Fecal Microbiota Transplantation as a Therapeutic Strategy in the Progression of Chronic Kidney Disease
Phase: NA
Conditions: Chronic Kidney Disease Due to Hypertension, Chronic Kidney Disease Due to Type 2 Diabetes Mellitus
Sponsor: Hospital Universitario Dr. Jose E. Gonzalez

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UNIVERSIDAD AUTÓNOMA DE NUEVO LEÓN 
HOSPITAL UNIVERSITARIO 
"Dr. José Eleuterio González " 
 
 
 
 
 
 
Research protocol: 
 
 
 
Fecal microbiota transplantation as a therapeutic strategy in the progression of 
chronic kidney disease 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monterrey, Nuevo Leon; to July 26, 2018 
 
 
 
 
 

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1. Background: 
 
Chronic kidney disease (CKD) at its different stages, has a prevalence of 8 to 16% in the world’s 
population (1) being diabetes mellitus, essential hypertension and glomerulonephritis the leading 
causes (1). The increasing incidence of this disease has raised for health systems unsustainable renal 
replacement therapies including peritoneal dialysis, hemodialysis and kidney transplantation (1). Once 
CKD is set the main treatment goal is to slow the progression and cardiovascular complications due to 
traditional risk factors such as hypertension, atherosclerosis, among others and non-traditional as the 
chronic inflammatory state described in CKD patients (2). 
 
In recent years information regarding intestinal microbiota (IM) and its modulatory influence in 
inflammatory conditions has increased (3). It’s been found it to influence systemic diseases such as; 
multiple CKD, metabolic diseases, autoimmune pathologies, neuro-psychiatric diseases, obesity, 
chronic ulcerative colitis, Clostridiodes difficile infection etc. (4, 5). The IM unbalance due quantitative 
and qualitative changes in its composition and metabolic activities is called dysbiosis (6). This 
disruption in the symbiotic relationship with the host is associated with the onset and development of 
complications and progression of many diseases (4). In CKD compounds such as indoles, phenols 
and ammonia are produced by the fermentation of IM undigested products that are then absorbed by 
the host to subsequently be excreted by the kidneys and in CKD accumulate due the decreased renal 
clearance (7,8).  
 
Uremic toxins generated in the intestine favor oxidative stress in addition to inflammatory conditions 
present in these patients such increased indoxyl sulfate (IS) and p-Cresol sulfate (PCS) have been 
associated with a greater number of cardiovascular events and increased mortality in patients with 
CKD as well as persistent anemia, mineral metabolism disorders and increase in the progression of 
CKD (9, 10). It is increasingly clear that local and systemic consequences of kidney damage may 
result largely from changes in IM (7). Ramezani et. al. proposed understanding the pathological effects 
of dysbiosis on the IM as a therapeutic target in order to restore symbiosis (6). Studies have shown 
that administration of synbiotics, probiotics and prebiotics show a significant decrease in the levels of 
PCS and IS sulfate in adults with CKD in pre dialytic stage after altering stool microbiome (11, 12, 13, 
14).   
 
Fecal microbiota transplantation (FMT) from healthy donors is an alternative therapy with high success 
rates to correct dysbiosis. So far, this therapy is recommended by European guidelines as a medical 
therapy for relapsing C. difficile infections or refractory to standard medical treatments with an IA 

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evidence level. (15). Because of the exponential increase of people with CKD and the lack of effective 
measures to stop the progression of the disease it is necessary to study simple alternatives that could 
positively modify its natural course. The FMT is a safe simple measure able to reduce the systemic 
inflammatory process of CKD patients and therefore its progression. Once installed the CKD’s main 
treatment’s objective is to stop the decline in glomerular filtration rate (GFR). The inflammatory status 
of patients with CKD increases the progression of the disease, decreasing the GFR ranges from 1 to 5 
ml / min /1.73 m2 per year; according to KDIGO the average is 3 ml / min / 1.73 m2 and  ≥5 ml / min / 
1.73 m2 per year or a 25% GFR decreased from the baseline in those with rapid progression. This is a 
reason why our randomized double-blind clinical trial seeks to identify the impact of the FMT on the 
progression of chronic kidney disease and to evaluate the modification of intestinal microbiome in 
patients with chronic before kidney disease and after being subjected to FMT. A browse in PubMed 
database showed article in which FMT had been used to address this matter up to date June 2017, 
demonstrating the originality of the project. 
 
