First, what is nitrogen?
As stated, nitrogen is the waste product from your body consuming protein. We see these nitrogen waste products in our blood work as blood urea nitrogen or BUN
Here are the steps our bodies take when we consume protein:
- Protein is broken down into amino acids
- The body/liver removes the nitrogen component from these amino acids, creating keto analogues (like the one in protein supplements)
- The removed nitrogen waste product is sent to the kidneys to be excreted in our urine
- We cannot excrete these waste products fast enough compared to our consumption of protein, so our blood urea nitrogen and creatinine levels rise above the normal range.
As this nitrogen waste builds up in our bloodstream, it makes us sick (Uremia) or have high BUN levels. In fact, the entire reason dialysis was invented was to remove these toxic waste products. The nitrogen wastes are so toxic, we would die in a few weeks if they are not removed by our kidneys or dialysis.
High BUN levels increase the speed of kidney and heart disease progression. Accelerated heart disease caused by uremia or high BUN levels is called “Uremic vascular calcification.”
The level of nitrogen in foods is directly proportional to the protein content. High levels of dietary protein equal higher levels of nitrogen intake.
Some amount of nitrogen is contained in many foods, but meats, cheese, and eggs have the highest amounts. Fruits and vegetables usually contain nitrogen but in lower amounts.
Common sense time:
Decreasing nitrogen intake is the entire reason behind low- or very-low protein diets. Let me say this again: The only reason low- or very low-protein diets exist is to lower nitrogen intake. This reduces the workload on your kidneys so kidney progression can be slowed by bringing your blood and urine tests back into or closer to normal ranges.
The amount of benefit you will get from any combination of a low-protein diet combined with a protein supplement is directly related to how much nitrogen (protein) you consume daily compared to your current GFR or kidney function.
You can make or break any kidney diet by varying the amount of nitrogen intake. Let’s start with protein supplements.
We can use the following chart for comparisons of nitrogen content:
|Essential amino acids only||1,550 mg|
|1970’s and 1980’s calcium based amino acids/keto analog blend||864 mg|
|Albutrix S3, S4 and S5||180 to 200 mg|
We can see that regular amino acids are 750% higher in nitrogen content than modern amino acid/keto analog blends. We can also see that the 1970’s version is over 400% higher in nitrogen.
Multiple studies document that amino acids do not slow kidney disease progression at all or do so at a reduced rate compared to amino acid/keto analog blends. Using the above chart, it’s easy to see why. The nitrogen content is not lowered enough compared to current kidney function.
See chapter 31 in “Stopping Kidney Disease” for over 80 studies on this issue.
Think of it this way: If your kidneys are operating at 20% of normal levels, you need an 80%+ reduction in nitrogen load to improve your numbers greatly. We need a drastic reduction in nitrogen waste products, not a small reduction.
How supplemental nitrogen content affects your dietary choices
It’s pretty simple: the higher your nitrogen intake from protein supplements, the less protein you can consume from dietary intake. This means your diet has to be more restrictive to compensate for the extra nitrogen intake.
Using the same list as before:
|Type of protein supplements||Dietary restrictions|
|Essential amino acids only||most restricted|
|1970’s and 1980’s keto analogue amino acid blends||medium restriction|
|Albutrix S3,S4, and S5||least restriction|
If you take amino acids or the 1970’s/1980’s calcium blends, you will have to restrict your protein intake to a lower level than modern options. This is the primary reason these combinations of protein supplements and diets failed in the past. The restriction is just too hard or extreme for most of us, so amino acids and calcium-based amino acid/keto analog blends have a questionable past for this reason. I know first hand as someone who was on the diets as part of a medical trial.
You can eat more dietary protein per day using modern low-nitrogen protein supplements and have a less restricted diet, which makes our lives a little bit easier.
The last thing most of us want is more restrictions added to our diets.
Dietary intake of nitrogen
We advocate a very specific or prescribed diet in the “Stopping Kidney Disease” books. The diet is designed to be as low in nitrogen as possible. You can buy Albutrix, the lowest nitrogen protein supplement in the world, and combine it with the low nitrogen diet for a 40%+ reduction in blood urea nitrogen levels (BUN). However, if you are eating cheeseburgers every day, it’s not going to help. You can undo any benefits by eating foods high in nitrogen.
This is important for two reasons: slowing kidney disease progression, and your money. If you are on a random diet and don’t know how much nitrogen/protein you are consuming each day, you will likely get very little if any benefit from any protein supplement. Some amount of protein or nitrogen is in just about everything we eat. The odds that you can successfully do this by winging it are very low. We have worked with hundreds of patients and we see this almost daily. Random choices and guessing is the wrong approach. Time is the enemy for us so guessing and randomness have no place here.
The second reason is you can save your money
If the protein supplement you buy or are shopping for does not come with a prescribed or recommended low-nitrogen diet, failure is much more common than success. Buying a random protein supplement and combining it with a random diet almost guarantees failure. We have watched patients spend thousands of dollars with no or reduced results by not taking a proven, coordinated approach.
