Gut-derived uremic toxins and cardiovascular health in chronic kidney disease

Uremic toxins (UTs) are bioactive compounds that accumulate in chronic kidney disease (CKD) due to impaired renal clearance, exacerbating disease progression and cardiovascular (CV) complications. These toxins originate from endogenous metabolism, gut microbiota, and dietary intake and include protein-bound UTs such as p-cresyl sulfate, indoxyl sulfate, and indole acetic acid, as well as small, water-soluble toxins such as trimethylamine-N-oxide and phenylacetylglutamine. Their accumulation promotes oxidative stress, inflammation, and endothelial dysfunction, contributing to vascular damage and associated with CV risk. Current management strategies focus on dietary interventions, prebiotics, probiotics, oral sorbents, emerging pharmacological approaches, and advanced dialysis techniques, but clinical outcomes remain inconsistent. Recent trials have demonstrated the potential of agents such as sevelamer, high-amylose-resistant starch, and AST-120 to reduce UT levels and improve certain vascular markers. However, more robust, long-term studies are necessary to fully establish the therapeutic efficacy and optimize treatment strategies to mitigate the impact of gut-derived UTs on CKD and CV health.