 
 
2. Overall objective: 
Identify the impact of intestinal microbiota transplantation in the progression of chronic kidney disease 
 
3. Hypothesis: 
Modification of intestinal microbiome in CKD patients by FMT decreases the CKD progression 
 
4. Null Hypothesis: 
Modification of intestinal microbiome of CKD patients by FMT doesn’t lessens the CKD progression 
 
5. Specific objectives: 
 
Evaluate changes of bowel microbiome in CKD patients before and after undergoing FMT 
 
Evaluate the behavior of CKD progression markers in patients undergoing FMT 
 
Evaluate whether a decrease of inflammation markers in CKD patients is after FMT treatment 
is developed 
 
6. Materials and methods: 
 
A) Methodological Study design:  

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Observational  
 
 
or 
Experimental  
X 
Cross  
            
 
 
or  
Longitudinal  
 
Comparative  
 
 
or 
Descriptive 
 
 
Prospective 
            X 
or 
Retrospective  
 
 
Not blind 
 
 
or 
Blind  
            X 
 
B) Type of study: 
1) 
Survey or cross cohort  
 
  
2) 
Cases and controls  
 
  
 
3) 
Cohorts   
        
 
 
 
4) 
Controlled Clinical Trial  
 
X 
5) 
Study Diagnostic Test 
 
 
 
 
 
 
 
 
C) Population Studies: 
 
Number of patients: Outpatient Nephrology  
 
Number of subjects to include and basis of calculation: 28 
 
Population characteristics: kidney disease stage 4 
 
A. Inclusion criteria:  
 
Being diagnosed with CKD, creatinine clearance less than 60 mL/minute, secondary 
hypertension and / or diabetes 
 
Older than 18 years of age 
 
B. Exclusion criteria:  
 
Malignancies’ treatment within the last 5 years 
 
Antibiotic treatment for any reason during the month prior to enrollment 
 
Use of probiotics in the last 3 months 
 
Diagnosed Clostridiodes difficile infection in the last year 
 
Previous FMT treatment 
 
Exacerbations of CKD during the 3 months prior or present at the time of enrollment 
 

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C. Elimination criteria: 
 
Failure to comply the structured patient monitoring 
 
Non-delivery of stool samples at set times 
 
The patient decides to no longer participate in the study 
 
D.- Landmark and recruitment method:  
 
Medical consult at the Nephrology Department, University Hospital "Dr. José Eleuterio 
González " 
  
 
D) Description of the design (describing the methodology to be performed for each of the 
specific objectives):   
After being selected and randomized patients who meet the criteria for inclusion and exclusion, will be 
assigned to a group to start treatment; one group with FMT-C (Frozen capsules of fecal microbiota) or 
another with placebo capsules which shall consist of an excipient harmless to the body (capsules 
frozen saline), treatment and follow-up of both groups will be developed in the service Infectología.  
Both groups receive frozen for ingestion orally capsules (comprised of FMT or placebo according to 
the randomisation) with a frequency of 15 capsules each 12hrs for 4 doses on days 1, 10 and 30 of 
the study. Each capsule must be ingested over a period no longer than 1 hour. 
measurements characteristic factors of the progression of kidney disease day 0,10, 30, 60, 90, 120 
and 180 be made consisting of: 
 
Proteins in urine 24 hours 
 
Creatinine clearance 24 hours 
 
CBC 
 
serum creatinine 
 
Urea Nitrogen 
 
Urea 
 
Glucose 
 
Uric acid  
 
IS  
 
venous gases 
 
Blood samples were taken by puncture of peripheral vein by laboratory personnel to assess renal 
function, urine samples will be collected by the patient at home and transported to the laboratory, none 
of these samples will be used for genetic analysis, only samples of feces they underwent genomic 

