This is part of a series of blogs discussing an individualized comprehensive gut restoration protocol in chronic kidney disease. Here, we talk about the final step: Gut rebalance and kidney health.

The Gut-Kidney Connection

Recent studies have focused on the significance of a relationship between gastrointestinal (GI) integrity and microbiome diversity with various chronic diseases including kidney disease

In previous blogs, we discussed the impact of exposure to food and environmental triggers that impact the gut lining (or mucosa)integrity and microbiome balance leading to intestinal permeability (IP or “leaky gut”). The impact of leaky gut on kidney health and progression of chronic kidney disease (CKD) has been referred to as the gut-kidney connection is the result of complex biochemical and immune mechanisms.

5R stage 5 is Rebalance

A comprehensive approach to CKD includes addressing the health of the GI at the root of it. Furthermore, this means not simply supplementing with probiotics, but instead addressing all the mechanisms that underlie probiotic need. This includes modification of microbiota balance, integrity of the mucosa and epithelium of the GI tract, improving GI motility, absorption and digestion, and modulation of the immune system. 

Below we will explore the fifth step, Rebalance. But first, let’s quickly review the first four steps of the comprehensive gut restoration protocol. A reminder that the 5R Protocol addresses leaky gut as a foundational approach to reduce the risk of progression of CKD.

The 5 steps of the 5R protocol for healing leaky gut are:

1) Remove potential triggers, including polypharmacy, pathogenic organisms, food intolerances, sensitivities and allergies, or toxic exposure.  

2) Replace digestive aid to support improved nutrient absorption and metabolism, including digestive enzymes, or agents that promote improved motility and regular bowel movements.  

3) Reinoculate provide an environment where good bacteria can thrive and where bad ones cannot. 

4) Repair support of the cellular repair process through the above, as well as by providing specific nutritional support for the regeneration of the GI protective barrier. 

5) Rebalance lifestyle factors that influence the gut bacteria such as stress, sleep, exercise and relationships and assure ongoing gut health.


The goal of the fifth step is maintenance and prevention of recurrence of IP or leaky gut. There are various factors that lead to IP that involve dietary and lifestyle influences*, including:

·      Standard American Diet (SAD) which is low in fiber, high in processed foods, and highly inflammatory

·      Poor eating habits (for example, multitasking and not chewing adequately)

·      Inadequate hydration and/or electrolyte imbalance

·      Motility issues leading to constipation or unfavorable formation/frequency of stool

·      Stress and poor sleep 

·      Not enough exercise

To reduce risk of CKD, we must work towards improving diet and lifestyle habits that support continued GI health.

*Read more about medications that impact gut health and ultimately increase risk for KD progression here.

Where to start?

Address lifestyle factors that impact gut health

Long term dietary goals focus on a plant-based diet that is high in fiber and a wide range of key nutrients. Organic sources of animal protein can beneficial when eaten in moderation. However, the key is to load up on naturally antiinflammatory, low carbohydrate vegetables to maximize vitamins, minerals, phytonutrients and, of course, fiber. Reduce intake of starchy vegetables and eat more**:

·      Dark leafy greens (like spinach, arugula, and romaine)

·      Cruciferous veggies (like broccoli, cauliflower, and kale)

·      Fresh whole fruit (preferably lower sugar berries and avocados, and limit to two servings per day)

·      Some colorful starchy veggies can be OK (for example, carrots, sweet potatoes, beets, and squashes)

Those veggies listed above promote a healthy microbiome and improve alkalinity associated with improved kidney health. In addition to those sources of prebiotic fiber, include probiotic sources like fermented vegetables and drinks like raw sauerkraut, kimchi, pickles, apple cider vinegar, and kombucha. It’s recommended these are eaten raw because pasteurization process will destroy the bacterial content of these foods.

In general, reduce processed carbs, like bread, cereals, and high sugar foods, desserts and pastries. These types of foods are usually low in fiber and nutrients and help contribute to starving of beneficial gut bacteria. Furthermore,high carb diets have been associated with increased risk of cardiovascular (CV) disease and diabetes. Instead, moderately consume whole grains like brown rice, quinoa, oatmeal, and legumes**.

