#3023 Dietary protein intake modulates the tubular handling of the uremic retention solute indoxyl sulfate
Authors: Lauriola Mara , Dejongh Sander , Farré Ricard , Evenepoel Pieter , Meijers Björn 
Published: May 2024

Abstract

Background and Aims
Nutritional intervention constitutes a key part of the clinical management of individuals with chronic kidney disease (CKD). The gut emerged as an important source of uremic retention solutes, including indoxyl sulfate, p-cresyl sulfate and TMAO among the others. Indoxyl sulfate (IS) is produced through the gut microbial fermentation of tryptophan into indole and its conversion into indoxyl sulfate in the liver. Previous authors hypothesised that higher amounts of gut microbial metabolites can be sensed by kidney's proximal tubule cells through the use of receptors and signaling pathways. Particular evidence points to the involvement of kidney Organic Anion Transporters’(OATs') in controlling the gut-kidney communication. According to the so-called remote sensing hypothesis, kidney tubular cells respond to uremic toxins plasma fluctuations altering the activity of OAT1. Few studies have investigated whether in CKD the protein content in the diet affects gut generation, plasma retention and excretion mechanisms of indolic uremic toxins including kidney cells OAT1 expression.

Method
Eighteen male Sprague-Dawley rats (Janvier, France) aged 7-8 weeks and weighing between 270 and 388 g were randomly assigned to a low protein (LP) diet (n = 10) or a high protein (HP) diet (n = 8) after undergoing a 5/6 nephrectomy to develop CKD. For each diet, a sham-operated control group (n = 7 and n = 8 correspondingly) was used. After 7 weeks, urine was collected, and 8 weeks after the disease was induced, euthanasia was performed. Samples of kidney and blood were taken. mRNA and protein expression of OAT1 were sought via qPCR and Western blot.
Forty patients with CKD were recruited in a cross-sectional study investigating eating habits and uremic toxins levels. Eating habits were searched via a food diary. Protein and energy intake were therefore calculated. Blood and 48 h-urine were collected.
Blood creatinine and urea were determined with standard laboratory techniques. Total plasmatic and urinary IS concentrations were measured using LC-MS/MS. The fractional excretion (FE) i.e. the percentage of IS excreted relatively to the kidney filtered load, was calculated to assess IS remote sensing.

Results
Rats with chronic kidney disease (CKD) had considerably higher plasmatic levels of IS (p &lt; .001) than sham rats. Rats with CKD on an HP diet, however, did not differ in plasma IS from rats fed an LP diet (p = .63). On the other hand, CKD rats fed an HP diet showed a substantial rise in 24-hour urinary IS (p &lt; .001). The FE of IS was significantly higher (p = .005) in CKD rats on a HP diet and correlated with 24 h-urinary IS (Spearman r = .51, p value=.03) and with protein intake (Spearman r = .52, p value=.03) in CKD rats. OAT1 mRNA and protein expression was significantly higher in CKD rats given a HP diet (p = .025 and p = .009, respectively).
By dividing the CKD patients into two groups by the median of protein intake, the FE of IS was significantly higher (p = .018) in the patients consuming a larger portion of proteins.

Conclusion
A diet higher in protein content in 5/6 nephrectomized CKD rats as well as in CKD patients likely leads to an increased production of indole in the colon. This results in increased IS fractional excretion but unchanged IS plasma retention. These findings offer more evidence for the mechanisms behind the remote sensing and signaling of uremic toxins derived from indole. In summary, a low-protein diet is still advised for people with chronic kidney disease.