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Alvarenga L, Reis DCMV, Kemp JA, Teixeira KTR, Fouque D, Mafra D. Using the concept of food as medicine to mitigate inflammation in patients undergoing peritoneal dialysis. Ther Apher Dial 2024; 28:341-353. [PMID: 38163858 DOI: 10.1111/1744-9987.14101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/29/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024]
Abstract
The most common kidney replacement therapy (KRT) worldwide is hemodialysis (HD), and only 5%-10% of patients are prescribed peritoneal dialysis (PD) as KRT. Despite PD being a different method, these patients also present particular complications, such as oxidative stress, gut dysbiosis, premature aging, and mitochondrial dysfunction, leading to an inflammation process and high cardiovascular mortality risk. Although recent studies have reported nutritional strategies in patients undergoing HD with attempts to mitigate these complications, more information must be needed for PD patients. Therefore, this review provides a comprehensive analysis of recent studies of nutritional intervention to mitigate inflammation in PD patients.
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Affiliation(s)
- Livia Alvarenga
- Graduate Program in Nutrition Sciences, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
- Graduate Program in Biological Sciences - Physiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Drielly C M V Reis
- Division of Nephrology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Julie Ann Kemp
- Graduate Program in Nutrition Sciences, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
| | | | - Denis Fouque
- Department of Nephrology, Centre Hopitalier Lyon Sud, INSERM 1060, CENS, Université de Lyon, Lyon, France
| | - Denise Mafra
- Graduate Program in Nutrition Sciences, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
- Graduate Program in Biological Sciences - Physiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- Graduate Program in Medical Sciences, Fluminense Federal University (UFF), Niterói, Rio de Janeiro, Brazil
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Azad F, Hamidianshirazi M, Mazloomi SM, Shafiee M, Ekramzadeh M. Fortified synbiotic dessert for improving malnutrition in hemodialysis patients: A randomized, double-blind, controlled trial. Food Sci Nutr 2023; 11:8082-8092. [PMID: 38107115 PMCID: PMC10724616 DOI: 10.1002/fsn3.3728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 12/19/2023] Open
Abstract
As dysbiosis of gut microbiota is recognized as a major risk factor for malnutrition in hemodialysis (HD) patients, we aimed to assess the effects of fortified synbiotic dessert on malnutrition, oxidative stress, inflammation, and quality of life in patients undergoing hemodialysis. A total of 50 hemodialysis patients were randomized into two groups of intervention and control to consume either 50 g of synbiotic dessert fortified with vitamin D (1000 IU) and calcium (500 mg) (FSD) or 50 g of control dessert (CD) for 8 weeks, respectively. Changes in nutritional status [Subjective Global Assessment (SGA)], anthropometric measures, malondialdehyde (MDA), total antioxidant capacity (TAC), high-sensitivity C-reactive protein (hs-CRP), ferritin, biochemistry [serum albumin, vitamin D, creatinine, blood urea nitrogen (BUN), complete blood count (CBC), and electrolytes], and quality of life were assessed before and at the end of the trial. The SGA scores and serum ferritin levels decreased significantly in the FSD group compared to the control group (p = .01 and p = .03, respectively). Regarding other markers, no statistically significant changes were found comparing the two groups. This novel fortified synbiotic dessert as a functional food may be effective in reducing the severity of malnutrition by improving SGA score in short term in hemodialysis patients. Thus, it is suggested to do further studies to elucidate the possible mechanisms related to the effects of this dessert on microbiota, skeletal muscle mass, and inflammation in HD in long term.
