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Benefit and Use of Prebiotics in Patients With Chronic Kidney Disease

      Prebiotics are defined as a “nondigestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, thus improving host health.”
      • Slavin J.
      Fiber and prebiotics: mechanisms and health benefits.
      Better known as fiber, prebiotics present several possibilities for improving outcomes in patients with chronic kidney disease (CKD). Prebiotics work symbiotically with the probiotics to benefit the host. Probiotics are live microorganisms (“friendly” bacteria) that can provide benefits to the host when given in adequate amounts.
      • Zirker L.
      The relationship between gut microbiota and CKD: why use prebiotics in CKD patients?.
      In addition to providing fuel for healthy bacteria in the gut, prebiotics may also improve transit time (alleviate constipation), increase fecal weight (improve diarrhea), aid in calcium absorption, and improve immune function.
      • Slavin J.
      Fiber and prebiotics: mechanisms and health benefits.
      • Zirker L.
      The relationship between gut microbiota and CKD: why use prebiotics in CKD patients?.
      • Douglas L.C.
      • Sanders M.E.
      Probiotics and prebiotics in dietetics practice.
      There is also some evidence that increasing fiber intake may decrease inflammation and improve mortality rates in those with CKD.
      • Evenpoel P.
      • Meijers B.
      Dietary fiber and protein: nutrition therapy in chronic kidney disease and beyond.
      • Krishnamurthy V.
      • Wei G.
      • Baird B.C.
      • et al.
      High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease.
      Not all fiber is considered a prebiotic. To be considered a prebiotic, the nondigestible carbohydrate must meet the following qualifications: (1) be resistant to stomach acid and digestive enzymes, (2) be able to be fermented by gut bacteria, and (3) nourish and/or improve activity of gut bacteria.
      • Al-Sheraji S.
      • Ismail A.
      • Manap M.
      • Mustafa S.
      • Yusof R.
      • Hassan F.
      Prebiotics as functional foods: a review.
      Types of fiber that currently meet prebiotic criteria are fructans (fructooligosaccharides or FOS, inulin, oligosaccharides), lactulose, soybean oligosaccharides, and galactosaccharides.
      • Slavin J.
      Fiber and prebiotics: mechanisms and health benefits.
      It is estimated that CKD patients average only 15 g of fiber daily, compared with the 20 to 30 g recommended.
      • Evenpoel P.
      • Meijers B.
      Dietary fiber and protein: nutrition therapy in chronic kidney disease and beyond.
      Table 1 provides a list of widely available supplements and functional food products containing various types of prebiotics. Because there are so many supplements available, this table will be helpful for a practitioner or patient in identifying other supplements containing prebiotics. Although supplements are helpful to increase intake of prebiotics, adding supplements may mean increasing fluids and this can be challenging in fluid-restricted diets. Table 2 provides a list of prebiotics from food sources. Although it is optimal to get nutrients from foods, this can be a challenge for patients with CKD who must follow a low potassium diet. Awareness of supplement and food sources of prebiotics can allow the dietitian to provide individualized recommendations of prebiotic sources to the patient.
      Table 1Partial List of Prebiotics, Prebiotic Effect, and Supplements/Food Products
      • Slavin J.
      Fiber and prebiotics: mechanisms and health benefits.
      • Douglas L.C.
      • Sanders M.E.
      Probiotics and prebiotics in dietetics practice.
      Fibers With Prebiotic EffectsPrebiotic EffectSupplement/Food Products Containing Prebiotic
      This table is simply identifying products that contain certain prebiotics, not making claims as to the effects of the particular product.
      Wheat dextrinIncreased bacteriocidesBenefiber, Equate Clear Soluble Powder
      InulinBifidogenic
      Increases bifidobacteria growth.
