{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T17:43:35Z","timestamp":1785433415518,"version":"3.56.0"},"reference-count":197,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T00:00:00Z","timestamp":1781740800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"IRCCS INRCA"},{"DOI":"10.13039\/501100003196","name":"Italian Ministry of Health","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100003196","id-type":"DOI","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/00789fa95","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Chronic kidney disease (CKD) is a progressive condition characterized by persistent kidney abnormalities with systemic consequences. Beyond its metabolic and cardiovascular complications, CKD has been associated with structural and functional brain alterations that are particularly evident in advanced stages and in patients undergoing hemodialysis (HD). Deficits across multiple cognitive domains are frequently observed and may compromise treatment adherence, clinical management, and quality of life, yet remain largely underrecognized in clinical practice. Older adults are particularly vulnerable. Age-related brain changes and comorbidities may increase susceptibility to CKD-related cerebral alterations, while reduced cognitive reserve may amplify clinical impact. The gut\u2013kidney\u2013brain axis has emerged as a relevant biological pathway, with CKD-related dysbiosis potentially influencing inflammation, metabolic homeostasis, and the generation of uremic metabolites linked to neurological dysfunction. This review examines the mechanisms contributing to brain vulnerability in older adults with CKD, with specific attention to patients undergoing HD, and discusses challenges in the recognition and assessment of cognitive impairment in this population. It further explores microbiota-targeted nutritional strategies as potentially modifiable approaches to modulate gut-derived metabolic and inflammatory processes relevant to brain health, although current evidence for direct effects on cognitive outcomes remains limited.<\/jats:p>","DOI":"10.3390\/nu18121978","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T09:18:43Z","timestamp":1781860723000},"page":"1978","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mind the Gut: Cognitive Decline, Microbiota, and Nutrition-Related Modulators in Older Adults with Chronic Kidney Disease"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-9835-2617","authenticated-orcid":false,"given":"Lisa","family":"Bevilacqua","sequence":"first","affiliation":[{"name":"Biogerontology Center, IRCCS INRCA, 60121 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federica","family":"Lenci","sequence":"additional","affiliation":[{"name":"Unit of Nephrology and Dialysis, IRCCS INRCA, 60126 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2878-9432","authenticated-orcid":false,"given":"Leonardo","family":"Biscetti","sequence":"additional","affiliation":[{"name":"Neurology Unit, IRCCS INRCA, 60128 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Belinda","family":"Giorgetti","sequence":"additional","affiliation":[{"name":"Biogerontology Center, IRCCS INRCA, 60121 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1468-2140","authenticated-orcid":false,"given":"Robertina","family":"Giacconi","sequence":"additional","affiliation":[{"name":"Biogerontology Center, IRCCS INRCA, 60121 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3123-7903","authenticated-orcid":false,"given":"Marta","family":"Balietti","sequence":"additional","affiliation":[{"name":"Biogerontology Center, IRCCS INRCA, 60121 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1016\/S0140-6736(25)01942-7","article-title":"Chronic kidney disease","volume":"407","author":"Herrington","year":"2025","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"S117","DOI":"10.1016\/j.kint.2023.10.018","article-title":"KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease","volume":"105","author":"Stevens","year":"2024","journal-title":"Kidney Int."},{"key":"ref_3","unstructured":"World Health Organization (WHO) (2026, April 27). Reducing the Burden of Noncommunicable Diseases Through Promotion of Kidney Health and Strengthening Prevention and Control of Kidney Disease. Available online: https:\/\/apps.who.int\/gb\/ebwha\/pdf_files\/EB156\/B156_CONF6-en.pdf."},{"key":"ref_4","unstructured":"GBD 2023 Chronic Kidney Disease Collaborators (2025). Global, regional, and national burden of chronic kidney disease in adults, 1990\u20132023, and its attributable risk factors: A systematic analysis for the Global Burden of Disease Study 2023. Lancet, 406, 2461\u20132482."},{"key":"ref_5","unstructured":"Centers for Disease Control and Prevention (CDC) (2026, February 02). Chronic Kidney Disease in the United States, Available online: https:\/\/www.cdc.gov\/kidney-disease\/php\/data-research\/index.html."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1159\/000355760","article-title":"Aging and chronic kidney disease","volume":"38","author":"Nitta","year":"2013","journal-title":"Kidney Blood Press. Res."},{"key":"ref_7","unstructured":"Shahbaz, H., Rout, P., and Gupta, M. (2024). Creatinine clearance. StatPearls [Internet], StatPearls Publishing."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1002\/phar.1282","article-title":"Glomerular filtration rate equations overestimate creatinine clearance in older individuals enrolled in the Baltimore Longitudinal Study on Aging: Impact on renal drug dosing","volume":"33","author":"Dowling","year":"2013","journal-title":"Pharmacotherapy"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Wang, Y., Liu, J., Fang, Y., Zhou, S., Liu, X., and Li, Z. (2024). Estimating the global prevalence of secondary hyperparathyroidism in patients with chronic kidney disease. Front. Endocrinol., 15.","DOI":"10.3389\/fendo.2024.1400891"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Virz\u00ec, G.M., Clementi, A., Ronco, C., and Zanella, M. (2025). Red cell death in renal disease: The role of eryptosis in CKD and dialysis patients. Cells, 14.","DOI":"10.3390\/cells14130967"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Kourtidou, C., and Tzionalos, K. (2023). Epidemiology and Risk Factors for Stroke in Chronic Kidney Disease: A Narrative Review. Biomedicines, 11.","DOI":"10.3390\/biomedicines11092398"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1847","DOI":"10.1021\/acschemneuro.5c00050","article-title":"The vicious consequences of chronic kidney disease on cognitive impairment and Alzheimer\u2019s disease","volume":"16","author":"Roy","year":"2025","journal-title":"ACS Chem. Neurosci."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e2559834","DOI":"10.1001\/jamanetworkopen.2025.59834","article-title":"Chronic kidney disease severity and risk of cognitive impairment","volume":"9","author":"Huang","year":"2026","journal-title":"JAMA Netw. Open"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e47621","DOI":"10.1097\/MD.0000000000047621","article-title":"Bibliometric analysis of cognitive impairment secondary to chronic kidney disease","volume":"17","author":"Chen","year":"2026","journal-title":"Medicine"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Mendoza-Ruvalcaba, N.M., V\u00e1zquez-N\u00fa\u00f1ez, K.P., and Rodr\u00edguez-D\u00edaz, M. (2026). The role of cognitive reserve on successful aging in community-dwelling older adults. Appl. Neuropsychol. Adult, 1\u201311.","DOI":"10.1080\/23279095.2026.2623063"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"ii4","DOI":"10.1093\/ndt\/gfae253","article-title":"The role of the intestinal microbiome in cognitive decline in patients with kidney disease","volume":"40","author":"Wagner","year":"2025","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Coradduzza, D., Sedda, S., Cruciani, S., De Miglio, M.R., Ventura, C., Nivoli, A., and Maioli, M. (2023). Age-related cognitive decline, focus on microbiome: A systematic review and meta-analysis. