As the standard of care for stage G3b-5 CKD, we recommend that patients be encouraged to lower their dietary protein intake to 0.6–0.8 g/kg·standard body weight (SBW)/day. Actual protein intake should be estimated by analyzing the urea content in the 24-h urine sample using the Maroni formula; it should then be evaluated by comparing it with the results of previously published studies, which showed that the achieved protein intakes were 0.75–0.9 g/kg/day in clinical trials with protein restriction of 0.6–0.8 g/kg/day. Several studies also demonstrated both the efficacy and potential hazards of a very low protein diet. Therefore, the potential

benefits selleck inhibitor and risks of severe protein restriction should be specifically assessed for each patient. Digestibility and the amino acid score of protein sources should be taken into consideration when prescribing protein restriction diets. For early CKD with the risk of progression, we suggest encouraging patients to lower their protein intake to 0.8–1.0 g/kg·SBW/day. The extent of protein restriction should be individualized in accordance with each patient’s specific clinical condition, including severity, risk of progression, nutritional status, and adherence. Bibliography 1. Pan Y, et al. Am J Clin Nutr. 2008;88:660–6. (Level 1)   2. Gansevoort RT, et al. Nephrol Dial Transplant. 1995;10:497–504. (Level 3)

  3. Williams PS, et al. Q J Med. 1991;81:837–55. (Level selleck 2)   4. D’Amico G, et al. Nephrol Dial Transplant. 1994;9:1590–4. (Level 2)   5. Mircescu G, et al. J Ren Nutr. 2007;17:179–88. (Level 2)   6. Rosman JB, et al. Kidney Int Suppl. 1989;27:S96–102. (Level 2)   7. Cianciaruso B, et al. Am J Kidney Dis. 2009;54:1052–61. (Level 2)   8. Fouque D, et al. Cochrane Database Syst Rev. 2009:CD001892. (Level 1)   9. Pedrini MT, et al. Ann Intern Med. 1996;124:627–32. (Level 1)   10. Hansen HP, et al. Kidney Int. 2002;62:220–8. (Level 2)   11. Kasiske BL, et al. Am J Kidney Dis. 1998;31:954–61. (Level 1)   12. Robertson L, et al. Cochrane Database Syst Rev. 2007;CD002181.

RAS p21 protein activator 1 (Level 1)   13. Koya D, et al. Diabetologia. 2009;52:2037–45. (Level 2)   14. Feiten SF, et al. Eur J Clin Nutr. 2005;59:129–36. (Level 2)   15. Jungers P, et al. Kidney Int. 1987;22(Suppl):S67–71. (Level 2)   16. Cianciaruso B, et al. Nephrol Dial Transplant. 2008;23:636–44. (Level 2)   17. Malvy D, et al. J Am Coll Nutr. 1999;18:481–6. (Level 2)   18. Di Iorio BR, et al. Kidney Int. 2003;64:1822–8. (Level 2)   19. Ihle BU, et al. N Engl J Med. 1989;321:1773–7. (Level 2)   20. Levey AS, et al. Am J Kidney Dis. 1996;27:652–63. (Level 4)   21. Zeller K, et al. N Engl J Med. 1991;324:78–84. (Level 2)   22. Klahr S, et al. J Am Soc Nephrol. 1995;5:2037–47. (Level 3)   23. Walser M, et al. Am J Kidney Dis. 1996;28:354–64. (Level 5)   24. Chauveau P, et al. J Ren Nutr. 2007;17:250–7.