Microbiota-targeted interventions in chronic kidney disease: probiotics, prebiotics, synbiotics, fecal microbiota transplantation, and traditional Chinese medicine

Chronic kidney disease (CKD) is tightly associated with gut dysbiosis that fuels uremic toxin buildup, systemic inflammation, and renal fibrosis, yet conventional CKD therapies offer limited disease-modifying choices. This narrative review integrates preclinical and clinical evidence (searched PubMed, Web of Science, Cochrane up to May 31, 2026) for gut-microbiota interventions, probiotics, prebiotics, synbiotics, fecal microbiota transplantation (FMT), and traditional Chinese medicine (TCM), and compares their efficacy via network meta-analyses stratified by CKD stages. All microecological agents remodel gut flora, boost short-chain fatty acid producers and strengthen intestinal barriers to cut protein-bound uremic toxins, but eGFR benefits vary by strain, formulation, and disease stage, with most robust effects in non-dialysis CKD (stages 3-4). Dialysis patients gain minimal renal improvements, only mild anti-inflammatory and gastrointestinal relief. Network meta-analyses indicate distinct therapeutic strengths of each regimen, yet indirect cross-study comparisons yield low-to-moderate evidence certainty without direct head-to-head trials. FMT and herbal TCM show promising renoprotective gut-kidney regulatory effects in animal research and small preliminary human cohorts, though large controlled human trials remain absent. Subtype-specific CKD responses (diabetic nephropathy, IgA nephropathy) cannot be universally extrapolated. Despite encouraging mechanistic and early clinical signals, standardized testing, comparative trials and strict safety monitoring for fragile CKD patients are required before routine guideline use of gut-targeted therapies.