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Allergy, manifested in atopic eczema, allergic rhinitis, and asthma, is the most
common chronic disease in the westernized world. The prevalence of allergic
diseases seems to be increasing in developing and developed countries [1,2]. The
steep increase in prevalence that occurred in the 20th century has been attributed
to changes in environmental factors. The hygiene hypothesis of allergy suggests
that a lack of exposure to microbes early in childhood is a major factor in this
trend [3]. Studies have demonstrated that certain strains of gut microbiota possess
immunomodulatory properties that might be advantageous when combating
allergic diseases [4]. This article focuses on probiotics and their role in regulation
of allergic response.
The Academy of Finland and the Finnish Pediatric Research Foundation are acknowledged for
the financial support.
* Corresponding author. Department of Pediatrics, University of Turku and Turku University
Hospital, P.O. Box 52, FIN-20521, Turku, Finland.
E-mail address: marko.kalliomaki@utu.fi (M.A. Kalliom7ki).
0889-8561/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.iac.2004.06.006
740 M.A. Kalliomäki, E. Isolauri / Immunol Allergy Clin N Am 24 (2004) 739–752
their neonatal feces than did children who did not develop such reactivity [17].
These differences had disappeared by the age of 3 months. Using culture-
dependent methods, Bjfrksten et al [18] found that children who developed skin
prick test reactivity or atopic eczema by 2 years of age were colonized less often
with bifidobacteria during the first year of life than were children who did not
develop these disorders. These groups also exhibited differences in the colo-
nization of enterococci, clostridia, S aureus, and Bacteroides [18]. These studies
suggest that certain species of gut microbiota may contribute to the development
of a nonallergic immune system.
Probiotics are defined as live microbial food ingredients that beneficially
affect host health. They most often belong to the genera Bifidobacterium or
Lactobacillus [8,19]. Certain species of these two genera have been a part of the
human diet for millennia in the form of fermented food products [5,19]. Scientific
interest in these bacteria was raised by the Russian Nobel laureate Elie
Metchnikoff a century ago [20]. The term probiotic was introduced by Lilly and
Stillwell 3 decades ago to describe any organism or substance which contributes
to the intestinal microbial balance in animals [21]. Because of increased scientific
data concerning probiotics, the definition of the term has evolved through the
years [4].
Several criteria must be fulfilled before a bacterial strain can be regarded as a
probiotic. These factors include human origin; survival in the gut; ability to
adhere temporarily to the intestinal epithelium and to induce an immune
response; safe use in humans; scientifically documented beneficial effects; and
invariable properties during all stages of manufacturing, processing, and
preservation [4,8]. The latter criterion also includes administration (ie, native
beneficial strains of the gut microbiota are not probiotics unless they have been
isolated, purified, characterized, evaluated, and used as probiotics) [19]. Pro-
biotics must demonstrate measurable clinical health benefits [19]. All candidate
probiotic strains should be evaluated closely, and beneficial effects of a cer-
tain strain should not be related to any other strain without indisputable proof
[4,8,19]. Attachment to intestinal mucus, a critical component in a cascade lead-
ing to an immune response, reliably can be evaluated using endoscopic biopsies,
which have been shown to be superior to fecal samples in this regard [22].
Because of vigorous research in the field, these criteria should be under
continuous critical evaluation. Even the need of oral administration has been
challenged in a study addressing the role of probiotics in prevention and treat-
ment of experimental colitis [23].
Safety is a critical issue in the use of any potential therapeutic intervention.
According to one review, oral consumption of lactobacilli and bifidobacteria
by healthy people did not increase risk for bacterial diseases [24]. Even in
immunocompromised patients, the risk for severe bacterial infection is low [25].
Salminen et al [25] evaluated the clinical data from 89 patients with
Lactobacillus-induced bacteremia. In 11 patients, the isolated strain was identical
to the probiotic Lactobacillus rhamnosus GG. Cases of Lactobacillus-induced
bacteremia usually were associated with severe underlying comorbidities [25].
742 M.A. Kalliomäki, E. Isolauri / Immunol Allergy Clin N Am 24 (2004) 739–752
not occur in studies using nonviable probiotics, because a pilot study addressing
the effect of heat-inactivated L rhamnosus GG on atopic eczema was terminated
early because of adverse gastrointestinal symptoms [47].
