RESEARCH

Review

Continuing Education Questionnaire, page 652

Meets Learning Need Codes 2070, 4000, 4110, 5000, and 5340

Are High-Protein, Vegetable-Based Diets Safe for

Kidney Function? A Review of the Literature
ADAM M. BERNSTEIN, MD; LEO TREYZON, MD; ZHAOPING LI, MD

ABSTRACT
In individuals with chronic kidney disease, high-protein
diets have been shown to accelerate renal deterioration,
whereas low-protein diets increase the risk of protein
malnutrition. Vegetarian diets have been promoted as a
way to halt progression of kidney disease while maintaining adequate nutrition. We review the literature to date
comparing the effects of animal and vegetable protein on
kidney function in health and disease. Diets with conventional amounts of protein, as well as high-protein diets,
are reviewed. The literature shows that in short-term
clinical trials, animal protein causes dynamic effects on
renal function, whereas egg white, dairy, and soy do not.
These differences are seen both in diets with conventional
amounts of protein and those with high amounts of protein. The long-term effects of animal protein on normal
kidney function are not known. Although data on persons
with chronic kidney disease are limited, it appears that
high intake of animal and vegetable proteins accelerates
the underlying disease process not only in physiologic
studies but also in short-term interventional trials. The
long-term effects of high protein intake on chronic kidney
disease are still poorly understood. Several mechanisms
have been suggested to explain the different effects of
animal and vegetable proteins on normal kidney function, including differences in postprandial circulating

A. M. Bernstein is a doctoral student, Department of

Nutrition, Harvard School of Public Health, Boston,
MA. L. Treyzon is a clinical nutrition fellow, Center for
Human Nutrition, and a gastroenterology fellow, Department of Medicine, University of California at Los
Angeles. Z. Li is associate chief, Center for Human Nutrition, and associate clinical professor, Department of
Medicine, University of California at Los Angeles.
Address correspondence to: Adam M. Bernstein, MD,
Department of Nutrition, Harvard School of Public
Health, 665 Huntington Ave, Boston, MA 02115. E-mail:
abernste@hsph.harvard.edu
Copyright 2007 by the American Dietetic
Association.
0002-8223/07/10704-0013$32.00/0
doi: 10.1016/j.jada.2007.01.002

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Journal of the AMERICAN DIETETIC ASSOCIATION

hormones, sites of protein metabolism, and interaction

with accompanying micronutrients.
J Am Diet Assoc. 2007;107:644-650.

ore than 60% of adults in the United States aged

20 to 74 years are overweight or obese (1) and a
similar percentage of the population is reported to
be dieting at any one time (2). Popular weight-loss diets
today encourage increasing protein intake and decreasing carbohydrate intake to promote fat breakdown and
decrease total energy intake (3,4). The protein in these
diets may range from 71 g to 162 g per day (5), far in
excess of the Dietary Reference Intake, which suggests
0.8 g protein/kg/day/person, or 56 g protein/day for a 70
kg healthy male adult and 46 g protein/day for a 65 kg
healthy female adult (6). The protein content of these
high-protein diets even exceeds the amount of protein in
the typical American diet, which is approximately 1.2 g
protein/kg/day (Table 1) (7).
High-protein diets pose particular problems for patients with chronic kidney disease (CKD) because high
protein intake may accelerate CKD (8). At the same time,
and equally concerning, patients with CKD are at high
risk for protein malnutrition due to decreased protein
intake, uremia, depression, illness-induced hypercatabolism, acidemia-induced muscle breakdown, and, when applicable, dialysis (9-11). To halt progression of CKD while
preventing protein malnutrition, the National Kidney
Foundation (NKF) recommends a diet of 0.6 g protein/kg/
day for patients with advanced CKD (glomerular filtration rate 25 mL/min/1.73 m2 [0.41 mL/s/1.73 m2]) and
1.2 g protein/kg/day for patients with end-stage renal
disease (glomerular filtration rate 10 mL/min/1.73 m2
[0.16 mL/s/1.73 m2]), allowing for increased protein loss
from dialysis (12,13). There are no clear guidelines for
patients with mild to moderate kidney disease.
Recently, investigators observed different effects between animal and vegetable proteins on renal function
(Table 2) (14-27). Some, but not all, studies suggest that
diets high in vegetable protein do not accelerate CKD in
the same way that animal proteins do. Animal models of
CKD suggest vegetarian diets are nutritionally adequate
(28-32). These observations are meaningful because they
suggest that diets high in vegetable protein may permit