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms241813680"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"115068","DOI":"10.1016\/j.physbeh.2025.115068","article-title":"Gut microbiome mediates the causal relationship between chronic kidney disease and cognitive dysfunction: A Mendelian randomization study","volume":"301","author":"Zhou","year":"2025","journal-title":"Physiol. Behav."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1056\/NEJM197601152940306","article-title":"Neurologic disorders in renal failure (first of two parts)","volume":"294","author":"Raskin","year":"1976","journal-title":"N. Engl. J. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1056\/NEJM197601222940406","article-title":"Neurologic disorders in renal failure (second of two parts)","volume":"294","author":"Raskin","year":"1976","journal-title":"N. Engl. J. Med."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Marini, S., Georgakis, M.K., and Anderson, C.D. (2021). Interactions Between Kidney Function and Cerebrovascular Disease: Vessel Pathology That Fires Together Wires Together. Front. Neurol., 12.","DOI":"10.3389\/fneur.2021.785273"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"115693","DOI":"10.1016\/j.bbr.2025.115693","article-title":"Blood-brain barrier permeability in CKD: Link with inflammation and cognitive and mood impairment in rats","volume":"493","author":"Bobot","year":"2025","journal-title":"Behav. Brain Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1007\/s00395-025-01153-6","article-title":"From kidney injury to cardiac dysfunction: The central role of oxidative stress in diabetes and CKD","volume":"121","author":"Sen","year":"2026","journal-title":"Basic Res. Cardiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"4414","DOI":"10.1038\/s41598-022-08387-7","article-title":"Blood-brain barrier and gut barrier dysfunction in chronic kidney disease with a focus on circulating biomarkers and tight junction proteins","volume":"12","author":"Hernandez","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1053\/j.ajkd.2022.07.013","article-title":"Association of kidney function measures with signs of neurodegeneration and small vessel disease on brain magnetic resonance imaging: The Atherosclerosis Risk in Communities (ARIC) Study","volume":"81","author":"Scheppach","year":"2023","journal-title":"Am. J. Kidney Dis."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1053\/j.ajkd.2005.10.029","article-title":"Silent cerebral white matter lesions and their relationship with vascular risk factors in middle-aged predialysis patients with CKD","volume":"47","author":"Gutierrez","year":"2006","journal-title":"Am. J. Kidney Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e038711","DOI":"10.1161\/JAHA.124.038711","article-title":"Associations of cerebral small vessel disease and chronic kidney disease in patients with acute ischemic stroke","volume":"14","author":"Bi","year":"2025","journal-title":"J. Am. Heart Assoc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e209540","DOI":"10.1212\/WNL.0000000000209540","article-title":"Associations of cerebral small vessel disease and chronic kidney disease in patients with acute intracerebral hemorrhage: A cross-sectional study","volume":"103","author":"Nash","year":"2024","journal-title":"Neurology"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"4528","DOI":"10.1038\/s41598-026-36001-7","article-title":"Perivascular pathology, not macrovascular complexity, governs glymphatic-related dysfunction in preclinical cerebral small vessel disease","volume":"16","author":"Hein","year":"2026","journal-title":"Sci. Rep."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1159\/000550353","article-title":"Global trends and projections in chronic kidney disease burden from diabetes, hypertension, and glomerulonephritis: A population-based study","volume":"51","author":"Zhang","year":"2026","journal-title":"Kidney Blood Press. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"224","DOI":"10.4093\/dmj.2017.0065","article-title":"Higher prevalence and progression rate of chronic kidney disease in elderly patients with type 2 diabetes mellitus","volume":"42","author":"Kim","year":"2018","journal-title":"Diabetes Metab. J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1007\/s11682-025-00976-0","article-title":"Regional high iron deposition on brain quantitative susceptibility mapping correlates with cognitive decline in chronic kidney disease patients","volume":"19","author":"Li","year":"2025","journal-title":"Brain Imaging Behav."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1016\/S1474-4422(14)70117-6","article-title":"The role of iron in brain ageing and neurodegenerative disorders","volume":"13","author":"Ward","year":"2014","journal-title":"Lancet Neurol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"135963","DOI":"10.1016\/j.neulet.2021.135963","article-title":"Dihydromyricetin attenuates D-galactose-induced brain aging of mice via inhibiting oxidative stress and neuroinflammation","volume":"756","author":"Qian","year":"2021","journal-title":"Neurosci. Lett."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Neyra Chauca, J.M., VanDyck, M.V., Espinoza Santana, A., Mart\u00ednez, G.G.R., Romero Vega, K.A., Garc\u00eda Quintana, N., and S\u00e1nchez, V.F. (2026). Microvascular failure in the aging brain: Converging pathways of oxidative stress, inflammation, and endothelial decline. Biomedicines, 14.","DOI":"10.3390\/biomedicines14010130"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Yu, J., Li, Y., Zhu, B., Shen, J., and Miao, L. (2025). Research progress on the kidney-gut-brain axis in brain dysfunction in maintenance hemodialysis patients. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1538048"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1208","DOI":"10.1681\/ASN.0000000675","article-title":"Uremic toxins, CKD, and cognitive dysfunction","volume":"36","author":"Andrews","year":"2025","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1736","DOI":"10.7150\/ijms.109245","article-title":"Indoxyl sulfate is associated with cognitive impairment in ESRD patients by activating the extrinsic apoptosis in the neuronal cells during differentiating process","volume":"22","author":"Hsieh","year":"2025","journal-title":"Int. J. Med. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2988","DOI":"10.1016\/j.ekir.2024.07.021","article-title":"Increased blood-brain barrier permeability and cognitive impairment in patients with ESKD","volume":"9","author":"Bobot","year":"2024","journal-title":"Kidney Int. Rep."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"S\u00e1nchez-Ospina, D., Mas-Fontao, S., Gracia-Iguacel, C., Avello, A., Gonz\u00e1lez de Rivera, M., Mujika-Marticorena, M., and Gonzalez-Parra, E. (2024). Displacing the burden: A review of protein-bound uremic toxin clearance strategies in chronic kidney disease. J. Clin. Med., 13.","DOI":"10.3390\/jcm13051428"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"756","DOI":"10.1111\/1744-9987.13755","article-title":"Efficacy of medium cut-off dialyzers and comparison with high-flux dialyzers in patients on maintenance hemodialysis: A systematic review and meta-analysis","volume":"26","author":"Yang","year":"2022","journal-title":"Ther. Apher. Dial."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Zhu, Y., Li, J., Lu, H., Shi, Z., and Wang, X. (2024). Effect of hemodiafiltration and hemodialysis on mortality of patients with end-stage kidney disease: A meta-analysis. BMC Nephrol., 25.","DOI":"10.1186\/s12882-024-03810-9"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1080\/0886022X.2022.2048855","article-title":"Efficacy and safety of expanded hemodialysis in hemodialysis patients: A meta-analysis and systematic review","volume":"44","author":"Zhao","year":"2022","journal-title":"Ren. Fail."