Current Hypertension Reports (2020) 22: 14

https://doi.org/10.1007/s11906-020-1020-1

NUTRITION AND HYPERTENSION (T MORI, SECTION EDITOR)

Diet and Kidney Function: a Literature Review

A. C. van Westing 1 & L. K. Küpers 1 & J. M. Geleijnse 1

Published online: 3 February 2020

# The Author(s) 2020

Abstract
Purpose of Review The burden of chronic kidney disease (CKD) is increasing worldwide. For CKD prevention, it is important to
gain insight in commonly consumed foods and beverages in relation to kidney function.
Recent Findings We included 21 papers of prospective cohort studies with 3–24 years of follow-up. We focused on meat, fish,
dairy, vegetables, fruit, coffee, tea, soft drinks, and dietary patterns. There was convincing evidence that a healthy dietary pattern
may lower CKD risk. Plant-based foods, coffee, and dairy may be beneficial. Unhealthy diets and their components, such as red
(processed) meat and sugar-sweetened beverages, may promote kidney function loss. For other foods and beverages, associations
with CKD were neutral and/or the number of studies was too limited to draw conclusions.
Summary Healthy dietary patterns are associated with a lower risk of CKD. More research is needed into the effects of specific
food groups and beverages on kidney function.

Keywords Dietary patterns . Foods . Beverages . Kidney function . Chronic kidney disease . Prospective cohort studies .
Glomerular filtration rate

Introduction that, there is increasing scientific interest in the potential role

of diet [15, 16]. High salt intake is an established risk factor for
Chronic kidney disease (CKD) is a major public health burden kidney function decline [17, 18], mainly through its adverse
[1, 2], with a global prevalence of ~ 11% in the general adult effect on blood pressure and vascular health [19–21]. Less is
population [1]. If left untreated, CKD slowly progresses to end- known about other dietary factors. Therefore, we reviewed the
stage renal disease, which requires dialysis or kidney transplant current evidence on foods, beverages, and overall dietary
[2, 3]. CKD is bidirectionally associated with cardiovascular quality in relation to the risk of incident CKD using data from
diseases (CVD) [4, 5]. Hypertension [6] and type 2 diabetes prospective cohort studies.
mellitus (T2DM) [7, 8] are independent risk factors for CKD [6,
7], and their global prevalences are increasing [9, 10], which
will likely impact CKD. Worldwide, a 31.7% increase of CKD Methods
mortality was observed over the last decade [11].
Lifestyle factors, including smoking [12], alcohol use [13], We performed a comprehensive search in PubMed of papers
and physical inactivity [14], could promote CKD. Apart from published until August 2019 describing prospective cohort
studies, supplemented by manual searches of reference lists
from appropriate studies. The review is based on prospective
This article is part of the Topical Collection on Nutrition and
Hypertension cohort studies with at least 3 years of follow-up that reported
on the relation between food groups, beverages, and dietary
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11906-020-1020-1) contains supplementary
patterns and kidney function in populations free from CKD
material, which is available to authorized users. (defined as mean estimated glomerular filtration rate (eGFR)
> 60 ml/min/1.73 m2).
* A. C. van Westing Foods of interest were red (processed) meat, poultry, fish,
[email protected] dairy, vegetables, legumes, nuts, and fruits. Beverages includ-
ed coffee, tea, sugar-sweetened beverages (SSBs), and diet
1
Division of Human Nutrition and Health, Wageningen University, beverages. Dietary patterns included adherence to the
Stippeneng 4, 6708 WE Wageningen, The Netherlands Dietary Approach to Stop Hypertension (DASH) diet,
14 Page 2 of 9 Curr Hypertens Rep (2020) 22: 14

