Simplified colonic dialysis with hemodialysis solutions delays the progression of chronic kidney disease

Exploring the clinical efficacy and mechanism of high-position colon dialysis combined with Traditional Chinese Medicine retention enema in real-world patients with stage 3-5 chronic kidney disease (non-dialysis) based on the theory of the Gut-Kidney axis

Background: With societal and economic development, the annual incidence of chronic kidney disease (CKD) is increasing. Current treatments for CKD are limited, and once patients progress to the uraemic stage, it places a significant economic burden on families and society. Based on the "gut-kidney axis" theory and real-world research, this study aims to evaluate the clinical efficacy, safety, and potential mechanism of high-position colon dialysis combined with traditional Chinese medicine (TCM) retention enema in treating stage 3-5 chronic kidney disease (non-dialysis). Additionally, it seeks to identify new therapeutic targets and approaches for CKD treatment. Methods: The TCM decoction was analyzed using Ultra-Performance Liquid Chromatography-Quadrupole-Orbitrap-High Resolution Mass Spectrometry (UPLC-Q-Orbitrap-HRMS). Participants meeting the inclusion criteria were divided into a control group (n = 153) and a treatment group (n = 159) based on their preferences and physicians' recommendations. Both groups adhered to a high-quality low-protein, low-salt, low-phosphorus, and low-fat diet supplemented with essential amino acids, and were monitored for blood pressure, blood glucose, and blood lipids. The treatment group received high-position colon dialysis combined with TCM retention enemas (administered at least 12 times every other day). Results: Thirteen compounds were identified from the herbs by UPLC-Q-Orbitrap-HRMS. The CKD3-5 treatment group exhibited improvements in blood biochemistry and other laboratory indices, with significant enhancements in renal function-related indices for CKD4 and CKD5 stages (p < 0.05). Following treatment, indoxyl sulfate (IS), endotoxin, and D-lactic acid levels decreased to a certain extent in both groups, with a statistically significant difference observed within the treatment group (p < 0.05). The treatment group displayed a significant reduction in aerobic bacterial colonies, an increase in anaerobic bacterial colonies, a decrease in Escherichia coli colonies, and an increase in Bifidobacterium and Lactobacillus colonies (p < 0.05). No significant changes in colony numbers were observed in the control group. Conclusion: High-position colon dialysis combined with TCM retention enema may serve as an adjuvant treatment for CKD4-5 (non-dialysis), and its mechanism may be related to the reduction of uraemic toxins, improvement of intestinal mucosal barrier function, and regulation of intestinal microecology. Clinical Trial Registration: https://www.chictr.org.cn/, identifier ChiCTR2200062852.

Exploring a Complex Interplay: Kidney-Gut Axis in Pediatric Chronic Kidney Disease

The human intestinal microbiota is a highly intricate structure with a crucial role in promoting health and preventing disease. It consists of diverse microbial communities that inhabit the gut and contribute to essential functions such as food digestion, nutrient synthesis, and immune system development. The composition and function of the gut microbiota are influenced by a variety of factors, including diet, host genetics, and environmental features. In pediatric patients, the gut microbiota is particularly dynamic and vulnerable to disruption from endogenous and exogenous factors. Recent research has focused on understanding the interaction between the gut and kidneys. In individuals with chronic kidney disease, there is often a significant disturbance in the gut microbiota. This imbalance can be attributed to factors like increased levels of harmful toxins from the gut entering the bloodstream, inflammation, and oxidative stress. This review looks at what is known about the link between a child's gut-kidney axis, how dysbiosis, or an imbalance in the microbiome, affects chronic kidney disease, and what treatments, both pharmaceutical and non-pharmaceutical, are available for this condition.

Derivation and elimination of uremic toxins from kidney-gut axis

Uremic toxins are chemicals, organic or inorganic, that accumulate in the body fluids of individuals with acute or chronic kidney disease and impaired renal function. More than 130 uremic solutions are included in the most comprehensive reviews to date by the European Uremic Toxins Work Group, and novel investigations are ongoing to increase this number. Although approaches to remove uremic toxins have emerged, recalcitrant toxins that injure the human body remain a difficult problem. Herein, we review the derivation and elimination of uremic toxins, outline kidney-gut axis function and relative toxin removal methods, and elucidate promising approaches to effectively remove toxins.

Gut Microbiota-Targeted Interventions in the Management of Chronic Kidney Disease

Recent advances in microbiome research have informed the potential role of the gut microbiota in the regulation of metabolic, cardiovascular, and renal systems, and, when altered, in the pathogenesis of various cardiometabolic disorders, including chronic kidney disease (CKD). The improved understanding of gut dysbiosis in cardiometabolic pathologies in turn has led to a vigorous quest for developing therapeutic strategies. These therapeutic strategies aim to investigate whether interventions targeting gut dysbiosis can shift the microbiota toward eubiosis and if these shifts, in turn, translate into improvements in (or prevention of) CKD and its related complications, such as premature cardiovascular disease. Existing evidence suggests that multiple interventions (eg, plant-based diets; prebiotic, probiotic, and synbiotic supplementation; constipation treatment; fecal microbiota transplantation; and intestinal dialysis) might result in favorable modulation of the gut microbiota in patients with CKD, and thereby potentially contribute to improving clinical outcomes in these patients. In this review, we summarize the current understanding of the characteristics and roles of the gut microbiota in CKD and discuss the potential of emerging gut microbiota-targeted interventions in the management of CKD.

Novel intestinal dialysis interventions and microbiome modulation to control uremia

PURPOSE OF REVIEW

In patients with chronic kidney disease (CKD), the gut plays a key role in the homeostasis of fluid and electrolyte balance and the production and disposal of uremic toxins. This review summarizes the current evidence on the gut-targeted interventions to control uremia, fluid overload, hyperkalemia and hyperphosphatemia in CKD.

