probiotic and dialysis

1. Probiotics and Gastrointestinal Concerns of
the Dialysis Patient
Karen Madsen, PhD
University of Alberta
Karen Madsen, PhD
University of Alberta
Edmonton, Alberta, Canada

2. Objectives
 To gain an understanding of the human gut microbiome
and how it can influence human health
 To learn what probiotics are and their mechanisms of
action
 To gain knowledge of the efficacy of probiotic therapy in
patients with renal disease

3. 3
Presentation Title Here |
Welcome to your
microbial life!

4. Bacteria
>50 different phyla
~5 phyla found in gut
What kinds of microbes are found in the gut?
• Over 50 known bacterial phyla
• Generally only 6 phyla found in gut
• Bacteroidetes*
• Firmicutes*
• Actinobacteria
• Proteobacteria
• Verrucomicrobria
• Fusobacteria
• 10-100 trillion organisms
• >1000 different species
• Bacteria, fungi, viruses

5. Microbial species and abundance change over the
length of the GI track

6. Microbial Ecology of the Gut
 Species have a characteristic geographic distribution along
both the length and the diameter of the gut

7. Bacterial phyla have specific site-distribution
in healthy humans
Nature 449, 811-818. 2007
Bacteroidetes
Firmicutes
COLON
SKIN
MOUTH
ESOPHAGUS
STOMACH
VAGINA

8. Gut Microbiota have a Role in Health and Disease

10. A fine balance of gut microbes
PATHOGENS
 Sepsis, infection
 Inflammation
 Liver damage
 Production of carcinogens
 Diarrhea, constipation
COMMENSALS
 Inhibit pathogen growth
 Convert pro-drugs to active
metabolites
 Degrade polysaccharides of plant
origin
 Produce folate and Vitamin K
 Produce short-chain fatty acids
 Stimulate and modulate immune
function
 Regulate body fat storage
 Maintain barrier function and stimulate
epithelial repair
 Stimulate gut motility

11. Low diversity and imbalances in gut microbiota
are associated with human disease states
Health
• High biodiversity and richness
• Stable
• Primarily Bacteroides and Firmicutes
Disease
• Low biodiversity
• Unstable
• Increased abundances of Proteobacteria,
Fusobacteria, Verrucomicrobia
• C. Difficile colitis, IBD, IBS, obesity,
metabolic syndrome, peripheral vascular
disease, renal disease, diabetes

12. A “dysbiosis” of the gut microbiota can
result from different mechanisms…
Anti Pro
Pro-
inflammatory
microbes
Anti-
inflammatory
microbes
Healthy
Excess “bad”
bacteria
Too few “good”
bacteria
Balanced

13. GUT BARRIER FUNCTION
AND MICROBIOTA

14. A barrier exists between microbes and the immune
system
TOLERANCE

15. Components of the intestinal barrier
Image adapted from: Hooper LV (2009) Nat Rev Microbiol 7(5):367-74
Physical barrier
(the epithelium)
Chemical barrier
(mucus layer)
Immunological
barrier
(immune cells of the lamina
propria)
Microbial barrier
(commensal bacteria)
Muscle layers
(smooth muscle intestinal
wall)

16. Tight junctions maintain barrier between
epithelial cells

17. A breakdown in gut barrier function has been
linked with numerous diseases
 Inflammatory bowel disease
 Chronic kidney disease
 Sepsis
 Necrotizing pancreatitis
 Celiac disease
 Type 1 diabetes
 Food allergies
 Alcoholic liver disease

18. WHAT IS THE ROLE OF THE MICROBIOTA
AND GUT PERMEABILITY IN KIDNEY
DISEASE?

19. Secretory
Erythropoietin Vitamin D,
Renin
Excretory
Urea, uric acid,
creatinine,
nitrogenous wastes
Regulatory
Maintains homeostasis;
Na, K, Po4,trace
elements.
Kidney Function
Kibow Biotech, Inc.

20. Page | 20
Impaired Kidney Function results in Waste
Accumulation
Kibow Biotech, Inc.
Toxins Retained
•Urea
•Uric acid
•Creatinine
•Indoxyl sulphate
•Parathyroid hormone
•Para cresyl sulphate
•Phenol
•P-cresol
•Oxalate
Blood with waste
Renal artery
Filtered blood
Renal vein
Water
Toxins
Waste in urine

21. Urea Accumulation Fluid retention
Hemodialysis
Urea influx into gut
Increase urease-expressing microbes
Generation of urea-derived ammonia
Disruption of epithelial tight junctions
Translocation of endotoxin and microbial components
Local and systemic inflammation
Bowel edema
Dialysis-
induced
hypotension
Bowel ischemia
Wong et al. Am J Nephrology 39:230. 2014

22. Kibow Biotech, Inc.
Unbalanced microbiota in CKD patients has higher
number of pathogens
CKD Patients
• Increased
•Actinobacteria
•Clostridia
•Proteobacteria
Nosratola D Vaziri et al. Kidney International 19th Sept 2012,
Kibow Biotech, Inc.
Kibow Biotech, Inc.