Mediterranean diet, and other healthy dietary patterns. per day (high intake). In the Atherosclerosis Risk in
Unhealthy diets were high fat, high sugar diets, and diets Communities (ARIC) study of ~ 12,000 US participants with
with a high acid load. 23 years of follow-up, a total of 2632 participants developed
Concerning kidney function, we selected studies with data CKD [25••]. In this population, the HR for high versus low
on the eGFR, derived from the Chronic Kidney Disease intake of red meat and CKD risk was 1.19 (95% CI, 1.03;
Epidemiology Collaboration (CKD-EPI) equation [22, 23] 1.36; Fig. 1) [25••]. In a study of 4881 Iranian participants
and Modification of Diet in Renal Disease (MDRD) [24]. followed for 3 years, 613 participants developed CKD with
Reasons for exclusion of articles were studies with (1) an OR of 1.73 (95% CI, 1.33; 2.24) for high versus low red
follow-up less than 3 years, (2) study design other than pro- meat intake (Fig. 1) [26••]. Findings for processed meat were
spective cohort study, (3) study population with T2DM and similar to those for red meat in both studies, and no significant
analgesic use, (4) no full-text available, and (5) focus on end- associations with kidney function were found for poultry
stage renal disease. The selection process is shown in eFig. 1. (Fig. 1) [25••].
From selected papers, we extracted data on population
characteristics, study design, intakes of foods and/or bever- Fish
ages, kidney function outcomes, risk estimates for diet-
kidney function associations, and potential confounders. Two studies evaluated the association between fish consump-
The primary outcome for this review was “incident CKD” tion and incident CKD (Fig. 1) [25••, 27]. The Strong Heart
based on eGFR cutoff criteria, described in eTable 1. Study among American Indians followed 2261 participants
Associations between foods, beverages, and incident CKD for 5.4 years of whom 4% developed CKD. Fish intake was
in different studies were expressed as odds ratios (OR), ob- analyzed in four categories ranging from 0 to > 15 g per day
tained from logistic regression analysis, or hazard ratios (HR), [27]. No significant associations were found with an OR of
obtained from Cox proportional hazard analysis with corre- 1.46 (95% CI, 0.65; 3.26) for high versus zero fish intake [27].
sponding 95% confidence intervals (CI). In this review, OR In the ARIC study [25••], fish intake was analyzed in quintiles
and HR are both denoted as relative risks (RRs). Continuous ranging from 0.07 to 0.64 servings per day. A borderline sig-
associations between food groups, beverages, and change in nificant HR of 0.89 (95% CI, 0.78; 1.01) was found in the
eGFR are expressed as beta regression coefficients, obtained upper versus lower quintile of intake (Fig. 1) [25••].
from multivariable linear regression.
RRs and betas from fully adjusted models are reported in Dairy
tables with potential confounders. When these models includ-
ed possible intermediates (i.e., factors could play a role in the Dairy consumption and incident CKD were examined in the
biological pathway), risk estimates from less adjusted models ARIC study among US individuals (Fig. 1) [25••]. Intake of
are given. Two-sided P values < 0.05 for risk estimates were low-fat dairy ranged from 0.00 to 2.04 servings per day and
considered statistically significant. intake of high-fat dairy from 0.13 to 1.61 servings per day
[25••]. A significantly lower risk of CKD was found for
low-fat dairy intake, with a HR of 0.75 (95% CI, 0.65; 0.85)
Results for high versus low intake. High-fat dairy intake was also
inversely associated with CKD, albeit non-significant
An overview of studies of foods, beverages, and dietary pat- (Fig. 1) [25••].
terns and their associations with incident CKD is presented in
eTable 1. Studies that focused on eGFR change, albuminuria, Vegetables
or hyperuricemia are described in eTable 2 and eTable 3.
Graphical displays of the point estimates with 95% CI related We found 3 studies of vegetable intake and CKD risk (Fig. 1)
to incident CKD using forest plots are presented in Figs. 1, 2, [28•, 29••, 30]. In a study of 1780 Iranians from the Tehran
and 3. Lipid Glucose Study (TLGS), followed for 6 years, 319 par-
ticipants developed CKD [28•]. Allium vegetable intake was
Foods analyzed in tertiles ranging from 1 to 39 g per week [28•]. A
significant inverse association with CKD risk was found, with
Meat a HR of 0.68 (95% CI, 0.48; 0.98) in the upper versus lower
tertiles of intake [28•]. In 9229 participants from the Korean
Two studies evaluated the consumption of red (processed) Genome and Epidemiology Study, 1741 incident CKD cases
meat and poultry in relation to incident CKD (Fig. 1) [25••, were reported during 8.2 years [29••]. Intake of non-fermented
26••]. Red meat intake in these studies varied between 0.17 to vegetables ranged from 49 to 222 g per day, and intake of
0.34 servings per day (low intake) and 1.15 to 2.52 servings fermented vegetables from 164 to 227 g per day [29••].
Curr Hypertens Rep (2020) 22: 14 Page 3 of 9 14

