The impact of synbiotic on serum paraoxonase 1, (sCD163/sTWEAK) and lipid profile in patients with chronic heart failure: a randomized, triple-blind, controlled trial

doi:10.21203/rs.3.rs-2442805/v1

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The impact of synbiotic on serum paraoxonase 1, (sCD163/sTWEAK) and lipid profile in patients with chronic heart failure: a randomized, triple-blind, controlled trial

https://doi.org/10.21203/rs.3.rs-2442805/v1

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Background: Cardiovascular disease is one of the leading causes of death worldwide. Evidence suggests that alterations in the gut microbiome could play a role in cardiovascular diseases including heart failure.

Objective: The purpose of this study was to evaluate the effect of synbiotics on serum paraoxonase 1(PON1), (sCD163/sTWEAK) and lipid profile, which are involved in heart failure in patients with chronic heart failure.

Method: In this triple-blind randomized clinical trial, 90 eligible patients were included in the study. They were randomly assigned to receive one capsule (500 mg) of synbiotics or a placebo per day for 10 weeks. serum paraoxonase 1(PON1), (sCD163/sTWEAK), and lipid profile were measured at the beginning and end of the study. The data were analyzed by SPSS 24, and the p-value <0.05 was considered statistically significant.

Result: Among 90 patients who met the inclusion criteria, 80 patients completed the study. At the end of the intervention, and after adjusting for the effect of confounders, the levels of total cholesterol (TC), LDL-c, Triglyceride and TC/HDL-C showed a significant decrease. However, we found no significant differences between the groups when considering other study indices.

Conclusion: A favorable effect of synbiotics on the lipid profile of patients with heart failure was observed, but no statistically significant effect was found on paraoxinase1, sCD163, and sTWEAK factors

Registration number: IRCT20091114002709N55

Synbiotic

Heart Failure

lipid profile

paraoxonase

sCD163/sTWEAK

Cholesterol

Heart failure (HF) is a syndrome caused by a disorder in the ability of the heart to fill with or eject blood. Any disorder that affects the structural or functional integrity of the heart can lead to HF(1). The prevalence of HF is 1–2% of the adult population in developed countries, which is growing to more than 10% among people over 70 years of age(2). The American Heart Association statistical update for 2021 estimates the prevalence of HF at 6 million, which is 1.8% of the total US population. (3) Heart failure has a variety of pathological processes which can appear as biomarkers in the bloodstream, and since there is a need for proper screening and early diagnosis of the disease, these markers have attracted the attention of researchers. Controlling the concentration of these biomarkers can play an important role in prognosis and treatment strategies(4). Paraoxonase-1 (PON-1) is a high-density lipoprotein HDL-associated protein with anti-inflammatory and antioxidant properties. Oxidative stress is known as one of the pathological factors of heart failure while paraoxonase 1(PON1) is associated with the antioxidant function of HDL(5). The results of a cohort study of patients with heart failure showed that decreased PON1 activity led to more long-term side effects, including death, myocardial infarction, and stroke(6). Recent case-control studies have shown that serum PON1 concentrations are reduced in patients with CHD(7). Some studies have shown that PON1 activity could be a good diagnostic marker to predict outcomes in patients with chronic heart failure, in such a way that by reducing the level of PON1 activity, the risk of heart failure increases(6, 8). HDL is synthesized in the gut, where probiotics are highly functional. On the other hand, the gut’s ability to produce and release PON1 into circulation has been reported (9). Impaired serum lipoproteins and lipids are observed in patients with heart failure, and HDL cholesterol has been shown to play an antioxidant, anti-inflammatory, and antithrombotic role in heart failure(10). Low HDL is believed to be a metabolic syndrome component in heart failure patients (11). If this parameter of metabolic syndrome is removed, we will take an important step toward improving the prevalence and prognosis of heart failure. The results of a cohort study have also shown that elevated HDL levels are associated with reduced mortality from heart failure (10, 12, 13). Inflammatory cytokines and their receptors play a key role in heart regeneration and the progression of heart failure(14). One of the most important inflammatory cytokines which have been studied thus far is tumor necrosis factor (TNF) and members of the interleukin family(15, 16). TWEAK (TNF - like weak inducer of apoptosis) is a multifunctional cytokine from the TNF family which regulates cell growth, migration, and survival(17). TWEAK, as a membrane protein released into the bloodstream, and called soluble TWEAK (sTWEAK), has angiogenic properties, and is known to induce myoblast differentiation as well as atrophy and tumor apoptosis(18–20). In patients with heart failure, unlike other cytokines, sTWEAK decreases, and is associated with dysfunction and risk of death in patients(21). The mechanisms that lead to a decrease in serum sTWEAK levels are not yet well understood, but there are possible mechanisms. One of them is attributed to the pathological effects of sTWEAK occurring through its binding to the Fn14 receptor. This receptor is not present in the healthy human aortic wall and increases greatly under pathological conditions. Decreased levels of serum sTWEAK may be due to its uptake by the Fn14 receptor within the arterial wall under pathological conditions, resulting in decreased levels in the blood and increased inflammation due to its binding to the receptor. Moreover, sTWEAK levels may also decrease by clearance through the CD163 scavenger receptor. CD163 is a membrane protein with a soluble type (sCD163) which can be measured in serum and reflects membrane-bound CD163 stores. sTWEAK is removed from the bloodstream by sCD163. CD163 is known as a scavenger receptor, which is expressed by monocytes and macrophages. CD163 is involved in clearing the hemoglobin – haptoglobin (Hb – Hp) compound, protecting tissue against oxidative damage and inflammation. The biological function of sCD163 is unclear, but it has been observed that sCD163 increases rapidly in inflammation or activation of macrophages. Cardiovascular disease is associated with an increase in the sCD163 / sTWEAK ratio, which is a more appropriate marker for cardiovascular disease than for each of these molecules and is significantly associated with cardiovascular mortality(22, 23). Lower plasma levels of sTWEAK predict an unfavorable prognosis independent of known risk markers such as NT-proBNP(21).