2007 by the American Dietetic Association

Table 1. Recommended protein intake for a 70 kg male (based on an average 2,000 kcal/day diet; 1 g protein4 kcal)
Diet type

Protein as % of daily
energy intake

Protein
g/kg/d

US Dietary Reference Intake (6)

11

0.8

56

0.6

42

Complete proteins composed of animal

and/or vegetable proteins
50% should be of high biological value

16

1.2

84

50% should be of high biological value

27
23
16

1.9
1.6
1.2

135
115
84

National Kidney Foundation (advanced

kidney disease without dialysis) (8)
National Kidney Foundation (for end-stage
renal disease) (9)
High protein diet: Atkins (7)
High protein diet: South Beach (7)
Average American (7)

safe weight loss in overweight or obese patients with

CKD. Furthermore, such diets may represent an alternative for patients with CKD who are unable to follow the
traditional NKF low-protein diet.
We reviewed the literature to date examining differences between animal and vegetable protein and kidney
function. We examined both conventional and high-protein diets in normal renal function and CKD. Animal
protein sources include red meat, white meat, fish, dairy,
and eggs; for the purpose of this article, vegetable proteins include soy and wheat gluten. We considered a
high-protein diet one that includes protein in excess of
the Dietary Reference Intake recommendation for a person without kidney disease (ie, 0.8 g/kg/day) or in excess
of the NKF recommendation for a person with kidney
disease not undergoing dialysis (ie, 0.6 g/kg/day).
Kidney function is described primarily in terms of glomerular filtration rate, recognized in the executive summary of the NKF Disease Outcome Quality Initiative as
the best overall measure of kidney function (33). When
glomerular filtration rate is not measured, we report on
creatinine clearance, which is an alternative, though imperfect, measure of glomerular filtration, because creatinine is both filtered and secreted in the kidneys. Where
appropriate, we also report renal vascular resistance,
renal plasma flow, and protein excretion, which offer
additional measurements of glomerular perfusion and
injury. Of note, normal kidney function is regarded as a
glomerular filtration rate 89 mL/min/1.73 m2. A lower
glomerular filtration rate indicates kidney disease. For
persons with a low glomerular filtration rate, a further
decrease in glomerular filtration rate indicates progression toward end-stage renal disease, while a rise in
glomerular filtration rate indicates an improvement in
kidney function.
EFFECTS OF DIETARY ANIMAL AND VEGETABLE PROTEIN ON
NORMAL RENAL FUNCTION
Single-Meal Studies
Early studies of the renal hemodynamic response to a
one-time highanimal-protein meal showed an acute rise
in renal plasma flow, glomerular filtration rate, and proteinuria (18,23,34,35). These meals, however, were often
composed of several different types of animal protein

Total protein
g/day

Main source of protein

Meat, fish, eggs, cheese

Lean meat, fish, eggs, cheese, nuts
Mixed protein sources; typically
nonlean meats

(including red meat and dairy) or did not specifically

identify the type of meat. Later studies looked at meals
composed of protein from one specific source (25,26). Nakamura and colleagues (27) showed that in subjects with
normal renal function, the glomerular filtration rate rose
significantly after ingestion of tuna fish, although there
was no significant difference in glomerular filtration rate
after ingestion of egg white, in the amount of either 0.7 g
protein per kilogram body weight or 1.4 g protein per
kilogram body weight. The glomerular filtration rate of
patients with diabetes after ingestion of each of the meals
was similar to that in healthy volunteers. In a separate
study, Nakamura and colleagues (26) showed no significant difference in glomerular filtration rate after ingestion of cheese and soy, suggesting their effect on renal
hemodynamics is similar to that of egg white.
Clinical Trials
Short-term clinical trials show similar results to singlemeal physiologic studies. Kontessis and colleagues (24)
placed patients with normal renal function on either a 1.1
g/kg/day highanimal-protein diet or a 0.95 g/kg/day
highvegetable-protein diet for 4 weeks and found that
those on the animal-protein diet had higher glomerular
filtration rate and albuminuria compared to those receiving the vegetable protein. In a separate study, they randomized patients to 3 weeks of a high-protein diet (1
g/kg/day) of either soy, animal protein (types of protein
not described), or animal protein diet supplemented with
fiber. They reported that those on the animal protein diet
had significantly higher renal plasma flow, glomerular
filtration rate, and proteinuria compared to those consuming the soy diet, and that fiber did not significantly
effect these outcomes (23). Jibani and colleagues (21)
reported that an 8-week prospective study of persons
with type 1 diabetes, who when switched from a mixed
animalvegetable-protein diet (vegetable protein 0.3
g/kg) to a diet higher in vegetable protein (vegetable
protein 0.7g/kg), showed no change in glomerular filtration rate but did demonstrate a decrease in albuminuria
by 50%. However, total protein intake before intervention
was 1.3 g/kg and during intervention was 1.0 g/kg. In a
retrospective analysis of 1,150 patients with diabetes,
Mollsten and colleagues (36) similarly showed that high

