Maintenance dialysis is a burden for the global health systems globally and is growing at an unprecedented rate. A recent analysis of the prevalence of end stage renal disease led to the conclusion that the prevalence of maintenance dialysis has grown more rapidly during the last two decades than predicted [
1]. Efforts to delay the progression to end stage renal disease (ESRD) mainly rely on control of blood pressure and diabetes. Unfortunately, in many countries nephrologists generally do not examine CKD patients until dialysis is imminent and they have few options for delaying the time to dialysis. However, increasing the time until transition to dialysis therapy may improve patient’s quality of life and can reduce the financial strain on the healthcare system. Consequently, postponing dialysis initiation should receive a high priority in majority of patients with advanced CKD. In fact, there is evidence that many patients will be able to postpone the transition to dialysis, reportedly, more than 60 % of all CKD patients can experience a persistently low GFR (i.e., below 25 ml/min/1.73 m
2) during the two years prior to initiation of dialysis [
2,
3]. In short, there is opportunity to reduce the drivers of chronic kidney disease, including poorly controlled hypertension and decreased symptoms of uremia using a low protein diet supplemented with ketoanalogues in countries where these agents are available and including dietary salt restriction [
4,
5]. In jurisdictions without approved ketoacids such as the United States or Canada, essential amino acids can be used instead. These strategies were concisely reviewed in 2013 [
6], therefore this review will focus on evidence for efficacy that has become available since. In addition, it should be recalled that the currently available ketoanalogues (KA) preparations are marketed with other essential amino acids (EAA), which will be referred as KA/EAA below in text.