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Green DM, Lahiri T, Raraigh KS, Ruiz F, Spano J, Antos N, Bonitz L, Christon L, Gregoire-Bottex M, Hale JE, Langfelder-Schwind E, La Parra Perez Á, Maguiness K, Massie J, McElroy-Barker E, McGarry ME, Mercier A, Munck A, Oliver KE, Self S, Singh K, Smiley M, Snodgrass S, Tluczek A, Tuley P, Lomas P, Wong E, Hempstead SE, Faro A, Ren CL. Cystic Fibrosis Foundation Evidence-Based Guideline for the Management of CRMS/CFSPID. Pediatrics 2024; 153:e2023064657. [PMID: 38577740 DOI: 10.1542/peds.2023-064657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
A multidisciplinary committee developed evidence-based guidelines for the management of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen-positive, inconclusive diagnosis (CRMS/CFSPID). A total of 24 patient, intervention, comparison, and outcome questions were generated based on surveys sent to people with CRMS/CFSPID and clinicians caring for these individuals, previous recommendations, and expert committee input. Four a priori working groups (genetic testing, monitoring, treatment, and psychosocial/communication issues) were used to provide structure to the committee. A systematic review of the evidence was conducted, and found numerous case series and cohort studies, but no randomized clinical trials. A total of 30 recommendations were graded using the US Preventive Services Task Force methodology. Recommendations that received ≥80% consensus among the entire committee were approved. The resulting recommendations were of moderate to low certainty for the majority of the statements because of the low quality of the evidence. Highlights of the recommendations include thorough evaluation with genetic sequencing, deletion/duplication analysis if <2 disease-causing variants were noted in newborn screening; repeat sweat testing until at least age 8 but limiting further laboratory testing, including microbiology, radiology, and pulmonary function testing; minimal use of medications, which when suggested, should lead to shared decision-making with families; and providing communication with emphasis on social determinants of health and shared decision-making to minimize barriers which may affect processing and understanding of this complex designation. Future research will be needed regarding medication use, antibiotic therapy, and the use of chest imaging for monitoring the development of lung disease.
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Affiliation(s)
- Deanna M Green
- Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Thomas Lahiri
- University of Vermont Children's Hospital, Burlington, Vermont
| | - Karen S Raraigh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jacquelyn Spano
- Stanford University School of Medicine, Stanford, California
| | - Nicholas Antos
- Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Lynn Bonitz
- Cohen Children's Medical Center of NY/Northwell Health, New Hyde Park, New York
| | - Lillian Christon
- Medical University of South Carolina, Charleston, South Carolina
| | - Myrtha Gregoire-Bottex
- Advanced Pediatric Pulmonology, Pllc, Miramar, Florida
- Memorial Health Network, Hollywood, Florida
| | - Jaime E Hale
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | | | - Álvaro La Parra Perez
- John B. Goddard School of Business and Economics, Weber State University, Ogden, Utah
| | - Karen Maguiness
- Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John Massie
- University of Melbourne Murdoch Childrens Research Institute, Melbourne, Australia
| | | | - Meghan E McGarry
- University of California San Francisco, San Francisco, California
| | - Angelique Mercier
- Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Anne Munck
- Hospital Necker Enfants malades, AP-HP, Paris, France
| | | | - Staci Self
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Singh
- University of California, Irvine, Orange, California Miller Children's and Women's Hospital, Long Beach, California
| | | | | | | | | | - Paula Lomas
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Elise Wong
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Albert Faro
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Clark CCA, Holder P, Boardman FK, Moody L, Cowlard J, Allen L, Walter C, Bonham JR, Chudleigh J. International Perspectives of Extended Genetic Sequencing When Used as Part of Newborn Screening to Identify Cystic Fibrosis. Int J Neonatal Screen 2024; 10:31. [PMID: 38651396 PMCID: PMC11036278 DOI: 10.3390/ijns10020031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/04/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
There is increasing interest in using extended genetic sequencing (EGS) in newborn screening (NBS) for cystic fibrosis (CF). How this is implemented will change the number of children being given an uncertain outcome of CRMS/CFSPID (cystic fibrosis transmembrane conductance regulator (CFTR)-related metabolic syndrome/CF Screen Positive Inconclusive Diagnosis), probable carrier results, and the number of missed CF diagnoses. An international survey of CF health professionals was used to gather views on two approaches to EGS-specific (may reduce detection of CRMS/CFSID but miss some CF cases) versus sensitive (may increase detection of CRMS/CFSPID but avoid missing more CF cases). Health professionals acknowledged the anxiety caused to parents (and health professionals) from the uncertainty surrounding the prognosis and management of CRMS/CFSPID. However, most preferred the sensitive approach, as overall, identifying more cases of CRMS/CFSPID was viewed as less physically and psychologically damaging than a missed case of CF. The importance of early diagnosis and treatment for CF to ensure better health outcomes and reducing diagnostic odysseys for parents were highlighted. A potential benefit to identifying more children with CRMS/CFSPID included increasing knowledge to obtain a better understanding of how these children should best be managed in the future.