In recent years, a positive effect of intestinal microbiota and its effect on cardiovascular diseases, including heart failure, has been observed. Changes in the intestinal microbial population in patients with HF have been reported in several studies. Dysbiosis, which is a change in the gut microbiota, can cause systemic inflammation involved in the pathophysiology of HF. New treatment strategies, including probiotics and synbiotics, can modulate the susceptibility of cardiovascular diseases and prevent progression to HF by altering the microbial composition of the gut(24). A large number of studies have shown that probiotic supplements may help control cardiovascular risk factors such as hyperlipidemia, hypertension, and inflammation(25). Reduction of inflammatory factors by probiotics may be through epithelial barrier repair, which reduces proinflammatory stimuli such as lipopolysaccharides, increases the production of short-chain fatty acids, modulates and enhances the systemic and local immune response, and improves intestinal barrier function. Also, some bacteria and their metabolites induce T cell apoptosis, modulate the NF-κb pathway, increase the production of anti-inflammatory cytokines (IL10) and decrease the production of proinflammatory markers (IL-6) and (TNF-α)(26, 27).

The present study was conducted, by considering the aforementioned reasons and documents, and no study, to the best of our knowledge, has yet examined the effect of synbiotics on the serum ratio of sCD163 to sTWEAK, lipoproteins, and PON1 in patients with heart failure. We hypothesized that synbiotics can reduce this ratio in patients with heart failure due to their anti-inflammatory effects.

2.1. Participants

The participants were selected from patients with heart failure who were referred to Shahid Rajaie hospital, Tehran, Iran between October 2019 and August 2020. All items included in the checklist of Extending the CONSORT Statement to Randomized Trials of Nonpharmacologic Treatment were fulfilled. The eligibility criteria were: heart failure patients aged between 30 and 70 years with LVEF < 40 (left ventricular ejection fraction), who had been approved by a cardiologist and had received standard treatments for heart failure for at least 3 months, and the medications had reached the maximum tolerable and constant dose; patients were in one of I–III stages of the New York Heart Association classifications (NYHA). Exclusion criteria were considered as follows: being reluctant to cooperate, having other diseases including chronic and acute liver disorders (hepatitis B, C, etc.), diabetes, thyroid disorders, severe renal impairment (creatinine ≥ 300 mmol / l), lung diseases, inflammatory and autoimmune diseases, cancer, and acute infections, smoking, taking any nutritional supplements within the last 2 months, taking corticosteroids within the last 4 weeks, taking antibiotics in the last 3 months, taking anti-inflammatory drugs except low-dose aspirin (80 mg daily), having a history of gastrointestinal surgery and rheumatic heart disease, having prosthetic heart valve, pregnancy, and lactation, insulin injection, BMI > 30, consuming less than 80% of supplements during the study period, and having changes in the type and dose of heart failure medication.

