Do Ketoanalogues Still Have a Role in Delaying Dialysis Initiation in CKD Predialysis Patients?

Abstract

Early versus later start of dialysis is still a matter of debate. Low-protein diets have been used for many decades to delay dialysis initiation. Protein-restricted diets (0.3-0.6 g protein/kg/day) supplemented with essential amino acids and ketoanalogues (sVLPD) can be offered, in association with pharmacological treatment, to motivated stage 4-5 chronic kidney disease (CKD) patients not having severe comorbid conditions; they probably represent 30-40% of the concerned population. A satisfactory adherence to such dietary prescription is observed in approximately 50% of the patients. While the results of the studies on the effects of this diet on the rate of progression of renal failure remain inconclusive, they are highly significant when initiation of dialysis is the primary outcome. The correction of uremic symptoms allows for initiation of dialysis treatment at a level of residual renal function lower than that usually recommended. Most of the CKD-associated complications of cardiovascular and metabolic origin, which hamper both lifespan and quality of life, are positively influenced by the diet. Lastly, with regular monitoring jointly assumed by physicians and dietitians, nutritional status is well preserved as confirmed by a very low mortality rate and by the absence of detrimental effect on the long-term outcome of patients once renal replacement therapy is initiated. On account of its feasibility, efficacy and safety, sVLPD deserves a place in the management of selected patients to safely delay the time needed for dialysis.

A Delphi consensus panel on nutritional therapy in chronic kidney disease

“…The consensus on a low-normal amount of proteins is in broad agreement with the KDIGO (lowering protein intake to 0.8 g/kg/day in adults with or without diabetes and GFR \30 ml/min/1.73 m 2 ) [22] and KHA-CARI (normal protein diet of 0.75-1.0 g/kg/day in early CKD) guidelines [21]. A broad consensus was reached on the reduction of protein to at least 0.6-0.7 g/kg/day in patients with CKD stages 4-5, eventually supported, in selected cases, by the administration of essential amino acids or their respective keto-analogs in addition to a more severe dietary protein restriction (0.3-0.4 g/kg/day) [6,25]. This is in agreement with the American Dietetic Association guidelines and previous studies showing that very-low protein diets supplemented with keto-analogs of essential amino acids are effective in ameliorating metabolic disturbances of advanced CKD and delaying the initiation of dialysis without deleterious effects on nutritional status [24,26].…”

Strategies to promote adherence to nutritional advice in patients with chronic kidney disease: a narrative review and commentary

“…In many developing countries, the use of vegetarian diets along with keto acids has been shown to delay progression as well. [28][29][30][31][32][33] The switch to emphasizing higher protein ($1.0 g/kg/day) intake starts when the patient is in kidney failure and undergoing maintenance dialysis therapy. 34 Protein-energy wasting and chronic inflammation associated with malnutrition are often associated with hypoalbuminemia.…”

Non-Traditional Aspects of Renal Diets: Focus on Fiber, Alkali and Vitamin K1 Intake

“…Apart from these traditional dietary manipulations, dietary supplements may play an important role in obtaining both beneficial effects and nutritional safety in the CKD patient [11,12]. Essential amino acids plus ketoacids supplementation is mandatory in the course of a very low-protein diet in order to assure an adequate essential amino acid supply: the goal is to obtain the beneficial effect of a severe protein restriction while preventing malnutrition [13,14].…”