RECENT FINDINGS

Studies have emerged that support the concept of intestinal dialysis, such as colonic perfusion with a Malone antegrade continence enema stoma or colonic irrigation with a rectal catheter, as a promising adjuvant approach to control uremia in CKD, although most findings are preliminary. The use of AST-120, an oral adsorbent, has been shown to reduce circulating levels of indoxyl sulfate and p-cresol sulfate and have potential renoprotective benefits in patients with advanced CKD. Diarrhea or inducing watery stools may modulate fluid retention and potassium and phosphorus load. Accumulating evidence indicates that plant-based diets, low-protein diets, and pre-, pro-, and synbiotic supplementation may lead to favorable alterations of the gut microbiota, contributing to reduce uremic toxin generation. The effects of these gut-targeted interventions on kidney and cardiovascular outcomes are still limited and need to be tested in future studies including clinical trials.

SUMMARY

Interventions aimed at enhancing bowel elimination of uremic toxins, fluid and electrolytes and at modulating gut microbiota may represent novel therapeutic strategies for the management of uremia in patients with CKD.

Risk Factors and Management of Catheter Malfunction During Urgent-Start Peritoneal Dialysis

Background: Catheter malfunction is a common complication of peritoneal dialysis (PD). This study aimed to retrospectively analyze the risk factors and management of catheter malfunction in urgent-start PD.

Methods: Patients who underwent urgent-start PD were divided into catheter-malfunction and control groups. Baseline demographic and laboratory data of the two groups were compared, and the risk factors for catheter malfunction were analyzed. Primary outcome measure was catheter survival, and the secondary outcomes were surgical complications and malfunction treatment.

Results: Total of 700 patients was analyzed, among whom 143 (20.4%) experienced catheter malfunctions, specifically catheter migration (96, 67.1%), omental wrapping (36, 25.2%), and migration plus omental wrapping (11, 7.7%). Catheter survival time in the malfunction group (202.5 ± 479.4 days) was significantly shorter than that in the control group (1295.3 ± 637.0 days) (P < 0.001). Multivariate analysis revealed higher body mass index [hazard ratio (HR), 1.061; 95% confidence intervals (CI), 1.010–1.115; P = 0.018], lower surgeon count (HR, 1.083; 95% CI, 1.032–1.136; P = 0.001), and higher serum potassium (HR, 1.231; 95% CI, 1.041–1.494; P = 0.036) as independent risk factors for catheter malfunction, while older age (HR, 0.976, 95% CI, 0.962–0.991; P = 0.002) and colonic dialysis (HR, 0.384; 95% CI, 0.254–0.581; P < 0.001) as protective factors. Further subgroup analysis revealed a shorter catheter survival time in patients with younger age ( ≤ 40 years), higher serum potassium levels (≥5 mmol/L), while a longer catheter survival time in patients with colonic dialysis. PD tube and subcutaneous tunnel preservation was successful in 41 out of 44 patients with omental wrapping. All patients had good post-incision prognoses.

Conclusions: Urgent-start PD is safe and effective for unplanned PD patients. Adequate pre-operative colonic dialysis and serum potassium level control are conducive in preventing catheter malfunction. Conservative treatment is effective in managing catheter migration alone, while preservation of the PD tube and the subcutaneous tunnel is effective for omental wrapping.

Chronic kidney disease

Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.

Colonic dialysis can influence gut flora to protect renal function in patients with pre-dialysis chronic kidney disease

Chronic kidney disease (CKD) is a major public health burden around the world. The gut microbiome may contribute to CKD progression and serve as a promising therapeutic target. Colonic dialysis has long been used in China to help remove gut-derived toxins to delay CKD progression. Since disturbances in the gut biome may influence disease progression, we wondered whether colonic dialysis may mitigate the condition by influencing the biome. We compared the gut microbiota, based on 16S rRNA gene sequencing, in fecal samples of 25 patients with CKD (stages 3–5) who were receiving colonic dialysis(group CD), 25 outpatients with CKD not receiving colonic dialysis(group OP), and 34 healthy subjects(group HS). Richness of gut microbiota was similar between patients on colonic dialysis and healthy subjects, and richness in these two groups was significantly higher than that in patients not on colonic dialysis. Colonic dialysis also altered the profile of microbes in the gut of CKD patients, bringing it closer to the profile in healthy subjects. Colonic dialysis may protect renal function in pre-dialysis CKD by mitigating dysbiosis of gut microbiota.

Intestinal dialysis for conservative management of Uremia

PURPOSE OF REVIEW

Renal replacement therapies, such as hemodialysis are invasive and impose significant financial burden as well as burden on quality of life. Conservative and 'gentler' forms of renal replacement therapy for the frail and palliative care patient is an unmet medical need.

RECENT FINDINGS

The treatment of uremia using the gut as a substitute for the kidney has been proposed but is not practiced widely because of proven lack of long-term mortality benefit coupled with complications like edema and hyperchloremia. Mounting evidence showed that endotoxins from gastrointestinal tract are a major source of chronic inflammation in chronic kidney disease (CKD). The high load of nitrogenous waste elimination through the bowel could potentially serve as an alternative modality to remove uremic wastes especially in people who opt for conservative management for end-stage renal disease with some recent studies in Iran and China showing promising benefits in uremia.

SUMMARY

In this review, we will discuss the history, recent evidence and potential of these therapies and their implications in CKD for conservative and easy management of uremia.

Novel conservative management of chronic kidney disease via dialysis-free interventions

PURPOSE OF REVIEW

In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population.

RECENT FINDINGS

The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden.

SUMMARY

As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.