April 2007 Journal of the AMERICAN DIETETIC ASSOCIATION

645

Table 2. Human studies of animal (A) and vegetable (V) protein and kidney function
Study and year

Reference Protein
no.
type

Study design

Baseline kidney
function

Results

CKD

HPb A, V diets: decrease in GFRc

V (vegan) 1- to 7-mo trial

V (vegan) 4- to 6-mo trial
A, V
4-mo trial

CKD
CKD
Ne

18
19

A
A

Single meal
4-wk trial

N, CKD
N

Jenkins and colleagues, 2001 20

4-wk trial

Jibani and colleagues, 2001

Knight and colleagues, 2003

21
22

V
A, V

8-wk trial
11 y

N (diabetic)
N, CKD

Kontessis and colleagues,

1990

23

A, V

Single meal and N

3-wk trial

Kontessis and colleagues,

1995
Nakamura and colleagues,
1989

24

A, V

4-wk trial

25

A, V

Single meal

N (diabetic), CKD

Nakamura and colleagues,

1991
Nakamura and colleagues,
1993
Bergstrom and colleagues,
1985
Viberti and colleagues, 1987
Mollsten and colleagues,
2001

26

A, V

Single meal

27

A, V

Single meal

N (diabetic)

No change in CrCld
Decrease in GFR
Linear relation between both A and V protein
intake and CrCl
N, CKD: Acute rise in GFR, RPFf, proteinuria
Red meat replaced with chicken led to
decrease in GFR
HP diet: no change in creatinine clearance
compared to NPg
Decrease in albuminuria
N: no relation between protein and GFR;
CKD: HP non-dairy A protein greater
decrease in GFR than dairy, V protein diet
Single meal: acute rise in GFR, RPF,
proteinuria; 3 wk trial: A protein with
greater RPF, GFR, proteinuria compared to
protein
HP A: greater rise in GFR, albuminuria than
HP V
N: tuna: acute rise in GFR; bean curd
(NP and HP): no change CKD with
macroalbuminuria: tuna: decrease in GFR;
bean curd: no change
Tuna: increase in GFR; cheese, tofu, egg
white: no change
tuna: rise in GFR; egg-white: no change

34

Single meal

acute rise in GFR, RPF, proteinuria

35
36

A
A

Single meal
Case-control

N
N (diabetic)

Acute rise in GFR, RPF, proteinuria

Fish intake lowered odds for development of
microalbuminuria

Anderson and colleagues,

1998
Barsotti and colleagues, 1991
Barsotti and colleagues, 1996
Brandle and colleagues, 1996

14

A, V

15
16
17

Chan and colleagues, 1988

Gross and colleagues, 2002

8-wk trial

CKDchronic kidney disease.

HPhigh-protein diet.
c
GFRglomerular filtration rate.
d
CrClcreatinine clearance.
e
Nnormal kidney function.
f
RPFrenal plasma flow.
g
NPnormal protein diet (equal or less than US Recommended Dietary Intake).
b

fish intake protected against development of microalbuminuria. Differences between red meat and white meat were
examined in one study of persons with diabetes with normal
renal function who replaced their red meat diet with a
chicken-based diet and found that after 4 weeks there was
a decrease rather than increase in glomerular filtration rate
(19). Collectively, these studies suggest that high intakes
of red meat, but perhaps not white meat or fish or vegetables, increase glomerular filtration rate and proteinuria
in persons with normal renal function.
Despite evidence suggesting that vegetable protein,
dairy, and egg white do not affect normal renal function
acutely or over several weeks, data are mixed regarding
whether or not there is a threshold beyond which increasing amounts of these proteins may alter normal renal