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Affiliation(s)
| | - Pru Holder
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London SE5 9PJ, UK; (P.H.); (J.C.)
| | | | - Louise Moody
- Centre for Arts, Memory and Communities, Coventry University, Coventry CV1 5FB, UK;
| | - Jacqui Cowlard
- Paediatric Respiratory Medicine, Royal London Children’s Hospital, London E1 1FR, UK
| | | | | | - James R. Bonham
- Pharmacy, Diagnostics and Genetics, Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK;
| | - Jane Chudleigh
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London SE5 9PJ, UK; (P.H.); (J.C.)
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Holder P, Clark CC, Moody L, Boardman FK, Cowlard J, Allen L, Walter C, Bonham JR, Chudleigh J. Stakeholder Views of the Proposed Introduction of Next Generation Sequencing into the Cystic Fibrosis Screening Protocol in England. Int J Neonatal Screen 2024; 10:13. [PMID: 38390977 PMCID: PMC10885054 DOI: 10.3390/ijns10010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/02/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The project aimed to gather, analyse, and compare the views of stakeholders about the proposed UK cystic fibrosis (CF) screening protocol incorporating next generation sequencing (NGS). The study design was based on principles of Q-methodology with a willingness-to-pay exercise. Participants were recruited from 12 CF centres in the UK. The study contained twenty-eight adults who have experience with CF (parents of children with CF (n = 21), including parents of children with CF transmembrane conductance regulator (CFTR)-related metabolic syndrome (CRMS)/CF screen positive-inconclusive diagnosis (CFSPID), an uncertain outcome (n = 3), and adults with CF (n = 4)), and nine health professionals involved in caring for children with CF. Parents and health professionals expressed a preference for a sensitive approach to NGS. This was influenced by the importance participants placed on not missing any children with CF via screening and the balance of harm between missing a case of CF compared to picking up more children with an uncertain outcome (CRMS/CFSPID). Given the preference for a sensitive approach, the need for adequate explanations about potential outcomes including uncertainty (CFSPID) at the time of screening was emphasized. More research is needed to inform definitive guidelines for managing children with an uncertain outcome following CF screening.
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Affiliation(s)
- Pru Holder
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London SE5 9PJ, UK;
| | - Corinna C. Clark
- Warwick Medical School, Warwick University, Coventry CV4 7AL, UK; (C.C.C.); (F.K.B.)
| | - Louise Moody
- Centre for Arts, Memory and Communities, Coventry University, Coventry CV1 5FB, UK;
| | - Felicity K. Boardman
- Warwick Medical School, Warwick University, Coventry CV4 7AL, UK; (C.C.C.); (F.K.B.)
| | - Jacqui Cowlard
- Paediatric Respiratory Medicine, Royal London Children’s Hospital, London E1 1FR, UK;
| | - Lorna Allen
- Cystic Fibrosis Trust, London EC3N 1RE, UK; (L.A.); (C.W.)
| | - Claire Walter
- Cystic Fibrosis Trust, London EC3N 1RE, UK; (L.A.); (C.W.)
