Microbiota management: a perspective for kidney transplant patients

Cláudia Silva Souza^1,2Niels Olsen Saraiva Camara^1,2*Thaís Alves Da Silva^1,2*

• ¹University of São Paulo, São Paulo, Rio Grande do Sul, Brazil
• ²Universidade Federal de Sao Paulo Escola Paulista de Medicina, São Paulo, Brazil

Chronic kidney disease (CKD) is recognized as one of the most significant public health issues globally, with approximately 40% of patients progressing to end-stage kidney disease (ESKD). Transplantation remains the most indicated option for many patients with ESKD; however, these individuals frequently experience hospital readmissions and face a heightened risk of developing other complications. Although short-term allograft survival, typically around one year, tends to be satisfactory, long-term graft survival is often compromised due to acute and chronic rejection, which can be mediated by antibodies or other recipient-related factors. Recent studies and review articles have emphasized the relationship between intestinal dysbiosis and chronic renal failure, as well as the poor outcomes associated with kidney transplantation. The CKD itself, as well as the immunosuppressive medications used by organ transplant recipients, can lead to intestinal dysbiosis, which in turn increases the production of uremic toxins that can harm even the transplanted kidney. Clinical studies have demonstrated that the combination of prebiotics, probiotics, and synbiotics—supplements that aid in the establishment of intestinal microbiota—can effectively help control the production of nitrogenous substances, reduce renal inflammation, and alleviate gastrointestinal symptoms in patients with CKD. Experimental models have shown that short-chain fatty acids derived from gut fermentation of dietary fiber, such as butyrate and acetate, could improve renal function and reduce renal inflammation, allowing better acceptance of kidney allograft, partly by inducing T regulatory cells. Despite the growing evidence supporting the positive effects of maintaining a balanced microbiota, there is still a lack of comprehensive reviews in this field. Additionally, recent findings suggest that the type of fiber consumed may influence intestinal health and even increase susceptibility to colorectal cancer, depending on the fiber type. Therefore, we aim to explore how substances derived from gut fermentation of dietary fiber, in addition to probiotics, prebiotics, and synbiotics, contribute to allograft tolerance, with a particular focus on their potential application in establishing renal function in allograft recipients.