Probiotic interventions in peritoneal dialysis: A review of underlying mechanisms and therapeutic potentials

Abstract

Peritoneal dialysis (PD) is a commonly used modality for kidney replacement therapy for patients with end-stage kidney disease (ESKD). PD offers many benefits, including home-based care, greater flexibility, and preservation of residual kidney function compared to in-center hemodialysis. Nonetheless, patients undergoing PD often face significant challenges, including systemic inflammation, PD-related peritonitis, metabolic disorders, and cardiovascular issues that can negatively affect their quality of life and treatment outcomes. Recent studies have demonstrated the crucial role of the gut microbiome in overall health and treatment results, supporting the hypothesis that probiotics may bring potential benefits to the general population of ESKD patients. However, specific data on probiotic use in PD patients are limited. This opinion review aims to summarize the current knowledge on the relationship between PD and the gut microbiome and offers a novel perspective by specifically exploring how probiotic interventions could improve the outcomes of PD treatment. The review also outlines some clinical data supporting the effectiveness of probiotics in patients undergoing PD and considers the difficulties and restrictions in their application. Based on the current knowledge gaps, this study seeks to explore future research directions and their implications for clinical practice.

Keywords: Effectiveness; Gut; Inflammation; Microbiota; Peritoneal dialysis; Probiotics; Treatment.

Figure 1

Key mechanisms of probiotic activity. Probiotics exert their effects through several mechanisms to promote gut health. (1) Modulation of gut microbiota: Probiotics colonize the gut epithelium and promote the growth of beneficial bacteria while inhibiting harmful pathogens through competitive exclusion and the production of short-chain fatty acids and antimicrobial substances (bacteriocin); (2) Enhancement of gut barrier function: Probiotics tighten tight junctions between intestinal epithelial cells and stimulate mucin production, reducing gut permeability and protecting against harmful substances; and (3) Immunomodulation: Probiotics interact with immune cells, particularly dendritic cells (DCs) and macrophages, through pattern recognition receptors, such as TLRs. This interaction leads to reduced lipopolysaccharide (LPS) production, inhibition of the nuclear factor-kappa B inflammatory pathway, decreased proinflammatory cytokine production, and enhanced secretion of anti-inflammatory cytokines. Probiotics also increase the levels of immunoglobulin (Ig) A-secreting plasma cells, promoting the secretion of secretory IgA into the gut lumen, which helps prevent bacterial invasion. SCFA: Short-chain fatty acid; DC: Dendritic cell; LPS: Lipopolysaccharide; NF-Κb: Nuclear factor-kappa B; IgA: Immunoglobulin A; IL-10: Interleukin-10; TGF-β: Transforming growth factor-β; Th: T helper cells; Treg: Tegulatory T cells. Created in BioRender.com (Supplementary material).

Figure 2

Potential probiotic benefits in peritoneal dialysis. Created in BioRender.com (Supplementary material).