss, increases muscles strength, reduces medical complications and hospital stay. In agreement with both experimental and clinical intervention studies, large prospective epidemiologic observations indicate that relatively high protein intakes, including those from animal sources are associated with increased bone mineral mass and reduced incidence of osteoporotic fractures. As to the increased calciuria that can be observed in response to an augmentation in either animal or vegetal proteins it can be explained by a stimulation of the intestinal calcium absorption. Dietary proteins also enhance IGF-1, a factor that exerts positive activity on skeletal development and bone formation. Consequently, dietary proteins are as essential as calcium and vitamin D for bone health and osteoporosis prevention. Furthermore, there is no consistent evidence for superiority of vegetal over animal proteins on calcium metabolism, bone loss prevention and risk reduction of fragility fractures.

Aging↗

PubMed1986

Dietary protein restriction in established renal injury in the rat. Selective role of glomerular capillary pressure in progressive glomerular dysfunction.

Dietary protein restriction imposed before renal injury is established in the remnant kidney model in the rat reduces glomerular hypertension and hyperperfusion and renal injury. We demonstrate that dietary protein restriction (6% vs. 20%) imposed on a background of established renal injury in the remnant model leads to a greater preservation of renal function as measured by glomerular filtration rate and fractional clearances of albumin and IgG, despite the persistence of systemic hypertension. In similarly prepared rats, dietary protein restriction (6% vs. 20%) led to a lower glomerular capillary hydraulic pressure, a higher ultrafiltration coefficient, and similar single nephron filtration rates. In addition, less impairment of glomerular permselectivity was demonstrable after protein restriction. Our data demonstrate that the preservation of renal function with dietary protein restriction after established glomerular injury follows upon reduction of glomerular capillary hydraulic pressure, despite constancy of single nephron filtration rate and plasma flow and persistence of arterial hypertension.

Animals↗

PubMed1983

The effect of biotin deficiency and dietary protein content on lipogenesis, gluconeogenesis and related enzyme activities in chick liver.

Chicks were given biotin-deficient diets containing either suboptimal (low) or supraoptimal (high) concentrations of protein from 1-d-old until they were used during their fourth week of life. The low-protein diet predisposed chicks to develop fatty liver and kidney syndrome and the high-protein diet to develop classical biotin deficiency signs. Two other groups, as controls, received biotin-supplemented rations. Low dietary protein increased lipogenesis by isolated hepatocytes but had little effect on gluconeogenesis compared to high dietary protein. Low dietary protein decreased activities of hepatic isocitrate dehydrogenase (EC 1.1.1.42), fructose-1,6-bisphosphatase (EC 3.1.3.11) and glucose-6-phosphatase (EC 3.1.3.9; GP) and increased activities of fatty acid synthase (FAS), citrate cleavage enzyme (EC 4.1.3.8; CCE) and malate dehydrogenase (decarboxylating) (EC 1.1.1.39). When biotin deficiency was superimposed, the rate of lipogenesis by isolated hepatocytes (from fed birds) was decreased. Gluconeogenesis from lactate and glycerol was also depressed. Activity of GP was further decreased by biotin deficiency on the low-protein regimen and FAS and CCE were further increased. PK activity was increased by biotin deficiency.

Animals↗

PubMedDate not supplied

The effects of variation in dietary protein and ethanol on hepatic microsomal drug metabolism in the rat.

The effect of chronic ethanol consumption and variations in dietary protein content on microsomal drug metabolism were studied in rats pair-fed liquid diets containing 10, 20, ro 30% dietary protein with or without ethanol. In vitro drug metabolism was measured by aminopyrine breath tests and aminopyrine blood elimination kinetics. In vitro drug metabolism was assessed by measuring aminopyrine N-demethylase activity in the hepatic microsomal fraction. The rate of elimination of aminopyrine in vivo was increased in all ethanol-fed animals (p less than 0.05) regardless of the protein content of the diet. Animals receiving 10 or 20% protein diets with ethanol showed a 36% increase in drug elimination over pair-fed controls as compared to a 17% increase in drug elimination over controls in animals receiving 30% protein diets. Microsomal aminopyrine N-demethylase activities were similar in ethanol/fed animals and pair-fed controls. Cytochrome P-450 content was increased in all ethanol-fed animals (p less than 0.05) but the increase was not dependent on dietary protein content. These results indicate that the effect of chronic ethanol feeding in enhancing drug metabolism in vivo is influenced by the dietary protein content.

