Revolutionizing the Landscape of CKD Care through Medical Nutrition Therapy and Ketoanalogue Innovation
27 Mar 2024
The goal of chronic kidney disease (CKD) treatment is to prevent or slow further damage to the kidneys. The mainstay approach in kidney failure is dietary intervention, where balancing the intake of energy, protein, sodium, potassium, phosphorus, and fluid with biochemical markers and weight change show favorable effects in nutritional status and kidney progression.1
On February 19, 2024, Corbridge launched Renalog DS – a double strength alpha ketoanalogue and amino acid formulation – as well as Renalog Max, a granular ketoanalogue and amino acid formulation. The launch event entitled Renal Revolution: The New Age in CKD Management was held at Edsa Shangri-La Manila, and featured expert lectures on CKD management and discussions on medical nutrition therapy and updates on ketoanalogue therapy.
The expert guests at the event were speakers Dr Maricar Madridejos Esculto-Khan, RND, Chair, Nutrition Management Team and Chief of Subsection of Nutrition Medicine, Head of Nutrition and Dietary Department, Makati Medical Center; Dr Vimar A. Luz, FPCP, FPSN, MHA, Associate Director for Medical Education and Training, St. Luke’s Medical Center (SLMC), Global City, Officer of the Philippine Society of Nephrology (PSN); and facilitator Dr Frederick H. Verano, FPCS, FPSN, Active Consultant and Staff, Section of Nephrology, Makati Medical Center, Adventist Medical Center.
Experts answer questions from the audience during the panel discussion. From left: Dr. Frederick H. Verano, FPCS, FPSN, Dr. Vimar A. Luz, FPCP, FPSN, MHA, and Dr. Maricar Madridejos Esculto-Khan, RND.
Medical Nutrition Therapy for CKD: Practical Renal Nutrition Concepts for the Non-Nutritionist
In her lecture, Dr Maricar Madridejos Esculto-Khan discussed the importance of medical nutritional therapy – a strategy that makes use of diet and nutrition to affect patient outcomes – in CKD.1
In CKD, the main goals of nutrition therapy include delaying disease progression, reducing metabolic complications, preventing protein-energy wasting, maintaining fluid and electrolyte balance, and maintaining optimal body composition. While this may sound simple, it presents a number of challenges including undernutrition and overnutrition.2
This is where individualized nutrition management comes into play. Dr Esculto-Khan emphasized that nutritional care should be tailored to the patient’s needs, preferences, and goals. This as well as periodic counseling and patient education are essential to slowing CKD progression and decreasing mortality.3,4
Greatly reduced protein intake is an important part of nutritional therapy for CKD, with evidence showing that this can help mitigate disease progression and reduce the need for dialysis. Because patients on very low-protein diets (VLPDs) consume as low as 0.3 g/kg/day of protein, supplements like amino acid esters and ketoanalogues can be essential to maintain nitrogen balance and other nutritional metrics.5,6
Ketoanalogues: New Updates on an Old Therapy
In his lecture, Dr Vilmar Luz delved deep into ketoanalogue therapy as an integral component of CKD management, and the latest updates in the field.
A meta-analysis reviewing data from 1,456 patients across 17 clinical trials looking at CKD patients on different types of diets and different supplements found that protein restriction with ketoanalogues was associated with benefits for eGFR, proteinuria, serum phosphate levels, blood pressure and cholesterol. The same meta-analysis also suggested that VLPDs with ketoanalogues were even more effective than low-protein diets (LPDs) with ketoanalogues for CKD benefits.7
A meta-analysis of from 2022 looking at patients with diabetic kidney disease across 11 studies also found that reduced protein diets with ketoanalogue supplementation were associated with improved renal, metabolic and clinical outcomes.8
Real-world evidence also supports the use of ketoanalogues in reduced protein diets. A retrospective cohort study looked at a total of 1,042 CKD patients from King Chulalongkorn Memorial Hospital in Bangkok and compared patients on LPDs to patients on LPDs with supplemented ketoanalogues. After a median follow-up of 32.9 months, the group of patients taking ketoanalogues had a significantly lower risk of kidney function decline defined by a decline in eGFR greater than 5 mL/min or the initiation of dialysis.9
This study also found a dose-response analysis, with many benefits seeming to manifest at a dose of 6 ketoanalogue tablets per day or more (See Fig. 1).