2.2. Study design

This study was performed as a randomized, triple-blind, placebo-controlled, parallel-group clinical trial in patients with heart failure. The participants entered the run-in period and did not consume any probiotic products or yogurt, for two weeks before the beginning of the study. Patients were asked not to consume yogurt, any probiotic products, and any nutritional supplements during the study. They were also asked to maintain their regular life including physical activity and diet. The participants were randomly divided into two groups. The experimental group (n = 45) received one synbiotic capsule (each capsule = 0.5g) and the control group (n = 45) received one placebo capsule (each capsule = 0.5g) per day for 10 weeks. They were asked to keep the supplements in the refrigerator. The patients’ compliances were checked by telephone calls and they were requested to bring their capsule box on the last visit.

2.3. Sample size

For each of the study outcomes, and according to the available sources, the sample size for each group was calculated, leading to four people in each group based on the sCD163 variable. Four people were not enough to perform the study and since this is a supplementary article, the sample size was calculated and reported according to two secondary outcomes, and the highest number (39 samples according to diastolic blood pressure) was determined as the sample size. A sample size of 45 patients in each of the two study groups, with a dropout rate of up to 15%, a power of 80%, and a 5% probability of type 1 error was planned to detect a significant reduction in diastolic blood pressure in the symbiotic group, compared with the placebo group after 8 weeks, at the end of the study(28).

2.4. Randomization

All patients were distributed into two groups by quadratic-block randomization and a random list was prepared using statistical software. Randomization and blinding were performed to maintain concealment in the study.

2.5. Intervention

Participants were randomly divided into two groups. One group (n = 45) received one synbiotic capsule (0.5 g) which contained Lactobacillus casei (10⁹ CFU), Lactobacillus acidophilus (1.5×10¹⁰ CFU), Lactobacillus rhamnosus (3.5×10⁹ CFU), Lactobacillus bulgaricus (2.5×10⁸ CFU), Bifidobacterium breve (10¹⁰ CFU), Bifidobacterium longum (5×10⁸ CFU), Streptotus thermophilus (1.5×10⁸ CFU), and excipients including fructooligosaccharide (38.5 mg), lactose, magnesium stearate, talc, and silicon dioxide. The other group (n = 45) received one placebo capsule (0.5g) containing lactose, magnesium stearate, talc, and silicon dioxide per day for 10 weeks. Synbiotic and placebo capsules were produced by Zist-takhmir Company. In a study examining the effect of the probiotic Saccharomyces bulardii on patients with heart failure, it was found that the proposed treatment with probiotics was safe and well tolerated and there were no reports of side effects in patients(29). The synbiotic and placebo capsules were the same in appearance, odor, weight, and packaging, and only the code on the package (A or B) was different. Patients were asked to store synbiotic capsules in the refrigerator.

3.1. Anthropometric measures

The participants’ weight with minimum coverage and without shoes was measured by using Seca scales with an accuracy of 100 grams, and the standing height was measured without shoes by a gauge with an accuracy of 0.5 cm at the beginning and end of the study. BMI was calculated by using the formula (BMI = weight / height²). For most adults, an ideal BMI is in the range of 18.5–24.9 (kg/m2). BMI scores of 25–29.9 (kg/m²) are considered overweight. Normal and overweight BMI were included in the present study.

3.2. Dietary intake and physical activity

Dietary information was collected at the beginning of the study and the end of the 10th week by using 24-hour food recall for 3 days (2 non-holidays and 1 weekend). The usual intake of energy, macronutrient, and micronutrient was calculated by Nutritionist IV software. The amount of physical activity was assessed by using the short form of the International Physical Activity Questionnaire (IPAQ)(30) at the beginning and end of the study. The metabolic equivalent was defined as the sum of all physical activities per minute during the week.