Foods and incident CKD

Follow−up no. cases / total no. RR (95% CI)

RED MEAT
Haring et al. 2017 23.0y 2632 / 11952 1.19 (1.03; 1.36)
Mirmiran et al. 2019 3.1y 613 / 4881 1.73 (1.33; 2.24)

PROCESSED (RED) MEAT

Haring et al. 2017, processed meat 23.0y 2632 / 11952 1.12 (0.98; 1.29)
Mirmiran et al. 2019, processed red meat 3.1y 613 / 4881 1.99 (1.54; 2.56)

POULTRY
Haring et al. 2017 23.0y 2632 / 11952 0.94 (0.84; 1.06)

FISH
Lee et al. 2012 5.4y Unknown / 2261 1.46 (0.65; 3.26)
Haring et al. 2017 23.0y 2632 / 11952 0.89 (0.78; 1.01)

DAIRY
Haring et al. 2017, high−fat dairy 23.0y 2632 / 11952 0.93 (0.81; 1.06)
Haring et al. 2017, low−fat dairy 23.0y 2632 / 11952 0.75 (0.65; 0.85)

VEGETABLES
Bahadoran et al. 2017, allium vegetables 6.0y 319 / 1780 0.68 (0.46; 0.98)
Jhee et al. 2019, non−fermented vegetables 8.2y 1741 / 9229 0.86 (0.76; 0.98)
Jhee et al. 2019, fermented vegetables 8.2y 1741 / 9229 0.94 (0.83; 1.06)
Mirmiran et al. 2016, nitrate−containing vegetables 3.0y Unknown / 1299 0.93 (0.43; 2.02)

LEGUMES
Haring et al. 2017 23.0y 2632 / 11952 0.83 (0.72; 0.95)

NUTS
Haring et al. 2017 23.0y 2632 / 11952 0.81 (0.72; 0.92)

FRUITS
Jhee et al. 2019 8.2y 1741 / 9229 1.00 (0.88; 1.14)

0 1 2 3
RR (95% CI)

Fig. 1 Forest plot for associations between commonly consumed foods and incident chronic kidney disease

Non-fermented vegetables were inversely related to CKD risk, Fruits

with a HR of 0.86 (95% CI, 0.76; 0.98) for high versus low
intake (Fig. 1) [29••]. For fermented vegetables, an inverse but One study in 9229 South Koreans, followed for 8.2 years,
non-significant association was found (Fig. 1) [29••]. In the reported on fruit consumption and incident CKD [29••].
abovementioned TLGS, nitrate-containing vegetable intake Fruit intake ranged from 143 to 345 g per day and showed
ranged from 146 to 428 g per day [30]. No significant associ- no association with incident CKD (HR of 1.00) (Fig. 1) [29••].
ation with CKD risk was found after 3 years of follow-up
(Fig. 1) [30]. Beverages