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"5431","DOI":"10.1007\/s11357-024-01109-z","article-title":"Dialysis disequilibrium syndrome in neurosurgery: Literature review and illustrative case example","volume":"46","author":"Evans","year":"2024","journal-title":"Geroscience"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1317","DOI":"10.1681\/ASN.2017101088","article-title":"Hemodialysis induces an acute decline in cerebral blood flow in elderly patients","volume":"29","author":"Kuipers","year":"2018","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Guo, Y., Cui, W., Ye, P., and Luo, Y. (2024). Association between cerebral blood flow variation and cognitive decline in older patients undergoing hemodialysis. Front. Aging Neurosci., 16.","DOI":"10.3389\/fnagi.2024.1457675"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1093\/ckj\/sfaa078","article-title":"An update review of intradialytic hypotension: Concept, risk factors, clinical implications and management","volume":"13","author":"Kanbay","year":"2020","journal-title":"Clin. Kidney J."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1159\/000338135","article-title":"Chronic kidney disease and cognitive impairment: A systematic review and meta-analysis","volume":"35","author":"Etgen","year":"2012","journal-title":"Am. J. Nephrol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"925","DOI":"10.1053\/j.ajkd.2015.12.028","article-title":"Cognition in people with end-stage kidney disease treated with hemodialysis: A systematic review and meta-analysis","volume":"67","author":"Connors","year":"2016","journal-title":"Am. J. Kidney Dis."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1080\/17437199.2022.2132980","article-title":"Subjective cognitive complaints in end-stage renal disease: A systematic review and meta-analysis","volume":"17","author":"Chan","year":"2023","journal-title":"Health Psychol. Rev."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"e14390","DOI":"10.1097\/MD.0000000000014390","article-title":"The comparison of cognitive function and risk of dementia in CKD patients under peritoneal dialysis and hemodialysis: A PRISMA-compliant systematic review and meta-analysis","volume":"98","author":"Tian","year":"2019","journal-title":"Medicine"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1111\/jan.13907","article-title":"Correlates of cognitive impairment in patients with chronic kidney failure on haemodialysis: Systematic review and meta-analysis","volume":"75","author":"Oh","year":"2019","journal-title":"J. Adv. Nurs."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1186\/1744-859X-10-20","article-title":"Cognitive function among hemodialysis patients in Japan","volume":"10","author":"Odagiri","year":"2011","journal-title":"Ann. Gen. Psychiatry"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"462","DOI":"10.1093\/ckj\/sfv037","article-title":"Performance of a brief survey to assess health literacy in patients receiving hemodialysis","volume":"8","author":"Cavanaugh","year":"2015","journal-title":"Clin. Kidney J."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1111\/bjhp.12645","article-title":"Prevalence and trajectories of subjective cognitive complaints and implications for patient outcomes: A prospective study of haemodialysis patients","volume":"28","author":"Chan","year":"2023","journal-title":"Br. J. Health Psychol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"sfae294","DOI":"10.1093\/ckj\/sfae294","article-title":"Cognitive impairment in CKD patients: A guidance document by the CONNECT network","volume":"18","author":"Bolignano","year":"2024","journal-title":"Clin. Kidney J."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1111\/nep.13705","article-title":"Cognitive impairment, quality of life and healthcare utilization in patients with chronic kidney disease stages 3 to 5","volume":"25","author":"Thancharoen","year":"2020","journal-title":"Nephrology"},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Chan, F.H.F., Sim, P., Lim, P.X.H., Khan, B.A., Choo, J.C.J., and Griva, K. (2024). Screening for cognitive symptoms in dialysis patients with an extended version of Kidney Disease Quality of Life Cognitive Function subscale (KDQOL-CF): A validation study. BMC Nephrol., 25.","DOI":"10.1186\/s12882-024-03848-9"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1093\/ndt\/gfx314","article-title":"Prevalence and patterns of cognitive impairment in adult hemodialysis patients: The COGNITIVE-HD study","volume":"33","author":"Wong","year":"2018","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1681\/ASN.2019100988","article-title":"Evaluation of screening tests for cognitive impairment in patients receiving maintenance hemodialysis","volume":"31","author":"Drew","year":"2020","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_61","first-page":"e99003","article-title":"Co-occurrence of cognitive dysfunction and depressive disorders in hemodialysis patients: Demographic patterns and unmet diagnostic needs","volume":"17","author":"Gautam","year":"2025","journal-title":"Cureus"},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Par\u00e9, M., Zola, N., Coudert, L., Phaneuf, J.-C., Lavall\u00e9e, R., Caplette-Gingras, A., Fortier, C., and Agharazii, M. (2025). A mixed-methods protocol to explore psychological distress and psychosocial needs along the continuum of CKD care: A single healthcare network. BMC Nephrol., 26.","DOI":"10.1186\/s12882-025-04563-9"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"12401","DOI":"10.1038\/s41598-023-39614-4","article-title":"The prevalence and predictors of geriatric giants in community-dwelling older adults: A cross-sectional study from the Middle East","volume":"13","author":"Badrkhahan","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_64","first-page":"150","article-title":"The silent geriatric giant: Anxiety disorders in late life","volume":"11","author":"Cassidy","year":"2008","journal-title":"Geriatr. Aging"},{"key":"ref_65","unstructured":"World Health Organization (WHO) (2026, April 29). Mental Health of Older Adults. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/mental-health-of-older-adults."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/0022-3956(82)90033-4","article-title":"Development and validation of a geriatric depression screening scale: A preliminary report","volume":"17","author":"Yesavage","year":"1982","journal-title":"J. Psychiatr. Res."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1017\/S1041610206003504","article-title":"Development and validation of the Geriatric Anxiety Inventory","volume":"19","author":"Pachana","year":"2007","journal-title":"Int. Psychogeriatr."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1017\/S1041610217002332","article-title":"Reliability, concurrent validity, and cultural adaptation of the Geriatric Depression Scale and the Geriatric Anxiety Inventory for detecting depression and anxiety symptoms among older Chinese immigrants: An Australian study","volume":"30","author":"Dow","year":"2018","journal-title":"Int. Psychogeriatr."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1080\/13607860903071014","article-title":"Age and education effects and norms on a cognitive test battery from a population-based cohort: The Monongahela-Youghiogheny Healthy Aging Team","volume":"14","author":"Ganguli","year":"2010","journal-title":"Aging Ment. Health"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1017\/S1355617723000760","article-title":"Mayo normative studies: Regression-based normative data for ages 30\u201391 years with a focus on the Boston Naming Test, Trail Making Test and Category Fluency","volume":"30","author":"Karstens","year":"2024","journal-title":"J. Int. Neuropsychol. Soc."