3.3. Biochemical Assessment

To measure blood factors, venous blood samples were taken from patients at the beginning of the study and at the end of the 10th week after 10–12 hours of fasting by an expert laboratory technician. Blood samples were stored at -80°C during the study. The concentration of sCD163, sTWEAK, and (PON1) were measured by using the ELISA method (Crystalday kit, China), Photometric method was used to determine the serum lipid profile levels.

After collecting data, demographic, descriptive information, and the relationship between variables were examined by using statistical tests. Data were analyzed by SPSS-24 software. Quantitative data were described as mean ± SD and median. Qualitative variables were also reported as the frequency in percentage. Kolmogorov-Smirnov test and other indicators of normality were used to check the normality of the data. Value for between-group comparison of qualitative data was performed by using Chi-square or Fisher’s exact test. Intergroup comparison of quantitative data was performed by using the independent-samples T-test and intragroup comparison was performed by using the paired-samples T-test. ANCOVA method was used to evaluate the effect of the intervention performed after adjusting based on the baseline values of the outcomes.

Among the participants enrolled in the clinical trial, 90 patients who met the inclusion criteria were randomly assigned to the synbiotic and placebo groups. During the study, four patients were excluded from the synbiotic group and six patients from the placebo group, while 80 patients completed the study (Figure.1). There were no significant differences between the characteristics of the two groups before the intervention, indicating that an accurate randomization procedure was performed. There were no significant differences between the two groups in terms of gender, marriage, age, weight, body mass index (BMI), duration of heart failure, ejection fraction, and physical activity. The findings regarding medications, disease-related variables, and smoking, also showed that there were no significant differences between the two groups (Tables 1 and 2). No significant differences between the two groups in the intake of energy, intake of macronutrients, and micronutrients were observed (Supplementary Table 1)

Table 1

Individual characteristics of study participants
	Groups
Variable	Synbiotic (n = 41)	Placebo (n = 39)	p-value
Age (years)	50.54 ± 11.4	50.1 ± 10.56	0.86
Sex, n (%)
Female	9 (22)	14 (35.9)	0.16
Male	32 (78)	25 (64.1)	0.16
LVEF	26.20 ± 6.82	24.23 ± 8.7	0.26
NYHA classification, n (%)
Class 1	18 (43.9)	15 (38.5)	0.72
Class 2	19 (46.3)	18 (46.2)
Class 3	4 (9.8)	6 (15.4)
stent, n (%)			1
Yes	4 (9.8 )	3 (7.7)
No	37 (90.2)	36 (92.3)
pacemaker, n (%)
Yes	3 (7.3)	6 (15.4)	0.3
No	38 (92.7)	33 (84.6)
Duration of the disease (month)	4615 ± 42.93	43.36 ± 35.51	0.75
Taking statins, n (%)
Yes	12(29.3)	9(23.1)	0.52
No	29(70.7)	30(76.9)	0.52
Taking MRAs , n (%)
Yes	32(78)	36(92.3)	0.07
No	9(22)	3(7.7)	0.07
Taking diuretics, n (%)
Yes	27(65.9)	30(76.9)	0.27
No	14(34.1)	9(23.1)	0.27
Taking beta-blockers, n (%)
Yes	34(82.9)	36(92.3)	0.31
/No	7(17.1)	3(7.7)	0.31
/Digoxin, n (%)
Yes	5(12.2)	6(15.4)	0.67
No	36(87.8)	33(84.6)	0.67
ACEI.ARBs, n (%)
Yes	36(87.8)	31(79.5)	0.31
No	5(12.2)	8(20.5)	0.31
Taking anticoagulants, n (%)
Yes	21(51.2)	15 (38.5)	0.25
No	20 (48.8)	24 (61.5)	0.25
Taking vasodilators, n (%)
Yes	1 (2.4)	2 (5.1)	0.61
No	40 (97.6)	37 (94.9)	0.61
Smoking, n (%)
Yes	7 (17.1)	4 (10.3)	0.37
No	34 (82.9)	35 (89.7)	0.37
Note: Data are presented as mean (SD) for quantitative and frequency (%) for qualitative variables. Value for between-group comparison of qualitative data was performed by using Chi square or Fisher’s exact test and between-group comparison of parametric quantitative data was performed by using independent sample t-test. Abbreviations: ACEI., Angiotensin-Converting Enzyme Inhibitors; ARBs, Angiotensin II type I receptor blockers; LVEF, left ventricular ejection fraction; MRAs:Mineralocorticoid Receptor Antagonists; NYHA, New York Heart Association.