In a retrospective cohort study of pre-dialysis CKD patients, 1042 CKD patients were recruited, with 543 patients being treated with LPD–KAs. The primary outcome was either a rapid estimated glomerular filtration rate (eGFR) decline > 5 mL/min/1.73m2/year or commencing dialysis. The serum creatinine level and eGFR were determined as markers of kidney function. Untimed urinary albumin-to-creatinine ratios (UACR) and other metabolic laboratories, including electrolytes, lipid profiles, fasting plasma glucose, and hemoglobin A1C levels were also collected. At the median follow up of 32.9 months, patients treated with LPD–KAs had a significantly lower risk of kidney function decline. According to KAs dose–response analysis, the daily dose of equal or less than 5 tablets was conversely associated with a higher risk of the primary endpoint, whereas the association disappeared among patients receiving a dose of more than 6 tablets per day (Figure 1).9
Figure 1. Unadjusted and fully adjusted hazard ration (HR) with 95% confident interval (CI) of primary composite endpoint per an integral increment of daily dose of ketoanalogues among CKD participants receiving supplementation.
Bridging the gap: Double and triple strength KAs
Dosage seems to play a role in the benefits of ketoanalogue supplementation, but having to take a large number of pills every day can be a detriment for some patients.
This is one of the reasons why Corbridge has launched Renalog DS and Renalog Max. Renalog DS provides a double dose of ketoanalogues in tablet form, while Renalod Max provides a triple strength ketoanalogue dose in granule form. These can help reduce the number of pills CKD patients need to take, potentially aiding patient adherence.
Key advantages of these innovative formulations include:
Streamlined dosing. The increased dosage streamlines treatment regimens, reducing the pill burden for patients: a crucial factor in long-term disease management.
Cost-Efficiency. By offering a higher concentration of active ingredients at a comparable price point (Renalog DS is priced 47 pesos/tablet), the double-dose ketoanalogue presents a cost-effective alternative, making essential therapies more accessible to patients.
Optimal Dosing. With a doubled dosage, clinicians can more easily prescribe a wider range of therapeutic doses for patients.
Addressing the gaps on nutrition therapy and ketoanalogue prescription necessitates a multifaceted approach encompassing education, advocacy, and collaborative decision-making between healthcare providers and patients. Additionally, patient education and engagement play a pivotal role in fostering understanding and acceptance of dietary intervention and ketoanalogue therapy as an essential component of CKD management. By fostering a culture of innovation, collaboration, and patient-centered care, healthcare providers can optimize outcomes for patients battling CKD.
References: 1. Li A, Lee HY, Lin YC. Nutrients 2019 Apr 26;11(5):957. doi: 10.3390/nu11050957. 2. Jadeja YP, Kher V. Indian J Endocrinol Metab 2012 Mar;16(2):246-51. doi: 10.4103/2230-8210.93743. 3. Kim SM, Jung JY. Korean J Intern Med 2020 Nov;35(6):1279-1290. doi:10.3904/kjim.2020.408. 4. Ameh OI, et al. BMC Nephrol 2016;17:68. doi:10.1186/s12882-016-0297-4. 5. Tom K, et al. Am J Physiol 1995;268(4 Pt 1):E668–77. doi: 10.1152/ajpendo.1995.268.4.E668. 6. Masud T, et al. Kidney Int 1994;45:1182–92. doi: 10.1038/ki.1994.157. 7. Chewcharat A, et al. J Ren Nutr 2020;30:189–99. doi: 10.1053/j.jrn.2019.07.005. 8. Bellizzi V, et al. Nutrients 2022 Jan 19;14(3):441. doi: 10.3390/nu14030441. 9. Ariyanopparut S, et al. Sci Rep 2023 Sep 19;13(1):15459. doi: 10.1038/s41598-023-42706-w.