Alcoholism↗

PubMed2000

Effect of habitual dietary-protein intake on appetite and satiety.

To investigate whether appetite response to a high-protein test meal varies inversely with habitual protein intake, the satiating influence of dietary protein was investigated in 14 subjects. Subjects were divided into two groups on the basis of habitual protein intake: means of 1.0 g/kg/day (LP) and 1.4 g/kg/day (HP). Appetite was assessed in each group following high protein meals (test a). A 13-day period of dietary manipulation increased differences in protein intake between groups to a mean of 0.75 g/kg/day (LP) and 1.96 g/kg/day (HP) and a second satiety test (b) was performed. A third test (c) was performed in the HP group after protein intakes were reduced for 2 days to a mean of 0.85 g/kg/day. Differences in satiety were most marked, with significant correlations between satiety after the three meals and daily protein intake (r=-0.36). LP satiety was significantly greater than HP after test b (p=0.025), and approached significance when satiety response during LPb was compared with HPc (p=0.07). Results support the hypothesis that the satiating effect of dietary protein varies inversely with habitual protein intake.

Adult↗

PubMed2002

Effect of dietary protein on prepubertal mammary development in rapidly growing dairy heifers.

The objective was to determine whether increased dietary protein would enhance mammary development in prepubertal heifers fed for rapid body growth (1.2 kg/d). Fifty-four Holstein heifers (weighing approximately 134 kg) were assigned to one of three treatments. Heifers were fed a total mixed ration with metabolizable energy at 2.85 Mcal/kg and metabolizable protein at low, standard, or high concentrations (37, 41, or 44 g/Mcal of metabolizable energy, respectively) from 3.5 mo of age until slaughter at approximately 46 d after puberty. Heifers fed low, standard, and high protein gained 1130, 1170, and 1180 g/d, respectively. Dietary protein did not affect age or weight of heifers at puberty or slaughter, withers height gain, or carcass composition. Average mammary parenchymal DNA content for heifers on diets of low, standard, and high protein was 595, 619, and 670 mg/100 kg of body weight, respectively, and was not significantly different. However, for heifers that attained puberty early, those fed low protein had 33% less parenchymal DNA than those fed high protein, even though their body growth and carcass composition were not compromised. We conclude that dietary protein does not have a major effect on mammary development of rapidly grown prepubertal heifers, provided the diet contains adequate protein for normal body growth. But we suggest that feeding low-protein diets increases the risk of impaired mammary development when heifers are fed for rapid growth and attain puberty early and that the new National Research Council guidelines for protein relative to energy seem adequate for optimal mammary development.

Aging↗

PubMed2000

Effects of dietary protein type on oxidized cholesterol-induced alteration in age-related modulation of lipid metabolism and indices of immune function in rats.

Exogenous oxidized cholesterol disturbs both lipid metabolism and immune functions. Therefore, it may perturb these modulations with ageing. Effects of the dietary protein type on oxidized cholesterol-induced modulations of age-related changes in lipid metabolism and immune function was examined using differently aged (4 weeks versus 8 months) male Sprague-Dawley rats when casein, soybean protein or milk whey protein isolate (WPI) was the dietary protein source, respectively. The rats were given one of the three proteins in diet containing 0.2% oxidized cholesterols mixture. Soybean protein, as compared with the other two proteins, significantly lowered both the serum thiobarbituric acid reactive substances value and cholesterol, whereas it elevated the ratio of high density lipoprotein-cholesterol/cholesterol in young rats, but not in adult. Moreover, soybean protein, but not casein and WPI, suppressed the elevation of Delta6 desaturation indices of phospholipids in both liver and spleen, particularly in young. On the other hand, WPI, compared to the other two proteins, inhibited the leukotriene B4 production of spleen, irrespective of age. Soybean protein reduced the ratio of CD4(+)/CD8(+) T-cells in splenic lymphocytes. Therefore, the levels of immunoglobulin (Ig)A, IgE and IgG in serum were lowered in rats given soybean protein in both age groups except for IgA in adult, although these observations were not shown in rats given other proteins. Thus, various perturbations of lipid metabolism and immune function caused by oxidized cholesterol were modified depending on the type of dietary protein. The moderation by soybean protein on the change of lipid metabolism seems to be susceptible in young rats whose homeostatic ability is immature. These observations may be exerted through both the promotion of oxidized cholesterol excretion to feces and the change of hormonal release, while WPI may suppress the disturbance of immune function by oxidized cholesterol in both ages. This alleviation may be associated with a large amount of lactoglobulin in WPI. These results thus showed a possibility that oxidized cholesterol-induced perturbations of age-related changes of lipid metabolism and immune function can be moderated by both the selection and combination of dietary protein.

