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Probiotics may reduce urea in patients with non-dialysis CKD
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Probiotic supplements are generally beneficial in the reduction of urea in patients with non-dialysis chronic kidney disease, whereas no evidence suggested that probiotics possessed meaningful impacts on the reduction of uric acid, C-reactive protein, creatinine and eGFR preservation of CKD population.
“Gut microbiota played key roles in the urea hydrolysis to produce the majority of fecal ammonium, while the urea and ammonium concentrations were closely related to the progression of CKD,” Sibei Tao, MD, and colleagues wrote. “Consequently, the elevated gut pH and increased aerobic bacteria were exposed to the relatively high urea and ammonium concentrations. Interestingly, probiotics have been reported to prevent the growth of aerobic bacteria and normalize intestinal microbiota in CKD patients [36], which could explain the urea decrease in non-dialysis CKD population.”
The researchers noted the potential for probiotics to reduce uremic toxins, which may hinder CKD progression. They also underscored that no individual probiotic could be expected to inherently have all necessary effects for reduction because organisms might behave differently when applied as a single strain vs. a combination of probiotic strains.
Patients in the studies assessed were diagnosed with CKD, whether undergoing dialysis or not, and those in intervention groups had to receive probiotics in any form, at any dose and for any duration. Patients in control groups had to receive placebo for comparison, and studies reported an outcome that included either urea, uric acid, C-reactive protein, creatinine or eGFR.
Limitations of the meta-analysis, according to the authors, include different diets, diversity of strains and a limited number of probiotic species.
“Further studies are needed to assess the effect of long-term administration of probiotics on clinical outcomes in CKD,” the researchers wrote. “Strict control of diet and selection of strains should be emphasized. Well-designed studies and cost-effective analyses are also necessary to explore the full potential of probiotics on CKD.” – by Joe Gramigna
Perspective
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Maryanne Henderson, RD, LDN, CSR
Nutrition management of patients at all stages of CKD, for both slowing progression or mitigating associated complications, has always been a challenge. As we further come to understand the impact of the “health” of gut microbiota on disease process, it is becoming clearer that diet and supplement recommendations for CKD will most likely have to change, too.
Many conditions common in CKD patients – diet, medications, impaired protein absorption, increased transit time, uremia – along with repeated use of antibiotics increase the risk for a diminished gut microflora and intestinal immunity.
A prebiotic is a non-digestible food ingredient that can stimulate growth or activity of certain colonic bacteria. The beneficial effect is through its selective stimulation of the growth or activity of one or a limited number of bacteria in the colon. Examples of potential beneficial prebiotics are inulin and fructo-oligosaccharides. Probiotics are live bacteria found in yogurt and fermented foods. Traditional diet management for CKD has advised avoiding fiber, particularly fruits and vegetables and fermented foods such as yogurt. This provides a challenge for CKD patients to consume foods containing probiotics.
Definitive clinical evidence to support the benefits of specific probiotic/prebiotic strains is lacking. However, promotion of a diet that includes foods that promote the growth of beneficial bacteria in the gut is a more practical method for enhancing the body’s natural ability to protect itself. Beneficial bacteria include Bifidobacterial species, lactobacilli, and streptococci.
As seen in practice, some gastroenterologists are prescribing probiotics for patients with irritable bowel syndrome, antibiotic and C. difficile-associated diarrhea. Improvements have been noted with probiotic treatment of functional constipation as well. What has not been clearly defined is which probiotics/prebiotics on the market are the ones to use and for which condition. Based on the large volume of research that is being done in the field, we hope for more clarity in the future.
In the meantime, educating patients, physicians and other health professionals on the “foods to include” for CKD patients that support maintaining/improving the gut microbiome is a practical, economical approach to addressing the growing belief that if the gut is healthy our patients are more likely to feel better and may have fewer medical complications related to their CKD.
References
Ramazani A, et al. JASN, 2014;doi:org/10.1681/ASN.2013080905.
Riezzo G, et al. Beneficial Microbes. 2018;doi: 10.3920/BM2018.0050.
Williams MD, et al. J Clin Gastroenterol. 2010;doi:10.1097/MCG.0b013e3181d47f5b.
Titan & Bay City Lights Lead Dietitian
DaVita Kidney Care – Briggs Chaney
Silver Spring, MD
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