HONOLULU—Adding ketoanalogues to very low-protein diets for patients with chronic kidney disease (CKD) could significantly delay dialysis initiation, according to new data presented at the XVI International  Congress on Nutrition and Metabolism in Renal Disease.

A recent Romanian study indicated that patients on a ketoanalogue-supplemented very-low-protein diet (sVLPD) had a slower decline in renal function than patients on a conventional low-protein diet (LPD).

To evaluate the effectiveness of sVLPD as compared to the conventional LPD, Liliana Garneata, MD, PhD, Assistant Professor of Nephrology, Gabriel Mircescu, MD, PhD, Professor of Nephrology, and colleagues at the “Dr Carol Davila” Teaching Hospital of Nephrology in Bucharest, performed a randomized trial at their institution that included 207 adult patients with an eGFR of less than 30 mL/min/1.73 m2 without uremic complications, feeding inability, or relevant comorbid conditions. Diabetic patients were not considered for enrollment because of the difficulty to achieve the recommended energy intake while restricting both proteins and carbohydrates in the diet.

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The sVLPD consisted of 0.3 g of vegetable proteins/kg/day plus one capsule of Ketosteril/5 kg/day, while the LPD comprised 0.6 mixed proteins/kg/day. The overall energy intake of each diet was approximately 30 kcal/kg/day.

Optimum blood pressure control was achieved and maintained during the study, with similar proportions in both groups taking antihypertensive medications, and, specifically, ACE inhibitors.

Only 11% of the patients on sVLPD patients required dialysis during the 48 weeks of follow-up compared with 30% of the LPD subjects, a difference that was statistically significant. Furthermore, the time to end-stage renal disease was significantly longer with sVLPD (33 vs. 19 weeks), and the decline in eGFR was slower with sVLPD than LPD (2.1 vs. 4.9 mL/min/1.73 m2).

“This represents a 57% slower decline in their renal function, which translates into a gain of almost one year without the need for dialysis,” Dr. Garneata explained. “These patients were safely managed by nutritional intervention and monitoring for almost one year, rather than having to go on dialysis immediately.” These data, she noted, are consistent with those of similar studies published previously by Walser M et al (J Am Soc Nephrol 1999;10:110-116) and Brunori G et al (Am J Kidney Dis 2007;49:569-580), as well as to those of a recent meta-analysis by Fouque D et al (Cochrane Database Syst Rev 2009;3:CD001892).

The researchers also observed an amelioration of certain metabolic disturbances of advanced CKD with sVLPD (lower serum urea levels and better control of acid-base balance and calcium-phosphorus metabolism abnormalities), which allowed postponement of dialysis initiation.

A delay in dialysis start also translates into cost-savings, as the same group led by Dr. Garneata and Dr. Mircescu found in an earlier study (J Ren Nutr 2009;19[Suppl 5]:S19-S21). The authors determined that use of sVLPD in stage 4/5 CKD patients and the resultant delay of dialysis would result in a 10% reduction in costs.

Nutritional status was well preserved in both groups throughout the study, thus showing that sVLPD does not lead to malnutrition, Dr. Garneata noted.

In daily practice, Dr. Garneata and Dr. Mircescu consider sVLPD in selected patients with stages 4/5 CKD who adhere closely to a conventional diet, have a good nutritional status, are decidedly motivated to postpone dialysis, and have enough social and family support to allow them to follow the special diet.