Continuous lines- Promotion, Discontinuous lines- Inhibition; * Effect exerted by probiotics in animal studies, # Effect exerted by probiotics in human studies; eNOS, Endothelial Nitric Oxide Synthase; ICAM-1, Intercellular Adhesion Molecule 1; IκBα, Nuclear Factor Kappa B Inhibitor Alpha; IL-6, Interleukin-6; LPS, Lipopolysaccharides; MAPK, Mitogen-Activated Protein Kinase; MyD88, Myeloid Differentiation Primary Response 88; NADPH, Nicotinamide Adenine Dinucleotide Phosphate; NF-κB, Nuclear Factor Kappa B; NO, Nitric Oxide; ROS, Reactive Oxygen Species; TLR4, Toll-like Receptor 4; VCAM-1, Vascular Cell Adhesion Molecule 1.

High blood pressure (BP) presents a significant public health challenge. Recent findings suggest that altered microbiota can exert a hypertensive effect on the host. One of the possible mechanisms involved is the chronic translocation of its components, mainly lipopolysaccharides (LPS) into systemic circulation leading to metabolic endotoxemia. In animal models, LPS has been commonly used to induce endothelial dysfunction and vascular inflammation. In human studies, plasma LPS concentration has been positively correlated with hypertension, however, the mechanistic link has not been fully elucidated. It is hypothesised here that the LPS-induced direct alterations to the vascular endothelium and resulting hypertension are possible targets for probiotic intervention.

The methodology of this review involved a systematic search of the literature with critical appraisal of papers. Three tranches of search were performed: 1) existing review papers; 2) primary mechanistic animal, in vitro and human studies; and 3) primary intervention studies. A total of 70 peer-reviewed papers were included across the three tranches and critically appraised using SIGN50 for human studies and the ARRIVE guidelines for animal studies. The extracted information was coded into key themes and summarized in a narrative analysis.

Results highlight the role of LPS in the activation of endothelial toll-like receptor 4 (TLR4) initiating a cascade of interrelated signalling pathways including: 1) Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase/ Reactive oxygen species (ROS)/ Endothelial nitric oxide synthase (eNOS) pathway leading to endothelial dysfunction; and 2) Mitogen-Activated Protein Kinase (MAPK) and Nuclear factor kappa B (NF-κB) pathways leading to vascular inflammation. Findings from animal intervention studies suggest an improvement in vasorelaxation, vascular inflammation and hypertension following probiotic supplementation, which was mediated by downregulation of LPS-induced pathways. Randomised controlled trials (RCTs) and systematic reviews provided some evidence for the anti-inflammatory effect of probiotics with statistically significant antihypertensive effect in clinical samples and may offer a viable intervention for the management of hypertension.