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April 2007 Volume 107 Number 4

function. Jenkins and colleagues (20) reported a 1-month

randomized cross-over study of 20 patients with normal
renal function and showed that those on a diet high in
vegetable protein (139 g gluten/day), when compared to
those on a lowervegetable-protein diet (59 g gluten/day),
had increased blood urea as well as lower levels of oxidized low-density lipoprotein cholesterol, but no significant difference in creatinine clearance. By contrast, a
4-month retrospective study by Brandle and colleagues
(17) of 88 subjects with normal renal function consuming
protein ranging from 0.29 g/kg/day (17 g/day) to 2.6 g/kg/
day (212 g/day) showed a positive, nonlinear relationship
between protein intake and creatinine clearance. This
relationship was seen in subjects eating vegan and lactovegetarian diets and those eating mixed animalvegeta-

ble protein diets. Creatinine clearance reached a plateau

at 181 mL/min/1.73 m2, (3.02 mL/s/1.73 m2), which corresponded to an intake of 125 g protein/day, whereas
further increases in protein intake had little influence on
creatinine clearance. The Nurses Health Study followed
the dietary habits of 1,624 women with normal or mild
renal insufficiency across 11 years. Animal and vegetable
protein intake ranged from 60 g to 93 g protein/day. The
study found no significant association between protein
intake and change in glomerular filtration rate in women
with normal renal function, and a subanalysis of animal
protein, dairy protein, and vegetable protein showed that
none of the individual sources of protein were associated
with a change in glomerular filtration rate in women with
normal renal function (22). From these studies, it is difficult to conclude whether or not there is a long-term
association between amount of animal or vegetable protein intake and change in normal renal function. This
inconclusiveness may be attributed to methodological differences among studies, including study duration, range
of protein intake, and heterogeneity of protein source.
EFFECTS OF DIETARY ANIMAL AND VEGETABLE
PROTEIN ON CKD
Single-Meal Studies
Patients with CKD respond to varying amounts of animal
and vegetable protein differently than those with normal
renal function. This difference is observed in both singlemeal studies and in clinical trials. In Nakamura and
colleagues study (25) of patients eating a high-protein
load of tuna fish (1 g/kg), within 3 hours in patients with
diabetes and macroalbuminuria, glomerular filtration
rate decreased, rather than increased, as it did with normal subjects. Glomerular filtration rate did not change
after eating soy. Yet in Chan and colleagues study (18) of
patients with nondiabetic nephropathy, within 3 hours of
eating 1.5 g/kg meal of steak, eggs, and milk, renal
plasma flow and glomerular filtration rate increased. Although these physiologic studies suggest that fish protein
influences CKD hemodynamics differently than other animal proteins, and that diabetic and nondiabetic CKD
respond differently to dietary animal protein, there is
insufficient evidence at this point to arrive at substantiated conclusions.
Clinical Trials
Longer duration studies of CKD have not borne out the
differences observed in single-meal studies. Anderson
and colleagues (14) reported an 8-week randomized crossover study of eight people with diabetes with proteinuria
and moderate renal insufficiency. A decrease in glomerular filtration rate was observed both in patients receiving a 1 g/kg animal protein diet and in patients receiving
a 1 g/kg soy protein diet, suggesting that there is no
advantage to soy-protein based diet in diabetic CKD.
Barsotti and colleagues (15) followed patients with nondiabetic nephropathy and moderate to severe renal insufficiency on a vegan protein diet at 0.7 g/kg/day for 3
months. Compared to a conventional animal-based lowprotein diet (0.6 g/kg body weight), the patients receiving
the vegan diet did not have significantly lower creatinine

