Patients on
hemodialysis (HD) have a high burden of chronic
inflammation induced associated with multiple comorbidities including poor nutritional status.
Endotoxin (ET) is a Gram-negative bacterial cell wall component and a potent stimulus for innate immune system activation leading to the transcription of proinflammatory
cytokines (e.g., IL-1, IL-6, and TNFα) that adversely affect
protein metabolism and nutrition. Several cross-sectional observational studies have found that elevated serum ET concentrations in
hemodialysis patients are associated with lower
serum albumin, higher proinflammatory
cytokine, and
C-reactive protein concentrations. Possible sources of ET in the systemic circulation are bacterial translocation from the gastrointestinal tract and
iron supplementation, potentially leading to intestinal bacterial overgrowth.
Sevelamer is a nonabsorbable
hydrogel approved for use as a
phosphate binder in HD patients. Reductions in serum ET concentrations in
hemodialysis patients have been observed with
sevelamer therapy in observational studies and the few published interventional studies. Reduction of ET concentrations was associated with concomitant reductions in TNFα,
IL-6, and CRP and improvement in
serum albumin in the majority of these small studies. Additional studies are needed to evaluate the potential effects of
sevelamer treatment on nutritional status in
chronic kidney disease (CKD) patients with elevated ET.