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Affiliation(s)
- Farzaneh Azad
- Student Research Committee, School of Nutrition and Food SciencesShiraz University of Medical SciencesShirazIran
| | - Maryam Hamidianshirazi
- Student Research Committee, School of Nutrition and Food SciencesShiraz University of Medical SciencesShirazIran
| | - Seyed Mohammad Mazloomi
- Department of Food Hygiene and Quality Control, Health and Food Quality Control, Food and Supplements Safety Research CenterShiraz University of Medical SciencesShirazIran
| | - Maryam Shafiee
- Shiraz Nephro‐Urology Research CenterShiraz University of Medical SciencesShirazIran
| | - Maryam Ekramzadeh
- Department of Clinical Nutrition, Nutrition Research Center, School of Nutrition and Food SciencesShiraz University of Medical SciencesShirazIran
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Cooper TE, Khalid R, Chan S, Craig JC, Hawley CM, Howell M, Johnson DW, Jaure A, Teixeira-Pinto A, Wong G. Synbiotics, prebiotics and probiotics for people with chronic kidney disease. Cochrane Database Syst Rev 2023; 10:CD013631. [PMID: 37870148 PMCID: PMC10591284 DOI: 10.1002/14651858.cd013631.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a major public health problem affecting 13% of the global population. Prior research has indicated that CKD is associated with gut dysbiosis. Gut dysbiosis may lead to the development and/or progression of CKD, which in turn may in turn lead to gut dysbiosis as a result of uraemic toxins, intestinal wall oedema, metabolic acidosis, prolonged intestinal transit times, polypharmacy (frequent antibiotic exposures) and dietary restrictions used to treat CKD. Interventions such as synbiotics, prebiotics, and probiotics may improve the balance of the gut flora by altering intestinal pH, improving gut microbiota balance and enhancing gut barrier function (i.e. reducing gut permeability). OBJECTIVES This review aimed to evaluate the benefits and harms of synbiotics, prebiotics, and probiotics for people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) measuring and reporting the effects of synbiotics, prebiotics, or probiotics in any combination and any formulation given to people with CKD (CKD stages 1 to 5, including dialysis and kidney transplant). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was independently carried out by two authors using a standard data extraction form. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Forty-five studies (2266 randomised participants) were included in this review. Study participants were adults (two studies in children) with CKD ranging from stages 1 to 5, with patients receiving and not receiving dialysis, of whom half also had diabetes and hypertension. No studies investigated the same synbiotic, prebiotic or probiotic of similar strains, doses, or frequencies. Most studies were judged to be low risk for selection bias, performance bias and reporting bias, unclear risk for detection bias and for control of confounding factors, and high risk for attrition and other biases. Compared to prebiotics, it is uncertain whether synbiotics improve estimated glomerular filtration rate (eGFR) at four weeks (1 study, 34 participants: MD -3.80 mL/min/1.73 m², 95% CI -17.98 to 10.38), indoxyl sulfate at four weeks (1 study, 42 participants: MD 128.30 ng/mL, 95% CI -242.77 to 499.37), change in gastrointestinal (GI) upset (borborymgi) at four weeks (1 study, 34 participants: RR 15.26, 95% CI 0.99 to 236.23), or change in GI upset (Gastrointestinal Symptom Rating Scale) at 12 months (1 study, 56 participants: MD 0.00, 95% CI -0.27 to 0.27), because the certainty of the evidence was very low. Compared to certain strains of prebiotics, it is uncertain whether a different strain of prebiotics improves eGFR at 12 weeks (1 study, 50 participants: MD 0.00 mL/min, 95% CI -1.73 to 1.73), indoxyl sulfate at six weeks (2 studies, 64 participants: MD -0.20 μg/mL, 95% CI -1.01 to 0.61; I² = 0%) or change in any GI upset, intolerance or microbiota composition, because the certainty of the evidence was very low. Compared to certain strains of probiotics, it is uncertain whether a different strain of probiotic improves eGFR at eight weeks (1 study, 30 participants: MD -0.64 mL/min, 95% CI -9.51 to 8.23; very low certainty evidence). Compared to placebo or no treatment, it is uncertain whether synbiotics improve eGFR at six or 12 weeks (2 studies, 98 participants: MD 1.42 mL/min, 95% CI 0.65 to 2.2) or change in any GI upset or intolerance at 12 weeks because the certainty of the evidence was very low. Compared to placebo or no treatment, it is uncertain whether prebiotics improves indoxyl sulfate at eight weeks (2 studies, 75 participants: SMD -0.14 mg/L, 95% CI -0.60 to 0.31; very low certainty evidence) or microbiota composition because the certainty of the evidence is very low. Compared to placebo or no treatment, it is uncertain whether probiotics improve eGFR at eight, 12 or 15 weeks (3 studies, 128 participants: MD 2.73 mL/min, 95% CI -2.28 to 7.75; I² = 78%), proteinuria at 12 or 24 weeks (1 study, 60 participants: MD -15.60 mg/dL, 95% CI -34.30 to 3.10), indoxyl sulfate at 12 or 24 weeks (2 studies, 83 participants: MD -4.42 mg/dL, 95% CI -9.83 to 1.35; I² = 0%), or any change in GI upset or intolerance because the certainty of the evidence was very low. Probiotics may have little or no effect on albuminuria at 12 or 24 weeks compared to placebo or no treatment (4 studies, 193 participants: MD 0.02 g/dL, 95% CI -0.08 to 0.13; I² = 0%; low certainty evidence). For all comparisons, adverse events were poorly reported and were minimal (flatulence, nausea, diarrhoea, abdominal pain) and non-serious, and withdrawals were not related to the study treatment. AUTHORS' CONCLUSIONS We found very few studies that adequately test biotic supplementation as alternative treatments for improving kidney function, GI symptoms, dialysis outcomes, allograft function, patient-reported outcomes, CVD, cancer, reducing uraemic toxins, and adverse effects. We are not certain whether synbiotics, prebiotics, or probiotics are more or less effective compared to one another, antibiotics, or standard care for improving patient outcomes in people with CKD. Adverse events were uncommon and mild.