Again, I was one of these patients. I was advised to be on a very strict low-protein diet and then basically told “good luck,” with very little instruction or education. I was expected to solve most of the dietary issues on my own. I was overwhelmed and made more bad choices than good at the time.
Matching diet and protein supplement for the lowest possible nitrogen intake
In the past, all protein supplements were designed to give 100% of the recommended daily amounts (RDA) regardless of dietary intake. This approach is deeply flawed and again almost guarantees our failure in many ways.
All of us get essential amino acids in our everyday diet. For some amino acids we may get 80% to 90% of the RDA, and others we may only get 50% if we are on a low-protein diet. The 1970’s approach was to give every patient 100% of the RDA regardless of dietary intake. Again, in the 1970’s, the risks of excess amino acid intake were less known than today.
Are there risks in taking 150% to 300% of the RDA for essential amino acids?
A study of over 11,000 adults published online in “The Lancet” in 2020 gives us something to think about. The study finds that:
“Higher intake of SAA (Sulphur amino acids), Methionine (an essential amino acid), and Cysteine were associated with significant increases in composite cardiometabolic disease risk scores, independent of protein intake, and with several individual risk factors including serum cholesterol, glucose, uric acid, BUN, and insulin and glycated hemoglobin (p < 0.01).”
Author’s comment from Penn State College of Medicine on the same study:
"This study provides the first epidemiologic evidence that excessive dietary intake of sulfur amino acids may be related to chronic disease outcomes in humans."
Methionine amount varies widely depending on the protein supplement used. While we need methionine in our diet, we need to get to 100% of the RDA and not 150% or 250% of the RDA. It’s all risk with no known benefits.
Another study in 2019 comments on branched-chain amino acids, which are essential amino acids contained in just about every protein supplement:
“Elevated branched-chain amino acids (BCAAs) are associated with obesity and insulin resistance. How long-term dietary BCAAs impact late-life health and lifespan is unknown. “
“Long-term exposure to high BCAA diets leads to hyperphagia (increased appetite), obesity and reduced lifespan. “
Looking at current research, we can see that excess amino acid intake may have more risk than we thought. As this is a new area of study, I don’t know if we can say how risky it is yet. What we can say is that getting in excess of the RDA is just extra workload for our kidneys with no known benefit, only potential risks.
This is important because many kidney patients take all kinds of protein supplements. Some are made for kidney patients and some are made for the healthy public. This is a mistake on our part.
The reason is we are getting excess amino acids that either do us no good or in some cases we may not be able to excrete the excess intake.
What can we say and be standing on solid ground when it comes to essential amino acid or essential keto analogue intake? A few things:
- No research we could find suggests excess amino acid intake is good for us.
- The most current research suggests that excess amino acid intake may have health risks.
- Dietary amino acid supplementation in excess of the RDA increases workload on our kidneys by increasing nitrogen intake with no known benefits, only potential risks.
Here is the truth:
We can only determine the proper amount of essential amino acid supplementation intake after dietary intake has been determined.
If we don’t know what dietary intake is, then a protein supplement cannot be formulated correctly. Diet must come first, protein supplements second.
Albutrix S3, S4, and S5 are calibrated to the “Stopping Kidney Disease Food Guide” recommended diet. This ensures 100% of the RDA for essential amino acids are being met, with the lowest possible workload. This is the best path to reducing nitrogen intake by the maximum amount.
Nitrogen content on protein supplement labels
Buying a protein supplement without the amount of nitrogen listed on the label is like buying a vitamin C supplement without the amount of vitamin C listed on the label. It’s a little nuts and goes against everything we know about the reason for low-protein diets and slowing kidney disease progression.
If the entire reason and benefit of low-protein diets is dramatically lowering nitrogen intake, why in the world would we buy a protein supplement without the amount of nitrogen listed on the label?
It defies logic from any perspective if we actually understand what we are doing and why we are doing it.
Educated kidney patients should want to know what is in the product so they can see if they will get a benefit or how restrictive their diet will have to be to get a benefit.
If any one number will determine how much your blood urea nitrogen (BUN) and creatine numbers will drop or GFR will rise it is the combination of dietary and supplemental nitrogen intake. It cannot be any other way. We know this is how our kidneys work. This is a common sense issue, as we don’t have studies detailing the exact milligrams of nitrogen intake at this time.
Read the label for nitrogen content. The best results will always come from combining the lowest nitrogen diet and lowest nitrogen protein supplement. If anyone tells you a diet or protein supplement is better for you because it has higher nitrogen content, they are dead wrong and do not understand how kidneys function.
Most of us want the lowest nitrogen protein supplement so we can have a less restrictive diet. If you don’t know how much nitrogen is in the protein supplement, you will end up guessing. We know this is the worst approach.