clearance. In a separate study, Barsotti and colleagues

(16) followed 20 patients with nondiabetic nephrosis transitioned from a mixed animalvegetable diet (1.0 to 1.3
g/kg/day) to a vegan diet (0.7 g/kg/day). After an average
of 4 to 6 months, the patients showed significant decrease
in glomerular filtration rate and proteinurea; however, in
this study the total protein intake was simultaneously
decreased, making it difficult to understand the etiology
for these changes. The Nurses Health Study followed
patients with normal kidney function and mild renal
insufficiency (22). In the mild renal insufficiency group,
an increase in protein intake correlated with a decrease
in glomerular filtration rate. Women consuming highprotein diets (average 93 g protein/day) had a 4.77 mL/
min/1.73 m2 (0.08 mL/s/1.73 m2) lower glomerular filtration rate than those consuming conventional-protein
diets (average 60 g protein/day). Subanalysis revealed the
consumption of nondairy animal protein led to greater
decreases in glomerular filtration rate than either dairy
or vegetable protein; however, high intakes of each had
deleterious effects.
These studies suggest that a predominantly or exclusively vegetable-based protein diet may not protect
against progression of CKD and that high protein intake,
from either vegetable or animal source, may accelerate
CKD.
NUTRITIONAL ADEQUACY OF VEGETABLE PROTEIN-BASED
DIETS IN CKD
Protein-energy malnutrition is common among patients
with CKD and particularly in those undergoing dialysis.
Reports suggest that the prevalence of this condition
varies from roughly 18% to 70% of adult maintenance
dialysis patients (11). In adults, the presence of such
malnutrition is one of the strongest predictors of morbidity and mortality (11).
Vegetarian diets have been studied as means to halt
progression of CKD while maintaining adequate protein
nutrition. In mouse models of polycystic kidney disease,
soy, when compared to the milk protein casein, retards
cyst formation, renal enlargement, macrophage infiltration, and fibrosis without significantly affecting body
weight, serum total protein, or serum albumin (28-31). In
Zucker rats with obesity-related nephropathy, a soy diet,
again when compared to casein, improved renal function,
proteinuria, glomerulosclerosis, and interstitial fibrosis
and at the same time led to weight gain (32).
There are limited studies in human beings examining
the nutritional adequacy of vegetarian diets in persons
with CKD. In Jibani and colleagues study (21) of patients
with diabetes with proteinuria placed on a predominantly
vegetable protein diet (0.7 g/kg) for 8 weeks, there was a
significant increase in midarm muscle circumference, but
no significant difference in body weight or triceps skinfold
thickness, even as the patients consumed less total protein per day than before the study (1.4 g/kg/day vs 1.0
g/kg/day). DAmico and colleagues (37) 8-week study of
patients with nephrotic syndrome receiving a vegetable
protein diet (0.7 g/kg) showed a decrease in body weight
but no significant change in serum albumin and transferrin (37). Similarly, Barsotti (16) saw no significant
change in serum total protein or albumin in patients with
diabetes transitioned from a traditional 1.0 to 1.3 g pro-

April 2007 Journal of the AMERICAN DIETETIC ASSOCIATION

647

Table 3. Comparison of select animal and vegetable proteins from studies of chronic kidney disease

Source

Serving
size (g)

Total
proteina
(g)

Lysine content
(mg/g total
nitrogen)b

Alanine content
(mg/g total
nitrogen)b

Iron
content
(mg)a

Phosphorous
content
(mg)a

Isoflavone content
(mg/100 g
protein)c

Beef (lean)
Chicken, light meat
Tuna, fresh
Milk, nonfat
Egg white
Soybeans (mature)
Whole-wheat flour

85 (3 oz)
84 (3 oz)
85 (3 oz)
244 (1 c)
33 (1 large egg)
172 (1 c)
120 (1 c)

22.04
27.57
25.47
8.26
3.64
28.62
16.44

570
581
555
559
420
531
194

400
340
287
NA
288
278
194

2.21
0.96
0.8
0.07
0.03
8.84
4.66

168
194
208
247
5
471
415

1.86
NAd
NA
NA
NA
128.53
NA

a
US Dept of Agriculture National Nutrient Database for Standard Reference, Release 18. Available at: http://www.ars.usda.gov/Service/docs.htm?docid9673. Accessed August 3, 2006.
(Beef is 85% lean patty; chicken is light meat.)
b
US Dept of Health, Education, and Welfare and FAO Food, Policy, and Nutrition Division. Food composition table for use in East Asia 1972, Part II, Section A, FAO corporate document
repository. Available at: http://www.fao.org/docrep/003/x6878e/x6878E00.htm#toc. Accessed August 3, 2006. (Beef is fresh, chicken is raw; tuna is yellowtail; soybeans are immature;
wheat is whole grain; alanine content of milk unavailable.)
c
US Dept of Agriculture - Iowa State University Database on Isoflavone Content of Foods, 1999. Available at: http://www.ars.usda.gov/Service/docshtm?docid6382. Accessed August
2, 2006. (US Department of Agriculture beef patty; soybeans are raw and mature, US food quality.)
d
NANot available.

tein/kg/day diet to a 0.7 g protein/kg/day vegan diet.