Include antiinflammatory fats focusing primarily on omega 3 sources from fish, nuts, seeds, and mono- and polyunsaturated (MUFA and PUFA) like avocados and olive oil. Even though the topic of saturated fats is more controversial, recent evidence suggest that moderate intake of certain saturated fats like that found in beef, organ meat, or ghee (clarified butter) derived from grass-fed cows and virgin coconut oil might have health benefits. Everyone agrees, however, that trans fats(aka hydrogenated oils and artificial products like margarine) or excessive intake of processed and fried fats contributes to inflammation and increased risk of disease.

Ensuring adequate hydration, drinking at least half your body weight (pounds) in ounces of water, not only helps to maintain good kidney health, it also helps support daily regular bowel movements. 

It’s well established that regular exercise can be beneficial for many reasons, including improved blood pressure, blood sugar, hypertension, stress relief, and even improved digestion and GI motility. In fact, exercise has been associated with improved microbiome balance as well as beneficial modulation of the immune system

Poor sleep quality and stress are also deeply tied to many underlying factors impacting of GI health. Reduced sleep duration and quality has been associated with increased inflammatory markers (including TNF, IL-1, and IL-6) associated with GI disease like GERD and Irritable Bowel Disease/Syndrome (IBD/IBS) disrupting digestion and nutrient absorption. Furthermore, sleep has been shown to affect kidney health directly and indirectly, including associated risk of CV disease, diabetes, obesity, and hypertension(read more about the relationship between sleep and kidney health here).

**NOTE: Due to individual variations and progress of disease, work with a nutritionist to assess if you need to maintain any specific restrictions due to your unique case and needs.

The role of supplements

Because of the unique needs of kidney disease patients, many need to rely on supplements to help obtain adequate amounts of key nutrients to maintain GI and kidney health.

This may include GI and motility support including but not limited to digestive enzymes, bitters, probiotics, and magnesium citrate and triphala for motility). Furthermore certain individuals may benefit from supplementation of certain vitamins and important minerals, high potency antioxidants, and/or support of certain key underlying cellular mechanisms impacting mitochondrial health, detoxification and nitric oxide production

That said, many factors must be taken into consideration when choosing appropriate supplements for each patient. Supplement quality and contamination are a common concern, as are potential interactions with medication or contraindications in certain commonly associated chronic disease. We suggest working under the care and guidance of a practitioner or team of providers who are trained in integrative and functional medicine and understand the unique needs of kidney patients. 

Next steps

Unfortunately, addressing gut health is only the beginning. As mentioned above, kidney disease is often associated with multiple chronic diseases including CV disease, diabetes, high blood pressure, and obesity. 

The comprehensive approach to kidney care means addressing the underlying causes of this constellation of diseases which is best accomplished by a Functional Medicine approach. The goal is to identify and then rebalance the biochemical and pathophysiological dysfunction at the root of chronic disease, we can stop the progression of kidney damage and preserve kidney function. 

Bottom Line

In the final step in the 5R individualized gut restoration protocol, we Rebalance the foundational factors that impact the gut-kidney axis.

Although this might be the last step in the 5R protocol, within the broader context of kidney disease, it might signal the transition to a comprehensive therapeutic protocol that includes management of the underlying dysfunction associated with related conditions such as CV disease, diabetes, obesity, and hypertension.

Working with an integrative or functional medicine provider is essential to help you navigate the comprehensive program successfully, but can help you stabilize blood sugar, lower blood pressure, lose weight, and reduce the risk of CV and ultimately, KD.

More from InKidney on the gut-kidney connection:

·       Comprehensive Gut Restoration Protocol

·       Feeding Gut Bacteria in Kidney Disease

·       Kidney-Gut Axis: Nutrition can slow the progress of kidney disease

·       Inflammation, Leaky Gut And Kidney Disease

·       Leaky Gut And Kidney Disease: 6 Classes Of Medication That Might Be Contributing