      Benefiber, Luna bars, Clif bars, Builder's bar, Kashi cereals, drink mixes and cereal bars, various Stonyfield Farms products
      Acacia gumBifidogenicNow Acacia fiber powder, GoLive probiotic and prebiotic (contains 40 mg K per serving)
      PsylliumPrebiotic potential
      Not currently classified as a prebiotic, only a functional fiber.
      Metamucil (contains 30 mg K per serving), various brands of psyllium husk capsules or powders
      FructooligosaccharidesBifidogenicSkinny Cow low-fat ice-cream sandwiches, ZonePerfect shakes, Ensure fiber, various products from Horizon Organic
      This table is simply identifying products that contain certain prebiotics, not making claims as to the effects of the particular product.
      Increases bifidobacteria growth.
      Not currently classified as a prebiotic, only a functional fiber.
      Table 2Partial List of Prebiotics Naturally Found in Foods
      • Al-Sheraji S.
      • Ismail A.
      • Manap M.
      • Mustafa S.
      • Yusof R.
      • Hassan F.
      Prebiotics as functional foods: a review.
      • Gropper S.
      • Smith J.
      Advanced Nutrition and Human Metabolism.
      Type of PrebioticFood Source
      Fructans-Fructooligosaccharides, inulin, oligofructoseAsparagus, sugar beets, garlic, chicory, onion, Jerusalem artichoke, wheat, honey, banana, barley, tomato, and rye
      IsomaltuloseHoney, sugarcane juice
      XylooligosaccharidesBamboo shoots, fruits, vegetables, milk, honey and wheat bran, whole grain breakfast cereals
      Raffinose oligosaccharidesSeeds of legumes, lentils, peas, beans, chickpeas, mallow composite, and mustard
      Soybean oligosaccharidesSoybean
      LactuloseMilk
      Enzyme-resistant dextrinPotato starch
      ArabinoxylooligosaccharidesWheat bran, whole grain breakfast cereals
      To date, no recommendations for prebiotics have been made for CKD patients. However, health benefits are seen with intake of 3 g of short-chain FOS and up to 8 g for mixed short- and long-chain inulin.
      • Douglas L.C.
      • Sanders M.E.
      Probiotics and prebiotics in dietetics practice.
      Prebiotics may improve constipation and diarrhea, aid in calcium absorption, and improve immune function.
      • Slavin J.
      Fiber and prebiotics: mechanisms and health benefits.
      • Zirker L.
      The relationship between gut microbiota and CKD: why use prebiotics in CKD patients?.
      • Douglas L.C.
      • Sanders M.E.
      Probiotics and prebiotics in dietetics practice.
      Decreased inflammation and improved mortality rates may be another positive outcome associated with increased prebiotic intake.
      • Evenpoel P.
      • Meijers B.
      Dietary fiber and protein: nutrition therapy in chronic kidney disease and beyond.
      • Krishnamurthy V.
      • Wei G.
      • Baird B.C.
      • et al.
      High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease.
      Both food and supplement sources of prebiotics are available for CKD patients.

      References

        • Slavin J.
        Fiber and prebiotics: mechanisms and health benefits.
        Nutrients. 2013; 5: 1417-1435
        • Zirker L.
        The relationship between gut microbiota and CKD: why use prebiotics in CKD patients?.
        Ren Nutr Forum. 2014; 33: 1-7
        • Douglas L.C.
        • Sanders M.E.
        Probiotics and prebiotics in dietetics practice.
        J Am Diet Assoc. 2008; 108: 510-521
        • Evenpoel P.
        • Meijers B.
        Dietary fiber and protein: nutrition therapy in chronic kidney disease and beyond.
        Kidney Int. 2012; 81: 227-229
        • Krishnamurthy V.
        • Wei G.
        • Baird B.C.
        • et al.
        High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease.
        Kidney Int. 2011; 81: 300-306
        • Al-Sheraji S.
        • Ismail A.
        • Manap M.
        • Mustafa S.
        • Yusof R.
        • Hassan F.
        Prebiotics as functional foods: a review.
        J Funct Foods. 2013; 5: 1542-1553
        • Gropper S.
        • Smith J.
        Advanced Nutrition and Human Metabolism.
        6th ed. Wadsworth, Cencage Learning, Belmont, CA2013