Information for Dietitians

Click below to view 4 short videos presented by Dr. Elizabeth Sussman PhD RD, Associate Professor of Nutrition and Dietetics specializing in renal nutrition and research, reviewing clinical data on the use of low protein diets supplemented with keto-analogues as a tool to slow the progression of CKD and maintain nutrition.

  • 2.1g of Keto & Amino Acids per dose (3 capsules).
  • 5.1 g protein per dose with proper diet (3 capsules).
  • To be used in conjunction with low or very low protein diets.
  • May be a tax deductible medical expense.
  • Made in the USA in an FDA inspected facility

About Ketorena

Ketorena is a keto-acid analogue of essential amino acids (keto-analogue) used to maintain or improve nutrition and slow the progression of CKD for those on a low or very low protein diet.

Each dose (3 capsules) of Ketorena contains 2100 mg or 2.1g of Keto & Amino Acids. 2.1g of ketorena offer 5.1 g protein when combined with a proper protein restricted diet.

The 2020 KDOQI Clinical Practice Guideline For Nutrition in CKD. Guideline 3 Protein and Energy Intake.

Protein Restriction, CKD patients not on dialysis and without diabetes

  • In adults with CKD 3-5 who are metabolically stable, we recommend under close clinical supervision, protein restriction with or without keto acid analogues, to reduce the risk of end stage kidney disease (ESKD)/death (1A) and improve quality of life (QoL)
  • A low protein diet providing 0.55-0.60g dietary protein/Kg body weight/day or
  • A very low protein diet providing 0.28-0.43g dietary protein/Kg/body weight/day with additional keto acid/amino acid analogues to meet protein requirements )0.55-0.60 g/Kg/body weight/day.

  • Low protein diet or very low protein diet supplemented with a keto-analogue

  • Low protein diet (LPD) or very low protein diet + keto-analogue (VLPD + KA) are both considerations
  • Protein restriction plus KA supplementation (page S45): For adults with CKD without diabetes, not receiving dialysis, with an eGFR <20 ml/min/1.73m2, a VLPD providing 0.28-0.43 g/Kg BW /day with the addition of KAs to meet protein requirements may be recommended.
  • A VLPD supplemented with KAs could help preserve kidney function in patients with CKD 3-5 (Page S46)

  • Considerations of metabolically stable

    In the context of these recommendations, metabolically stable indicates:
  • The absence of any active inflammatory or infectious disease.
  • No hospitalization within 2 weeks.
  • Absence of poorly controlled diabetes and consumptive disease such as cancer.

  • Find the full guideline here:
    KDIGO 2020 Nutrition in CKD guideline

    Ketorena Dosing

    The guideline states that there are two options to restricting protein to slow CKD as you can read above.

    The details of the guideline state that many people with CKD can live a healthy life while restricting protein to 0.55-0.60g of protein per kilo of body weight per day. This is considered a low protein diet or LPD.

    The guideline also states that to further reduce the decline in kidney function beyond the benefit of an LPD, a very low protein diet or VLPD of 0.28-0.43g of protein per kilo of body weight per day plus the addition of a keto-analogue is an option.

    To understand dosing let's start with an example:

    Julia weighs 130lbs. 130/2.2 = 59 Kg.

    59 x 0.55 or 0.60 is about 32.5 or 35.5. So if Julia wants to protect her kidneys from further decline she should eat between 32.5g and 35.5g of protein per day.

    Let's say Julia is interested in slowing her CKD as much as she can so she wants to try a very low protein diet + Ketorena.

    59 x 0.28 or 0.43 is about 16.5 or 25.5. With the VLPD Julia is protein deficient and needs to make it up with the low nitrogen low acid load Ketorena Keto-analogue.

    Ketorena is used to bridge the protein gap between the very low protein diet and the low protein diet while keeping the nitrogen and acid loads as low as possible.

    Each dose of Ketorena has 2.1g of Keto-analogue per dose which in combination with a proper VLPD offers 5.1g of protein. There is a very important distinction that has to be made: both LPDs and VLPDs have to be done properly. This is why we have a list lower down on this page of consultant renal dietitians who can help with a proper LDP or VLPD. Please remember Ketorena is a medical food an needs to managed under the care of a qualified health care provider.

    Let's go back to Julia. So Julia decides to use the VLPD and she eats 0.30g of protein per kg of body weight per day so she eats 17.7g. (59 x 0.30) . But the guideline indicates she needs 32.5g - 35.5g of protein per day. The gap filler is Ketorena. each dose offers 5.1g. So 5.1 x 3 doses per day = 15.3g. 17.7g from Julia's VLPD + 15.3g from Ketorena = 33g protein per day.