| | - James R. Bonham
- Pharmacy, Diagnostics and Genetics, Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK;
| | - Jane Chudleigh
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London SE5 9PJ, UK;
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Bell SC, Mall MA, Gutierrez H, Macek M, Madge S, Davies JC, Burgel PR, Tullis E, Castaños C, Castellani C, Byrnes CA, Cathcart F, Chotirmall SH, Cosgriff R, Eichler I, Fajac I, Goss CH, Drevinek P, Farrell PM, Gravelle AM, Havermans T, Mayer-Hamblett N, Kashirskaya N, Kerem E, Mathew JL, McKone EF, Naehrlich L, Nasr SZ, Oates GR, O'Neill C, Pypops U, Raraigh KS, Rowe SM, Southern KW, Sivam S, Stephenson AL, Zampoli M, Ratjen F. The future of cystic fibrosis care: a global perspective. THE LANCET RESPIRATORY MEDICINE 2020; 8:65-124. [DOI: 10.1016/s2213-2600(19)30337-6] [Citation(s) in RCA: 351] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/19/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
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Sermet-Gaudelus I, Brouard J, Audrézet MP, Couderc Kohen L, Weiss L, Wizla N, Vrielynck S, LLerena K, Le Bourgeois M, Deneuville E, Remus N, Nguyen-Khoa T, Raynal C, Roussey M, Girodon E. Guidelines for the clinical management and follow-up of infants with inconclusive cystic fibrosis diagnosis through newborn screening. Arch Pediatr 2017; 24:e1-e14. [PMID: 29174009 DOI: 10.1016/j.arcped.2017.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 06/21/2017] [Accepted: 07/04/2017] [Indexed: 01/17/2023]
Abstract
Neonatal screening for cystic fibrosis (CF) can detect infants with elevated immunoreactive trypsinogen (IRT) levels and inconclusive sweat tests and/or CFTR DNA results. These cases of uncertain diagnosis are defined by (1) either the presence of at most one CF-associated cystic fibrosis transmembrane conductance regulator (CFTR) mutation with sweat chloride values between 30 and 59mmol/L or (2) two CFTR mutations with at least one of unknown pathogenic potential and a sweat chloride concentration below 60mmol/L. This encompasses various clinical situations whose progression cannot be predicted. In these cases, a sweat chloride test has to be repeated at 12 months, and if possible at 6 and 24 months of life along with extended CFTR sequencing to detect rare mutations. When the diagnosis is not definite, CFTR functional explorations may provide a better understanding of CFTR dysfunction. The initial evaluation of these infants must be conducted in dedicated CF reference centers and should include bacteriological sputum analysis, chest radiology, and fecal elastase assay. The primary care physicians in charge of these patients should be familiar with the current management of CF and should work in collaboration with CF centers. A follow-up should be performed in a CF reference center at 3, 6, and 12 months of life and every year thereafter. Any symptom indicative of CF requires immediate reevaluation of the diagnosis. These guidelines were established by the "neonatal screening and difficult diagnoses" working group of the French CF society. Their objective is to standardize the management of infants with unclear diagnosis.
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Affiliation(s)
- I Sermet-Gaudelus
- Cystic fibrosis center, Necker-Enfants-Malades hospital, 75015 Paris, France; Inserm U1151, 75993 Paris, France.
