{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T01:56:01Z","timestamp":1777427761323,"version":"3.51.4"},"reference-count":43,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2019,1,8]],"date-time":"2019-01-08T00:00:00Z","timestamp":1546905600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003669","name":"Korea Centers for Disease Control &amp; Prevention","doi-asserted-by":"publisher","award":["2011E3300300, 2012E3301100, 2013E3301600, 2013E3301601, 2013E3301602, and 2016E3300200"],"award-info":[{"award-number":["2011E3300300, 2012E3301100, 2013E3301600, 2013E3301601, 2013E3301602, and 2016E3300200"]}],"id":[{"id":"10.13039\/501100003669","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Studies on the effect of dietary protein intake (DPI) on chronic kidney disease (CKD) progression, along with the potential hazard of protein-energy wasting (PEW), are scarce. We evaluated the association between DPI and kidney function both cross-sectionally and longitudinally, particularly emphasizing the role of PEW, in a large-scale, observational, multicenter, prospective study. We enrolled 1572 patients with non-dialysis CKD between 2011 and 2016. CKD progression was defined by a &gt;50% estimated glomerular filtration rate (eGFR) decrease, serum creatinine doubling, or dialysis initiation. A Cox proportional hazard regression analysis was conducted. During the mean follow-up period of 41.6 months, CKD progression was observed in 296 patients. Cross-sectionally, increased DPI was significantly associated with increased eGFR. Similarly, increased DPI tertile was significantly associated with increased renal survival in a Kaplan\u2013Meier curve analysis. In the multivariate Cox proportional hazard regression analysis, the statistical significance of the DPI tertile group in CKD progression was lost when PEW-related variables were added as covariates. In penalized spline curve analysis, the adjusted odds ratio of PEW significantly increased as DPI decreased. DPI, per se was not a major determinant of CKD progression. An intimate association between reduced DPI and PEW may be a more important predictor of CKD progression than DPI.<\/jats:p>","DOI":"10.3390\/nu11010121","type":"journal-article","created":{"date-parts":[[2019,1,9]],"date-time":"2019-01-09T03:06:06Z","timestamp":1547003166000},"page":"121","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":32,"title":["Dietary Protein Intake, Protein Energy Wasting, and the Progression of Chronic Kidney Disease: Analysis from the KNOW-CKD Study"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4419-3938","authenticated-orcid":false,"given":"Sung Woo","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yong-Soo","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul 06591, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yeong Hoon","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Inje University, Busan Paik Hospital, Busan 47392, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wookyung","family":"Chung","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Gachon University, Gil Hospital, Incheon 21565, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sue K.","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Preventive Medicine, Seoul National University College of Medicine, Seoul 03082, Korea"},{"name":"Cancer Research Institute, Seoul National University, Seoul 08826, Korea"},{"name":"Department of Biomedical Science, Seoul National University Graduate School, Seoul 03081, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kyu Hun","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul 03722, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Curie","family":"Ahn","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9525-2179","authenticated-orcid":false,"given":"Kook-Hwan","family":"Oh","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2019,1,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1934","DOI":"10.1046\/j.1523-1755.2003.00924.x","article-title":"Review on uremic toxins: Classification, concentration, and interindividual variability","volume":"63","author":"Vanholder","year":"2003","journal-title":"Kidney Int."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1016\/S0140-6736(48)91923-0","article-title":"Protein katabolism in uraemia; effects of protein-free diet, infections, and blood-transfusions","volume":"1","author":"Borst","year":"1948","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1000","DOI":"10.1016\/S0140-6736(64)91919-1","article-title":"A Low-Nitrogen Diet with Proteins of High Biological Value for Severe Chronic Uraemia","volume":"1","author":"Giovannetti","year":"1964","journal-title":"Lancet"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1056\/NEJMoa1000552","article-title":"A randomized, controlled trial of early versus late initiation of dialysis","volume":"363","author":"Cooper","year":"2010","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1111\/sdi.12134","article-title":"Dialysis initiation: What\u2019s the rush?","volume":"26","author":"Rosansky","year":"2013","journal-title":"Semin. Dial."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1053\/j.ajkd.2007.02.278","article-title":"Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: A prospective randomized multicenter controlled study","volume":"49","author":"Brunori","year":"2007","journal-title":"Am. J. Kidney Dis."