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

Abstract

The widespread use of proton pump inhibitors (PPIs) has
raised safety concerns, especially among patients with
chronic kidney disease (CKD), where long-term use has
been linked with acute interstitial nephritis (AIN),
hypomagnesaemia, and potential progression to endstage
kidney disease (ESKD). Recent observational studies
and meta-analyses have yielded mixed evidence, calling for
a nuanced and individualized approach to acid suppression
in CKD. The concept of gut guardianship emphasizes
cautious, indication-based prescribing, dose minimization,
and structured deprescribing to preserve gut–renal health.
This article reviews the current evidence and proposes a
clinical toolkit for rational PPI use in CKD, based on risk
stratification, guideline-based indications, and ongoing
monitoring.
Keywords: Acid suppression, Chronic kidney disease, Gut
microbiome, Nephrotoxicity, Proton pump inhibitors