Two randomized, placebo-controlled clinical studies have evaluated the effects
of lactobacilli on respiratory allergic diseases. Wheeler et al [48] conducted a
crossover trial with yogurt containing Lactobacillus acidophilus in adult patients
with moderate asthma. They found that consumption of this yogurt containing
tended to increase IFN- g production in stimulated lymphocytes and decrease
levels of eosinophilia, although no changes in clinical asthma parameters were
detected [48]. No beneficial treatment effect of L rhamnosus GG was found in
teenagers and young adults who were allergic to birch pollen and had intermittent
respiratory symptoms [49].
The authors previously have addressed whether probiotics might prevent early
atopic disease. In one study, L rhamnosus GG was administered perinatally to
mothers and infants up to 6 months of age [50]. Children had a family history of
atopic disease. The administration of the probiotic halved the incidence of atopic
eczema during the first 2 years of life. There were no differences in IgE-mediated
allergic hypersensitivity as measured by skin prick test reactivity and serum IgE
concentrations [50]. The extension of the preventive effect beyond infancy was
demonstrated in the 4-year follow-up of the study cohort [51]. Consumption of
L rhamnosus GG by pregnant and lactating mothers increased the amount of
TGF-b in breast milk. The risk for atopic eczema during infancy was reduced
among infants whose mothers consumed the probiotic strain [52].
The impact of probiotics on allergic diseases has been studied in a few animal
models. Lactobacillus plantarum L-137 was shown to inhibit antigen-specific
IgE production in DBA/2 mice that were fed a casein diet. The suppressive effect
of the strain was related to enhanced production of IL-12, an inducer of the Th1
response, by peritoneal macrophages [53]. The Lactobacillus casei strain Shirota
was found to suppress IgE and IgG1 responses and systemic anaphylaxis in a
food allergy model with ovalbumin-specific T-cell–receptor transgenic mice. The
effect was mediated by induction of IL-12 production [54]. In both of these
studies, probiotics were administered by intraperitoneal injection.
In two murine models, Sudo et al [55] studied the effects of antibiotic-induced
alterations of gut microbiota and probiotic supplementation on the development
of Th2-skewed immune response. BALB/c mice who were treated with
kanamycin during the neonatal period developed a Th2-skewed immune
response. The change was reversed by oral introduction of Enterococcus faecalis
or L acidophilus (the latter to a lesser extent) [55]. Inoculation with Bacteroideus
vulcatus increased the Th2-skewed immune response. C57BL/6 mice that
genetically are biased toward Th1-immunity were resistant to kanamycin
treatment [55].
M.A. Kalliomäki, E. Isolauri / Immunol Allergy Clin N Am 24 (2004) 739–752 745
Food and other orally consumed products, including probiotics, are subjected
to gastrointestinal characteristics, including peristalsis, gastric juice, bile, and
digestive enzymes. These factors assist in digestion and down-regulation of the
immune response because without degradation unresponsiveness to dietary
antigens is not achieved [59]. L rhamnosus GG has been found to enhance the
degradation of dietary antigens in rats [60]. Bovine casein degraded with
L rhamnosus GG-derived proteases was shown to suppress lymphocyte prolifera-
tion in a dose-dependent manner and reduce the anti-CD3–stimulated IL-4
production by peripheral blood mononuclear cells in children with atopic eczema
[61,62]. In one study, homogenates derived from B lactis, L acidophilus, and
Lactobacillus delbrueckii subspecies bulgarius (but not from Streptococcus
thermophilus) suppressed proliferation of human mononuclear cells in vitro,
although not as much as L rhamnosus GG did [63]. Bovine casein degraded with
L rhamnosus GG-derived proteases suppressed T-cell activation by inhibition
of protein kinase C activation [64]. Activation of protein kinase C is an
indispensable stage in the nuclear factor kB (NF-kB) activation cascade in T cells,
ultimately leading to the expression of gene products that mediate innate and
adaptive immunity [65]. These studies suggest that certain probiotic strains may
contribute to the processing of dietary antigens in the intestinal lumen in such a
way as to reduce their immunogenicity by suppressing T-cell activation.