Coffee
Legumes and Nuts
Three studies examined coffee consumption and incident
In the ARIC study with 23 years of follow-up, legume intake CKD (Fig. 2) [31–33]. The Iranian TLGS compared coffee
ranged from 0.07 to 0.68 servings per day and nut intake drinkers (median intake 8.3 ml per day) to non-drinkers [31].
ranged from 0.03 to 0.86 servings per day [25••]. Both le- In the ARIC study in the USA [32] and the Korean Genome
gumes and nuts were significantly associated with lower risks and Epidemiology Study in South Korea [33], those drinking
of CKD, with HRs of 0.83 (95% CI, 0.72; 0.95) and 0.81 at least 3 cups [32] or at least 2 cups [33] were compared with
(95% CI, 0.72; 0.92) for high versus low intakes, respectively non-coffee drinkers. In the Iranian study, a non-significant
(Fig. 1) [25••]. direct association between coffee and CKD was found [31],
14 Page 4 of 9 Curr Hypertens Rep (2020) 22: 14

Beverages and incident CKD

Follow−up no. cases / total no. RR (95% CI)

COFFEE

Gaeini et al. 2019 6.4y 318 / 1780 1.17 (0.90; 1.51)

Hu et al. 2018 24.0y 3845 / 14209 0.84 (0.75; 0.94)

Jhee et al. 2018 11.3y 828 / 8717 0.80 (0.65; 0.98)

TEA

Gaeini et al. 2019 6.4y 318 / 1780 0.92 (0.68; 1.25)

SSBs

Bomback et al. 2010 9.0y 1160 / 14002 0.82 (0.59; 1.16)

Rebholz et al. 2019 8.0y 185 / 3003 1.37 (0.86; 2.16)

Yuzbashian et al. 2016 3.0y 172 / 1690 1.92 (1.05; 3.48)

DIET BEVERAGES

Rebholz et al. 2019 8.0y 185 / 3003 0.80 (0.51; 1.25)

0 0.5 1 1.5 2 2.5 3

RR (95% CI)
Fig. 2 Forest plot for associations between commonly consumed beverages and incident chronic kidney disease. SSB, sugar-sweetened beverages

whereas in the US and Korean studies, significant inverse additives [31]. No significant association with incident CKD
associations were observed in those with higher coffee in- was found (Fig. 2) [31].
takes, with HR of 0.84 [32] and 0.80 [33], respectively
(Fig. 2).
Soft Drinks

Tea Three studies reported on SSBs and incident CKD (Fig. 2)

[35–37], of which one American study also reported on diet
The Iranian TLGS also reported on tea consumption, ranging beverages (Fig. 2) [36]. In the ARIC study with 9 years of
from < 250 ml (low intake) to > 750 ml per day (high intake) follow-up, consumption of SSB (cutoff 1 drink per day) was
(Fig. 2) [31]. Unfortunately, data on the type of tea and its not significantly associated with CKD risk [35]. In the
preparation method was not collected [31]. However, a previ- Jackson Heart Study (3003 participants, 185 CKD cases) with
ous study reported that in Iran, black tea is often consumed 8 years of follow-up, a direct, non-significant association of
[34] with added sweets and sugar, including a variety of SSB with CKD risk was found [36]. In the Iranian TLGS, SSB
Curr Hypertens Rep (2020) 22: 14 Page 5 of 9 14

Dietary patterns and incident CKD

Follow−up no. cases / total no. RR (95% CI)

ADHERENCE TO HEALTHY DIETS

Asghari et al. 2017, DASH diet 6.1y 220 / 1630 0.41 (0.24; 0.70)

Liu et al. 2017, DASH diet 5.0y 38 / 1534 0.68 (0.38; 1.19)

Rebholz et al. 2016, DASH diet 23.0y 3720 / 14882 0.86 (0.79; 0.93)

Khatri et al. 2014, Mediterranean diet 6.9y 115 / 900 0.50 (0.31; 0.81)

Hu et al. 2019, Mediterranean diet 24.0y 3980 / 12155 0.89 (0.81; 0.99)

Hu et al. 2019, Healthy Eating Index 24.0y 3980 / 12155 0.86 (0.77; 0.96)

Hu et al. 2019, Alternative Healthy Eating Index 24.0y 3980 / 12155 0.81 (0.73; 0.90)