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1093\/ndt\/gfu340","article-title":"Low-protein diets in chronic kidney disease: Are we finally reaching a consensus?","volume":"30","author":"Fouque","year":"2015","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1056\/NEJM198209093071104","article-title":"Dietary protein intake and the progressive nature of kidney disease: The role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease","volume":"307","author":"Brenner","year":"1982","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1084\/jem.70.6.615","article-title":"The Effect of Dietary Protein on the Course of Nephrotoxic Nephritis in Rats","volume":"70","author":"Farr","year":"1939","journal-title":"J. Exp. Med."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Kalantar-Zadeh, K., Moore, L.W., Tortorici, A.R., Chou, J.A., St-Jules, D.E., Aoun, A., Rojas-Bautista, V., Tschida, A.K., Rhee, C.M., and Shah, A.A. (2016). North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease. BMC Nephrol., 17.","DOI":"10.1186\/s12882-016-0304-9"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1056\/NEJM199403313301301","article-title":"The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group","volume":"330","author":"Klahr","year":"1994","journal-title":"N. Engl. J. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1053\/j.ajkd.2008.08.009","article-title":"Effect of a very low-protein diet on outcomes: Long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study","volume":"53","author":"Menon","year":"2009","journal-title":"Am. J. Kidney Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1038\/sj.ki.5002585","article-title":"A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease","volume":"73","author":"Fouque","year":"2008","journal-title":"Kidney Int."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1163","DOI":"10.3945\/ajcn.112.036418","article-title":"Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: Reconciling low protein intake with nutritional therapy","volume":"97","author":"Kovesdy","year":"2013","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1111\/nep.12814","article-title":"Diagnosis and Prevalence of Protein-Energy Wasting and Its Association with Mortality in Japanese Haemodialysis Patients","volume":"22","author":"Kanazawa","year":"2017","journal-title":"Nephrology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"16026","DOI":"10.1038\/cddiscovery.2016.26","article-title":"Is low-protein diet a possible risk factor of malnutrition in chronic kidney disease patients?","volume":"2","author":"Noce","year":"2016","journal-title":"Cell Death Discov."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1688","DOI":"10.1046\/j.1523-1755.2000.00014.x","article-title":"Relationship between nutritional status and the glomerular filtration rate: Results from the MDRD study","volume":"57","author":"Kopple","year":"2000","journal-title":"Kidney Int."},{"key":"ref_18","first-page":"CD001892","article-title":"Low protein diets for chronic kidney disease in non diabetic adults","volume":"3","author":"Fouque","year":"2009","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Nezu, U., Kamiyama, H., Kondo, Y., Sakuma, M., Morimoto, T., and Ueda, S. (2013). Effect of low-protein diet on kidney function in diabetic nephropathy: Meta-analysis of randomised controlled trials. BMJ Open, 3.","DOI":"10.1136\/bmjopen-2013-002934"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2164","DOI":"10.1681\/ASN.2015040369","article-title":"Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression","volume":"27","author":"Garneata","year":"2016","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1733","DOI":"10.1093\/ndt\/gfu056","article-title":"Protein intake and kidney function in the middle-age population: Contrast between cross-sectional and longitudinal data","volume":"29","author":"Cirillo","year":"2014","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1712","DOI":"10.3945\/ajcn.116.137679","article-title":"Association of dietary protein and dairy intakes and change in renal function: Results from the population-based longitudinal Doetinchem cohort study","volume":"104","author":"Biesbroek","year":"2016","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1502","DOI":"10.3945\/jn.110.135814","article-title":"Higher biomarker-calibrated protein intake is not associated with impaired renal function in postmenopausal women","volume":"141","author":"Beasley","year":"2011","journal-title":"J. Nutr."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1053\/j.jrn.2017.11.008","article-title":"Protein Intake and Long-term Change in Glomerular Filtration Rate in the Jackson Heart Study","volume":"28","author":"Malhotra","year":"2018","journal-title":"J. Ren. Nutr."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.ekir.2017.08.010","article-title":"Association of a Low-Protein Diet With Slower Progression of CKD","volume":"3","author":"Metzger","year":"2018","journal-title":"Kidney Int. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1186\/1471-2369-15-80","article-title":"KNOW-CKD (KoreaN cohort study for Outcome in patients With Chronic Kidney Disease): Design and methods","volume":"15","author":"Oh","year":"2014","journal-title":"BMC Nephrol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"604","DOI":"10.7326\/0003-4819-150-9-200905050-00006","article-title":"A new equation to estimate glomerular filtration rate","volume":"150","author":"Levey","year":"2009","journal-title":"Ann. Intern. