Low Daily Protein Intake and Risk of Kidney Failure and Mortality in Chronic Kidney Disease
10 affiliations
- 1Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
- 2Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
- 3Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
- 4Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- 5Gachon University College of Medicine, Incheon, Korea
- 6Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- 7Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- 8Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- 9Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Korea
- 10for the Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) Investigators
Abstract
Importance: While protein restriction is a cornerstone of chronic kidney disease (CKD) management, its long-term benefits on clinical outcomes in Asian populations, who often have lower body mass and muscle reserves, remain unclear.
Objective: To investigate the association between daily protein intake (DPI) and the risk of kidney failure requiring replacement therapy (KFRT) and all-cause mortality in patients with non–dialysis-dependent CKD.
Design, Setting, and Participants: This prospective cohort study used data from the Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD). Participants with CKD at stages ranging from 1 to predialysis 5 were enrolled between 2011 and 2016 from 9 tertiary hospitals in South Korea. The study observation period ended on January 31, 2024. Data analysis was performed from February 2024 to May 2026.
Exposures: DPI was objectively estimated using 24-hour urinary nitrogen excretion at baseline. The participants were categorized by DPI: less than 0.6, 0.6 to less than 0.8, 0.8 to less than 1.0, 1.0 to less than 1.2, and 1.2 or greater.
Main Outcomes and Measures: The primary outcome was the onset of KFRT. Secondary outcomes included all-cause mortality and major adverse cardiovascular events (MACEs). Fine-Gray subdistribution hazard models were used to account for the competing risk of death.
Results: A total of 1861 participants (mean [SD] age, 53.7 [12.0] years; 1304 [61.1%] male) were analyzed, with a median (range) follow-up of 9.3 (0.01-12.37) years. The lowest DPI group (<0.6 g/kg/d) was associated with increased risk of KFRT (subdistribution hazard ratio [sHR], 1.42; 95% CI, 1.09-1.85) as well as all-cause mortality (sHR, 2.17; 95% CI, 1.17-4.03), but not MACEs, compared with the highest DPI group (>1.2 g/kg/d). Furthermore, a nonlinear association was observed, where excessively low protein intake was associated with an increased risk of KFRT.
Conclusions and Relevance: In this cohort study of 1861 patients with nondialysis CKD, low protein intake was not associated with significant nephroprotection and was associated with a higher risk of KFRT and all-cause mortality. These findings suggest that rigid protein restriction should be balanced with nutritional monitoring to prevent protein-energy wasting, particularly in populations with lower muscle mass, and a more individualized approach to dietary protein management in CKD may be warranted.
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BibTeX
@article{suh2026daily,
title = {{Low Daily Protein Intake and Risk of Kidney Failure and Mortality in Chronic Kidney Disease}},
author = {Sang Heon Suh and Hong Sang Choi and Chang Seong Kim and Eun Hui Bae and Jayoun Kim and Ji Yong Jung and Jong Cheol Jeong and Kyu-Beck Lee and Kook-Hwan Oh and Seong Kwon Ma and Soo Wan Kim and Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) Investigators and Young Youl Hyun and Yeong Hoon Kim and Ho Jun Chin and Sue K Park and Yaeni Kim and Seung Hyeok Han and Tae-Hyun Yoo and Jung Soon Kim and Sooyoung Cho},
journal = {JAMA Network Open},
year = {2026},
month = oct,
doi = {10.1001/jamanetworkopen.2026.34568},
url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855702},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Low Daily Protein Intake and Risk of Kidney Failure and Mortality in Chronic Kidney Disease
AU - Sang Heon Suh
AU - Hong Sang Choi
AU - Chang Seong Kim
AU - Eun Hui Bae
AU - Jayoun Kim
AU - Ji Yong Jung
AU - Jong Cheol Jeong
AU - Kyu-Beck Lee
AU - Kook-Hwan Oh
AU - Seong Kwon Ma
AU - Soo Wan Kim
AU - Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) Investigators
AU - Young Youl Hyun
AU - Yeong Hoon Kim
AU - Ho Jun Chin
AU - Sue K Park
AU - Yaeni Kim
AU - Seung Hyeok Han
AU - Tae-Hyun Yoo
AU - Jung Soon Kim
AU - Sooyoung Cho
PY - 2026
DA - 2026/10/01
JO - JAMA Network Open
DO - 10.1001/jamanetworkopen.2026.34568
UR - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855702
AB - Importance: While protein restriction is a cornerstone of chronic kidney disease (CKD) management, its long-term benefits on clinical outcomes in Asian populations, who often have lower body mass and muscle reserves, remain unclear. Objective: To investigate the association between daily protein intake (DPI) and the risk of kidney failure requiring replacement therapy (KFRT) and all-cause mortality in patients with non–dialysis-dependent CKD. Design, Setting, and Participants: This prospective cohort study used data from the Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD). Participants with CKD at stages ranging from 1 to predialysis 5 were enrolled between 2011 and 2016 from 9 tertiary hospitals in South Korea. The study observation period ended on January 31, 2024. Data analysis was performed from February 2024 to May 2026. Exposures: DPI was objectively estimated using 24-hour urinary nitrogen excretion at baseline. The participants were categorized by DPI: less than 0.6, 0.6 to less than 0.8, 0.8 to less than 1.0, 1.0 to less than 1.2, and 1.2 or greater. Main Outcomes and Measures: The primary outcome was the onset of KFRT. Secondary outcomes included all-cause mortality and major adverse cardiovascular events (MACEs). Fine-Gray subdistribution hazard models were used to account for the competing risk of death. Results: A total of 1861 participants (mean [SD] age, 53.7 [12.0] years; 1304 [61.1%] male) were analyzed, with a median (range) follow-up of 9.3 (0.01-12.37) years. The lowest DPI group (<0.6 g/kg/d) was associated with increased risk of KFRT (subdistribution hazard ratio [sHR], 1.42; 95% CI, 1.09-1.85) as well as all-cause mortality (sHR, 2.17; 95% CI, 1.17-4.03), but not MACEs, compared with the highest DPI group (>1.2 g/kg/d). Furthermore, a nonlinear association was observed, where excessively low protein intake was associated with an increased risk of KFRT. Conclusions and Relevance: In this cohort study of 1861 patients with nondialysis CKD, low protein intake was not associated with significant nephroprotection and was associated with a higher risk of KFRT and all-cause mortality. These findings suggest that rigid protein restriction should be balanced with nutritional monitoring to prevent protein-energy wasting, particularly in populations with lower muscle mass, and a more individualized approach to dietary protein management in CKD may be warranted.
SN - 2574-3805
ER -