Objective: To evaluate the effects on the nutritional and metabolic parameters of a very-low-protein diet supplemented with ketoacids (VLPD þ KA) in comparison with a conventional low-protein diet (LPD) in chronic kidney disease (CKD) patients. Design: Prospective, randomized, controlled clinical study. Setting: Outpatient Clinic of the Nephrology Division of Federal University of São Paulo, Brazil. Subjects: The study involved 24 patients with advanced CKD (creatinine clearance o25 ml/min) that were randomly assigned to either a VLPD þ KA (VLPD þ KA group, 12 patients) or to a conventional LPD with 0.6 g/kg/day (LPD group, 12 patients). The patients were followed for 4 months. Results: Nutritional status was adequately maintained with both diets for the studied period. Protein intake and serum urea nitrogen decreased significantly only in the VLPD þ KA group (from 0.6870.17 to 0.4370.12 g/kg/day, Po0.05; from 61.4712.8 to 43.6714.9 mg/dl, Po0.001; respectively). Ionized calcium did not change in the VLPD þ KA group but tended to decrease in the LPD group. Serum phosphorus tended to decrease in the VLPD þ KA group probably as a result of a significant reduction in dietary phosphorus (5297109 to 3737125 mg/day, Po0.05) associated to the phosphorus-binding effect of the ketoacids. No change in these parameters was found in the LPD group. Serum parathormone increased significantly only in the LPD group (from 2417138 to 4947390 pg/ml, Po0.01). The change in PTH concentration was negatively correlated with changes in ionized calcium concentration (r ¼ À0.75, P ¼ 0.02) and positively correlated with changes in serum phosphorus (r ¼ 0.71, P ¼ 0.03) only in the LPD group. Conclusion: This study indicates that a VLPD þ KA can maintain the nutritional status of the patients similarly to a conventional LPD. Besides, an improvement in calcium and phosphorus metabolism and a reduction in serum urea nitrogen were attained only with the VLPD þ KA. Thus, VLPD þ KA can constitute another efficient therapeutic alternative in the treatment of CKD patients. Sponsorship: This study was supported by CAPES, Oswaldo Ramos Foundation and Fresenius Kabi, Ltda.

Objective: To analyze the spontaneous food intake and the nutritional parameters of patients with different degrees of chronic renal insufficiency (CRI) at the onset of predialysis treatment. Design: Cross-sectional. Setting: Outpatient Clinic of the Nephrology Division of Federal University of São Paulo, Brazil. Subjects: The analysis involved 487 (187 women and 300 men) patients with moderate to advanced CRI who were evaluated in the first visit to the clinic. Results: Patients were divided according to creatinine clearance (CrCl) quartiles. CrCl in the first quartile was lower than 19.9 ml/min/1.73 m 2 and in the fourth one was higher than 43 ml/min/1.73 m 2 . Energy intake was significantly (Po0.05) lower in the first quartile when compared with the fourth one while protein intake estimated by protein equivalent of nitrogen appearance (PNA) was significantly lower in the first, second and third quartiles in comparison with the fourth (Po0.05). Body mass index (BMI) and percentage of ideal body weight were significantly decreased in the three lowest levels of renal function. Standard per cent of triceps skinfold thickness was lower in the first quartile when compared with the fourth one. Compared with the fourth quartile, standard per cent of midarm muscle circumference (MAMC) was lower in the second and in the third quartile. CrCl correlated directly and significantly with PNA (r ¼ 0.30; Po0.01), energy intake (r ¼ 0.17; Po0.01), and MAMC (r ¼ 0.20; Po0.01). In a multiple linear regression analysis, controlling for energy and protein intake, CrCl correlated significantly and positively with BMI and MAMC. Conclusion: This study suggests that a spontaneous decrease in energy and protein intake as well as in anthropometric indices follows a decline in renal function in patients with no previous dietary intervention. Sponsorship: This study was supported by CAPES and Oswaldo Ramos Foundation.

The VLPD+KA is safe to maintain the nutritional status of patients of CKD until the AV fistula is made or the PD training is given.