Assessment for usage of laxatives and probiotics ,and its role in improving uremic parameters of CKD as GFR, UREA ,CREATININE, CLINICAL and UREMIC assessment (lower limb edema ,UOP,base of chest ,vomiting ,dyspnea,blood pressure measurement)

with advanced CKD stages ,also have been linked to the high prevalence of constipation in CKD,Lactulose is a synthetic disaccharide.Lactulose is poorly absorbed from the gastrointestinal tract remains virtually unchanged and is then fermented by gut microbiota that increase osmotic effects and intraluminal gas formation . lactulose reduces the nitrogen products and urea, creatinine, uric acid, and b2- microglobulin levels. Lactulose also suppress tubulointerstitial fibrosis in a rat model of a kidney disease study . Lactulose modifies the gut microbiota, increasing the abundance of Bifidobacteria and Lactobacilli after 8 weeks of 30 ml lactulose syrup thrice daily, and ameliorates CKD progression by suppressing uremic toxin production .probiotics include vast array of products with living organisms whose purpose is to improve intestinal microbial balance and produce beneficial effect on ones health .probiotics is an alternative therapy for patients with CKD

Inclusion Criteria:

• CKD stages 3,4,5 with non-dialysis receiving a diagnosis of constipation
• DM nephropathy

Exclusion Criteria:

• IBS (ulcerative colitis -crohns)
• HCV ,HBV ,
• autoimmune patients,
• malignancy pt
• cirrhotic patients
• haemodialysis patients
• cardiovascular patients
• abdominal surgery,
• gut obstruction,
• pregnancy,
• patients with ESRD on dialysis,
• history of lactulose allergy.

1. group A (50 PT DM and Non DM CKD Stage 3,4,5 not ON dialysis and receive lactulose 30 ml per day divided in 3 doses
2. -group B (50 patients DM and Non DM CKD stage 3.4,5 not on dialysis and receive lactobacillus acidophilus one tab twice daily
3. Group C control group (50 PT DM and Non DM CKD stage 3,4,5 not on dialysis and receive neither lactulose ,nor lactobacillus acidophilus .