Abstract
Phosphate is a key uremic toxin associated with adverse outcomes. As chronic kidney disease (CKD) progresses, the kidney capacity to excrete excess dietary phosphate decreases, triggering compensatory endocrine responses that drive CKD-mineral and bone disorder (CKD-MBD). Eventually, hyperphosphatemia develops, and low phosphate diet and phosphate binders are prescribed. Recent data have identified a potential role of the gut microbiota in mineral bone disorders. Thus, parathyroid hormone (PTH) only caused bone loss in mice whose microbiota was enriched in the Th17 cell-inducing taxa segmented filamentous bacteria. Furthermore, the microbiota was required for PTH to stimulate bone formation and increase bone mass, and this was dependent on bacterial production of the short-chain fatty acid butyrate. We review current knowledge on the relationship between phosphate, microbiota and CKD-MBD. Topics include microbial bioactive compounds of special interest in CKD, the impact of dietary phosphate and phosphate binders on the gut microbiota, the modulation of CKD-MBD by the microbiota and the potential therapeutic use of microbiota to treat CKD-MBD through the clinical translation of concepts from other fields of science such as the optimization of phosphorus utilization and the use of phosphate-accumulating organisms.
Highlights
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identified lower serum 3indolepropionic acid (IPA) is a tryptophan metabolite produced by Clostridium sporogenes that has been considered as a healthy microbiota marker, as it was increased in individuals with high dietary fiber intake, has potent oxygen radical scavenging properties, activates the pregnane X receptor (PXR) and has been associated with neuroprotection and with a lower risk for type 2 diabetes [133]
Much less is known regarding the interaction between phosphate, another uremic toxin, and the microbiota
Summary
Restricting dietary phosphate implies changing the diet while phosphate binder prescription implies ingesting molecules that bind phosphate and potentially other nutrients, while releasing other components to the gut lumen. While both maneuvers may theoretically modulate the gut microbiota, this has received scarce attention until recently [20]. Only 50% of organic phosphate in vegetables and around 70–80% of organic phosphate in animal protein-rich products is absorbed. It is suggested that patients with CKD avoid excess dietary protein, mix both animal and vegetable protein, and avoid processed foods rich in phosphate-containing additives [17]
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