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CKD — Nutritional Supplement (Very Low Protein Diet) Pregnancy: Seek specialist opinion — VLPD is generally contraindicated in pregnancy (inadequate protein for fetal development); ketoanalogues not recommended in pregnancy

Ketoanalogues of Essential Amino Acids

Brand names: Ketosteril

Adult dose

Dose: 1 tablet per 5 kg body weight per day (e.g., 70 kg patient = 14 tablets/day), taken with meals
Route: Oral
Frequency: Divided with meals (typically TDS)
Max: Per body weight calculation
Keto acid/amino acid supplement for use alongside a very low protein diet (VLPD: 0.3-0.4 g protein/kg/day) in pre-dialysis CKD stages 4-5. Ketoanalogues are transaminated in the body to essential amino acids, reducing nitrogen waste load on the kidneys while maintaining nutritional adequacy. Requires specialist renal dietitian input.

Paediatric dose

Route: Oral
Seek specialist paediatric nephrology and dietitian opinion — not licensed in children; growth monitoring essential

Dose adjustments

Renal

Specifically designed for use in CKD stages 4-5 to delay dialysis initiation. VLPD + Ketosteril reduces uraemic symptoms and slows GFR decline. Not for use in dialysis patients (inadequate protein provision for dialysis-related losses).

Hepatic

No dose adjustment required

Clinical pearls

  • Mechanism: ketoanalogues (alpha-keto acids) are nitrogen-free precursors to essential amino acids. Once ingested, they are transaminated using endogenous nitrogen (from urea cycle) to form essential amino acids — effectively recycling nitrogen rather than generating new waste. This reduces BUN without compromising essential amino acid status.
  • VLPD + Ketosteril can delay dialysis by 1-2 years in motivated patients with CKD stage 4-5 — the Chauveau study and Garneata trial (NEJM 2016) demonstrated 2-year delay in need for renal replacement therapy vs standard low-protein diet.
  • Calcium monitoring: Ketosteril contains significant calcium (each tablet = ~50 mg). In patients also on calcitriol, calcium supplements, or calcium-based phosphate binders, hypercalcaemia can develop. Check calcium monthly.
  • Patient selection: requires a highly motivated patient who will strictly adhere to VLPD. Inadequate adherence to the low-protein component negates the benefit. Renal dietitian involvement is MANDATORY.
  • Phosphate control bonus: VLPD naturally restricts phosphate intake alongside protein — useful in CKD-MBD management, potentially reducing phosphate binder requirements.

Contraindications

  • Hypercalcaemia (each Ketosteril tablet contains calcium — monitor calcium)
  • Amino acid metabolism disorders
  • Hypersensitivity to any component

Side effects

  • Hypercalcaemia (each tablet contains 50 mg calcium as calcium ketovaline/leucine — monitor serum calcium, especially if on active vitamin D)
  • Nausea (take with meals to reduce)
  • Malnutrition if VLPD not supervised by renal dietitian

Interactions

  • Calcium supplements and active vitamin D (calcitriol/alfacalcidol) — additive hypercalcaemia risk; reduce or stop calcium-containing phosphate binders if calcium rises
  • Tetracyclines and quinolones — calcium in Ketosteril reduces absorption; separate by 2 hours

Monitoring

  • Serum calcium (monthly — hypercalcaemia risk)
  • Serum albumin and pre-albumin (nutritional adequacy)
  • eGFR (disease progression)
  • BUN/urea (efficacy of nitrogen recycling)
  • Phosphate
  • Body weight and nutritional status

Reference: BNFc; BNF 90; Garneata et al. NEJM 2016 (VLPD + Ketosteril trial); ERA-EDTA CKD Nutrition Guidelines; SPC Ketosteril; KDOQI Nutrition Guidelines 2020. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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