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Nat. Rev. Nephrol. doi:10.1038/nrneph.2017.16 Figure 3 Potential mechanisms by which intestinal dysbiosis might promote the development of non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) Figure 3 | Potential mechanisms by which intestinal dysbiosis might promote the development of non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD). An imbalance in intestinal microbiota (dysbiosis) resulting in an increase in Gram-negative bacteria leads to an increase in lipopolysaccharide (LPS) production, which can damage the intestinal epithelium resulting in increased gut permeability. This increased gut permeability enables further egress of bacterial content, LPS and small molecules into the portal and systemic circulations causing inflammation. Dysbiosis also promotes the increased production of secondary bile acids such as deoxycholic acid. Following their return to the liver as part of the enterohepatic circulation, secondary bile acids have been linked to chronic inflammation, cholestasis and carcinogenesis through their actions on farnesoid X Receptor (FXR; with downstream effects on cholesterol metabolism) and by inducing cellular senescence and causing damage to mitochondrial and cell membranes. The intestinal microbiota also generates molecules such as trimethylamine (TMA), p-cresol and indole from dietary choline, phenylalanine/tyrosine and tryptophan, respectively. TMA is oxidized in the liver to trimethylamine oxide (TMAO), which promotes atherosclerotic vascular disease. Indole and p-cresol are metabolised in the liver to indole sulphate and p-cresol sulphate, which are cleared by the proximal tubules and are potentially nephrotoxic. Other molecules produced by microbiota metabolism, such as phenylacetic acid and hippuric acid, are also potentially toxic to the kidney. Reduced levels of short-chain fatty acids (SCFAs) as a consequence of dysbiosis can also induce decreased lipogenesis and increased gluconeogenesis, leading to insulin resistance, further dysfunction of the liver and kidney, and to the development of type 2 diabetes mellitus (T2DM). Targher, G. & Byrne, C. D. (2017) Non-alcoholic fatty liver disease: an emerging driving force in chronic kidney disease Nat. Rev. Nephrol. doi:10.1038/nrneph.2017.16