Table 2

anthropometric indices at baseline, at the end of the study and changes between the synbiotic and placebo groups
Variables		Synbiotic (n = 41)	Placebo (n = 39)	p-value
Weight (kg)	Baseline	75.14 ± 12.60	77.47 ± 13.72	0.43
	10th week	73.64 ± 11.62	78.64 ± 13.82	0.08
	Change	-1.50 ± 1.71	1.17 ± 1.69	< 001/0
	p-value	< 001/0	< 001/0
BMI (kg/m²)	Baseline	25.51 ± 3.77	26.53 ± 2.87	0.18
	10th week	25.10 ± 3.42	27.06 ± 2.97	0.008
	Change	-0.41 ± 0.81	0.53 ± 0.66	< 001/0
	p-value	0.002	< 001/0
Physical activity (MET-minutes/week)	Baseline	184.15 ± 190.1	216.21 ± 252.89	0.52
	10th week	118.22 ± 126	155.49 ± 192.67	0.3
/	Change	-65.92 ± 125.45	-60.71 ± 228.25	0.89
	p-value	0.002	0.1
Note: Data are presented as mean (SD). Intergroup comparison of quantitative data was performed by using independent-samples T test and intragroup comparison was performed using paired-samples T test.

After 10 weeks, there was no statistically significant difference in paraoxenase1 levels in each group, compared to respective initial values, and between the two groups (Tables 3).

Table 3

**Biochemical measurement at baseline, at the end of the study and changes between the synbiotic and placebo groups** Note: Data are presented as mean (SD). Intergroup comparison of quantitative data was performed by using independent-samples T test and intragroup comparison was performed by using paired-samples T test. Adjusted p-value 1 was performed by using ANCOVA test on baseline values. sCD163, Soluble Cluster of Differentiation 163; sTWEAK, Soluble Tumor Necrosis Factor-Like Weak Inducer of Apoptosis.
Variable		Synbiotic (n = 41)	Placebo (n = 39)	p-value	Adjusted p-value
sCD163 (pg/ml)	Baseline	(52/9) ± 50/7	(86/10) 96/7	83/0	83/0
	10th week	(65/4) ± 48/4	(66/5) 64/4	89/0
	Change	(56/5) ± 01/3-	(10/7) 31/3-	83/0
	p-value	001/0	006/0		88/0
sTWEAK (pg/ml)	Baseline	(13/1231) 69/971	(15/1215) 60/945	92/0
	10th week	(74/920) 26/736	(22/805) 00/638	61/0
	Change	(16/481) 43/235-	(54/581) 60/307-	54/0
	p-value	003/0	002/0
sCD.sTWEAK (pg/mL)	Baseline	(001/0) 008/0	(003/0) 008/0	377/0	0/49
	10th week	(003/0) 008/0	(003/0) 008/0	694/0
	Change	(003/0) 000/0	(004/0) 000/0	800/0
	p-value	648/0	970/0
	Baseline	(03/168) 56/116	(18/167) 84/109	858/0
Paraxonase 1	10th week	(51/285) 26/164	(00/285) 19/158	924/0	0/75
	Change	(93/160) 70/47	(76/169) 35/48	986/0
	p-value	065/0	083/0

Triglyceride (TG) levels decreased in the synbiotic group and increased in the control group, although these changes were not significant. Also, no significant changes were observed between the two groups at the end of the intervention. Total cholesterol (TC) levels in the synbiotic group at the end of the study were significantly lower than at the beginning of the study (p-value = 0.01), but no significant changes were observed between the two groups at the end of the intervention. After adjusting for the baseline values, a significant difference between the two groups in TC was observed at the end of the study) p-value < 0.001). LDL cholesterol levels in synbiotic and also control groups had a significant decrease at the end of the intervention compared to beginning values (p-value = 0.02 and p-value = 0.04, respectively); however, no significant change between the two groups was observed at the end of the study. HDL‌ cholesterol levels significantly reduced in the synbiotic and control groups (p-value = 0.08 and p-value < 0.001, respectively) although a greater decrease was observed in the control group and these changes between the two groups were significant at the end of the study (p-value = 0.04). The TC / HDL-C ratio in the synbiotic group decreased at the end of the study, while it increased significantly compared to the beginning of the study in the placebo group (P = 0.34 and P = 0.04, respectively). However, at the end of the study, no significant changes in TC / HDL-C ratio were observed between the two groups (P = 0.27) but adjusting for the baseline values showed a significant difference between the two groups at the end of the study (P = 0.04) (Tables 4). In terms of LDL-C/ HDL-C ratio, no significant differences were observed between the two groups at the end of the study, nor within each group before and after the study.