On February 19, 2024, Corbridge launched Renalog DS – a double strength alpha ketoanalogue and amino acid formulation – as well as Renalog Max, a granular ketoanalogue and amino acid formulation. The launch event entitled Renal Revolution: The New Age in CKD Management was held at Edsa Shangri-La Manila, and featured expert lectures on CKD management and discussions on medical nutrition therapy and updates on ketoanalogue therapy.
The expert guests at the event were speakers Dr Maricar Madridejos Esculto-Khan, RND, Chair, Nutrition Management Team and Chief of Subsection of Nutrition Medicine, Head of Nutrition and Dietary Department, Makati Medical Center; Dr Vimar A. Luz, FPCP, FPSN, MHA, Associate Director for Medical Education and Training, St. Luke’s Medical Center (SLMC), Global City, Officer of the Philippine Society of Nephrology (PSN); and facilitator Dr Frederick H. Verano, FPCS, FPSN, Active Consultant and Staff, Section of Nephrology, Makati Medical Center, Adventist Medical Center.
Experts answer questions from the audience during the panel discussion. From left: Dr. Frederick H. Verano, FPCS, FPSN, Dr. Vimar A. Luz, FPCP, FPSN, MHA, and Dr. Maricar Madridejos Esculto-Khan, RND.
Medical Nutrition Therapy for CKD: Practical Renal Nutrition Concepts for the Non-Nutritionist
In her lecture, Dr Maricar Madridejos Esculto-Khan discussed the importance of medical nutritional therapy – a strategy that makes use of diet and nutrition to affect patient outcomes – in CKD.1
In CKD, the main goals of nutrition therapy include delaying disease progression, reducing metabolic complications, preventing protein-energy wasting, maintaining fluid and electrolyte balance, and maintaining optimal body composition. While this may sound simple, it presents a number of challenges including undernutrition and overnutrition.2
This is where individualized nutrition management comes into play. Dr Esculto-Khan emphasized that nutritional care should be tailored to the patient’s needs, preferences, and goals. This as well as periodic counseling and patient education are essential to slowing CKD progression and decreasing mortality.3,4
Greatly reduced protein intake is an important part of nutritional therapy for CKD, with evidence showing that this can help mitigate disease progression and reduce the need for dialysis. Because patients on very low-protein diets (VLPDs) consume as low as 0.3 g/kg/day of protein, supplements like amino acid esters and ketoanalogues can be essential to maintain nitrogen balance and other nutritional metrics.5,6
Ketoanalogues: New Updates on an Old Therapy
In his lecture, Dr Vilmar Luz delved deep into ketoanalogue therapy as an integral component of CKD management, and the latest updates in the field.
A meta-analysis reviewing data from 1,456 patients across 17 clinical trials looking at CKD patients on different types of diets and different supplements found that protein restriction with ketoanalogues was associated with benefits for eGFR, proteinuria, serum phosphate levels, blood pressure and cholesterol. The same meta-analysis also suggested that VLPDs with ketoanalogues were even more effective than low-protein diets (LPDs) with ketoanalogues for CKD benefits.7
A meta-analysis of from 2022 looking at patients with diabetic kidney disease across 11 studies also found that reduced protein diets with ketoanalogue supplementation were associated with improved renal, metabolic and clinical outcomes.8
Real-world evidence also supports the use of ketoanalogues in reduced protein diets. A retrospective cohort study looked at a total of 1,042 CKD patients from King Chulalongkorn Memorial Hospital in Bangkok and compared patients on LPDs to patients on LPDs with supplemented ketoanalogues. After a median follow-up of 32.9 months, the group of patients taking ketoanalogues had a significantly lower risk of kidney function decline defined by a decline in eGFR greater than 5 mL/min or the initiation of dialysis.9
This study also found a dose-response analysis, with many benefits seeming to manifest at a dose of 6 ketoanalogue tablets per day or more (See Fig. 1).