},{"key":"ref_71","doi-asserted-by":"crossref","unstructured":"Tiffin-Richards, F.E., Costa, A.S., Holschbach, B., Frank, R.D., Vassiliadou, A., Kr\u00fcger, T., Kuckuck, K., Gross, T., Eitner, F., and Floege, J. (2014). The Montreal Cognitive Assessment (MoCA)\u2014A sensitive screening instrument for detecting cognitive impairment in chronic hemodialysis patients. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0106700"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.3233\/JAD-215629","article-title":"Montreal Cognitive Assessment: Normative data for cognitively healthy Swedish 80- to 94-year-olds","volume":"87","author":"Classon","year":"2022","journal-title":"J. Alzheimer\u2019s Dis."},{"key":"ref_73","doi-asserted-by":"crossref","unstructured":"Scheenen, M.E., van den Brink, R.H.S., Konstantinidou, S., Lugtenburg, A., Spit, J., Hendriks, G.-J., Naarding, P., de Vent, N.R., Kessels, R.P.C., and Oude Voshaar, R.C. (2025). Montreal Cognitive Assessment (MoCA) norms for older patients with a depressive disorder. Med. Sci., 13.","DOI":"10.3390\/medsci13040312"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1111\/ene.15123","article-title":"Development and validation of the dialysis dementia risk score: A retrospective, population-based, nested case-control study","volume":"29","author":"Ling","year":"2022","journal-title":"Eur. J. Neurol."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"6869","DOI":"10.1007\/s11357-025-01797-1","article-title":"The aging choroid plexus and its relationship with gut dysbiosis and Klotho decline: Possible intervention strategies","volume":"47","author":"Lai","year":"2025","journal-title":"Geroscience"},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"724","DOI":"10.1016\/j.chom.2020.08.003","article-title":"The gut virome database reveals age-dependent patterns of virome diversity in the human gut","volume":"28","author":"Gregory","year":"2020","journal-title":"Cell Host Microbe"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1016\/j.chom.2022.01.013","article-title":"Caudovirales bacteriophages are associated with improved executive function and memory in flies, mice, and humans","volume":"30","author":"Puig","year":"2022","journal-title":"Cell Host Microbe"},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"1064","DOI":"10.1038\/s41564-023-01370-6","article-title":"Centenarians have a diverse gut virome with the potential to modulate metabolism and promote healthy lifespan","volume":"8","author":"Johansen","year":"2023","journal-title":"Nat. Microbiol."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1136\/gutjnl-2021-326298","article-title":"Mapping the human gut mycobiome in middle-aged and elderly adults: Multiomics insights and implications for host metabolic health","volume":"71","author":"Shuai","year":"2022","journal-title":"Gut"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1186\/s40168-023-01586-y","article-title":"Enterotypes of the human gut mycobiome","volume":"11","author":"Lai","year":"2023","journal-title":"Microbiome"},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1111\/j.1758-2229.2009.00116.x","article-title":"Molecular evaluation of the human gut methanogenic archaeal microbiota reveals an age-associated increase of the diversity","volume":"2","author":"Mihajlovski","year":"2010","journal-title":"Environ. Microbiol. Rep."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1111\/j.1600-0463.2012.02899.x","article-title":"Age-related prevalence of Methanomassiliicoccus luminyensis in the human gut microbiome","volume":"120","author":"Dridi","year":"2012","journal-title":"APMIS"},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1038\/s41522-022-00366-0","article-title":"Gut microbiota as an antioxidant system in centenarians associated with high antioxidant activities of gut-resident Lactobacillus","volume":"8","author":"Wu","year":"2022","journal-title":"npj Biofilms Microbiomes"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"110412","DOI":"10.1016\/j.isci.2024.110412","article-title":"The gut mycobiome signatures in long-lived populations","volume":"27","author":"Pu","year":"2024","journal-title":"iScience"},{"key":"ref_85","doi-asserted-by":"crossref","unstructured":"Mohammadzadeh, R., Mahnert, A., Shinde, T., Kumpitsch, C., Weinberger, V., Schmidt, H., and Moissl-Eichinger, C. (2025). Age-related dynamics of predominant methanogenic archaea in the human gut microbiome. BMC Microbiol., 25.","DOI":"10.1186\/s12866-025-03921-9"},{"key":"ref_86","doi-asserted-by":"crossref","unstructured":"Chen, H., Wang, J., Ouyang, Q., Peng, X., Yu, Z., Wang, J., and Huang, J. (2023). Alterations of gut microbes and their correlation with clinical features in middle and end-stages chronic kidney disease. Front. Cell. Infect. Microbiol., 13.","DOI":"10.3389\/fcimb.2023.1105366"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1186\/s13059-023-03056-y","article-title":"Metagenome-wide analysis uncovers gut microbial signatures and implicates taxon-specific functions in end-stage renal disease","volume":"24","author":"Zhang","year":"2023","journal-title":"Genome Biol."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1080\/0886022X.2020.1864404","article-title":"Specific alterations in gut microbiota in patients with chronic kidney disease: An updated systematic review","volume":"43","author":"Zhao","year":"2021","journal-title":"Ren. Fail."},{"key":"ref_89","doi-asserted-by":"crossref","unstructured":"Stanford, J., Charlton, K., Stefoska-Needham, A., Ibrahim, R., and Lambert, K. (2020). The gut microbiota profile of adults with kidney disease and kidney stones: A systematic review of the literature. BMC Nephrol., 21.","DOI":"10.1186\/s12882-020-01805-w"},{"key":"ref_90","doi-asserted-by":"crossref","unstructured":"Candeliere, F., Simone, M., Leonardi, A., Rossi, M., Amaretti, A., and Raimondi, S. (2022). Indole and p-cresol in feces of healthy subjects: Concentration, kinetics, and correlation with microbiome. Front. Mol. Med., 2.","DOI":"10.3389\/fmmed.2022.959189"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"e18991","DOI":"10.1016\/j.heliyon.2023.e18991","article-title":"Chronic kidney disease and gut microbiota","volume":"9","author":"Asgharzadeh","year":"2023","journal-title":"Heliyon"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"1624","DOI":"10.1136\/gutjnl-2024-334634","article-title":"Toxic microbiome and progression of chronic kidney disease: Insights from a longitudinal CKD-Microbiome Study","volume":"74","author":"Laiola","year":"2025","journal-title":"Gut"},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1111\/ggi.12811","article-title":"Age-dependent increase in serum levels of indoxyl sulphate and p-cresol sulphate is not related to their precursors: Tryptophan and tyrosine","volume":"17","author":"Giebultowicz","year":"2017","journal-title":"Geriatr. Gerontol. Int."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1159\/000360010","article-title":"Expansion of urease- and uricase-containing, indole- and p-cresol-forming and contraction of short-chain fatty acid-producing intestinal microbiota in ESRD","volume":"39","author":"Wong","year":"2014","journal-title":"Am. J. Nephrol."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"9483","DOI":"10.1038\/s41598-020-66421-y","article-title":"Neurobehavioral effects of uremic toxin-indoxyl sulfate in the rat model","volume":"10","author":"Karbowska","year":"2020","journal-title":"Sci. Rep."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1007\/s11095-006-9183-2","article-title":"Involvement of indoxyl sulfate in renal and central nervous system toxicities during cisplatin-induced acute renal failure","volume":"24","author":"Iwata","year":"2007","journal-title":"Pharm. Res."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"137594","DOI":"10.1016\/j.neulet.2023.137594","article-title":"Effects of the uremic toxin indoxyl sulfate on seizure activity, learning and brain oxidative stress parameters in mice","volume":"820","author":"Raszewski","year":"2024","journal-title":"Neurosci. Lett."