746 M.A. Kalliomäki, E. Isolauri / Immunol Allergy Clin N Am 24 (2004) 739–752
Probiotics have been shown to amplify the gut mucosal barrier. L rhamnosus
GG and L plantarum 299v, but not L acidophilus DDS-1, adhered effectively to
HT 29 intestinal epithelial cells and increased expression of MUC2 and MUC3
intestinal mucins [66,67]. This up-regulation of mucins inhibited the adherence of
E coli to the cell line [66,67]. This finding may be important in allergy, because
total serum IgE concentration correlated directly with fecal E coli counts in
infants with early onset food-allergy and atopic eczema [68]. Supplementation
with B lactis Bb-12 resulted in decreased numbers of E coli, as measured by
fluorescence in situ hybridization [68]. L rhamnosus GG reversed the increased
intestinal permeability that was induced by cow’s milk in suckling rats [69]. The
permeability was measured by absorption of horseradish peroxidase across
segments containing Peyer’s patches and patch-free jejunal segments [69]. The
same method was used to show that antigen transfer across the gut mucosal
barrier is increased in children with atopic eczema [70]. In theory, by reducing
antigen transfer to the lamina propria, probiotics might reduce the quantity and
quality of the antigenic load on the gut-associated lymphatic tissue in children
with atopic eczema.
Beyond physical support, a single layer of epithelial cells between the
intestinal lumen and lamina propria constitutes a major compartment of the gut
immune system [71]. Intestinal epithelial cells possess delicate mechanisms that
allow symbiotic coexistence with abundant resident luminal bacteria while
maintaining alert responsiveness to enteropathogenic intruders [71–73]. Lacto-
bacilli are likely to maintain homeostasis in intestinal epithelial cells. Treatment
with L johnsonii La1, L acidophilus La10, or lipoteichoic acids from these
stains did not result in a proinflammatory response in a co-culture with human
intestinal HT29 cells [74]. The lipoteichoic acids, however, antagonized the
proinflammatory response of HT29 cells induced by lipopolysaccharide and
gram-negative bacteria [74]. L rhamnosus GG prevented cytokine-induced
apoptosis in mouse and human colon cells [75]. This effect was mediated by
activation of anti-apoptotic Akt and protein kinase B, a part of the phospho-
inositide 3-kinase pathway, and inactivation of the pro-apoptotic p38 mitogen-
activated protein kinase (p38 MAPK) signaling pathway [75]. p38 MAPK
and NF-kB pathways are downstream of a common myloid differention
factor 88-dependent signaling pathway [76]. p38 MAPK, a novel target of anti-
inflammatory therapies, has been linked to a wide range of inflammatory re-
sponses in the gut [77]. L acidophilus and L casei also stimulated Akt activation
but did not inactivate the p38 MAPK pathway [75]. These findings indicate
that lactobacilli may have strain-specific anti-inflammatory effects in the intesti-
nal epithelium.
Dendritic cells have a pivotal role in orchestration of the immune system [78].
In the gastrointestinal tract, they reside in the Peyer’s patches, lamina propria, and
draining mesenteric lymph nodes, representing the principal stimulators of naRve
T cells [79]. Intestinal dendritic cells can sample microbes and other intestinal
antigens by way of M cells in Peyer’s patches, directly from the intestinal lumen
by reaching between adjacent epithelial cells and indirectly by sampling
M.A. Kalliomäki, E. Isolauri / Immunol Allergy Clin N Am 24 (2004) 739–752 747
Table 1
Potential antiallergic properties of probiotics
Site of action Effects
Gastrointestinal mucus Processing of enteral antigens
and epithelium Inhibition of attachment of pathogenic bacteria
Amplification of permeability barrier
Suppression of proinflammatory responses elicited
by pathogenic bacteria
Prevention of apoptosis
Lamina propria Maturation of dendritic cells with Th1-type
and suppressive properties
Production of Th1 and suppressive cytokines
by myeloid-derived immune cells
[89]. These chemokines were shown to stimulate Th1 cell chemotaxis [88].
Studies with murine macrophages suggest that lactobacilli induce their effect on
these cells, at least partially, by way of TLR2 that is stimulated by lipoteichoic
acids [81].
Summary
The first clinical trials with probiotics, especially in the treatment of atopic
eczema, have yielded encouraging results. Experimental studies have found that
probiotics exert strain-specific effects in the intestinal lumen and on epithelial
cells and immune cells with anti-allergic potential. These effects include
enhancement in antigen degradation and gut barrier function and induction of
regulatory and proinflammatory immune responses, the latter of which occurs
more likely beyond the intestinal epithelium (Table 1). Future studies should
address more accurately how these and other possible mechanisms operate in the
complex gastrointestinal macroenvironment in vivo and how these mechanisms
are related to the clinical effects in a dose-dependent manner.
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