Table 4

lipid profile measurement at baseline, at the end of the study and changes between the synbiotic and placebo groups
Variable		Synbiotic (n = 41)	Placebo (n = 39)	p-value	Adjusted p-value
TG (mg/dl)	Baseline	(62/202) 85/195	(06/140) 97/210	70/0	0.09
	10th week	(80/106) 02/183	(17/212) 17/239	13/0
	Change	(36/129) 82/12-	(90/156) 19/28	20/0
	p-value	52/0	26/0		< 001/0
TC (mg/dl)	Baseline	(06/49) 09/186	(20/63) 57/201	22/0
	10th week	(76/49) 17/176	(86/51) 23/186	37/0
	Change	(92/24) 92/9-	(51/70) 34/15-	64/0
	p-value	01/0	18/0
LDL-C (mg/dl)	Baseline	(32/32) 12/90	(43/41) 17/106	05/0	< 001/0
	10th week	(12/31) 17/83	(56/49) 45/97	12/0
	Change	(31/18) 95/6-	(32/26) 71/8-	72/0
	p-value	02/0	04/0
HDL-C (mg/dl)	Baseline	(18/11) 94/38	(21/11) 82/38	96/0	0.31
	10th week	(65/9) 07/37	(46/9) 15/34	17/0
	Change	(70/6) 87/1-	(55/5) 66/4-	04/0
	p-value	08/0	001/0 >
TC/HDL-C (mg/dl)					0.04
	Baseline	(85/21) 17/8	(85/1) 00/5	37/0
	10th week	(96/1) 02/5	(35/2) 61/5	22/0
	Change	(22/21) 14/3-	(83/1) 60/0	27/0
	p-value	34/0	04/0
Note: Data are presented as mean (SD). Intergroup comparison of quantitative data was performed by using independent-samples T test and intragroup comparison was performed by using paired-samples T test. Adjusted p-value 1 was performed by using ANCOVA test on baseline values. TG, Triglyceride; TC, Total cholesterol; LDL, low-density lipoprotein; HDL, high-density lipoprotein.

About sCD163 and sTWEAK, sCD163 and sTWEAK values decreased in the synbiotic group compared to baseline values (P = 0.001), but the change rates between the two groups were not significant at the end of the study. The ratio of sCD163/sTWEAK in the synbiotic and also control groups were not significantly different from the baseline values. Furthermore, at the end of the study, the difference in this ratio between the two groups was not significant (Table 3).