Aging↗

PubMed1993

Effects of dietary proteins on linoleic acid desaturation and membrane fluidity in rat liver microsomes.

The effect of dietary protein, casein (CAS) and soybean protein (SOY), on linoleic acid desaturation in liver microsomes was studied in rats. The activity of delta 6 desaturase in total and rough endoplasmic reticula (ER and RER) was significantly higher in the CAS group than in the SOY group. In ER and smooth endoplasmic reticulum, the steady-state fluorescence anisotropy of 1,6-diphenyl-1,3,5-hexatriene, when incorporated into the membrane, was decreased in the SOY group and accompanied by a reduction in the cholesterol/phospholipid (CHOL/PL) ratio, consistent with an increase in membrane fluidity. In a separate study, the effect of varying dietary proteins, CAS, milk whey protein, egg albumin, SOY, potato protein and wheat gluten, on the relationship between the delta 6 desaturase activity and microsomal membrane fluidity was also examined. The results indicated that the dietary protein-dependent change in the liver microsomal CHOL/PL ratio affected membrane fluidity, and subsequently the activity of delta 6 desaturase in liver microsomes. However, since dietary protein influenced the delta 6 desaturase activity in RER without influencing membrane fluidity, it is possible that some regulation might have taken place at the level of enzyme synthesis.

Animals↗

PubMed2005

Dietary protein and lactose increase translation initiation factor activation and tissue protein synthesis in neonatal pigs.

Protein synthesis and eukaryotic initiation factor (eIF) activation are increased in muscle and liver of pigs parenterally infused with amino acids and insulin. To examine the effects of enteral protein and carbohydrate on protein synthesis, pigs (n = 42, 1.7 kg body wt) were fed isocaloric milk diets containing three levels of protein (5, 15, and 25 g x kg body wt(-1) x day(-1)) and two levels of lactose (low = 11 and high = 23 g x kg body wt(-1) x day(-1)) from 1 to 6 days of age. On day 7, pigs were gavage fed after 4-h food deprivation, and tissue protein synthesis rates and biomarkers of mRNA translation were assessed. Piglet growth and protein synthesis rates in muscle and liver increased with dietary protein and plateaued at 15 g x kg body wt(-1) x day(-1) (P < 0.001). Growth tended to be greater in high-lactose-fed pigs (P = 0.07). Plasma insulin was lowest in pigs fed 5 g x kg body wt(-1) x day(-1) protein (P < 0.0001). Plasma branched-chain amino acids increased as protein intake increased (P < 0.0001). Muscle (P < 0.001) and liver (P < or = 0.001) ribosomal protein S6 kinase-1 and eIF4E-binding protein phosphorylation increased with protein intake and plateaued at 15 g x kg body wt(-1) x day(-1). The results indicate that growth and protein synthesis rates in neonatal pigs are influenced by dietary protein and lactose intake and might be mediated by plasma amino acids and insulin levels. However, feeding protein well above the piglet's requirement does not further stimulate the activation of translation initiation or protein synthesis in skeletal muscle and liver.

Administration, Oral↗

PubMed1989

The influence of dietary protein on the synthesis of vasoactive substances in subtotally nephrectomized spontaneously hypertensive rats.

