Gut Guardianship: Recommendations for Rational Use of Proton Pump Inhibitors in Chronic Kidney Disease

The widespread use of proton pump inhibitors (PPIs) hasraised safety concerns, especially among patients withchronic kidney disease (CKD), where long-term use hasbeen linked with acute interstitial nephritis (AIN),hypomagnesaemia, and potential progression to endstagekidney disease (ESKD). Recent observational studiesand meta-analyses have yielded mixed evidence, calling fora nuanced and individualized approach to acid suppressionin CKD. The concept of gut guardianship emphasizescautious, indication-based prescribing, dose minimization,and structured deprescribing to preserve gut–renal health.This article reviews the current evidence and proposes aclinical toolkit for rational PPI use in CKD, based on riskstratification, guideline-based indications, and ongoingmonitoring.