Intestinal dialysis for conservative management of Uremia

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.

Anephric Neonate and Evolution of our Study on Intestinal Dialysis

Purpose:

Intestinal dialysis for end-stage renal disease (ESRD) is a proposed renal replacement therapy, and studies are going on worldwide to make it practicable. We are also doing the same study in our institution and would like to share our experience in managing an anephric neonate with intestinal dialysis in the perspective of our ongoing study of intestinal dialysis since 2010.

Patients and Methods:

We did double-ended jejunostomy in an isolated loop of the jejunum keeping the main tract intact with jejunojejunal anastomosis in this anephric neonate. Following that, we started irrigation with peritoneal dialysis fluid from the 3^rd postoperative day (POD) in that jejunal loop through jejunostomy.

Results:

This patient had no uremic features since re-admission and showed better laboratory and clinical outcomes with combined jejunal loop and colonic dialysis for 7 days. However, the patient died on the 9^th POD following severe hypoglycemia.

Conclusions:

From this study, it seems intestinal dialysis, with necessary modifications done in our subsequent patients, which might be recommended for ESRD in children as well as in adults.

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.