| | - J Brouard
- Cystic fibrosis reference center, hôpital de la Côte-de-Nacre, 14033 Caen, France
| | - M-P Audrézet
- Molecular genetic laboratory, CHRU de Brest, 29609 Brest, France
| | - L Couderc Kohen
- Cystic fibrosis reference center, Charles-Nicolle hospital, 76000 Rouen, France
| | - L Weiss
- Cystic fibrosis reference center, Hautepierre hospital, 67200 Strasbourg, France
| | - N Wizla
- Cystic fibrosis reference center, Jeanne-de-Flandres hospital, 59000 Lille, France
| | - S Vrielynck
- Cystic fibrosis reference center, child and mother hospital, 69677 Lyon, France
| | - K LLerena
- Cystic fibrosis center, university hospital, 38700 Grenoble, France
| | - M Le Bourgeois
- Cystic fibrosis center, Necker-Enfants-Malades hospital, 75015 Paris, France
| | - E Deneuville
- Cystic fibrosis center, CHU de Rennes, 35000 Rennes, France
| | - N Remus
- Cystic fibrosis center, Créteil intercommunal hospital, 94000 Créteil, France
| | - T Nguyen-Khoa
- Cystic fibrosis center, Necker-Enfants-Malades hospital, 75015 Paris, France
| | - C Raynal
- UMR 5535, molecular genetic institute, 34293 Montpellier, France
| | - M Roussey
- Association française pour le dépistage et la prévention des handicaps de l'Enfant, 75015 Paris, France
| | - E Girodon
- Inserm U1151, 75993 Paris, France; Molecular genetics laboratory, Cochin hospital, 75014 Paris, France
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Wagener JS, Millar SJ, Mayer-Hamblett N, Sawicki GS, McKone EF, Goss CH, Konstan MW, Morgan WJ, Pasta DJ, Moss RB. Lung function decline is delayed but not decreased in patients with cystic fibrosis and the R117H gene mutation. J Cyst Fibros 2017; 17:503-510. [PMID: 29100868 DOI: 10.1016/j.jcf.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) experience variable lung disease phenotypes. The R117H mutation is often associated with preserved lung function. Our objective was to compare the rate of lung function decline in patients with the R117H mutation and patients homozygous for the F508del mutation. METHODS Rate of decline in percentage-of-predicted FEV1 (ppFEV1) was analyzed using the 2006-2010 US CF Foundation Patient Registry. RESULTS 4-year rate of decline was slower in 156 R117H patients compared with 6251 F508del patients (-0.61 vs -2.03 ppFEV1/year, P<0.001). Rates of decline in children were slower in R117H vs F508del patients (6-12-year-olds: +0.73 vs -1.91 ppFEV1/year, P<0.001 and 13-17-year-olds: -1.55 vs -2.66 ppFEV1/year, P=0.046), whereas rates in adults were not significantly different (18-24-year-olds: -1.52 vs -2.12, P=0.26 and ≥25-year-olds: -1.17 vs -1.40, P=0.33). CONCLUSIONS These findings are consistent with a delayed onset, but ultimately similar progression, of lung disease in R117H compared with homozygous F508del patients.
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Affiliation(s)
| | | | - Nicole Mayer-Hamblett
- US CFF Patient Registry Committee, Bethesda, MD, USA; Department of Pediatrics and Biostatistics, University of Washington, Seattle, WA, USA
| | - Gregory S Sawicki
- US CFF Patient Registry Committee, Bethesda, MD, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Edward F McKone
- Thoracic Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Christopher H Goss
- US CFF Patient Registry Committee, Bethesda, MD, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Wayne J Morgan
- US CFF Patient Registry Committee, Bethesda, MD, USA; Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | | | - Richard B Moss
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
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Aziz DA, Billoo AG, Qureshi A, Khalid M, Kirmani S. Clinical and laboratory profile of children with Cystic Fibrosis: Experience of a tertiary care center in Pakistan. Pak J Med Sci 2017; 33:554-559. [PMID: 28811770 PMCID: PMC5510102 DOI: 10.12669/pjms.333.12188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: To determine the clinical presentation, diagnostic investigations and laboratory workup done in admitted children with cystic fibrosis at Aga Khan University Hospital Karachi, Pakistan. Methods: This is athree years retrospective study from January 2013 to December 2015 conducted at The Aga Khan University Hospital Karachi Pakistan, enrolling admitted patient from birth to 15 years of either gender, diagnosed with CF on the basis of clinical features and positive sweat chloride test. Different clinical presentations were noted including initial presentations. Sweat chloride values more than 60mmol/L were labeled as positive and consistent with diagnosis of CF. Available Delta F-508 mutation analyses were noted. Relevant laboratory and radiological investigations including sputum culture and HR-CT chest findings were documented. Results were analyzed using SPSS version 20. Results: Total 43 children were selected according to the inclusion criteria. Chronic cough (69.76%) was the most common initial clinical presentation. Mean age at onset of symptoms was 14.41± 26.18 months and mean age at diagnosis was 47.20 ± 45.80 months Respiratory features were most common in our cohort including chronic productive cough (90.71%), recurrent bronchopneumonia (72.09%) and asthma like presentation (44.19%) with wheezing and cough. 86% patients presented with failure to thrive. Gastroenterological features including steatorrhea were seen in 55.81% patients and 44.19% patients had abdominal distension. Mean sweat chloride value in our population was 82.70± 22.74. Gene analysis for Delta F-508 was identified in 12 (27.90%) patients. Bronchiectatic pulmonary changes on HRCT were seen in 18 patients (41.86%). Pseudomonas grew in 12 patients (27.90%) in sputum cultures at the time of diagnosis. Conclusion: Respiratory presentations predominate in CF children followed by gastrointestinal features. Nearly half of our patient had bronchiectatic changes on CT scan chest and more than quarter had pseudomonas colonization in the airways at the time of diagnosis. Delta F-508 mutation was found to be uncommon in our study population. There is significant delay in diagnosing patients with CF.