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Affiliation(s)
- Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Rabia Khalid
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Samuel Chan
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
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Devi R, Sharma E, Thakur R, Lal P, Kumar A, Altaf MA, Singh B, Tiwari RK, Lal MK, Kumar R. Non-dairy prebiotics: Conceptual relevance with nutrigenomics and mechanistic understanding of the effects on human health. Food Res Int 2023; 170:112980. [PMID: 37316060 DOI: 10.1016/j.foodres.2023.112980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 06/16/2023]
Abstract
The increasing health awareness of consumers has made a shift towards vegan and non-dairy prebiotics counterparts. Non-dairy prebiotics when fortified with vegan products have interesting properties and widely found its applications in food industry. The chief vegan products that have prebiotics added include water-soluble plant-based extracts (fermented beverages, frozen desserts), cereals (bread, cookies), and fruits (juices & jelly, ready to eat fruits). The main prebiotic components utilized are inulin, oligofructose, polydextrose, fructooligosaccharides, and xylooligosaccharides. Prebiotics' formulations, type and food matrix affect food products, host health, and technological attributes. Prebiotics from non-dairy sources have a variety of physiological effects that help to prevent and treat chronic metabolic diseases. This review focuses on mechanistic insight on non-dairy prebiotics affecting human health, how nutrigenomics is related to prebiotics development, and role of gene-microbes' interactions. The review will provide industries and researchers with important information about prebiotics, mechanism of non-dairy prebiotics and microbe interaction as well as prebiotic based vegan products.
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Affiliation(s)
- Rajni Devi
- Department of Microbiology, Punjab Agricultural University, Ludhiana 141004, India
| | - Eshita Sharma
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar 143005, India
| | - Richa Thakur
- Division of Silviculture and Forest Management, Himalayan Forest Research Institute, Conifer Campus, Shimla, India
| | - Priyanka Lal
- Department of Agricultural Economics and Extension, School of Agriculture, Lovely Professional University, Jalandhar GT Road (NH1), Phagwara, India
| | - Awadhesh Kumar
- Division of Crop Physiology and Biochemistry, ICAR-National Rice Research Institute, Cuttack, India
| | | | - Brajesh Singh
- ICAR-Central Potato Research Institute, Shimla 171001, India
| | | | - Milan Kumar Lal
- ICAR-Central Potato Research Institute, Shimla 171001, India.
| | - Ravinder Kumar
- ICAR-Central Potato Research Institute, Shimla 171001, India.
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Kuskunov T, Tilkiyan E, Doykov D, Boyanov K, Bivolarska A, Hristov B. The Effect of Synbiotic Supplementation on Uremic Toxins, Oxidative Stress, and Inflammation in Hemodialysis Patients-Results of an Uncontrolled Prospective Single-Arm Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1383. [PMID: 37629672 PMCID: PMC10456308 DOI: 10.3390/medicina59081383] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023]
Abstract
Introduction: Numerous studies to date have shown that the development of dysbiotic gut microbiota is a characteristic finding in chronic kidney disease (CKD). A number of uremic toxins progressively accumulate in the course of CKD, some of them generated by the intestinal microbiome, such as indoxyl sulfate (IS) and p-cresyl sulfate (p-CS). They are found to be involved in the pathogenesis of certain complications of uremic syndrome, including low-grade chronic inflammation and oxidative stress. The aim of the present study is to research the serum concentration of IS and p-CS in end stage renal disease (ESRD) patients undergoing conventional hemodialysis, as well as to study the possibilities of influencing some markers of inflammation and oxidative stress after taking a synbiotic. Materials and Methods: Thirty patients with end-stage renal disease (ESRD) undergoing hemodialysis treatment who were taking a synbiotic in the form of Lactobacillus acidophilus La-14 2 × 1011 (CFU)/g and prebiotic fructooligosaccharides were included in the study. Serum levels of total IS, total p-CS, Interleukin-6 (IL-6), and Malondialdehyde (MDA) were measured at baseline and after 8 weeks. Results. The baseline values of the four investigated indicators in the patients were significantly higher-p-CS (29.26 ± 58.32 pg/mL), IS (212.89 ± 208.59 ng/mL), IL-6 (13.84 ± 2.02 pg/mL), and MDA (1430.33 ± 583.42 pg/mL), compared to the results obtained after 8 weeks of intake, as we found a significant decrease in the parameters compared to the baseline-p-CS (6.40 ± 0.79 pg/mL, p = 0.041), IS (47.08 ± 3.24 ng/mL, p < 0.001), IL-6 (9.14 ± 1.67 pg/mL, p < 0.001), and MDA (1003.47 ± 518.37 pg/mL, p < 0.001). Conclusions: The current study found that the restoration of the intestinal microbiota in patients with CKD significantly decreases the level of certain uremic toxins. It is likely that this favorably affects certain aspects of CKD, such as persistent low-grade inflammation and oxidative stress.
