Table 2.

Therapies that modify the human intestinal microbiome and bacterial byproduct metabolism in kidney disease

Study DesignInterventionSubjectsPrimary OutcomeSecondary OutcomesRef.
Adsorbent
 RCT, 1:1 active versus placebo, 189-wk EPPIC1, 170-wk EPPIC2AST-120CKD 4, n=2035No change in time to kidney disease progressionaNo change in time to kidney disease progression,a including death40
Synbiotic
 RCT, 2:1 active versus placebo, 30 dProbinul NeutraAfter kidney transplant, n=36↓ p-CresolNo change in kidney function, glycemia, lipids, albumin41
 RCT, active versus placebo, 6-wk crossover, 4-wk washoutSynbioticCKD 3–4, n=37No change in indoxyl sulfate↓ p-Cresol; significant change in microbiome; ↑ albuminuria; no change in eGFR, urinary kidney injury molecule-1, serum inflammatory, or oxidative stress biomarkers42
 RCT, 1:1 active versus placebo, 30 dProbinul NeutraCKD 3–4, n=30↓ p-CresolNo change in gastrointestinal symptoms43
 RCT, 1:1 active versus placebo, 2 moSynbioticESKD, n=18↑ Stool bifidobacterial counts↓ Gastrointestinal symptoms44
 RCT, 1:1 active versus placebo, 2 moSynbioticESKD, n=44↓ Gastrointestinal symptoms↓ Markers of malnutrition and serum CRP and TNF-α levels (NS)45
Prebiotic
 RCT, active versus placebo, 6-wk crossover, 4-wk washoutArabinoxylan oligosaccharidesCKD 3–4, n=39↓ TMAO; no change in urea, p-cresyl sulfate, p-cresyl glucuronide, indoxyl sulfate, phenylacetylglutamineNo change in urinary excretion of urea, p-cresyl sulfate, p-cresyl glucuronide, indoxyl sulfate, phenylacetylglutamine, TMAO; no change in insulin resistance46
Sevelamer
 RCT, 1:1 active versus placebo, 3 moSevelamerCKD 3–5 (predialysis), n=69↓ p-Cresol↓ LDL and serum phosphorus8
Dietary fiber
 Single blinding, 12 wkDietary fiberCKD 3, n=13↓ p-Cresol↑ Stool frequency; no change in quality of life47
 RCT, 1:1 active versus placebo, 6 wkDietary fiberESKD, n=40↓ Indoxyl sulfate; ↓ p-cresol (NS)No change in predialysis weight, BUN, serum albumin, prealbumin, CRP, phosphorus, or KDQOL-3648
Antibiotics
 Observational, 28 dSingle 250-mg oral dose of vancomycinESKD, n=10↓ Indoxyl sulfate; ↓ p-cresyl sulfateDecrease in gut microbiome diversity9
  • RCT, randomized, controlled trial; EPPIC1, Evaluating Prevention of Progression of CKD 1; EPPIC2, Evaluating Prevention of Progression of CKD 2; CRP, C-reactive protein; NS, nonsignificant; TMAO, trimethylamine-N-oxide; KDQOL-36, Kidney Disease Quality of Life 36 instrument.

  • a Composite of dialysis initiation, kidney transplant, and serum creatinine doubling.