Low Carb High Fat - Ketogenic

A discussion elsewhere on lemmy piqued my interest in the literature on KMT and kidney health. This seemed like a good, recent over-view article.

This is from the "Clinical Kidney Journal" in their "debate" series, so there is a pro and con article for the topic.

Notes

We use the term ‘ketogenic metabolic therapy’ (KMT) instead of ‘ketogenic diet’ to make it clear that we are discussing a form of medical nutrition therapy (MNT) to address certain health conditions related to chronic kidney disease (CKD), in contrast to ‘diet’ or culinary preferences. KMT can be as effective as pharmacological interventions and is a therapeutic option that should be in the armamentarium of every physician and dietitian.

Diet really does diminish what are are often trying to convey.

Fasting is arguably the oldest form of MNT, practiced since time immemorial. KMT using ketogenic diets is not a new therapy but has been employed since prepharmacological times as routine therapy for diabetes mellitus [1] and childhood epilepsy [2]. Clearly, ketogenic diets are not recent ‘fad’ diets as they are sometimes incorrectly labeled.

1877 - Keto for Diabetes.

Medical professionals commonly confuse ‘ketosis’ with ‘ketoacidosis’. However, besides the fact that they rhyme, they have nothing in common.

heh, plus I think its impossible to get ketoacidosis if your not t1d, since insulin will suppress ketogenesis... which is also why "cheating" often leads to falling off the wagon on keto.

A common misconception is the incorrect belief that carbohydrates, also commonly abbreviated as carbs, are essential nutrients. As known in biochemistry, they are not. The human body can synthesize all needed carbohydrates. .... It is often mistakenly believed that the body has to ‘run on glucose’ or that the brain requires high blood glucose levels to function. .... It is important to remember basic physiology and that the human body stores fat (triglycerides in adipose tissue, liver and other organs) besides glucose (glycogen). The brain is well adapted to utilize ketones over glucose as its energy source

It should be noted that sodium–glucose cotransporter 2 (SGLT2) inhibitors, which are now widely prescribed to CKD patients and often hailed as a breakthrough treatment, work on the same principle as KMT, albeit less effectively [17]. SGLT2 inhibition causes renal excretion of up to 80 g of glucose per day, thereby partially relieving the high carbohydrate burden from patients’ diets. Arguably, the same effect could be achieved by ingesting 80 g less sugar/starch per day, which is the equivalent to about two cans of soda. Using a ketogenic diet, sugar/starch consumption can be further reduced. SGLT2 inhibition also leads to elevation of blood ketone levels, which likely contributes to the benefit [18]. Altogether, SGLT2 inhibition could be considered a ‘light’ version of KMT that, unfortunately, is accompanied by drug-induced adverse effects [19].

This is super fucking interesting. I wasn't aware of slgt2 increase in glucose urination. The perspective of slgt2 as being medically induced keto is a new spin.

The second most common cause of CKD is hypertension, and antihypertensive medication is commonly prescribed for CKD. KMT using ketogenic diets has been shown to significantly lower blood pressure

KMT has been shown to lead to halting of CKD progression or, in some reported cases, may even induce remission.

A randomized controlled trial comparing a 2-year intervention with a ketogenic (low carbohydrate, high fat/protein) diet versus a Mediterranean diet versus a conventional low fat diet in 322 overweight or obese participants with mild–moderate CKD (stages 1–3) showed that the dietary interventions led to weight loss and improved renal function [25]. The ketogenic diet generally had the greatest beneficial effect on renal function, especially in participants with CKD stage 3 [estimated glomerular filtration rate (eGFR) improvement by 7.1 points over 2 years] [25].

In a baseline-controlled, real-life observational prospective study, 92 obese participants were subjected to a ketogenic diet for 15 weeks, including 38 subjects with mild CKD (stage 2) [26]. The intervention resulted in significant fat weight loss, improvement of hypertension, a reduction in total cholesterol and triglycerides and other metabolic improvements. Remarkably, in 27.7% of those with CKD, the intervention led to remission of CKD, leading to an eGFR ≥90 [26]. No safety concerns arose during the study.

A baseline-controlled, retrospective analysis of routine clinical data during the span of 7 years in 143 patients with T2D revealed the following. Patients were prescribed a very low carbohydrate ketogenic diet that not only led to significant weight loss, improvement of glycemic control and HbA1c and a T2D remission rate of 48%, but also led to significant improvements in renal function as shown in the form of creatinine/eGFR and urine albumin:creatinine ratio [27].

A recent study compared intervention with a ketogenic diet via continuous remote telemedicine care in 262 individuals with T2D and an eGFR <90 ml/min/1.73 m2 with 87 matched individuals receiving usual care over 2 years [30]. The eGFR slope was negative (worsened CKD) in the usual care group but was positive (improved CKD) in the ketogenic intervention group, with a significant difference between groups. Interestingly, subgroup analysis showed that renal function improved most in individuals who achieved sustained nutritional ketosis (consistently ≈1 mM BHB), suggesting a dose-dependent relationship with endogenous ketone concentration [30].

A recent meta-analysis estimated that ≈8% of individuals on ketogenic diets develop kidney stones during a follow-up of ≈4 years [41]. It is difficult to judge whether this represents an increase compared with the general population, which has a similar risk of developing kidney stones [42]. However, interestingly, ≈50% of the kidney stones in subjects on ketogenic diets were uric acid stones and an additional 28% were mixed uric acid and calcium stones [41], suggesting a potential link to animal protein intake as a known cause of high uric acid burden. In contrast, calcium oxalate stones are by far the most common stones in the general population. Temporary increases in serum uric acid levels have been reported during the transition into ketosis, which is followed by a long-term decrease below baseline [14]. Urine acidification that occurs in ketosis may increase the risk of forming both uric acid and calcium oxalate stones. Consequently, the Ren.Nu dietary program for ADPKD utilizes an alkalinizing, plant-focused ketogenic diet and the medical food KetoCitra to facilitate the normalization of urine pH and urine citrate levels, along with increased water intake, in order to reduce the risk of kidney stones [9].

This is interesting, so different composition and based on uric acid... I wonder if this holds in carnivore or just plant based keto?

Continued research and utilization of KMT for CKD management will lead to its widespread adoption. KMT does not have to be combined with medications and can be implemented inexpensively anywhere in the world.