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Affiliation(s)
- Teodor Kuskunov
- Department of Propaedeutics of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
- Hemodialysis Unit, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
| | - Eduard Tilkiyan
- Second Department of Internal Diseases, Section “Nephrology”, Medical Faculty, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
- Nephrology Clinic, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
| | - Daniel Doykov
- Second Department of Internal Diseases, Section “Gastroenterology”, Medical Faculty, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
- Gastroenterology Clinic, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
| | - Krasimir Boyanov
- Department of Medical Biochemistry, Faculty of Pharmacy, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria; (K.B.); (A.B.)
| | - Anelia Bivolarska
- Department of Medical Biochemistry, Faculty of Pharmacy, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria; (K.B.); (A.B.)
| | - Bozhidar Hristov
- Second Department of Internal Diseases, Section “Gastroenterology”, Medical Faculty, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
- Gastroenterology Clinic, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
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Biruete A, Chen NX, Metzger CE, Srinivasan S, O’Neill K, Fallen PB, Fonseca A, Wilson HE, de Loor H, Evenepoel P, Swanson KS, Allen MR, Moe SM. The Dietary Fermentable Fiber Inulin Alters the Intestinal Microbiome and Improves Chronic Kidney Disease Mineral-Bone Disorder in a Rat Model of CKD. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.29.526093. [PMID: 36778372 PMCID: PMC9915522 DOI: 10.1101/2023.01.29.526093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Dietary fiber is important for a healthy diet, but intake is low in CKD patients and the impact this has on the manifestations of CKD-Mineral Bone Disorder (MBD) is unknown. Methods The Cy/+ rat with progressive CKD was fed a casein-based diet of 0.7% phosphate with 10% inulin (fermentable fiber) or cellulose (non-fermentable fiber) from 22 weeks to either 30 or 32 weeks of age (~30 and ~15 % of normal kidney function). We assessed CKD-MBD, cecal microbiota, and serum gut-derived uremic toxins. Two-way ANOVA was used to evaluate the effect of age and inulin diet, and their interaction. Results In CKD animals, dietary inulin led to changes in microbiota alpha and beta diversity at 30 and 32 weeks, with higher relative abundance of several taxa, including Bifidobacterium and Bacteroides , and lower Lactobacillus . Inulin reduced serum levels of gut-derived uremic toxins, phosphate, and parathyroid hormone, but not fibroblast growth factor-23. Dietary inulin decreased aorta and cardiac calcification and reduced left ventricular mass index and cardiac fibrosis. Bone turnover and cortical bone parameters were improved with inulin; however, bone mechanical properties were not altered. Conclusions The addition of the fermentable fiber inulin to the diet of CKD rats led to changes in the gut microbiota composition, lowered gut-derived uremic toxins, and improved most parameters of CKD-MBD. Future studies should assess this fiber as an additive therapy to other pharmacologic and diet interventions in CKD. Significance Statement Dietary fiber has well established beneficial health effects. However, the impact of fermentable dietary fiber on the intestinal microbiome and CKD-MBD is poorly understood. We used an animal model of progressive CKD and demonstrated that the addition of 10% of the fermentable fiber inulin to the diet altered the intestinal microbiota and lowered circulating gut-derived uremic toxins, phosphorus, and parathyroid hormone. These changes were associated with improved cortical bone parameters, lower vascular calcification, and reduced cardiac hypertrophy, fibrosis and calcification. Taken together, dietary fermentable fiber may be a novel additive intervention to traditional therapies of CKD-MBD.
