title: Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many?
abstract: BACKGROUND
  Low-protein diets are often mentioned but seldom used to slow chronic kidney disease (CKD) progression. The aim of the study was to investigate the potential for implementation of a simplified low-protein diet supplemented with alpha-keto analogues (LPD-KA) as part of the routine work-up in CKD patients.
  
  
  METHODS
  In an implementation study (December 2007-November 2011), all patients with CKD Stages IV-V not on dialysis, rapidly progressive Stage III and/or refractory proteinuria, were offered either a simplified LPD-KA, or commercially available low-protein food. LPD-KA consisted of proteins 0.6 g/kg/day, supplementation with Ketosteril 1 pill/10 Kg, 1-3 free-choice meals/week and a simplified schema based on 'allowed' and 'forbidden' foods. 'Success' was defined as at least 6 months on LPD-KA. Progression was defined as reduction in glomerular filtration rate (GFR)[(Chronic Kidney Disease Epidemiology Collaboration) formula CKD-EPI] in patients with at least 6 months of follow-up.
  
  
  RESULTS
  Of about 2500 patients referred (8% CKD Stages IV-V), 139 started LPD-KA; median age (70 years) and prevalence of comorbidity (79%) were in line with the dialysis population. Start of dialysis was the main reason for discontinuation (40 cases, unplanned in 7); clinical reasons were recorded in 7, personal preference in 14 and improvement and death in 8 each. The low gross mortality (4% per year) and the progression rate (from -8 to 0 mL/min/year at 6 months) are reassuring concerning safety. None of the baseline conditions, including age, educational level, comorbidity or kidney function, discriminated the patients who followed the diet for at least 6 months.
  
  
  CONCLUSIONS
  Our data suggest a wider offer of LPD-KA to patients with severe and progressive CKD. The promising results in terms of mortality and progression need confirmation with different study designs.
authors.affiliation: SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Turin, Orbassano, Turin, Italy.
authors.forename: Giorgina B
authors.initials: GB
authors.lastname: Piccoli
authors.forename: Martina
authors.initials: M
authors.lastname: Ferraresi
authors.forename: Maria C
authors.initials: MC
authors.lastname: Deagostini
authors.forename: Federica Neve
authors.initials: FN
authors.lastname: Vigotti
authors.forename: Valentina
authors.initials: V
authors.lastname: Consiglio
authors.forename: Stefania
authors.initials: S
authors.lastname: Scognamiglio
authors.forename: Irene
authors.initials: I
authors.lastname: Moro
authors.forename: Roberta
authors.initials: R
authors.lastname: Clari
authors.forename: Federica
authors.initials: F
authors.lastname: Fassio
authors.forename: Marilisa
authors.initials: M
authors.lastname: Biolcati
authors.forename: Francesco
authors.initials: F
authors.lastname: Porpiglia
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000601:Amino Acids, Essential / Q000008:administration & dosage*; D015331:Cohort Studies; D015897:Comorbidity; D018753:Diet, Protein-Restricted; D019587:Dietary Supplements; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D051436:Renal Insufficiency, Chronic / Q000628:therapy*
chemical_list: D000601:Amino Acids, Essential; C048995:ketosteril
keywords: chronic kidney disease; nutrition; progression of chronic renal failure; vegetarian diet