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analysis, collection of stool samples will days 0, 5, 10 30, 90 and 180 (on 10, 30, 90 and 180 with a 
range of +/- 2 days). 
adverse effects questionnaires on days 1, 5, 30 and 60 is performed and quality of life assessment on 
days 0, 10, 30, 90 and 180. 
Monitoring will face on a weekly basis to register if they have submitted infections, adverse effects and 
whether changes have received treatment. Visits will be made in the epidemiology and the Regional 
Center for Kidney Diseases University Hospital 
 
Fecal microbiota sample preparation  
Fecal microbiota donors will be chosen based on their medical history, weight, lack of risk behaviors, 
or medication with antibiotics and/or proton pump inhibitors, as well as no record of trips in the last 3 
months or diarrhea in the last 6 months. Absence of chronic infections such as hepatitis B, C and HIV 
will be determined by immunoassay.  
The first step involves combining the sample with recombinant antigens and diluent, the antibodies 
present in the sample will bind to the antigen coated microparticles after washing. The second step is 
to add human acridinium-labeled conjugate after a second wash cycle to subsequently add pre-
activating and activating solutions to the mixture. The resulting chemiluminescent reaction is 
measured as units of reactive light in the ARCHITECT equipment. If the sample is greater 
chemiluminescent the cutoff point will be considered reactive. Feces also should be analyzed to rule 
Entamoeba spp., Campylobacter jejuni, Yersinia enterocolitica, Salmonella spp., Shigella spp., 
enterohemorrhagic E. coli., Giardia lamblia, cestodes and nematodes by feces culture. the presence 
of rotavirus by agglutination of latex particles and Helicobacter pylori stool antigen test is detected. 
 
All samples will be mixed with 10% glycerol and frozen at -70° C within a 60-minute period after their 
collection. They will be mixed and then suspended in a 0.9% saline solution. The final mixture will be 
filtered to remove particles bigger than 330 microns, finally, glycerol will be added as bacterial cryo-
protector. Once this mixture is finished, the encapsulation will be performed with a 50 wells capsule 
filler using two sizes of sterile capsules for enteral release. The capsules will be filled with the feces 
mixture and sealed with its counterpart, then sealed capsule will be encapsulated in a second capsule. 
The final product will be stored frozen until 60 minutes prior use. The administration will be oral. 
 
Randomization 
The scrambling process will be performed by a random number generator which correspond to the 
even numbers and odd arm to another. This randomization by foreign medical staff will intervention, 
monitoring and treatment of patients. 

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7. Calculation of the sample size: 
 
In order to demonstrate a difference in the progression of renal failure as measured by the cup of 
glomerular filtration rate in patients with renal insufficiency treated with transplantation of fecal 
microbiota, a formula for hypothesis testing and difference of two halves was used, with an average 
expected difference of at least 5 ml / min with a zα 1.96 significance level of 95% for two tails, and zβ 
value of 0.84 with a power of 80%, a sample of 15 participants per group was obtained. Moreover, as 
the second main objective ratio correction dysbiosis is compared. Using a formula for hypothesis 
testing and difference of two proportions, with a difference of expected proportions of at least 50% with 
zα 1.96 significance level of 95% for two tails, 
 
8. Statistical analysis: 
 
Descriptive statistics were used with measures of central tendency and dispersion. Categorical 
variables for use Chi square test or Fisher exct. For continuous variables T Student or Mann Whitney 
is used. Multivariate analysis be performed by ANOVA. We consider an equal or lesser value to 0.05 
as statistically significant. 
 
9. Activities PhD student in conducting this research: 
 
 
Recruitment and clinical monitoring of patients 
 
Explanation and signing of informed consent 
 
Coordinate administration of FMT / Placebo and collection of blood samples, feces and urine 
 
Analysis of results and statistical analysis of the variables 
 
Determining changes in the progression of kidney disease 
 
Analysis of changes in the gut microbiome (together with microbiologists) 
 
Write a manuscript for publication 
 
 
 
 
References 
 

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