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Multifaceted role of synbiotics as nutraceuticals, therapeutics and carrier for drug delivery. Chem Biol Interact 2022; 368:110223. [DOI: 10.1016/j.cbi.2022.110223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
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Yu Z, Zhao J, Qin Y, Wang Y, Zhang Y, Sun S. Probiotics, Prebiotics, and Synbiotics Improve Uremic, Inflammatory, and Gastrointestinal Symptoms in End-Stage Renal Disease With Dialysis: A Network Meta-Analysis of Randomized Controlled Trials. Front Nutr 2022; 9:850425. [PMID: 35445065 PMCID: PMC9015659 DOI: 10.3389/fnut.2022.850425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Probiotics, prebiotics, and synbiotics are three different supplements to treat end stage renal disease (ESRD) patients by targeting gut bacteria. The comprehensive comparison of the effectiveness of different supplements are lacking. Objectives The purpose of this network meta-analysis (NMA) is to assess and rank the efficacy of probiotics, prebiotics, and synbiotics on inflammatory factors, uremic toxins, and gastrointestinal symptoms (GI symptoms) in ESRD patients undergoing dialysis. Methods Randomized clinical trials were searched from the PubMed, Embase, and Cochrane Register of Controlled Trials databases, from their inception until 4 September 2021. Random-effect model were used to obtain all estimated outcomes in network meta-analysis (NMA). Effect estimates were presented as mean differences (Mean ± SD) with 95% confidence interval (CI). The comprehensive effects of all treatments were ranked by the surface under the cumulative ranking (SUCRA) probabilities. Results Twenty-five studies involved 1,106 participants were included. Prebiotics were superior in decreasing Interleukin-6 (IL-6; SMD –0.74, 95% CI [–1.32, –0.16]) and tumor-necrosis factor-α (TNF-α; SMD –0.59, 95% CI [–1.09, –0.08]), synbiotics were more effective in declining C-reactive protein (CRP; SMD –0.69, 95% CI [–1.14, –0.24]) and endotoxin (SMD –0.83, 95% CI [–1.38, –0.27]). Regarding uremic toxins, prebiotics ranked highest in reducing indoxyl sulfate (IS; SMD –0.43, 95% CI [–0.81, –0.05]), blood urea nitrogen (BUN; SMD –0.42, 95% CI [–0.78, –0.06]), and malondialdehyde (MDA; SMD –1.88, 95% CI [–3.02, –0.75]). Probiotics were rated as best in alleviating GI symptoms (SMD: –0.52, 95% CI [–0.93, –0.1]). Conclusion Our research indicated prebiotics were more effective in declining IL-6, TNF-α, IS, MDA, and BUN, synbiotics lowering CRP and endotoxin significantly, and probiotics were beneficial for alleviating GI symptoms, which may contribute to better clinical decisions. This study was registered in PROSPERO (Number: CRD42021277056). Systematic Review Registration [http://www.crd.york.ac.uk/PROSPERO], identifier [CRD42021277056].
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Affiliation(s)
- Zixian Yu
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Jin Zhao
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Yunlong Qin
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Yuwei Wang
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Yumeng Zhang
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
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9
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Huang L, Luo X, Chen M. Effects and safety of traditional Chinese medicine on the gut microbiota of an adult with chronic kidney disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28847. [PMID: 35363181 PMCID: PMC9282022 DOI: 10.1097/md.0000000000028847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Studies have reported that changes in the abundance of gut microbiota may explain the medically helpful responses towards traditional Chinese medicine (TCM), an essential part of alternative and complementary medicine, in treating chronic kidney disease (CKD). This study aimed to illuminate the changes in the abundance of gut microbiota of TCM with CKD. METHODS The meta-analysis was performed in the PubMed, Web of Science, EMBASE CNKI, WanFang, VIP, and CBM databases, from its inception to October 2021 to discriminate randomized controlled trials and examine the effects of TCM on CKD. Two researchers independently performed literature selection, data extraction, and quality assessment. The risk of bias of the included studies was estimated by taking into consideration the characteristics including random sequence generation, allocation concealment, blinding of patients, blinding of outcome assessment, completeness of outcome data, selective reporting, and other bias using Cochrane Collaboration's tool for assessing the risk of bias. RESULTS AND CONCLUSIONS From the perspective of intestinal flora, this study will provide high-quality evidence for the effectiveness and safety of TCM for CKD. It provides a new therapeutic approach for treating CKD with Chinese herbal medicine combined with Western medicine. INPLASY REGISTRATION NUMBER INPLASY2021100118.
