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CPD ACTIVITY 81 Protein supplements and kidney damage: should we be worried? 2 CPD CREDITS A word on PrEP PrEP (pre-exposure prophylaxis) for HIV represents a significant step forward in public safety for men who have unprotected sex with men, transgender or gender diverse, heterosexual people with high risk of HIV and people who inject drugs.12 PrEP is recommended to be taken daily for people who are medium to high risk of contracting HIV.12 PrEP consists of tenofovir disoproxil (in either the fumarate, maleate or phosphate salt) and emtricitabine. It’s recommended to monitor serum creatinine, urine protein to creatinine ratio four weeks after starting PrEP and then every three months for the first year and then six to 12 monthly if the patient is considered lower risk for CKD.12 The concern with these preparations and high protein consumption associated with heavy workouts is pre-renal AKI caused by dehydration. The tenofovir disoproxil salt of PrEP requires a dose reduction for people with a GFR <50 ml/ min12. Tenofovir disoproxil can cause intrinsic renal toxicity and this risk is increased if the patient is more adherent to their therapy than if they intermittently take their PrEP. Tenofovir alafenamide does not carry the same renal risks as the disoproxil salt.12 PrEP can interact with many other medicines. It’s recommended not to use NSAIDs with PrEP.12 exercisers dehydration is a common cause. • Certain drugs, eg, NSAIDs, ACE, ARBS and PrEP may increase risk of AKI. • Adequate fluid intake is vital to reduce risk, particularly when taking protein, exercise and potentially at-risk drugs. References 1. Australian Health Survey: Nutrition First Results - Food and Nutrients Canberra: Australian Bureau of Statistics; 2014 \\\[updated 21/12/2015. Available from: https:// www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.007~2011- 12~Main%20Features~Supplements~400. 2. Complementary Medicines Australia. Australia’s Complementary Medicines Industry Audit Canberra: CMA Australia; 2019 \\\[Available from: http://www. cmaustralia.org.au/resources/Documents/CMA-INDUSTRY_AUDIT-V4.pdf. 3.Ashley C MC. ‘Introduction to renal therapeutics’. Ashley C MC, editor. London: Pharmaceutical Press; 2008. 301 p. 4. Kidney Health Australia. Chronic Kidney Disease Management in General Practice. Australia: Kidney Health Australia; 2015. 5. National Health and Medical Research Council. Nutient reference values for Australia and New Zealand: including recommended dietary intakes 2017. Available from: https://www.nhmrc.gov.au/sites/default/files/images/nutrient- refererence-dietary-intakes.pdf. 6. Martin W AL, Rodriguez N. ‘Dietary protein intake and renal function’. Nutrition and Metabolism, 2005; 2 (25): 1. 7. Maughan RJ, Burke LM, Dvorak J, Larson-Meyer DE, Peeling P, Phillips SM, et al. IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete. 2018; 28 (2): 104. 8. Kalantar-Zadeh K, Fouque D. ‘Nutritional management of chronic kidney disease’. New England Journal of Medicine, 2017; 377 (18): 1765-76. 9. Van Elswyk ME, Weatherford CA, McNeill SH. ‘A systematic review of renal health in healthy individuals associated with protein intake above the US recommended daily allowance in randomised controlled trials and observational studies’. Adv Nutr, 2018; 9 (4): 404-18. 10. Friedman AN. ‘High-protein diets: Potential effects on the kidney in renal health and disease’. American Journal of Kidney Diseases, 2004; 44 (6): 950-62. 11. Kanagasundaram N, Arunachalam C. ‘Assessment and initial management of acute kidney injury’. Medicine, 2015; 43 (8): 440-5. 12. Therapeutic Guidelines. Therapeutic Guidelines Antibiotic 2020. Available from: www.tg.org.au. Accreditation number: A2007RP3 (exp: 30/06/2022). This activity has been accredited for 1 hour of Group One CPD (or 1 CPD credit) suitable for inclusion in an individual pharmacist’s CPD plan which can be converted to 1 hour of Group Two CPD (or 2 CPD credits) upon successful completion of relevant assessment activities. 1. Which of the following statements about dietary protein is INCORRECT? A) The recommended dietary intake of protein is 50-80g per day. B) The average amount of protein in a dietary shake is about 30g per serve. C) The consequences of inadequate protein intake are known, but the implications of excessive protein intake are not fully understood. D) Proteins are broken down in the small intestine into amino acids with waste products urea and oxygen. E) Dietary protein can be derived from animal and plant sources. 2. Arron comes into your pharmacy and inquires about buying a protein/creatine supplement shake as he wants to build muscle. What information do you need to know about Arron to help you guide your advice to him? A) Age. B) Smoking status. C) Other medical conditions. D) Other medicines he is taking. E) All the above. 3. Arron informs you he is a heavy smoker, takes recreational drugs and PrEP, but only on weekends. What advice regarding the use of protein supplements would you provide Arron? (Select the TWO correct answers) A) Protein supplements are completely safe as they are just concentrated food. B) Protein supplements are generally considered safe, but little is known about the long-term effects of high-dose protein on the kidneys. C) Arron has some risk factors for CKD and AKI and so should be careful to reduce the risks of dehydration and AKI. D) Smoking is actually protective of kidney function as it increases haemoglobin. E) He should be taking his PrEP every day because that will reduce the risk of AKI when he is dehydrated from his gym workout. 4. Arron buys a protein powder to add to his smoothies. He returns to your pharmacy 10 days later. He tells you he wanted to bulk up fast to look good for a music festival. He took three times the recommended amount of protein powder and trained at the gym four hours a day for the previous seven days. He says today he is short of breath and his ankles are puffy. What questions are important to ask Arron? A) When did his symptoms start? B) What other medicines has he taken in the past few days? C) How much fluid has he been drinking after his training sessions? D) Has he noticed a change in the colour or the volume of his urine? E) All the above as you suspect he has an AKI. 5. Arron is admitted to the local hospital with an AKI. With appropriate supportive therapies he is discharged after a week with his GFR almost returning to normal. What advice is important for Arron regarding his long-term kidney health? (Select the TWO correct answers). A) Previous AKI is a risk factor for future AKI and CKD. B) Blood pressure control is not an important goal for healthy kidneys. C) Smoking is fine if it helps him keep his weight down. D) Lifestyle interventions – diet, exercise, quitting smoking and controlling blood pressure – are important for long-term kidney health. E) AKI is only a short-term condition so there is no need to change any of his activities. RETAIL PHARMACY • JUL 2020