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"825","DOI":"10.7326\/0003-4819-158-11-201306040-00007","article-title":"Evaluation and management of chronic kidney disease: Synopsis of the kidney disease: Improving global outcomes 2012 clinical practice guideline","volume":"158","author":"Stevens","year":"2013","journal-title":"Ann. Intern Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1111\/jch.12763","article-title":"Accuracy and Usefulness of Select Methods for Assessing Complete Collection of 24-Hour Urine: A Systematic Review","volume":"18","author":"John","year":"2016","journal-title":"J. Clin. Hypertens."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1038\/sj.jhh.1001307","article-title":"A simple method to estimate populational 24-h urinary sodium and potassium excretion using a casual urine specimen","volume":"16","author":"Tanaka","year":"2002","journal-title":"J. Hum. Hypertens."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1038\/ki.1985.10","article-title":"A method for estimating nitrogen intake of patients with chronic renal failure","volume":"27","author":"Maroni","year":"1985","journal-title":"Kidney Int."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Prospective Studies Collaboration, Whitlock, G., Lewington, S., Sherliker, P., Clarke, R., Emberson, J., Halsey, J., Qizilbash, N., Collins, R., and Peto, R. (2009). Body-mass index and cause-specific mortality in 900 000 adults: Collaborative analyses of 57 prospective studies. Lancet, 373, 1083\u20131096.","DOI":"10.1016\/S0140-6736(09)60318-4"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1093\/ajcn\/63.6.863","article-title":"Total-body skeletal muscle mass: Evaluation of 24-h urinary creatinine excretion by computerized axial tomography","volume":"63","author":"Wang","year":"1996","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1198\/016214504000000980","article-title":"Stable and efficient multiple smoothing parameter estimation for generalized additive models","volume":"99","author":"Wood","year":"2004","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Kitada, M., Ogura, Y., Monno, I., and Koya, D. (2018). A Low-Protein Diet for Diabetic Kidney Disease: Its Effect and Molecular Mechanism, an Approach from Animal Studies. Nutrients, 10.","DOI":"10.3390\/nu10050544"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1093\/ckj\/sfu125","article-title":"Low-protein diets in CKD: How can we achieve them? A narrative, pragmatic review","volume":"8","author":"Piccoli","year":"2015","journal-title":"Clin. Kidney J."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Rysz, J., Franczyk, B., Cialkowska-Rysz, A., and Gluba-Brzozka, A. (2017). The Effect of Diet on the Survival of Patients with Chronic Kidney Disease. Nutrients, 9.","DOI":"10.3390\/nu9050495"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Piccoli, G.B., Ventrella, F., Capizzi, I., Vigotti, F.N., Mongilardi, E., Grassi, G., Loi, V., Cabiddu, G., Avagnina, P., and Versino, E. (2016). Low-Protein Diets in Diabetic Chronic Kidney Disease (CKD) Patients: Are They Feasible and Worth the Effort?. Nutrients, 8.","DOI":"10.3390\/nu8100649"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Di Iorio, B.R., Di Micco, L., Marzocco, S., De Simone, E., De Blasio, A., Sirico, M.L., Nardone, L., and UBI Study Group (2017). Very Low-Protein Diet (VLPD) Reduces Metabolic Acidosis in Subjects with Chronic Kidney Disease: The \u201cNutritional Light Signal\u201d of the Renal Acid Load. Nutrients, 9.","DOI":"10.3390\/nu9010069"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1156","DOI":"10.1093\/ndt\/gfv026","article-title":"Population-based dose-response curve of glomerular filtration rate to dietary protein intake","volume":"30","author":"Cirillo","year":"2015","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Dam, M., Neelemaat, F., Struijk-Wielinga, T., Weijs, P.J., and van Jaarsveld, B.C. (2017). Physical performance and protein-energy wasting in patients treated with nocturnal haemodialysis compared to conventional haemodialysis: Protocol of the DiapriFIT study. BMC Nephrol., 18.","DOI":"10.1186\/s12882-017-0562-1"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1016\/j.nut.2016.06.014","article-title":"Serum adiponectin and protein-energy wasting in predialysis chronic kidney disease","volume":"33","author":"Hyun","year":"2017","journal-title":"Nutrition"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"724","DOI":"10.1038\/ki.2012.420","article-title":"The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines","volume":"83","author":"Moore","year":"2013","journal-title":"Kidney Int."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/11\/1\/121\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T12:24:28Z","timestamp":1760185468000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/11\/1\/121"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,1,8]]},"references-count":43,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2019,1]]}},"alternative-id":["nu11010121"],"URL":"https:\/\/doi.org\/10.3390\/nu11010121","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,1,8]]}}}