},{"key":"ref_98","doi-asserted-by":"crossref","unstructured":"Adesso, S., Magnus, T., Cuzzocrea, S., Campolo, M., Rissiek, B., Paciello, O., Autore, G., Pinto, A., and Marzocco, S. (2017). Indoxyl sulfate affects glial function increasing oxidative stress and neuroinflammation in chronic kidney disease: Interaction between astrocytes and microglia. Front. Pharmacol., 8.","DOI":"10.3389\/fphar.2017.00370"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1038\/ki.2012.345","article-title":"Chronic kidney disease alters intestinal microbial flora","volume":"83","author":"Vaziri","year":"2013","journal-title":"Kidney Int."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/bs.aambs.2016.06.002","article-title":"The role of the gut microbiome on chronic kidney disease","volume":"96","author":"Pestana","year":"2016","journal-title":"Adv. Appl. Microbiol."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1186\/s12974-025-03454-y","article-title":"Elucidating the specific mechanisms of the gut-brain axis: The short-chain fatty acids-microglia pathway","volume":"22","author":"Cao","year":"2025","journal-title":"J. Neuroinflamm."},{"key":"ref_102","doi-asserted-by":"crossref","unstructured":"Fock, E., and Parnova, R. (2023). Mechanisms of blood-brain barrier protection by microbiota-derived short-chain fatty acids. Cells, 12.","DOI":"10.3390\/cells12040657"},{"key":"ref_103","doi-asserted-by":"crossref","unstructured":"Mo\u021b\u0103\u021b\u0103ianu, A., \u0218erban, G., and Andone, S. (2023). The role of short-chain fatty acids in microbiota-gut-brain cross-talk with a focus on amyotrophic lateral sclerosis: A systematic review. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms242015094"},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"e70057","DOI":"10.1111\/acel.70057","article-title":"Causal analysis between gut microbes, aging indicator, and age-related disease, involving the discovery and validation of biomarkers","volume":"24","author":"Lu","year":"2025","journal-title":"Aging Cell"},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"e0189925","DOI":"10.1128\/aem.01899-25","article-title":"Prophages and their interactions with lytic phages in the human gut microbiota and their impact on microbial diversity, gut health, and disease","volume":"91","author":"Zhang","year":"2025","journal-title":"Appl. Environ. Microbiol."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"2819","DOI":"10.1007\/s11357-023-00799-1","article-title":"Unique trans-kingdom microbiome structural and functional signatures predict cognitive decline in older adults","volume":"45","author":"Chaudhari","year":"2023","journal-title":"Geroscience"},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1186\/s13195-023-01285-8","article-title":"A metagenomic study of gut viral markers in amyloid-positive Alzheimer\u2019s disease patients","volume":"15","author":"Ghorbani","year":"2023","journal-title":"Alzheimer\u2019s Res. Ther."},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"glag001","DOI":"10.1093\/gerona\/glag001","article-title":"Alterations of the gut virome in patients with Parkinson\u2019s disease","volume":"81","author":"Chen","year":"2026","journal-title":"J. Gerontol. A Biol. Sci. Med. Sci."},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"1642","DOI":"10.7150\/thno.101601","article-title":"A metagenome-wide study of the gut virome in chronic kidney disease","volume":"15","author":"Zhang","year":"2025","journal-title":"Theranostics"},{"key":"ref_110","doi-asserted-by":"crossref","unstructured":"Badillo-Pazmay, G.V., Fortunato, C., Cianfruglia, L., Novazzi, F., Spezia, P.G., Rosa, L., Limongi, D., Prezioso, C., D\u2019Argenio, V., and Scudiero, O. (2025). The gut and circulating virome: Emerging players in aging and longevity. Front. Aging, 6.","DOI":"10.3389\/fragi.2025.1731621"},{"key":"ref_111","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1080\/21505594.2016.1247140","article-title":"Fungi in the healthy human gastrointestinal tract","volume":"8","author":"Suhr","year":"2017","journal-title":"Virulence"},{"key":"ref_112","doi-asserted-by":"crossref","unstructured":"Hu, J., Wei, S., Gu, Y., Wang, Y., Feng, Y., Sheng, J., Hu, L., Gu, C., Jiang, P., and Tian, Y. (2022). Gut mycobiome in patients with chronic kidney disease was altered and associated with immunological profiles. Front. Immunol., 13.","DOI":"10.3389\/fimmu.2022.843695"},{"key":"ref_113","doi-asserted-by":"crossref","unstructured":"Qiu, J., Zhao, L., Cheng, Y., Chen, Q., Xu, Y., Lu, Y., Gao, J., Lei, W., Yan, C., and Ling, Z. (2023). Exploring the gut mycobiome: Differential composition and clinical associations in hypertension, chronic kidney disease, and their comorbidity. Front. Immunol., 14.","DOI":"10.3389\/fimmu.2023.1317809"},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1186\/s12967-024-05004-1","article-title":"Altered gut mycobiome in patients with end-stage renal disease and its correlations with serum and fecal metabolomes","volume":"22","author":"Ren","year":"2024","journal-title":"J. Transl. Med."},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"154056","DOI":"10.1016\/j.tox.2025.154056","article-title":"Environmental mycotoxins: A potential etiological factor for neurodegenerative diseases?","volume":"511","author":"Nie","year":"2025","journal-title":"Toxicology"},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"102950","DOI":"10.1016\/j.ebiom.2020.102950","article-title":"Gut mycobiome and its interaction with diet, gut bacteria and Alzheimer\u2019s disease markers in subjects with mild cognitive impairment: A pilot study","volume":"59","author":"Nagpal","year":"2020","journal-title":"EBioMedicine"},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1042\/BCJ20240621","article-title":"Interplay of constipation, intestinal barrier dysfunction and fungal exposome in aetiopathogenesis of Parkinson\u2019s disease: Hypothesis with supportive data","volume":"482","author":"Umamahesan","year":"2025","journal-title":"Biochem. J."},{"key":"ref_118","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1007\/s11033-025-10562-8","article-title":"Gut microbiota and NLRP3 inflammasome activation in hemodialysis patients: Exploring the link with systemic inflammation","volume":"52","author":"Mafra","year":"2025","journal-title":"Mol. Biol. Rep."},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.1007\/s11255-024-04273-5","article-title":"Is there a correlation between TMAO plasma levels and archaea in the gut of patients undergoing hemodialysis?","volume":"57","author":"Kemp","year":"2025","journal-title":"Int. Urol. Nephrol."},{"key":"ref_120","doi-asserted-by":"crossref","first-page":"2455506","DOI":"10.1080\/19490976.2025.2455506","article-title":"Archaea methanogens are associated with cognitive performance through the shaping of gut microbiota, butyrate and histidine metabolism","volume":"17","author":"Fumagalli","year":"2025","journal-title":"Gut Microbes"},{"key":"ref_121","doi-asserted-by":"crossref","first-page":"18906","DOI":"10.1038\/s41598-024-69742-4","article-title":"Metagenome-assembled microbial genomes from Parkinson\u2019s disease fecal samples","volume":"14","author":"Duru","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_122","doi-asserted-by":"crossref","first-page":"glaf053","DOI":"10.1093\/gerona\/glaf053","article-title":"Severe cognitive decline in long-term care is related to gut microbiome production of metabolites involved in neurotransmission, immunomodulation, and autophagy","volume":"80","author":"Shoubridge","year":"2025","journal-title":"J. Gerontol. A Biol. Sci. Med. Sci."