In the present study, PON1 activity increased in both the synbiotic (p = 0.065) and placebo groups (p = 0.083); however, no significant difference was observed between the synbiotic and the control groups at the end of the study. PON1 (paraoxonase 1) is an antioxidant enzyme that can protect LDL and HDL against oxidation and plays a key anti-atherosclerotic role. The results of a study suggest that PON1 levels may influence HF and reported a significant relationship between the antioxidant activity of PON-1 and the New York Heart Association classification for HF(31). In the study conducted in 2020 by Ahmadian et al (32), the effects of probiotics on antioxidant status in type 2 diabetic patients were evaluated. After 6 weeks, probiotics were observed to have no significant effect on total oxidant and paraoxonase status (P > 0.05), which is consistent with the results of the present study. However, in that study, only probiotic supplements were used and the duration of the study was 6 weeks, which was shorter than the duration of our intervention. Kullisaar et al.(33) reported an increase in HDL cholesterol and paraoxonase, levels which contradicts the results of our study. However, they used kefir enriched with lactobacillus fermentum; therefore other components of kefir may have influenced the results. The difference in the results observed, compared to the results of the present study could be explained by differences in the type and dose of probiotics. In line with our study, Shakeri et al.(34)reported a significant increase in serum HDL-C levels and a decrease in TC/HDL-C after 8 weeks of consuming synbiotic bread. One study found that HDL-C levels were inversely correlated with Hs-CRP levels and NYHA classification(12). It has also been shown that people with a better prognosis have higher HDL-C levels compared to patients with a poor prognosis. It has been suggested that HDL cholesterol has antioxidant, anti-inflammatory, and anti-thrombotic properties and can counteract the pro-inflammatory activity in patients with heart failure(10). Studies have shown that higher serum HDL levels lead to lower mortality in patients with heart failure of various etiologies. An increase of 1 mg/dl in HDL cholesterol has been shown to reduce mortality by 1%(10). In the present study, significant changes were observed between the two groups at the end of the intervention in terms of LDL and TC. The results of a systematic review and meta-analysis, conducted on the effect of probiotics consumption on lowering lipids and CVD risk factors, showed a decrease in LDL and TC, which is in line with the results of our study(35). Theoretically, lowering TC and LDL-C levels reduces the prevalence of cardiovascular disease, and clinical trials have shown that it may improve outcomes in patients with heart failure as well (35). In contrast, some observational studies have shown that higher TC and triglyceride levels are associated with longer life expectancy in patients with heart failure; however, the underlying mechanisms are unclear and require further research(36). It has been suggested that outcome benefits associated with a higher baseline TC level may be attributed to its nutritional performance and energy resource(37–39). Some studies have suggested that the ratio of total cholesterol (TC) and HDL-C (TC/HDL-C) is the most significant predictor of ischemic heart disease (IHD) (40). As mentioned earlier a significant change in serum TC/HDL-C was observed between the two groups at the end of the intervention after adjustment. Several mechanisms have been proposed for controlling the lipid profile via synbiotic administration, including the assimilation of cholesterol by probiotics and reduction of cholesterol uptake in the small intestine, deconjugation of bile via bile salt hydrolase, conversion of cholesterol to coprostanol, and signaling of Toll-like receptor 4, as a transmembrane protein, and reduction of proinflammatory cytokines(41). Probiotics can also produce short-chain fatty acids (SCFA) which leads to lower cholesterol and better lipid metabolism. A systematic review study that aimed to investigate the effect of synbiotics on lipid profile in diabetic patients, revealed that synbiotics as a supplement can have a greater effect on lipid profile than synbiotic foods (42).

According to the results, sTWEAK values in both synbiotic and control groups decreased compared to baseline values and there was a greater decrease in sTWEAK levels in the control group (P = 0.003 and P = 0.002, respectively), but no significant changes between the two groups were observed at the end of the study. Decreased levels of sTWEAK in inflammation may be due to the decreased synthesis and/or its removal by increased TWEAK receptors. The present study is the first to demonstrate the effect of synbiotic consumption on serum sTWEAK. A recent study comparing the effect of probiotic yogurt with regular yogurt on inflammatory, endothelial, adipose, and renal indices in CHF patients revealed that consuming probiotic yogurt for 10 weeks resulted in a significant increase in sTWEAK levels compared to the control group in patients with chronic heart failure just after adjusting for the effect of confounders, which has been a desirable effect to reduce the risk of heart failure(43). The difference in the results, despite the same intervention time, could be due to the synergistic effect of yogurt in reducing inflammation due to the consumption of probiotic yogurt. (44) sCD163 values decreased in both synbiotic and control groups compared to baseline values (P = 0.001 and P = 0.006, respectively), However, no significant differences were found between the groups at the end of the study. Also, the present study is the first to demonstrate the effect of synbiotic consumption on serum sCD163 levels. In a study on probiotic yogurt, in line with our study, no statistically significant changes were observed between groups(43). The shorter duration of the intervention compared to the studies reporting the effect of probiotics on sCD163, has been mentioned as the reason for the lack of favorable results (45, 46), and the use of a higher dose of probiotics (more than 109 CFU d − 1) has been suggested for better results. We also did not observe the effect of 10- week synbiotic supplementation on the sCD163 / sTWEAK ratio, so longer duration of the intervention (more than 3 months) may have significant effects on this factor. It has been observed that decreased sTWEAK concentration and increased sCD163/sTWEAK ratio were significantly and independently associated with long-term cardiovascular mortality(22). Moreover, the relationship between decreased sTWEAK concentration and adverse prognosis in patients with stable CHF has been reported in a 4-year observation study (21). The biological activity of sTWEAK is mediated by binding to the Fn14 receptor, while binding of sTWEAK by sCD163 leads to the neutralization of both molecules, and this binding leads to the inactivation of sTWEAK (21). Furthermore, SCD163 / STWEAK has been shown to reflect the severity of acute coronary syndrome and chronic heart failure (47). There is growing evidence that NYHA functional class is significantly correlated with sTWEAK plasma levels, and a significant decrease in sTWEAK has been observed with increasing NYHA class(21). Based on the aforementioned findings, it is suggested that further studies be performed in this field with different types of probiotics and prebiotics for a longer period.