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Affiliation(s)
- Li Huang
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
- Department of Nephropathy, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Xin Luo
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
- Department of Nephropathy, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
| | - Ming Chen
- Department of Nephropathy, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, PR China
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Liu J, Zhong J, Yang H, Wang D, Zhang Y, Yang Y, Xing G, Kon V. Biotic Supplements in Patients With Chronic Kidney Disease: Meta-Analysis of Randomized Controlled Trials. J Ren Nutr 2022; 32:10-21. [PMID: 34666930 PMCID: PMC9793596 DOI: 10.1053/j.jrn.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/01/2021] [Accepted: 08/10/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Gut flora imbalance characterizes patients with chronic kidney disease (CKD). Although biotic supplementation has been proposed to lessen inflammation and oxidative stress and, thus, reduce the risk of progressive kidney damage and cardiovascular disease, the effects remain controversial. We conducted a meta-analysis to assess the therapeutic benefits of biotics in CKD. METHODS PubMed, Embase, and Cochrane databases were systematically searched for randomized controlled trials that evaluated any biotic (prebiotic, probiotic, synbiotics) supplements in patients with CKD (CKD, stage 3-4 to end-stage renal disease). Primary endpoints included changes in renal function, markers of inflammation, and oxidative stress. Secondary endpoints included changes in levels of uremic toxins and variations in lipid metabolism. RESULTS Twenty-three eligible studies included 842 participants. In a pooled-analysis, biotics did not change estimated glomerular filtration rate (mean difference [MD] = 0.08, P = .92) or serum albumin (MD = -0.01, P = .86), although prebiotics reduced serum creatinine (standardized mean difference [SMD] = -0.23, P = .009) and blood urea nitrogen (MD = -6.05, P < .00001). Biotics improved total antioxidative capacity (SMD = 0.37, P = .007) and malondialdehyde (SMD = -0.96, P = .006) and reduced the inflammatory marker interleukin-6 (SMD = -0.30, P = .01) although not C-reactive protein (SMD = -0.22, P = .20). Biotic intervention reduced some uremic toxins, including p-cresol sulfate (SMD = -2.18, P < .0001) and indoxyl sulfate (MD = -5.14, P = .0009), which decreased in dialysis-dependent patients. Another toxin, indole-3-acetic acid (MD = -0.22, P = .63), did not change. Lipids were unaffected by biotic intervention (total cholesterol: SMD = -0.01, P = .89; high-density lipoprotein: SMD = -0.08, P = .76; low-density lipoprotein: MD = 3.54, P = .28; triglyceride: MD = -2.26, P = .58). CONCLUSION The results highlight the favorable influence of biotics on circulating markers of creatinine, oxidant stress (malondialdehyde, total antioxidative capacity), inflammation (interleukin-6), and uremic toxins (p-cresol sulfate) in patients with CKD. Biotics did not affect estimated glomerular filtration rate, albumin, indole-3-acetic acid, or lipids in either predialysis or dialysis patients.
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Affiliation(s)
- Jing Liu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou University Institute of Nephrology, Zhengzhou, China.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - JianYong Zhong
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - HaiChun Yang
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - DongQin Wang
- Dongjing Town Health Service Center, Songjiang District, Shanghai, China
| | - Ying Zhang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou University Institute of Nephrology, Zhengzhou, China
| | - YuMeng Yang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou University Institute of Nephrology, Zhengzhou, China
| | - GuoLan Xing
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou University Institute of Nephrology, Zhengzhou, China
| | - Valentina Kon
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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Synbiotics Easing Renal Failure by Improving Gut Microbiology II (SYNERGY II): A Feasibility Randomized Controlled Trial. Nutrients 2021; 13:nu13124481. [PMID: 34960037 PMCID: PMC8708915 DOI: 10.3390/nu13124481] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 01/14/2023] Open
Abstract
Synbiotics have emerged as a therapeutic strategy for modulating the gut microbiome and targeting novel cardiovascular risk factors, including uremic toxins indoxyl sulfate (IS) and p-cresyl sulfate (PCS). This study aims to evaluate the feasibility of a trial of long-term synbiotic supplementation in adults with stage 3-4 chronic kidney disease (CKD). Adult participants with CKD and estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m2) were recruited between April 2017 and August 2018 to a feasibility, double-blind, placebo-controlled, randomized trial of synbiotic therapy or matched identical placebo for 12 months. The primary outcomes were recruitment and retention rates as well as acceptability of the intervention. Secondary outcomes were treatment adherence and dietary intake. Exploratory outcomes were evaluation of the cardiovascular structure and function, serum IS and PCS, stool microbiota profile, kidney function, blood pressure, and lipid profile. Of 166 potentially eligible patients, 68 (41%) were recruited into the trial (synbiotic n = 35, placebo n = 33). Synbiotic and placebo groups had acceptable and comparable 12-month retention rates (80% versus 85%, respectively, p = 0.60). Synbiotic supplementation altered the stool microbiome with an enrichment of Bifidobacterium and Blautia spp., resulting in a 3.14 mL/min/1.73 m2 (95% confidence interval (CI), -6.23 to -0.06 mL/min/1.73 m2, p < 0.01) reduction in eGFR and a 20.8 µmol/L (95% CI, 2.97 to 38.5 µmol/L, p < 0.01) increase in serum creatinine concentration. No between-group differences were observed in any of the other secondary or exploratory outcomes. Long-term synbiotic supplementation was feasible and acceptable to patients with CKD, and it modified the gastrointestinal microbiome. However, the reduction in kidney function with synbiotics warrants further investigation.