},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1007\/s10157-020-02010-7","article-title":"Association between serum potassium levels and adverse outcomes in chronic kidney disease: The Fukushima CKD cohort study","volume":"25","author":"Tanaka","year":"2021","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_124","doi-asserted-by":"crossref","first-page":"106408","DOI":"10.1016\/j.ejim.2025.07.004","article-title":"Association between serum potassium variability during hospitalization and clinical outcomes in patients with heart failure","volume":"141","author":"Suzuki","year":"2025","journal-title":"Eur. J. Intern. Med."},{"key":"ref_125","first-page":"e94698","article-title":"Prevalence of electrolyte imbalances in critically ill medical intensive care unit patients and their association with clinical outcomes","volume":"17","author":"Iqbal","year":"2025","journal-title":"Cureus"},{"key":"ref_126","doi-asserted-by":"crossref","unstructured":"Guo, Y., Qiu, Y., Xue, T., Yan, P., Zhao, W., Wang, M., Liu, C., and Zhang, N. (2024). Association between admission baseline blood potassium levels and all-cause mortality in patients with acute kidney injury combined with sepsis: A retrospective cohort study. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0309764"},{"key":"ref_127","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.clinph.2013.06.022","article-title":"Evidence for a causal relationship between hyperkalaemia and axonal dysfunction in end-stage kidney disease","volume":"125","author":"Arnold","year":"2014","journal-title":"Clin. Neurophysiol."},{"key":"ref_128","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1093\/brain\/awf123","article-title":"Nerve excitability changes in chronic renal failure indicate membrane depolarization due to hyperkalaemia","volume":"125","author":"Kiernan","year":"2002","journal-title":"Brain"},{"key":"ref_129","doi-asserted-by":"crossref","first-page":"1962","DOI":"10.1007\/s12010-025-05513-9","article-title":"Taurine mitigates spironolactone-induced hyperkalemia and cognitive dysfunction: A biochemical and histological study in a rat model","volume":"198","author":"Babaker","year":"2026","journal-title":"Appl. Biochem. Biotechnol."},{"key":"ref_130","doi-asserted-by":"crossref","first-page":"3994","DOI":"10.1080\/10408398.2021.1996331","article-title":"Dietary strategies for gut-derived protein-bound uremic toxins and cardio-metabolic risk factors in chronic kidney disease: A focus on dietary fibers","volume":"63","author":"Melekoglu","year":"2023","journal-title":"Crit. Rev. Food Sci. Nutr."},{"key":"ref_131","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1053\/j.jrn.2016.02.005","article-title":"Nutrient non-equivalence: Does restricting high-potassium plant foods help to prevent hyperkalemia in hemodialysis patients?","volume":"26","author":"Goldfarb","year":"2016","journal-title":"J. Ren. Nutr."},{"key":"ref_132","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1053\/j.jrn.2018.06.006","article-title":"Adequacy of plant-based proteins in chronic kidney disease","volume":"29","author":"Joshi","year":"2019","journal-title":"J. Ren. Nutr."},{"key":"ref_133","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1016\/j.ajcnut.2024.06.025","article-title":"Plant-based diet in hyperkalemic chronic kidney disease patients receiving sodium zirconium cyclosilicate: A feasibility clinical trial","volume":"120","author":"Avesani","year":"2024","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_134","doi-asserted-by":"crossref","unstructured":"Michail, A., and Andreou, E. (2025). A plant-dominant low-protein diet in chronic kidney disease management: A narrative review with considerations for Cyprus. Nutrients, 17.","DOI":"10.3390\/nu17060970"},{"key":"ref_135","doi-asserted-by":"crossref","unstructured":"Zarantonello, D., and Brunori, G. (2023). The Role of Plant-Based Diets in Preventing and Mitigating Chronic Kidney Disease: More Light than Shadows. J. Clin. Med., 12.","DOI":"10.3390\/jcm12196137"},{"key":"ref_136","doi-asserted-by":"crossref","unstructured":"Shannon, O.M., Ranson, J.M., Gregory, S., Macpherson, H., Milte, C., Lentjes, M., Mulligan, A., McEvoy, C., Griffiths, A., and Matu, J. (2023). Mediterranean diet adherence is associated with lower dementia risk, independent of genetic predisposition: Findings from the UK Biobank prospective cohort study. BMC Med., 21.","DOI":"10.1186\/s12916-023-02772-3"},{"key":"ref_137","doi-asserted-by":"crossref","first-page":"630","DOI":"10.1001\/jamapsychiatry.2023.0800","article-title":"Association of the Mediterranean dietary approaches to stop hypertension intervention for neurodegenerative delay (MIND) diet with the risk of dementia","volume":"80","author":"Chen","year":"2023","journal-title":"JAMA Psychiatry"},{"key":"ref_138","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1016\/j.kint.2025.06.005","article-title":"Executive summary of the KDIGO 2026 clinical practice guideline for the management of anemia in chronic kidney disease (CKD)","volume":"109","author":"Babitt","year":"2026","journal-title":"Kidney Int."},{"key":"ref_139","doi-asserted-by":"crossref","first-page":"e264029","DOI":"10.1001\/jamanetworkopen.2026.4029","article-title":"Anemia and blood biomarkers of Alzheimer disease in dementia development","volume":"9","author":"Valletta","year":"2026","journal-title":"JAMA Netw. Open"},{"key":"ref_140","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1002\/ajh.25570","article-title":"Anemia predicts lower white matter volume and cognitive performance in sickle and non-sickle cell anemia syndrome","volume":"94","author":"Choi","year":"2019","journal-title":"Am. J. Hematol."},{"key":"ref_141","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1007\/s12325-020-01524-6","article-title":"Burden of anemia in chronic kidney disease: Beyond erythropoietin","volume":"38","author":"Hanna","year":"2021","journal-title":"Adv. Ther."},{"key":"ref_142","doi-asserted-by":"crossref","unstructured":"Greenwood, S.A., Beckley-Hoelscher, N., Asgari, E., Ayis, S., Baker, L.A., Banerjee, D., Bhandari, S., Bramham, K., Chilcot, J., and Burton, J. (2022). The effect of intravenous iron supplementation on exercise capacity in iron-deficient but not anaemic patients with chronic kidney disease: Study design and baseline data for a multicentre prospective double-blind randomised controlled trial. BMC Nephrol., 23.","DOI":"10.1186\/s12882-022-02896-3"},{"key":"ref_143","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1007\/s11255-022-03377-0","article-title":"Oral and intravenous iron treatment alter the gut microbiome differentially in dialysis patients","volume":"55","author":"Liu","year":"2023","journal-title":"Int. Urol. Nephrol."},{"key":"ref_144","doi-asserted-by":"crossref","unstructured":"Shearer, J., Shah, S., MacInnis, M.J., Shen-Tu, G., and Mu, C. (2024). Dose-responsive effects of iron supplementation on the gut microbiota in middle-aged women. Nutrients, 16.","DOI":"10.3390\/nu16060786"},{"key":"ref_145","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1053\/j.ajkd.2008.05.033","article-title":"Intravenous versus oral iron supplementation for the treatment of anemia in CKD: Systematic review and meta-analysis","volume":"52","author":"Paul","year":"2008","journal-title":"Am. J. Kidney Dis."},{"key":"ref_146","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1186\/s12967-022-03812-x","article-title":"The prebiotic effects of soluble dietary fiber mixture on renal anemia and the gut microbiota in end-stage renal disease patients on maintenance hemodialysis: A prospective, randomized, placebo-controlled study","volume":"20","author":"Li","year":"2022","journal-title":"J. Transl. Med."},{"key":"ref_147","unstructured":"Patel, P., and Hashmi, M.F. (2026). Chronic kidney disease-mineral bone disorder (CKD-MBD). StatPearls [Internet], StatPearls Publishing."},{"key":"ref_148","doi-asserted-by":"crossref","unstructured":"Li, T., Xie, Y., Bowe, B., Xian, H., and Al-Aly, Z. (2017). Serum phosphorus levels and risk of incident dementia. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0171377"},{"key":"ref_149","doi-asserted-by":"crossref","unstructured":"Rodr\u00edguez-Ortiz, M.E., Jurado-Montoya, D., Vald\u00e9s-D\u00edaz, K., Garc\u00eda-S\u00e1ez, R.M., Torralbo, A.I., Obrero, T., Vidal-Jim\u00e9nez, V., Jim\u00e9nez, M.J., Carmona, A., and Guerrero, F. (2024). Cognitive impairment related to chronic kidney disease is associated with a decreased abundance of membrane-bound Klotho in the cerebral cortex. Int. J. Mol. Sci., 25.","DOI":"10.3390\/ijms25084194"},{"key":"ref_150","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1007\/s00204-025-04274-y","article-title":"Dietary phosphate exposure-strategies to protect vulnerable population groups","volume":"100","author":"Lampen","year":"2026","journal-title":"Arch. Toxicol."},{"key":"ref_151","doi-asserted-by":"crossref","first-page":"e10837","DOI":"10.1002\/jbm4.10837","article-title":"The dietary fiber inulin slows progression of chronic kidney disease-mineral bone disorder (CKD-MBD) in a rat model of CKD","volume":"7","author":"Biruete","year":"2023","journal-title":"JBMR Plus"},{"key":"ref_152","doi-asserted-by":"crossref","unstructured":"Lai, S., Molfino, A., Testorio, M., Perrotta, A.M., Currado, A., Pintus, G., Pietrucci, D., Unida, V., La Rocca, D., and Biocca, S. (2019). Effect of low-protein diet and inulin on microbiota and clinical parameters in patients with chronic kidney disease. Nutrients, 11.","DOI":"10.3390\/nu11123006"},{"key":"ref_153","doi-asserted-by":"crossref","first-page":"2416609","DOI":"10.1080\/0886022X.2024.2416609","article-title":"Effects of resistant starch supplementation on renal function and inflammatory markers in patients with chronic kidney disease: A meta-analysis of randomized controlled trials","volume":"46","author":"Zhang","year":"2024","journal-title":"Ren. Fail."},{"key":"ref_154","doi-asserted-by":"crossref","first-page":"1861009","DOI":"10.1155\/2022\/1861009","article-title":"Effects of resistant starch on patients with chronic kidney disease: A systematic review and meta-analysis","volume":"2022","author":"Du","year":"2022","journal-title":"J. Diabetes Res."},{"key":"ref_155","doi-asserted-by":"crossref","first-page":"eads5286","DOI":"10.1126\/sciadv.ads5286","article-title":"Biomimetic wrinkled prebiotic microspheres with enhanced intestinal retention for hyperphosphatemia and vascular calcification","volume":"11","author":"Hu","year":"2025","journal-title":"Sci. Adv."},{"key":"ref_156","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1038\/sj.ki.5002585","article-title":"A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease","volume":"73","author":"Fouque","year":"2008","journal-title":"Kidney Int."},{"key":"ref_157","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1053\/j.jrn.2018.08.006","article-title":"Global prevalence of protein-energy wasting in kidney disease: A meta-analysis of contemporary observational studies from the International Society of Renal Nutrition and Metabolism","volume":"28","author":"Carrero","year":"2018","journal-title":"J. Ren. Nutr."},{"key":"ref_158","doi-asserted-by":"crossref","unstructured":"Hu, J., Zhong, X., Liu, Y., Yan, J., Zhou, D., Qin, D., Xiao, X., Zheng, Y., Wen, L., and Tan, R. (2022). Correlation between intestinal flora disruption and protein-energy wasting in patients with end-stage renal disease. BMC Nephrol., 23.","DOI":"10.1186\/s12882-022-02762-2"},{"key":"ref_159","doi-asserted-by":"crossref","unstructured":"Bi, X., Liu, Y., Yao, L., Ling, L., Lu, J., Hu, C., and Ding, W. (2024). Gut microbiota dysbiosis and protein energy wasting in patients on hemodialysis: An observational longitudinal study. Front. Nutr., 10.","DOI":"10.3389\/fnut.2023.1270690"},{"key":"ref_160","first-page":"1093","article-title":"Low-protein diet adherence and CKD progression during long-term follow-up","volume":"41","author":"Rosa","year":"2025","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_161","doi-asserted-by":"crossref","first-page":"1279","DOI":"10.3904\/kjim.2020.408","article-title":"Nutritional management in patients with chronic kidney disease","volume":"35","author":"Kim","year":"2020","journal-title":"Korean J. Intern. Med."},{"key":"ref_162","first-page":"CD001892","article-title":"Low protein diets for non-diabetic adults with chronic kidney disease","volume":"10","author":"Hahn","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_163","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1053\/j.ackd.2012.12.002","article-title":"Optimal nutrition in hemodialysis patients","volume":"20","author":"Ikizler","year":"2013","journal-title":"Adv. Chronic Kidney Dis."},{"key":"ref_164","doi-asserted-by":"crossref","unstructured":"Ebersolt, M., Machado, T.S., Mallmann, C., Mc-Kay, N., Dou, L., Bouchouareb, D., Brunet, P., Burtey, S., and Sall\u00e9e, M. (2022). Protein\/fiber index modulates uremic toxin concentrations in hemodialysis patients. Toxins, 14.","DOI":"10.3390\/toxins14090589"},{"key":"ref_165","doi-asserted-by":"crossref","first-page":"414","DOI":"10.34067\/KID.0000000892","article-title":"Portein Intake in Hemodialysis Patients Should Be Higher Than 1.2 g\/Kg per Day: CON","volume":"7","author":"Ozcan","year":"2026","journal-title":"Kidney360"},{"key":"ref_166","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1136\/gutjnl-2015-309957","article-title":"High-level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome","volume":"65","author":"Pellegrini","year":"2016","journal-title":"Gut"},{"key":"ref_167","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1038\/nature12820","article-title":"Diet rapidly and reproducibly alters the human gut microbiome","volume":"505","author":"David","year":"2014","journal-title":"Nature"},{"key":"ref_168","doi-asserted-by":"crossref","first-page":"735","DOI":"10.7150\/ijms.19816","article-title":"Effects of diet intervention on body composition in the elderly with chronic kidney disease","volume":"14","author":"Hung","year":"2017","journal-title":"Int. J. Med. Sci."},{"key":"ref_169","doi-asserted-by":"crossref","unstructured":"Yang, W.-C., Hsieh, H.-M., Chen, J.-P., Liu, L.-C., and Chen, C.-H. (2023). Effects of a low-protein nutritional formula with dietary counseling in older adults with chronic kidney disease stages 3\u20135: A randomized controlled trial. BMC Nephrol., 24.","DOI":"10.1186\/s12882-023-03423-8"},{"key":"ref_170","doi-asserted-by":"crossref","unstructured":"Liu, J., Wan, J., Chen, K., He, Y., Zhang, W., Luo, J., and Li, D. (2025). The relationship between protein-energy wasting and cognitive impairment in patients receiving maintenance hemodialysis. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1619083"},{"key":"ref_171","doi-asserted-by":"crossref","first-page":"326","DOI":"10.1111\/sdi.13146","article-title":"The association of cognition with protein energy wasting and synaptic transmission in chronic kidney disease","volume":"36","author":"Yang","year":"2023","journal-title":"Semin. Dial."},{"key":"ref_172","doi-asserted-by":"crossref","first-page":"2649487","DOI":"10.1080\/19490976.2026.2649487","article-title":"Circulatory dietary and gut-derived metabolites predict early cognitive decline","volume":"18","author":"Connell","year":"2026","journal-title":"Gut Microbes"},{"key":"ref_173","doi-asserted-by":"crossref","unstructured":"Pieniazek, A., Bernasinska-Slomczewska, J., and Gwozdzinski, L. (2021). Uremic toxins and their relation with oxidative stress induced in patients with CKD. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22126196"},{"key":"ref_174","doi-asserted-by":"crossref","unstructured":"Ticinesi, A., Guerra, A., Nouvenne, A., Meschi, T., and Maggi, S. (2023). Disentangling the complexity of nutrition, frailty and gut microbial pathways during aging: A focus on hippuric acid. Nutrients, 15.","DOI":"10.3390\/nu15051138"},{"key":"ref_175","doi-asserted-by":"crossref","first-page":"13757","DOI":"10.1021\/acs.jafc.4c02591","article-title":"Oat dietary fiber delays the progression of chronic kidney disease in mice by modulating the gut microbiota and reducing uremic toxin levels","volume":"72","author":"Xia","year":"2024","journal-title":"J. Agric. Food Chem."},{"key":"ref_176","doi-asserted-by":"crossref","unstructured":"Rocchetti, M.T., Di Iorio, B.R., Vacca, M., Cosola, C., Marzocco, S., di Bari, I., Calabrese, F.M., Ciarcia, R., De Angelis, M., and Gesualdo, L. (2021). Ketoanalogs\u2019 effects on intestinal microbiota modulation and uremic toxins serum levels in chronic kidney disease (Medika2 study). J. Clin. Med., 10.","DOI":"10.3390\/jcm10040840"},{"key":"ref_177","doi-asserted-by":"crossref","unstructured":"Liu, X., Zhang, M., Wang, X., Liu, P., Wang, L., Li, Y., Wang, X., and Ren, F. (2022). Fecal microbiota transplantation restores normal fecal composition and delays malignant development of mild chronic kidney disease in rats. Front. Microbiol., 13.","DOI":"10.3389\/fmicb.2022.1037257"},{"key":"ref_178","doi-asserted-by":"crossref","unstructured":"Barba, C., Soulage, C.O., Caggiano, G., Glorieux, G., Fouque, D., and Koppe, L. (2020). Effects of fecal microbiota transplantation on composition in mice with CKD. Toxins, 12.","DOI":"10.3390\/toxins12120741"},{"key":"ref_179","doi-asserted-by":"crossref","unstructured":"Arteaga-Muller, G.Y., Flores-Trevi\u00f1o, S., Bocanegra-Ibarias, P., Robles-Espino, D., Garza-Gonz\u00e1lez, E., Fabela-Valdez, G.C., and Camacho-Ortiz, A. (2024). Changes in the progression of chronic kidney disease in patients undergoing fecal microbiota transplantation. Nutrients, 16.","DOI":"10.3390\/nu16081109"},{"key":"ref_180","doi-asserted-by":"crossref","first-page":"e70461","DOI":"10.1002\/mnfr.70461","article-title":"Changyanning ameliorates dextran sodium sulfate-induced colitis by modulating gut microbiota inflammation and intestinal barrier in mice","volume":"70","author":"Ye","year":"2026","journal-title":"Mol. Nutr. Food Res."},{"key":"ref_181","doi-asserted-by":"crossref","first-page":"106949","DOI":"10.1016\/j.fitote.2025.106949","article-title":"Digestion characteristics of Changyanning formula and its regulatory effect on fecal microbiota and metabolites during in vitro fermentation","volume":"187","author":"Huang","year":"2025","journal-title":"Fitoterapia"},{"key":"ref_182","doi-asserted-by":"crossref","first-page":"6066","DOI":"10.1111\/jcmm.17626","article-title":"Bacteroides plebeius improves muscle wasting in chronic kidney disease by modulating the gut-renal muscle axis","volume":"26","author":"Pei","year":"2022","journal-title":"J. Cell. Mol. Med."},{"key":"ref_183","doi-asserted-by":"crossref","first-page":"e70014","DOI":"10.1111\/apm.70014","article-title":"Faecalibacterium prausnitzii suppresses mitophagy to alleviate muscle atrophy in chronic renal failure with protein-energy wasting","volume":"133","author":"Ni","year":"2025","journal-title":"APMIS"},{"key":"ref_184","doi-asserted-by":"crossref","first-page":"7493","DOI":"10.1038\/s41598-025-91033-9","article-title":"Synbiotics as a novel therapeutic approach for hyperphosphatemia and hyperparathyroidism in chronic kidney disease rats","volume":"15","author":"Anegkamol","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_185","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1159\/000488947","article-title":"Dietary changes involving Bifidobacterium longum and other nutrients delays chronic kidney disease progression","volume":"47","author":"Iwashita","year":"2018","journal-title":"Am. J. Nephrol."},{"key":"ref_186","doi-asserted-by":"crossref","first-page":"149","DOI":"10.4103\/ijn.IJN_341_19","article-title":"The effect of synbiotic and probiotic supplementation on mental health parameters in patients undergoing hemodialysis: A double-blind, randomized, placebo-controlled trial","volume":"31","author":"Haghighat","year":"2021","journal-title":"Indian J. Nephrol."},{"key":"ref_187","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1111\/nep.14149","article-title":"Synbiotic supplement for treatment of iron deficiency anaemia in haemodialysis patients: A randomized controlled trial","volume":"28","author":"Kooshki","year":"2023","journal-title":"Nephrology"},{"key":"ref_188","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1053\/j.jrn.2014.09.008","article-title":"Effect of a symbiotic gel (Lactobacillus acidophilus + Bifidobacterium lactis + inulin) on presence and severity of gastrointestinal symptoms in hemodialysis patients","volume":"25","year":"2015","journal-title":"J. Ren. Nutr."},{"key":"ref_189","doi-asserted-by":"crossref","unstructured":"Liu, C., Yang, L., Wei, W., and Fu, P. (2024). Efficacy of probiotics\/synbiotics supplementation in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1434613"},{"key":"ref_190","doi-asserted-by":"crossref","first-page":"110713","DOI":"10.1016\/j.nut.2019.110713","article-title":"Effects of synbiotic supplementation on microbiota-derived protein-bound uremic toxins, systemic inflammation, and biochemical parameters in patients on hemodialysis: A double-blind, placebo-controlled, randomized clinical trial","volume":"73","author":"Mirzaeian","year":"2020","journal-title":"Nutrition"},{"key":"ref_191","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1053\/j.jrn.2022.07.008","article-title":"The impact of synbiotic treatment on the levels of gut-derived uremic toxins, inflammation, and gut microbiome of chronic kidney disease patients\u2014A randomized trial","volume":"33","author":"Svorcan","year":"2023","journal-title":"J. Ren. Nutr."},{"key":"ref_192","doi-asserted-by":"crossref","unstructured":"Cedillo-Flores, R., Cuevas-Budhart, M.A., Cavero-Redondo, I., Kappes, M., \u00c1vila-D\u00edaz, M., and Paniagua, R. (2025). Impact of gut microbiome modulation on uremic toxin reduction in chronic kidney disease: A systematic review and network meta-analysis. Nutrients, 17.","DOI":"10.1101\/2025.02.21.25322662"},{"key":"ref_193","doi-asserted-by":"crossref","unstructured":"Favero, C., Giordano, L., Mihaila, S.M., Masereeuw, R., Ortiz, A., and Sanchez-Ni\u00f1o, M.D. (2022). Postbiotics and kidney disease. Toxins, 14.","DOI":"10.3390\/toxins14090623"},{"key":"ref_194","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1053\/j.ajkd.2020.05.006","article-title":"KDOQI clinical practice guideline for nutrition in CKD: 2020 update","volume":"76","author":"Ikizler","year":"2020","journal-title":"Am. J. Kidney Dis."},{"key":"ref_195","doi-asserted-by":"crossref","first-page":"310","DOI":"10.34067\/KID.0000000000000364","article-title":"Nutrition management in geriatric patients with CKD","volume":"5","author":"Ertuglu","year":"2024","journal-title":"Kidney360"},{"key":"ref_196","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/S2468-1253(24)00311-X","article-title":"International consensus statement on microbiome testing in clinical practice","volume":"10","author":"Porcari","year":"2025","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_197","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1053\/j.jrn.2018.08.008","article-title":"Prebiotic, probiotic, and synbiotic supplementation in chronic kidney disease: A systematic review and meta-analysis","volume":"29","author":"McFarlane","year":"2019","journal-title":"J. Ren. Nutr."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/12\/1978\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T04:27:24Z","timestamp":1782534444000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/12\/1978"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,18]]},"references-count":197,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["nu18121978"],"URL":"https:\/\/doi.org\/10.3390\/nu18121978","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,18]]}}}