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Dietary Patterns of Patients with Chronic Kidney Disease: The Influence of Treatment Modality
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Ketoacid Analogues Supplementation in Chronic Kidney Disease and Future Perspectives

Department of Nephrology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, F-69495 Pierre-Bénite, France
Univ Lyon, CarMeN Laboratory, INSA-Lyon, Inserm U1060, INRA, Université Claude Bernard Lyon 1, F-69621 Villeurbanne, France
Department of Medical Clinic, Botucatu Medical School, Universidade Estadual Paulista—UNESP, Botucatu 18618-687, Brazil
Author to whom correspondence should be addressed.
Nutrients 2019, 11(9), 2071;
Received: 11 July 2019 / Revised: 22 August 2019 / Accepted: 26 August 2019 / Published: 3 September 2019
(This article belongs to the Special Issue Targeted Nutrition in Chronic Disease)
Diet is a key component of care during chronic kidney disease (CKD). Nutritional interventions, and, specifically, a restricted protein diet has been under debate for decades. In order to reduce the risk of nutritional disorders in very-low protein diets (VLDP), supplementation by nitrogen-free ketoacid analogues (KAs) have been proposed. The aim of this review is to summarize the potential effects of this dietary therapy on renal function, uremic toxins levels, and nutritional and metabolic parameters and propose future directions. The purpose of this paper is also to select all experimental and randomized clinical studies (RCTs) that have compared VLDP + KA to normal diet or/and low protein diet (LPD). We reviewed the SCOPUS, WEB of SCIENCES, CENTRAL, and PUBMED databases from their inception to 1 January, 2019. Following duplicate removal and application of exclusion criteria, 23 RCTs and 12 experimental studies were included. LPD/VLPD + KAs appear nutritionally safe even if how muscle protein metabolism adapts to an LPD/VLPD + KAs is still largely unknown. VLPD + KAs seem to reduce uremic toxins production but the impact on intestinal microbiota remains unexplored. All studies observed a reduction of acidosis, phosphorus, and possibly sodium intake, while still providing adequate calcium intake. The impact of this diet on carbohydrate and bone parameters are only preliminary and need to be confirmed with RCTs. The Modification of Diet in Renal Disease study, the largest RCTs, failed to demonstrate a benefit in the primary outcome of the decline rate for the glomerular filtration rate. However, the design of this study was challenged and data were subsequently reanalyzed. However, when adherent patients were selected, with a rapid rate of progression and a long-term follow up, more recent meta-analysis and RCTs suggest that these diets can reduce the loss of the glomerular filtration rate in addition to the beneficial effects of renin-angiotensin-aldosterone system (RAAS) inhibitors. The current evidence suggests that KAs supplemented LPD diets should be included as part of the clinical recommendations for both the nutritional prevention and metabolic management of CKD. More research is needed to examine the effectiveness of KAs especially on uremic toxins. A reflection about the dose and composition of the KAs supplement, the cost-effective features, and their indication to reduce the frequency of dialysis needs to be completed. View Full-Text
Keywords: chronic kidney disease; low protein diet; ketoacid analogues; intestinal microbiota; dialysis chronic kidney disease; low protein diet; ketoacid analogues; intestinal microbiota; dialysis
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Koppe, L.; Cassani de Oliveira, M.; Fouque, D. Ketoacid Analogues Supplementation in Chronic Kidney Disease and Future Perspectives. Nutrients 2019, 11, 2071.

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