23. How does a gut dysbiosis alter metabolism in the
colon?
Short Chain Fatty Acids
Butyrate
Acetate
Propionate
Tyrosine Typtophan
p-cresol indole

24. Page | 24
p-Cresyl sulphate and indoxyl sulphate originate from
dietary amino acid bacterial fermentation the colon
Meijers et al Nephrol. Dial. Transplant. 2011;26:759-761
• Decreased protein absorption in small intestine
• Prolonged colonic transit time
• Increased luminal pH secondary to increased colonic urea diffusion
CKD

25.  Dialysis patients with intact colon and colectomized patients
were studied.
Page | 25
Role of the colon in systemic levels of uremic
solutes
Kibow Biotech, Inc.
T W Meyer et al. JASN 2011; 22:1769-1776
Metabolite
Normal Control
(n=7 to 10)
Dialysis Colectomy
(n=6)
Dialysis Intact colon
(n=9)
Plasma p-cresyl
sulphate (mg/dL)
0.19+0.13 0.06+0.09 4.1+1.6
Plasma indoxyl
sulphate (mg/dL)
0.06+0.02 0.08+0.06 2.8+1.3

26. Healthy Kidney Uremia/ CKD/ ESRD
Anders et al. Kidney Int Jan 16, 2013

27. How does CKD/ESRD induce a gut dysbiosis?
 Metabolic acidosis
 Retention of uremic toxins
 Volume overload with intestinal
wall congestion
 Frequent use of antibiotics
 Immune dysfunction
 Diet restrictions
 Oral iron usage

28. Can therapies aimed
at modulation of gut
microbiota help
patients with kidney
disease?

29.  Antibiotics
 Kill both good and bad bacteria
 Original microbiota usually return once drugs are removed
 Can allow for the growth of pathogens
 Probiotics
 Giving back live beneficial microorganisms
 Do not colonize
 Prebiotics
 Non-digestible food substances that provide substrate for existing
beneficial microbes already present in the gut
 Diet
 Changes activity of existing microbes
 Fecal transplants
 Changing complete gut ecosystem
How can you change your microbiota?

30. Names of Probiotics
Kibow Biotech, Inc.
Brand name
• Lactobacillus rhamnosus St11 = Lactobacillus fortis
Scientific name Commercial name
Lactobacillius rhamnosus GG
Page | 30

31. Lactobacillus Bifidobacteria Streptococcus Others
L acidophilus
L casei GG
L rhamnosom
L salavarius
L delbruecki
L reuteri
L brevis
L plantarum
L. bulgaricus
B bifidum
B infantis
B longum
B thermophilum
B adolescents
B. Lactis
B. breve
S thermophilus
S lactis
S salivarius
E. Coli Nissle 1917
Serotype
O6:K5:H1
Saccharomyces
boulardi
Common Probiotics

32. Some examples of food with probiotics….
1 billion/100 gm
B. Lactis and L.
acidophilus
10 billion/100 ml
L casei
1 billion/100 gm
B. lactis
(B. regularis)
1 billion/100 gm
B. Lactis and L.
acidophilus

33. Some Probiotic Supplements
1 billion
CFU
Bifidobacterium infantis 35624.
1.5 billion
CFU
Lactobacillus gasseri (KS-13)
Bifidobacterium bifidum (G9-1)
Bifidobacterium longum (MM-2)
30 billion CFU
S. Thermophilus KB19
L. Acidophilus KB27
B. Longum KN31
450 billion CFU
B. breve
B. longum
B. infantis
L. acidophilus
L. plantarum
L. paracasei
L. bulgaricus
S. thermophilus
15 billion
CFU
L. acidophilus, B. lactis
L. Bulgaricus, B. longum
L. rhamnosus, L. brevis,
S. thermophilus, L. casei, L. salivarius
L. lactis, B. breve, L. plantarum
L. paracasei, B. bifidum

34. Effects of probiotics are strain-specific
Strain Benefit Product
Bifidobacterium animalis DN-
173 010 (marketed as Bifidis
Regularis)
Decreased transit time – help
with constipation
Dannon Activia yogurt
Lactobacillus casei DN-114 001
(marketed as L. casei
immuntas)
Stimulates immune system Dannon’s DanActive dairy drink
Bifidobacterium infantis 35624 Alleviates symptoms of irritable
bowel syndrome
Procter and Gambles ALIGN
supplement
Bifidobacterium lactis Bb-12 Stimulates immune system Yo-Plus yogurt, Nestle Good
Start Infant Formula
Lactobacillus casei Shirota Stimulates immune system Yakult fermented dairy drink
Lactobacillus rhamnosus GR-1
in combination with L. reuteri
Helps eradicate vaginal
infections
RepHresh Pro-B and Fem-
Dophilus dietary supplements
BB-12® Bifidobacterium lactis,
and LA-5® Lactobacillus
acidophilus
Stimulates immune system Iogo Yogurt
Lactobacillus reuteri 55730 Reduce antibiotic-associated
diarrhea
BioGaia tablets, drops, and
lozenges
Saccharomyces boulardii Reduces antibiotic-associated
diarrhea
Florastor dietary supplement