Rebholz et al. 2016, healthy diet score 22.0y 2743 / 14832 0.99 (0.83; 1.18)

Foster et al. 2015, diet quality 6.6y 171 / 1802 0.63 (0.38; 1.07)

ADHERENCE TO UNHEALTHY DIETS

Asghari et al. 2018, high fat, high sugar diet 6.1y 220 / 1630 1.47 (1.03; 2.08)

Rebholz et al. 2015, dietary acid load 21.0y 2351 / 15055 1.14 (1.01; 1.28)

0 0.5 1 1.5 2
RR (95% CI)

Fig. 3 Forest plot for associations between dietary patterns and incident chronic kidney disease. DASH, Dietary Approach to Stop Hypertension

consumption ranged from < 0.5 to > 4 servings per week [37]. TLGS with 6.1 years of follow-up [39]. All studies suggested
A significantly elevated risk of CKD was found when com- a beneficial effect of the DASH diet, with RRs between 0.41
paring high with low intakes, with an OR (95% CI) of 1.92 and 0.86 for high versus low adherence (Fig. 3). The associ-
(1.05; 3.48) (Fig. 2) [37]. Diet beverages were studied in the ation was statistically significant for 2 studies [39, 41].
Jackson Heart Study and showed no significant association Mediterranean diet scores were examined in the Northern
with CKD risk (Fig. 2) [36]. Manhattan Study [38] and ARIC study [42••], with 6.9 years
[38] and 24 years [42••] of follow-up, respectively. Reduced
Dietary Patterns RRs of 0.50 [38] and 0.89 [42••] were found for high versus
low adherence, which were significant for both studies (Fig. 3).
Healthy Diets The ARIC study also examined [42••] adherence to
healthy dietary patterns assessed using the Healthy
A number of studies examined healthy dietary patterns and Eating Index-2015 (HEI-2015) and the alternative HEI-
incident CKD [38, 39, 40•, 41, 42••, 43, 44], including the 2010 [42••]. The HEI-2015 was designed to assess ad-
DASH diet [39, 40•, 41], Mediterranean diet [38, 42••], and herence to US Dietary Guidelines for Americans [45],
other healthy dietary patterns [42••, 43, 44], for which find- while the alternative HEI-2010 was designed to identify
ings are shown in Fig. 3. The DASH diet was examined in the key components associated with chronic diseases [46].
Healthy Aging in Neighborhoods of Diversity across the Life For both diet quality scores, significantly lower risks of
Span cohort with 5 years of follow-up [40•], in the ARIC CKD were found for higher adherence, with RRs of
study with 23 years of follow-up [41] and in the Iranian 0.86 and 0.81, respectively (Fig. 3) [42••].
14 Page 6 of 9 Curr Hypertens Rep (2020) 22: 14