The effects of dietary protein alterations on the synthesis of prostaglandins and kallikrein were examined in subtotally nephrectomized spontaneously hypertensive rats. Three diets containing 40, 24 and 8% protein were prepared. After subtotal nephrectomy, rats were given one of the three diets for the next 12 weeks. During the study, systolic blood pressure, urinary excretions of protein, 6-keto-prostaglandin F1 alpha, thromboxane B2 and kallikrein were measured every 2 weeks. Although the diets did not prevent the further elevation of systolic blood pressure, the rats on the low protein diet displayed lower serum creatinine levels and urinary protein levels. The urinary excretion of thromboxane B2 was unaffected by the amount of dietary protein, but the urinary excretion of 6-keto-prostaglandin F1 alpha was lower in the low protein diet group. Furthermore, the urinary excretion of kallikrein increased significantly in rats on high protein diet. These results suggest that manipulation of dietary protein may alter the natural course of renal failure induced by subtotal nephrectomy in spontaneously hypertensive rats.

6-Ketoprostaglandin F1 alpha↗

PubMed1994

Influence of dietary protein and recombinant porcine somatotropin administration in young pigs: III. Muscle fiber morphology and shear force.

Sixty crossbred barrows (average 30 kg) were used in a 5 x 2 factorial treatment array to examine interactions between dietary protein concentration (11, 15, 19, 23, or 27% CP) and recombinant porcine somatotropin (rpST: 0, excipient buffer vs 100 micrograms.kg-1.d-1) for 42 d on muscle fiber morphology and meat tenderness. Diets were isocaloric (3.8 Mcal of DE/kg) and of equal lysine (4.9 g/Mcal of DE) achieved by diluting soybean meal with cornstarch and by addition of crystalline lysine. Dosage of rpST and feed intake (80% of predicted ad libitum) were adjusted weekly. Four muscles (longissimus = LM; semimembranosus = SM; semitendinosus = ST; triceps brachii = TB) were evaluated. Percentages of muscle fiber types (beta R, alpha R, alpha W) for the LM, SM, and TB were not influenced by rpST treatment. More alpha R and fewer alpha W fibers were found in the ST muscle of rpST-treated pigs. No interactions were observed between rpST treatment and dietary protein for muscle fiber type distribution. Dietary protein had no consistent influence on the distribution of muscle fiber types in all four muscles. Area of fibers generally increased in rpST-treated pigs compared with controls when diets contained 19% or more CP. The LM shear force was increased (13%) by rpST treatment for chops frozen after 5 d of storage in the cooler, but not in those chops frozen within 1.5 h postmortem. Dietary protein had a variable influence on tenderness. These data indicate that muscle fiber growth (hypertrophy) in pigs is positively influenced by rpST treatment. Marginal dietary protein intake reduces muscle fiber growth responses to rpST.

Animals↗

PubMed1972

[Balance and assimilation of proteins in elderly people under various dietary protein rations].

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Aged↗

PubMed1996

Effect of dietary protein restriction on liver transcription factors.

The transcription of several genes that are preferentially expressed in the liver, including the serum albumin, transthyretin and carbamyl phosphate synthetase-I genes, is specifically decreased in animals consuming inadequate amounts of dietary protein. The high level of transcription of these genes in the liver is directed in part by a number of liver-enriched transcription factors, including hepatocyte nuclear factors (HNF)-1, -3, and -4, and proteins of the CCAAT/enhancer-binding protein (C/EBP) family. In the present study, we investigated the possibility that the co-ordinate decrease in transcription of the nutritionally sensitive genes in protein-deprived rats results from altered activity of one or more of the liver-enriched transcription factors. For HNF-4, Western blots indicated no change in the level of nuclear HNF-4 protein in liver of protein-deprived animals, whereas we observed a 40% reduction in the DNA binding activity of HNF-4 as measured by electrophoretic mobility shift assay (EMSA). Furthermore, the binding affinity of HNF-4 for DNA was unaltered by dietary protein deprivation, while the number of HNF-4 molecules able to bind to DNA (Bmax) was reduced, as determined by Scatchard analysis. This indicates that in the protein-restricted rats a portion of the pool of HNF-4 protein is inactivated or otherwise prevented from binding to DNA. The overall DNA binding activity of C/EBP alpha and beta was increased in protein-restricted animals. This change occurred in the absence of a change in the amount of the full-length forms of these two proteins, quantified by Western blotting. Interestingly, dietary protein restriction specifically increased the level of a truncated form of C/EBP beta (liver-enriched transcriptional inhibitory protein, LIP), which is a protein dominant negative inhibitor of C/EBP function. Analysis of HNF-3 DNA-binding activity by EMSA revealed that HNF-3 alpha and beta DNA binding was increased and that HNF-3 gamma DNA-binding activity was unchanged in protein-restricted animals. We also detected two apparently novel shift complexes with the HNF-3 probe by EMSA, both of which were decreased in protein-restricted animals. HNF-1 DNA-binding activity was increased by dietary protein restriction. We also examined the effect of protein restriction on the DNA-binding activity of two ubiquitous transcription factors, NF1 and Sp1. The DNA binding activity of the major NF1 isoforms was unchanged whereas the binding activity of Sp1 was increased in the protein-restricted animals. In summary, restriction of dietary protein resulted in a number of specific changes in the DNA-binding activity of various transcription factors. Because transcriptional activation typically involves the synergistic action of more than one transcription factor, small changes in the amount/activity of several factors, could have a strong net effect on the transcription of many genes.