    Keto-Acid Analogues

    The use of keto-analogues in combination with a low or very low protein diet is widely used for managing CKD in Europe, Asia and other parts of the world. Keto-analogue use has been limited in the United States because of its lack of availability here.

    When used with appropriate diet, keto-analogues have been shown to reduce CKD progression, slow the onset of uremic symptoms, and improve nutritional parameters and markers. Please see the section below titled: "Recent clinical Data on the use of keto-analogues with LPD/VLPD" for clinical references and further information.

    Keto-acid analogues of essential amino acids provide potential advantages for CKD patients. Ketoacids lack the amino group bound to the alpha carbon of an amino acid so they can be converted to their respective essential amino acids without providing additional nitrogen.

    Patient types who may benefit from a low or very low protein diet supplemented with Ketorena:

    • CKD patients with advanced disease who wish to avoid or delay dialysis.
    • All CKD 4-5 patients
    • CKD 3 patients with a progressive decline in GFR
    • Patients with Nephrotic syndrome who are being considered for a low protein diet
    • Post kidney transplant patients with CKD 3-5 or those with proteinuria
    • Dialysis patients (PD or incremental HD) with residual renal function

    The following beneficial effects may be found with a keto-analogue supplemented protein restricted diet:

    • Slow the progression of CKD
    • Delay the time until dialysis is required to treat uremic symptoms
    • Decrease levels of uremic toxins
    • Reduce proteinuria
    • Prevent malnutrition
    • Improve calcium-phosphate metabolism/hyperparathyroidism

    Recent clinical data on the use of keto-analogues with an LPD/VLPD

    Click on link to access.

    Ketoanalogues supplementation decreases dialysis and mortality risk in patients with anemic advanced chronic kidney disease. (Wu, Che-Hsiung et al. PLOS ONE May 5 2017)

    Effect of restricted protein diet supplemented with keto analogues in chronic kidney disease: a systematic review and meta analysis. (Jiang, Zheng et al. Int Urol Nephrol 2016)

    Adherence to ketoacids/essential amino acids-supplemented low protein diets and new indications for patients with chronic kidney disease (Fouque et al. BMC Nephrology 2016)

    Keto Supplemented Low Protein Diet: A valid therapeutic approach for patients with steroid-resitant proteinuria during early-stage chronic kidney disease. (Zhang, J et al. J Nutr Health Aging 2016)

    Very low protein diet plus ketoacids in chronic kidney disease and risk of death during end stage renal disease: a historical cohort controlled study. (Bellizzi, V et al. NDT (2015)30:71-77)

    Nephrologist perspectives on the use of keto-analogues in CKD

    Click on link to access.

    Is there a role for Ketoacid Supplements in the Management of CKD? (A. Shah MD; et al: AJKD, Vol 65, May 2015)

    Ketorena capsule ingredients:

    Frequently Asked Questions

    Q: How do patients access Ketorena?

    A: Currently Ketorena is available to purchase directly from Nephcentric on this site or by calling 1-844-980-9933. A 90 serving canister of Ketorena costs $159.50. We offer a $17.50 volume discount when purchasing 2 or more canisters. This brings the per canister price to $142.00. While this is expensive, other foreign sourced keto-analogues cost between $250-$450 per month.

    Q: How does Ketorena work?

    A: Keto-analogues of essential amino acids provide potential advantages for CKD patients. Keto-acids lack the amino group bound to the alpha carbon of an amino acid so they can be converted to their respective essential amino acids without providing additional nitrogen.

    Q: How much water or juice is mixed with a single dose or Ketorena?

    A: A single dose of Ketorena easily mixes into solution with as little as 3-4 ounces of water or juice. Ketorena is natural vanilla flavor.

    Q: How is Ketorena packaged?

    A: Ketorena is packaged as a drink mix powder with 60 doses in a canister. We also offer a tablet option with 3 tablets per dose.

    Q: What is a Medical Food?

    A: Unlike supplement,s a medical food, as defined in section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)), is “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” Medical Foods, including Ketorena can be purchased OTC without a prescription. Ketorena is made in the USA in an FDA inspected facility under cGMP guidelines.

    Q: How does the FDA classify Ketorena?

    A: The FDA classifies Ketorena as GRAS or Generally Recognized As Safe. This is a designation that ingredients added to food is considered safe by experts, and so is exempted from the usual Federal Food, Drug and Cosmetic Act (FFDCA) food additive tolerance requirements.