In a retrospective cohort study of pre-dialysis CKD patients, 1042 CKD patients were recruited, with 543 patients being treated with LPD–KAs. The primary outcome was either a rapid estimated glomerular filtration rate (eGFR) decline > 5 mL/min/1.73m2/year or commencing dialysis. The serum creatinine level and eGFR were determined as markers of kidney function. Untimed urinary albumin-to-creatinine ratios (UACR) and other metabolic laboratories, including electrolytes, lipid profiles, fasting plasma glucose, and hemoglobin A1C levels were also collected. At the median follow up of 32.9 months, patients treated with LPD–KAs had a significantly lower risk of kidney function decline. According to KAs dose–response analysis, the daily dose of equal or less than 5 tablets was conversely associated with a higher risk of the primary endpoint, whereas the association disappeared among patients receiving a dose of more than 6 tablets per day (Figure 1).9
Figure 1. Unadjusted and fully adjusted hazard ration (HR) with 95% confident interval (CI) of primary composite endpoint per an integral increment of daily dose of ketoanalogues among CKD participants receiving supplementation.
Bridging the gap: Double and triple strength KAs
Dosage seems to play a role in the benefits of ketoanalogue supplementation, but having to take a large number of pills every day can be a detriment for some patients.
This is one of the reasons why Corbridge has launched Renalog DS and Renalog Max. Renalog DS provides a double dose of ketoanalogues in tablet form, while Renalod Max provides a triple strength ketoanalogue dose in granule form. These can help reduce the number of pills CKD patients need to take, potentially aiding patient adherence.
Key advantages of these innovative formulations include:
Streamlined dosing. The increased dosage streamlines treatment regimens, reducing the pill burden for patients: a crucial factor in long-term disease management.
Cost-Efficiency. By offering a higher concentration of active ingredients at a comparable price point (Renalog DS is priced 47 pesos/tablet), the double-dose ketoanalogue presents a cost-effective alternative, making essential therapies more accessible to patients.
Optimal Dosing. With a doubled dosage, clinicians can more easily prescribe a wider range of therapeutic doses for patients.
Addressing the gaps on nutrition therapy and ketoanalogue prescription necessitates a multifaceted approach encompassing education, advocacy, and collaborative decision-making between healthcare providers and patients. Additionally, patient education and engagement play a pivotal role in fostering understanding and acceptance of dietary intervention and ketoanalogue therapy as an essential component of CKD management. By fostering a culture of innovation, collaboration, and patient-centered care, healthcare providers can optimize outcomes for patients battling CKD.
References: 1. Li A, Lee HY, Lin YC. Nutrients 2019 Apr 26;11(5):957. doi: 10.3390/nu11050957. 2. Jadeja YP, Kher V. Indian J Endocrinol Metab 2012 Mar;16(2):246-51. doi: 10.4103/2230-8210.93743. 3. Kim SM, Jung JY. Korean J Intern Med 2020 Nov;35(6):1279-1290. doi:10.3904/kjim.2020.408. 4. Ameh OI, et al. BMC Nephrol 2016;17:68. doi:10.1186/s12882-016-0297-4. 5. Tom K, et al. Am J Physiol 1995;268(4 Pt 1):E668–77. doi: 10.1152/ajpendo.1995.268.4.E668. 6. Masud T, et al. Kidney Int 1994;45:1182–92. doi: 10.1038/ki.1994.157. 7. Chewcharat A, et al. J Ren Nutr 2020;30:189–99. doi: 10.1053/j.jrn.2019.07.005. 8. Bellizzi V, et al. Nutrients 2022 Jan 19;14(3):441. doi: 10.3390/nu14030441. 9. Ariyanopparut S, et al. Sci Rep 2023 Sep 19;13(1):15459. doi: 10.1038/s41598-023-42706-w.