The key strength of the present is that this is the first study evaluating the effect of synbiotics in patients with heart failure. Moreover, the patients were selected in such a way that there was no significant difference between the characteristics of the two groups before the intervention, indicating that very accurate randomization was performed. Due to these distinctive features of the study, we believe that the results of our study are reliable. However, there are some limitations to the present study. We did not examine the intestinal microbiome at the beginning, during, and after consuming synbiotics due to financial limitations.

A favorable effect of synbiotics on the lipid profile of patients with heart failure was observed, but no significant effect was found on paraoxinase1, sCD163, and sTWEAK factors. Since this study is the first clinical study to evaluate the effect of synbiotics in patients with chronic heart failure, it is suggested that further clinical studies examine paraoxinase1, sTWEAK and sCD163 indices in these patients over a longer intervention period.

BMI, Body-mass index

BNP, Brain natriuretic peptide

CFU, colony-forming unit

CHD, Coronary heart disease

CHF, Chronic Heart Failure

EF, Ejection fraction

HDL, high-density lipoprotein

HF, Heart failure

IHD, Ischemic heart disease

IL-6, Interleukin 6

LDL, low-density lipoprotein

LVEF, Left ventricular ejection fraction

NF-Kb, nuclear factor kappa B

NTproBNP, N-Terminal pro-brain natriuretic peptide

NYHA, New York Heart Association

PON1, paraoxonase 1

sCD163, Soluble Cluster of Differentiation 163

sTWEAK, Soluble Tumor Necrosis Factor-Like Weak Inducer of Apoptosis

TC, Total cholesterol

TG, Triglyceride

TNF, tumor necrosis factor

Tweak, Tumor Necrosis Factor-Like Weak Inducer of Apoptosis

Ethics approval and consent to participate

This study was approved by the ethics committee of the Iran University of Medical Sciences (approval no. IR.IUMS.REC.1398.1329, IR.IUMS.REC.1399.707, IR.IUMS.REC.1398.1330) and was registered in the Iranian Clinical Trials Register (registration no. IRCT20091114002709N55). Informed consent forms and signatures were received from all the participants before any intervention. The participants were told that they could withdraw from the study at any stage of the project if they did not wish to complete the project, and were assured that their information would remain confidential.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This RCT was funded by the Iran university of medical sciences, Tehran, Iran.

Author Contributions

The authors’ responsibilities were as follows: Farzad Shidfar: Conceptualization, Methodology, Supervision Shakiba Shoaei Matin: Conceptualization, Methodology, Investigation, Formal analysis, Writing - Original Draft Nasim Naderi: Resources Ahmad Amin: Resources Fatemeh Sadat Hosseini-Baharanchi: Methodology, Formal analysis Afsaneh Dehnad: editing All authors: reviewed the manuscript and approved it before submission.

Acknowledgments

We would like to thank the study participants for their time and cooperation

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No competing interests reported.

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The impact of synbiotic on serum paraoxonase 1, (sCD163/sTWEAK) and lipid profile in patients with chronic heart failure: a randomized, triple-blind, controlled trial

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Abstract

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1. Background

2. Method

2.1. Participants

2.2. Study design

2.3. Sample size

2.4. Randomization

2.5. Intervention

3. Assessments

3.1. Anthropometric measures

3.2. Dietary intake and physical activity

3.3. Biochemical Assessment

4. Statistical Analysis

5. Results

6. Discussion

7. Conclusion

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