In the ARIC study with 22 years of follow-up, the Healthy shown in a study among Iranian TLGS participants, with
Diet Score based on American Heart Association’s Life’s 6.1 years of follow-up [50]. Consumption of whole grains
Simple 7 was studied, which appeared not to be associated has also been linked to less kidney function decline in the
with incident CKD [43]. In the Framingham Offspring cohort Doetinchem Study in The Netherlands, with 15 years of
followed for 6.6 years (1802 participants, 171 CKD cases), the follow-up [51]. In a study of vegetables and fruit intake in
Dietary Guidelines Adherence Index was borderline signifi- relation to kidney function decline, assessed by the annual
cantly inversely associated with CKD risk [44]. change in eGFR, inverse associations were found [51]
Healthy dietary patterns were also beneficially associated (Supplementary material; eTable 2), which strengthens our
with other renal function outcomes, such as rapid eGFR de- findings on healthy dietary patterns.
cline [40•, 44] and ≥ 25% eGFR decline [40•] (Supplementary We found no association of CKD with fish intake, which is
material; eTable 1). often considered part of a healthy diet. This was confirmed in
another study among American Indians with 5.4 years of fol-
Unhealthy Diets low-up, where fish intake was not related to change in kidney
function [27] (Supplementary material; eTable 2). For poultry,
Two studies reported on unhealthy dietary patterns and inci- we could only include one study, and more research is needed.
dent CKD (Fig. 3) [47, 48]. In the TLGS, a high-fat, high- Our results for coffee, indicating a potentially protective
sugar diet was related to a significantly higher risk of CKD, effect, are also in line with the results from a study on kidney
with OR of 1.46 [47]. In participants of the ARIC study, an function change [52] (Supplementary material; eTable 2). In
increased HR of 1.13 was found for a diet with a high acid this study, the coffee was mainly caffeinated [52] and likely to
load (12.2 to 100.7 mEq per day), which is characterized by be filtered. The Iranian study suggested an increased, albeit
high levels of salt, animal protein, and phosphorus, compared non-significant, risk of CKD, which could be attributable to
with a low acid load (− 119.1 to − 3.2 mEq per day). the regularly consumed unfiltered type of coffee in this coun-
try [31]. However, more information regarding the type of
coffee and its preparation methods is needed, including
Conclusion amounts of added sugar and other condiments, before results
can be correctly interpreted. We found no beneficial associa-
This review of 21 prospective cohort studies among individ- tions for tea and incident CKD, which was in line with the
uals with (relatively) normal kidney function shows a consis- results from a Dutch study on kidney function decline [52]
tently lower risk of CKD in those adhering to a healthy dietary (Supplementary material; eTable 2). However, our review in-
pattern [38, 39, 40•, 41, 42••, 43, 44]. For individual food cluded only one study on incident CKD from Iran [31]. More
groups and beverages, the observed associations were more information about the types of tea in relation to kidney func-
variable and weaker. We found adverse associations for red tion, including amounts of added sugar, is needed before
(processed) meat and SSBs in some studies and beneficial drawing conclusions.
associations for dairy, vegetables, legumes, and nuts. For low-fat dairy products and incident CKD, we found
Two recent reviews have indicated that healthy dietary pat- some evidence for a potentially protective effect on kidney
terns may prevent incident CKD [15, 16]. Ajjarapu et al. in- function, though based on only one study [25••]. This is in
cluded 26 prospective cohort studies and found that adherence line with a study in Dutch participants in which less kidney
to a DASH or Mediterranean diet may be useful to prevent function loss was found during 15 years of follow-up who
CKD [16]. Similar results were found in a meta-analysis of 15 consumed more milk and low-fat dairy [53] (Supplementary
prospective and retrospective cohort studies performed by material; eTable 2).
Bach et al. [15]. A low animal/vegetable protein ratio is often With regard to other kidney function outcomes
considered an indicator of a healthy dietary pattern. In this (Supplementary material; eTable 3), studies on the risk
regard, the ARIC study [25••] showed that after 23 years of of albuminuria [27, 35, 54, 55] and hyperuricemia [35]
follow-up, high (> 22.8 g per day) versus low (< 12.1 g per were in accordance with those for CKD. A higher, al-
day) intake of vegetable protein was significantly associated beit non-significant risk of hyperuricemia was found for
with lower risk of CKD, whereas no association was found for high versus low SSB consumption [35]. Also, a good
high (> 69.6 g per day) versus low (< 36.4 g per day) intake of versus poor diet quality, based on eight fundamental
animal protein [25••]. Similar results on animal protein intake DASH diet components, was associated with a lower
were found in 1135 participants with normal renal function risk of incident microalbuminuria [55], and fruit intake
(defined as eGFR > 80 ml/min/1.73 m2) from the Nurses’ was related to a lower risk of albuminuria [54]. Fish
Health Study [49]. intake was not associated with albuminuria [27, 56].
A lower risk of incident CKD for those consuming more To summarize, this review shows that a healthy dietary
vegetables and legumes may partly be attributable to fiber, as pattern may help prevent kidney function decline and lower
Curr Hypertens Rep (2020) 22: 14 Page 7 of 9 14

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