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12
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Nguyen TTU, Kim HW, Kim W. Effects of Probiotics, Prebiotics, and Synbiotics on Uremic Toxins, Inflammation, and Oxidative Stress in Hemodialysis Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:4456. [PMID: 34640474 PMCID: PMC8509328 DOI: 10.3390/jcm10194456] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 12/20/2022] Open
Abstract
The dysbiosis of gut microbiota may cause many complications in patients with end-stage renal disease, which may be alleviated by probiotic, prebiotic, and synbiotic supplementation. The aim of this systematic review and meta-analysis was to assess the effects of these supplementations on circulatory uremic toxins, biomarkers of inflammation, and oxidative stress in hemodialysis patients. We searched the EMBASE, MEDLINE, Web of Science, and Cochrane Library databases until 8 August 2021. Randomized controlled trials evaluating adult patients receiving hemodialysis were included. The pooled results from 23 studies with 931 hemodialysis patients indicated that interventions significantly decreased the circulating levels of p-cresyl sulfate (standardized mean difference (SMD): 0.38; 95% CI: -0.61, -0.15; p = 0.001), endotoxins (SMD: -0.58; 95% CI: -0.99, -0.18; p = 0.005), malondialdehyde (SMD: -1.16; 95% CI: -1.81, -0.52; p = 0.0004), C-reactive proteins (CRP) (SMD: -0.61; 95% CI: -0.99, -0.23; p = 0.002), and interleukin 6 (SMD: -0.92; 95% CI: -1.51, -0.33; p = 0.002), and improved the total antioxidant capacity (SMD: 0.89; 95% CI: 0.49, 1.30; p < 0.0001) and glutathione (SMD: 0.40; 95% CI: 0.14, 0.66; p = 0.003) when compared to the placebo group. Our results suggest that treatment with probiotics, prebiotics, and synbiotics may help alleviate uremic toxin levels, oxidative stress, and the inflammatory status in hemodialysis patients.
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Affiliation(s)
- Thi Thuy Uyen Nguyen
- Department of Histology, Embryology, Pathology and Forensic Medicine, Hue University of Medicine and Pharmacy, Hue University, Hue 52000, Vietnam;
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju 54896, Korea;
| | - Hyeong Wan Kim
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju 54896, Korea;
| | - Won Kim
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju 54896, Korea;
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
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13
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Mafra D, Kalantar-Zadeh K, Moore LW. New Tricks for Old Friends: Treating Gut Microbiota of Patients With CKD. J Ren Nutr 2021; 31:433-437. [PMID: 34294553 DOI: 10.1053/j.jrn.2021.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 01/28/2023] Open
Affiliation(s)
- Denise Mafra
- Post Graduation Program in Medical Sciences and Post-Graduation Program in Cardiovascular Sciences, Federal University Fluminense, Rio de Janeiro, Brazil.
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Irvine, California
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
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14
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Raheem A, Liang L, Zhang G, Cui S. Modulatory Effects of Probiotics During Pathogenic Infections With Emphasis on Immune Regulation. Front Immunol 2021; 12:616713. [PMID: 33897683 PMCID: PMC8060567 DOI: 10.3389/fimmu.2021.616713] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
In order to inhibit pathogenic complications and to enhance animal and poultry growth, antibiotics have been extensively used for many years. Antibiotics applications not only affect target pathogens but also intestinal beneficially microbes, inducing long-lasting changes in intestinal microbiota associated with diseases. The application of antibiotics also has many other side effects like, intestinal barrier dysfunction, antibiotics residues in foodstuffs, nephropathy, allergy, bone marrow toxicity, mutagenicity, reproductive disorders, hepatotoxicity carcinogenicity, and antibiotic-resistant bacteria, which greatly compromise the efficacy of antibiotics. Thus, the development of new antibiotics is necessary, while the search for antibiotic alternatives continues. Probiotics are considered the ideal antibiotic substitute; in recent years, probiotic research concerning their application during pathogenic infections in humans, aquaculture, poultry, and livestock industry, with emphasis on modulating the immune system of the host, has been attracting considerable interest. Hence, the adverse effects of antibiotics and remedial effects of probiotics during infectious diseases have become central points of focus among researchers. Probiotics are live microorganisms, and when given in adequate quantities, confer good health effects to the host through different mechanisms. Among them, the regulation of host immune response during pathogenic infections is one of the most important mechanisms. A number of studies have investigated different aspects of probiotics. In this review, we mainly summarize recent discoveries and discuss two important aspects: (1) the application of probiotics during pathogenic infections; and (2) their modulatory effects on the immune response of the host during infectious and non-infectious diseases.