These studies suggest that soy-based diets may provide
nutritional adequacy to persons with CKD.
MECHANISTIC MODELS TO EXPLAIN DIFFERENT EFFECTS OF
ANIMAL AND VEGETABLE PROTEIN ON RENAL FUNCTION
Hostetter and Brenners (38) hyperfiltration theory proposed that protein consumption acutely increases renal
plasma flow and glomerular filtration, leading to glomerular hyperfiltration and hypertension, which over time
leads to chronic glomerular injury, fibrosis, and mesangial cell proliferation (38). Glucagon (23), vasopressin,
renin, angiotensin (18), prostaglandins (23), and insulin
like growth factor-1 (24) have been implicated as mediators of this process. How dietary protein influences these
mediators remains unclear.
There are several important features in the composition of animal and vegetable proteins that may explain
their different effects on normal kidney function
(Table 3). Their different amino acid composition (25), or
the relative proportions of each, may be important.
Wheat and egg white both have a relatively small amount
of lysine compared to other proteins, but also of alanine,
which has been identified as a renal vasodilator (27). The
different sites of metabolism may also be relevant as
amino acids metabolized in the splanchnic region appear
to have greater renal effects than those metabolized peripherally (39-41).
Cholesterol metabolism may also play a significant
role. Soy consumption lowers low-density lipoprotein cholesterol levels, though the reduction may be only a few
percent, and the quantity of daily soy intake needed to
achieve such a reduction may be 50 g (42,43). Wheat
gluten similarly decreases levels of oxidized low-density
lipoprotein cholesterol particles and triglycerides (20). By
decreasing these serum lipid levels, vegetable proteins
may slow oxidized-lipoprotein induced glomerular damage and progression to the nephrotic syndrome (44). The
lipid-lowering effect of the fatty acids found with fish
protein may account for similar effects.

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April 2007 Volume 107 Number 4

Soy isoflavones and wheat phenolics may affect normal

renal function through other pathways, including blocking activation of the transforming growth factor- signals
(45,46), protecting low-density lipoprotein cholesterol
particles from oxidation (20,44), upregulating nitric oxide
generation (47), inhibiting cell growth and proliferation
via tyrosine protein kinases (48), inhibiting angiogenesis
(48), and suppressing platelet activating factor and platelet aggregation (48). Soy also contains less bioavailable
iron and phosphorous, and milk less iron, when compared
to red and white meat. The smaller amounts of these
minerals may protect normal kidney function, especially
in those at risk, such as persons with diabetes (49).
Why it is that animal and vegetable proteins have
different effects in a healthy kidney but similar effects in
CKD is unclear. It may be that the fibrosis and scarring
often present in a diseased kidney do not permit the
hemodynamic changes and remodeling that take place in
a healthy kidney. It may also be that the comorbidities
often seen in CKD, including the anemia, metabolic derangements, and cardiovascular changes, do not permit
the same response as in a healthy kidney. Further investigations are needed.
CONCLUSIONS
There are limited studies to date comparing the different
effects of animal vs vegetable protein on kidney function.
However, this review reveals several important early
findings.

In people with normal renal function, there are dynamic changes in renal function following consumption
of a single meal high in animal protein but not after
vegetable protein, dairy proteins, or egg white.
Substitution of vegetable protein or fish protein for
animal protein may protect against the development of
proteinuria in patients with diabetes.
Long-term consumption of high-protein diets, composed of either predominantly animal or vegetable protein, by persons with normal renal function may cause
renal injury.

High protein intake, from either vegetable or animal

source, likely accelerates CKD.
Vegetable protein diets appear to meet protein requirements and provide adequate nutrition in people with
CKD.

Future studies should continue to explore differences

between animal and vegetable protein on renal function.
Areas for investigation may include the long-term effects
of exclusively vegetarian diets in patients with overweight or obesity and CKD, studies in human beings of
the adequacy of vegetable protein diets for people with
CKD, differences in response of diabetic vs nondiabetic
kidney disease to proteins of varying source, and the role
of micronutrients in explaining the effect of protein on
kidney function.

13.

14.

15.
16.

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