Animals↗

PubMed1999

Serum calcitriol and dietary protein intake in idiopathic calcium stone patients.

In kidney stone patients, high protein intake and calcitriol overproduction are factors leading to hypercalciuria, but there are conflicting reports on the effects of dietary protein on calcitriol production. To investigate the relationships between serum calcitriol, dietary protein intake, and urinary calcium excretion, 33 male idiopathic calcium stone formers (aged 20-60 years), with normal renal function and on unrestricted diet, have been studied. Dietary protein intake was estimated by the protein catabolic rate determination. Abnormally elevated calcitriol levels were found in 16 patients (48.5%) who had similar levels of serum intact parathyroid hormone and phosphate, creatinine clearance, and calcium and phosphate urinary excretion, but lower protein catabolic rate (82+/-16 vs. 97+/-20 g/day, P<0.05) than the patients with normal calcitriol levels. The calcitriol to intact parathyroid hormone ratio was higher in hypercalciuric than in normocalciuric patients (2.4+/-1.1 vs. 1.6+/-0.8, P<0.05). Calcitriol was positively correlated with plasma calcium (r=0.41, P<0.01) and inversely with protein catabolic rate (r=-0.42, P<0.01). Protein catabolic rate was positively correlated with creatinine clearance (r=0.69, P<0.001) and urinary phosphate excretion (r=0.72, P<0.001). No relationship was observed between calcitriol and creatinine clearance. These results confirm the calcitriol overproduction in calcium stone disease and that the high calcitriol to intact parathyroid hormone ratio is the main feature associated with hypercalciuria. Calcitriol serum levels appear to be unrelated to creatinine clearance, whereas there is an inverse relationship with protein catabolic rate. This suggests that low rather than high dietary protein intake may favor the increase of calcitriol synthesis in male calcium stone formers with normal renal function.

Adult↗

PubMed2006

Longitudinal associations between dietary protein intake and survival in hemodialysis patients.

BACKGROUND: Decreased dietary protein intake may be associated with increased mortality risk in individuals with kidney failure undergoing maintenance hemodialysis (MHD). We hypothesized that longitudinal changes in dietary protein intake have independent associations with survival in MHD patients. METHODS: The relation between urea kinetic-based normalized protein nitrogen appearance (nPNA) and all-cause and cardiovascular mortality was examined in a 2-year (July 2001 to June 2003) cohort of 53,933 MHD patients from virtually all DaVita dialysis clinics in the United States, using both conventional and time-dependent (repeated-measure) Cox models to estimate death hazard ratios for quarterly averaged nPNA categories controlled for case-mix, comorbidity, dialysis dose (Kt/V), and available markers of malnutrition-inflammation complex syndrome (MICS). RESULTS: The best survival was associated with nPNA between 1.0 and 1.4 g/kg/d, whereas nPNA less than 0.8 or greater than 1.4 g/kg/d was associated with greater mortality in almost all models. Adjustment for MICS mitigated the associations substantially. A decrease in protein intake during the first 6 months in patients with an nPNA in the 0.8- to 1.2-g/kg/d range was associated incrementally with greater death risks in the subsequent 18 months, whereas an increase in nPNA tended to correlate with reduced death risk. CONCLUSION: Low daily protein intake or decrease in its magnitude over time is associated with increased risk for death in MHD patients. Whether the association between time-varying protein intake and survival is causal or a consequence of anorexia secondary to MICS or other factors needs to be explored further in interventional trials.

Aged↗