35. Probiotics interact with cells along the entire
intestinal tract but they do not colonize
Probiotics
Immune cells
Epithelial cells
Microflora
Immune Function
Barrier Function
Metabolism

36. Ohland C L Am J Physiol 2010;298:G807-G819
Modulate neural-muscular system
• Induce the expression of µ-opioid and
cannabinoid receptors
• Modulate visceral hypersensitivity
Probiotics interact with all components of the
gut barrier

37. Gut Microbes Modulate Gut Permeability
The type and quantity of bacterial species
present in the gut has a definitive role in
modulating intestinal permeability
Some microbes enhance barrier function
• Bifidobacterium infantis, Lactobacillus plantarum
Some microbes decrease barrier function

38. PROBIOTICS ALSO MODULATE
IMMUNE FUNCTION

39. Probiotic Effects on Immune Cells

40. Effects of probiotics on immune function
 Depending on the strain and host environment,
probiotics can:
 Stimulate immune function
 Increase phagocytosis (Lactobacillus casei, L. acidophilus, B. breve)
 Increase sIgA secretion
 Have an anti-inflammatory effect
 Reduce secretion of pro-inflammatory cytokines
 Increase secretion of anti-inflammatory cytokines
 Modulate NF-κ activity
 Have no effect at all

41. PROBIOTICS CAN
ALTER BOTH EXISTING
MICROBE AND HOST
METABOLISM

42. Probiotics rapidly alter microbial and host
metabolic activity
Gut microbial
activity
Systemic Effects
Host Metabolism
Altered Metabolites

43. How could probiotics help patients with
kidney disease?
 Altering bacterial composition to reduce production of
metabolites
 Probiotics could increase SCFA and decrease colonic pH
 Probiotics could repress activity of bacteria that produce toxic
metabolites
 Reducing colonic transit time
 Some strains have direct effect on gut motility
 Improving gut barrier function
 Through effects on tight junction proteins and mucous production
 Modulating immune function

44. Are probiotics safe?
 Commercially available probiotic strains are considered to be
GRAS (Generally regarded as safe) due to their long term
usage in fermented foods
 Risks appear to be minimal in most patients
 Few side effects – primarily gas and bloating which are usually
temporary
 Isolated case reports of systemic infections linked to
Lactobacillus rhamnosus (critically ill; severely
immunosuppressed) and S. boulardii (intravenous catheters)

45. Clinical applications
What is the evidence?

46. Int J Nephrol. 2012; 2012: 673631.
Meta-analysis for pre-pro- and synbiotic therapy on serum indoxyl-sulfate
in patients undergoing haemodialysis for ESKD

47. Type Strain Patient Type and
Number
Effect
Open label pilot study
Simenhoff Miner Electrolyte
Metabol 1996
L. acidophilus Hemodialysis
N=8
Serum dimethylamine
Nitrosodimethylamine
Prospective DBPRC
crossover
Ranganathan et al. Curr Med
Res Opin 2009
S. thermophilus, L.
acidophilus, B. longum
90 x 109 cfu/d
CKD Stages 3 and 4
N=13
6 months
BUN
Creatinine
Uric acid
Prospective DBPRC
crossover
Ranganathan Adv Ther 2010
S. thermophilus, L.
acidophilus, B. longum
90 x 109 cfu/d
CKD Stages 3 and 4
N=46
6 months
BUN
Uric acid
Improved QOL
Open label single arm
Nakabayashi Nephrol Dial
Transplant 2011
L. Casei Shirota
B. Breve Yakult +
galactooligosaccharides
1x 108
Hemodialysis
N=8
4 weeks
Serum p-cresol
Improved stool consistency
Randomized control trial
Alatriste Nutr Hosp 2014
Lactobacillus casei shirota
8x109
16x109
CKD Stages 3 and 4
N=30
8 weeks
blood urea in high dose
group
Clinical Trial Results

48. Conclusions
 The gut microbiota has an important role in human health and in
pathogenesis of disease
 Evidence is supportive of a role for colonic metabolism contributing
to uremia
 Manipulation of the gut microbiota is a promising new therapeutic
strategy for patients with renal disease
 However, to date, limited clinical trials have been done
 Limitations due to sample size, varying concentrations and types of pro-
and prebiotics used, dietary confounders

49. THE END