Level 1: Likely reliable evidence

In adults with moderate-to-severe chronic renal failure, reduced protein intake decreases the risk of end-stage renal disease, based on a systematic review of eight randomized trials with 1,524 patients who were followed for at least one year (Cochrane Database Syst Rev. 2006;[2]:CD001892). The trials compared different levels of protein intake (≤0.8 g/kg/day vs. 0.3-0.6 g/kg/day). Patients with diabetes were excluded. Renal death was defined as initiation of dialysis, kidney transplant, or patient death. The incidence of renal death was 13.5% in patients following the low-protein diet compared with 19.4% in patients receiving the higher-protein diet (P = .0007, NNT 17). However, there was insufficient evidence to determine the optimal level of protein intake.