Impact of Low Protein Diet Supplemented With Ketoanalogues Supplementation on Uremic Toxins Production

Study Overview
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Brief Summary
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Chronic kidney disease (CKD) is associated with accumulation of uremic toxins like p-cresyl sulfate and indoxyl sulfate that are associated of cardiovascular complication and perturbation of glucose metabolism. These toxins are produced by fermentation of protein by intestinal microbiota but the role of low protein diet and ketoanalogue supplementation on uremic toxins production and microbiota composition are unknown. Low protein diet supplemented with ketoanalogues is recommended inCKD patients to prevent progression of renal disease. The aim of this study is to determine the impact of uremic toxins concentration, microbiota composition and gut hormone involved in carbohydrate metabolism ( GLP-1, FGF19, bile acids) with low protein diet supplemented with ketoanalogues.

Official Title
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Impact of Low Protein Diet Supplemented With Ketoanalogues on Uremic Toxins Production and Glucose Metabolism in Chronic Kidney Disease

Conditions
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Renal Failure

Intervention / Treatment
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* Drug: keto-analogs


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: CKD stage 4-5 with estimated glomerular filtration rate < 30 ml/min/1,73m2 No dialysis No history of kidney transplantation Non-diabetic (fasting glucose <1.26 g / L, or no insulin or oral antidiabetic therapy) BMI between 18 and 30 kg / m2 Patient followed in the nephrology department of Professor FOUQUE at the Lyon Sud hospital For women of childbearing age, at least one method of contraception recognized as effective Patient who gave consent to open participation and signed the consent to participate in the study Exclusion Criteria: Patient with progressive inflammatory, infectious, cardiovascular or neoplastic disease Patient refusing a dietary follow-up Patient having a planned transplant or dialysis project in the next 6 months. Patient having a colectomy, resection of the small intestine or cholecystectomy Patient who has received antibiotics, prebiotics, probiotics in the last 3 months. Patient treated with more than 2 g of calcium per day Patient using laxatives (more than 2 per day) Patient having: Uncontrolled metabolic acidosis (bicarbonatemia <18 mM) Hyperparathyroidism (PTH greater than 5 times the upper limit of normal) Hypercalcemia (Calcium> 2.55 mmol / L) or hypophosphoremia <0.70 mmol / L Anemia (hemoglobinemia <80g / L) Undernutrition criteria: albumin <38 g / L or prealbumin <0.3 g / L Known hypersensitivity to any of the substances or excipients of Ketosteril Subject in exclusion period of a previous study Patient not affiliated to social security Patient under guardianship or in the interests of justice Patient who is pregnant, breastfeeding or likely to become pregnant during the study

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: referencial diet<br>0.8 g/kg/day of protein | |
| Experimental: protein very poor diet with additional keto-analogs<br>0.4 g/kg/day of protein and 1 pill of Ketosteril/ 5kg. | Drug: keto-analogs<br>* The patients that will be included in the experimental arm will have additional keto-analogs (1 pill/5 kg).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Indoxyl Sulfate Plasmatic concentration | Concentration mesure of Indoxyl Sulfate Plasmatic | After 3 months of diet | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| TMAO uremic toxin concentraction ( TMAO, PCS) in plasma | concentration mesure of uremic toxin in plasma | After 3 months | 
| TMAO uremic toxin concentraction in urine ( IS, PCS) | concentration mesure of uremic toxin in urine | After 3 months | 
| Composition of intestinal microbiota | sequencing 16s stool samples | Before three months | 
| Composition of intestinal microbiota | sequencing 16s stool samples | After three months | 
| Insulin sensitivity | oral glucose tolerance test | After 3 months | 
| Insulin secretion | oral glucose tolerance test | After 3 months | 
| Secretion of gut hormone like GLP-1 and FGF19 | oral glucose tolerance test | After 3 months | 
| Composition of bile acid | composition of bile acid mesure by chromatography | After 3 months | 
| Concentration of bile acid | concentration of bile acid mesure by Chromatography | After 3 months | 
| Concentration of endotoxinemia (LPS) | LPS concentration mesure | After 3 months | 
| Nutritional status | Nutrional status will be determined with body weight, body composition with bioimpedecemetry, albumin, prealbumin, muscle status with hand grip. | After 3 months | 
| Calcemia | calcemia mesure | After 3 months | 
| Observance of diet | counting of returned ketosteril tablets | After 3 months |