From the Guidelines
Ketoanalogues are a valuable adjunct in the management of chronic kidney disease (CKD) by reducing nitrogen waste accumulation and maintaining nutritional status, and should be considered in adults with CKD who are at risk of kidney failure, under close supervision, as part of a very low-protein diet supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/d) 1.
Mechanism of Action
Ketoanalogues are nitrogen-free versions of essential amino acids that can be converted into amino acids in the body without producing additional nitrogenous waste. When combined with a low-protein diet, ketoanalogues allow patients to decrease protein intake while preventing malnutrition.
Clinical Benefits
This approach helps slow CKD progression by reducing the workload on the kidneys, decreasing uremic symptoms, improving metabolic parameters like phosphate and parathyroid hormone levels, and potentially delaying the need for dialysis.
Key Considerations
- The standard dosage and administration should be individualized based on patient needs and response.
- Regular monitoring of nutritional status, kidney function, and electrolyte levels is crucial to ensure optimal benefit and minimize potential adverse effects.
- Initiation of ketoanalogues should be under the supervision of a nephrologist or a healthcare provider experienced in the management of CKD.
- While older guidelines such as those from 2006 provide valuable insights into the nutritional management of CKD, including the use of ketoanalogues 1, the most recent and highest quality evidence should guide current practice, emphasizing the importance of personalized and supervised care.
From the Research
Benefits of Ketoanalogues in Chronic Kidney Disease
- Ketoanalogues supplementation has been associated with a lower risk of long-term dialysis and mortality in patients with anemic advanced chronic kidney disease 2.
- A meta-analysis found that a restricted protein diet supplemented with ketoanalogues can significantly delay the progression of chronic kidney disease, particularly in patients with an estimated glomerular filtration rate (eGFR) > 18 mL/min/1.73 m2 3.
- Ketoacid analogues of essential amino acids can provide several potential advantages for people with advanced chronic kidney disease, including reducing the generation of potentially toxic metabolic products and the burden of potassium, phosphorus, and sodium 4.
Mechanisms of Action
- Ketoanalogues can be converted to their respective amino acids without providing additional nitrogen, which can help reduce the burden of waste products in the body 4.
- A low protein diet supplemented with ketoanalogues can help maintain good nutrition and reduce the risk of kidney function decline and dialysis initiation 5.
- Ketoanalogues can also help reduce phosphorous levels, increase calcium levels, and decrease parathyroid hormone (PTH) levels in patients with eGFR < 18 mL/min/1.73 m2 3.
Clinical Applications
- Ketoanalogues can be used as an additional therapeutic strategy to slow the progression of chronic kidney disease 2.
- A daily dose of more than 5.5 tablets of ketoanalogues has been associated with a lower risk of long-term dialysis and mortality 2.
- A daily dose of more than 6 tablets of ketoanalogues has been associated with a lower risk of kidney function decline and dialysis initiation 5.
- Adherence to ketoacids/essential amino acids-supplemented low protein diets can be improved with proper education and support, and can help delay the start of maintenance dialysis 6.