Should a low-protein diet and ketoanalogue supplementation be part of the management of advanced chronic kidney disease?

The vast majority of patients with advanced chronic kidney disease (CKD) who transition to end-stage kidney disease (ESKD) are treated with dialysis. Given that dialysis does not always have the intended effects of increasing longevity and/or improving health, particularly in those with high comorbidity burden and/or older age groups, there has been increasing emphasis on interventions that delay or avert the need for renal replacement therapy. Among the multi-disciplinary approaches used to reduce CKD progression, dietary interventions are a major cornerstone. Current guidelines support the role of a low-protein diet in patients with moderate to advanced CKD who are metabolically stable. In addition to dietary protein amount, there is evidence that dietary protein sources as well as nutrients in plant-based foods have an important impact on kidney health outcomes. Clinical practice guidelines, including the 2020 National Kidney Foundation and Academy of Nutrition and Dietetics Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in CKD, recommend a low protein diet for patients with moderate to advanced non-dialysis dependent (NDD)-CKD who are metabolically stable to reduce risk of ESKD and death. In addition to recommending lower protein intake, the recent 2024 Kidney Disease Improving Global Outcomes CKD Guidelines include a Practice Point advising that people with CKD eat more plant-based foods than animal-based foods. Increasing data also show that plant-based diets are associated with lower risk of progression of CKD and its complications including cardiovascular disease (cardio-kidney-metabolic syndrome), acid-base balance disorders, mineral bone disease, and dysglycemia.