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Affiliation(s)
- Abdul Raheem
- Institute of Animal Sciences, Chinese Academy of Agricultural Sciences, Beijing, China
- Scientific Observation and Experiment Station of Veterinary Drugs and Diagnostic Technology of Beijing, Ministry of Agriculture, Beijing, China
| | - Lin Liang
- Institute of Animal Sciences, Chinese Academy of Agricultural Sciences, Beijing, China
- Scientific Observation and Experiment Station of Veterinary Drugs and Diagnostic Technology of Beijing, Ministry of Agriculture, Beijing, China
| | - Guangzhi Zhang
- Institute of Animal Sciences, Chinese Academy of Agricultural Sciences, Beijing, China
- Scientific Observation and Experiment Station of Veterinary Drugs and Diagnostic Technology of Beijing, Ministry of Agriculture, Beijing, China
| | - Shangjin Cui
- Institute of Animal Sciences, Chinese Academy of Agricultural Sciences, Beijing, China
- Scientific Observation and Experiment Station of Veterinary Drugs and Diagnostic Technology of Beijing, Ministry of Agriculture, Beijing, China
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15
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Moore LW, Kalantar-Zadeh K. Global Approaches to Nutrition Assessment and Intervention for Patients With Kidney Disease. J Ren Nutr 2020; 30:271-273. [DOI: 10.1053/j.jrn.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 05/31/2020] [Indexed: 12/19/2022] Open
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16
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Zheng HJ, Guo J, Wang Q, Wang L, Wang Y, Zhang F, Huang WJ, Zhang W, Liu WJ, Wang Y. Probiotics, prebiotics, and synbiotics for the improvement of metabolic profiles in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials. Crit Rev Food Sci Nutr 2020; 61:577-598. [PMID: 32329633 DOI: 10.1080/10408398.2020.1740645] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This systematic review and meta-analysis of randomized controlled trials (RCTs) was performed to quantify the effects of probiotic, prebiotic, and synbiotic supplementation on biomarkers of inflammation and oxidative stress, as well as lipid profiles among patients with chronic kidney disease (CKD). Electronic databases, including PubMed, the Cochrane Database, and the Web of Science were searched from January 1, 2000, to May 15, 2019. All RCTs that investigated the effect of prebiotics, probiotics, and synbiotics on a circulating (serum and plasma) inflammatory marker (C-reactive protein [CRP]), oxidative stress indicators (malondialdehyde [MDA], glutathione [GSH], and total anti-oxidant capacity [TAC]); and lipid profiles (total cholesterol [TC], triglycerides [TG], low-density lipoprotein cholesterol [LDL-c], and high-density lipoprotein cholesterol [HDL-c]) among patients with CKD were included. Data were pooled and expressed as a standardized mean difference (SMD) with a 95% confidence interval (CI). The protocol for this meta-analysis is registered with PROSPERO; No. CRD42019139090. Thirteen trials that included 671 patients were identified for analysis. The methodological quality varied across studies. Meta-analysis indicated that microbial therapies significantly reduced CRP (SMD, -0.75; 95% CI, -1.03 to -0.47; p = 0.000), MDA (SMD, -1.06; 95% CI, -1.59 to -0.52; p = 0.000), TC (SMD, -0.33; 95% CI, -0.52 to -0.13; p = 0.000), and LDL-c (SMD, -0.44; 95% CI, -0.86 to -0.02; p = 0.000) levels; they also increased the GSH (SMD, 0.44; 95% CI, 0.25 to 0.65; p = 0.000), TAC (SMD, 0.61; 95% CI, 0.07 to 1.15; p = 0.000), and HDL-c (SMD, 0.45; 95% CI, 0.03 to 0.87; p = 0.000) levels in CKD patients, as compared to the placebo groups; however, there was no statistically significant TG concentration among patients with CKD. Subgroup analyses showed that other key factors, such as the duration of intervention, participants' baseline body mass index (BMI), type of intervention, and age, had an effect of microbial therapies on outcomes. This meta-analysis supports the potential use of probiotic, prebiotic, and synbiotic supplements in the improvement of established biomarkers of inflammation and oxidative stress, as well as lipid profiles among patients with CKD, which are well-known cardiovascular risk factors. Further research into these interventions should consider the limitations of our study to explore the effect of long-term administration of these supplements in the CKD population.
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Affiliation(s)
- Hui Juan Zheng
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Jing Guo
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Qiuhong Wang
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liansheng Wang
- The Community Health Service Center of Wangzuo in Fengtai District, Beijing, China
| | - Yahui Wang
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Fan Zhang
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Wei-Jun Huang
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Wenting Zhang
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Wei Jing Liu
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yaoxian Wang
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
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