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Affiliation(s)
- Danish Abdul Aziz
- Dr. Danish Abdul Aziz. MBBS, MRCPCH, FCPS. Senior Instructor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdul Gaffar Billoo
- Prof. Dr. Abdul Gaffar Billoo, MBBS, MRCP, FRCP. Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Ahad Qureshi
- Dr. Ahad Qureshi, MBBS. Graduate from Aga Khan University Hospital, Karachi, Pakistan. Aga Khan University Hospital, Karachi, Pakistan
| | - Misha Khalid
- Misha Khalid, Fourth Year Medical Student, Aga Khan University Hospital, Karachi, Pakistan
| | - Salman Kirmani
- Dr. Salman Kirmani, MBBS, FAAP. Associate Professor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
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De Boeck K, Vermeulen F, Dupont L. The diagnosis of cystic fibrosis. Presse Med 2017; 46:e97-e108. [PMID: 28576637 DOI: 10.1016/j.lpm.2017.04.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/18/2017] [Accepted: 04/27/2017] [Indexed: 01/09/2023] Open
Abstract
Establishing the diagnosis of cystic fibrosis (CF) is straight forward in the majority of patients: they present with a clear clinical picture (most frequently chronic respiratory symptoms plus malabsorption), the sweat chloride value is>60mmol/L and two known disease causing CFTR mutations are identified. In less than 5% of subjects, mainly those with a milder or limited phenotype, the diagnostic process is more complex, because initial diagnostic test results are inconclusive: sweat chloride concentration in the intermediate range, less than 2 CF causing mutations identified or both. These patients should be referred to expert centers where bioassays of CFTR function like nasal potential difference measurement or intestinal current measurement can be done. Still, in some patients, despite symptoms compatible with CF and some indication of CFTR dysfunction (e.g. only intermediate sweat chloride value), diagnostic criteria are not met (e.g. only 1 CFTR mutation identified). For these subjects, the term CFTR related disorder (CFTR-RD) is used. Patients with disseminated bronchiectasis, congenital bilateral absence of the vas deferens and acute or recurrent pancreatitis may fall in this category. CF has a very wide disease spectrum and increasingly the diagnosis is being made during adult life, mainly in subjects with milder phenotypes. In many countries, nationwide CF newborn screening (NBS) has been introduced. In screen positive babies, the diagnosis of CF must be confirmed by a sweat test demonstrating a sweat chloride concentration above 60mmol/L. To achieve the benefit of NBS, every baby in whom the diagnosis of CF is confirmed must receive immediate follow-up and treatment in a CF reference center. CF NBS is not full proof: some diagnoses will be missed and in some babies the diagnosis cannot be confirmed nor ruled out with certainty. Screening algorithms that include gene sequencing will detect a high number of such babies that are screen positive with an inconclusive diagnosis (CFSPID). Even in 2016, the most reliable and widely available diagnostic test for CF is the measurement of chloride concentration in sweat. The method of choice is sweat induction by pilocarpine iontophoresis, followed by sweat collection on a gauze or filter paper or in a Macroduct coil. Since mutation specific therapies have become available, it is important to identify the mutations responsible for CF in each individual patient.
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Affiliation(s)
- Kris De Boeck
- University of Leuven, Department of Pulmonology, 3000 Leuven, Belgium.
| | | | - Lieven Dupont
- University of Leuven, Department of Pulmonology, Leuven, Belgium
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9
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Genomic sequencing in cystic fibrosis newborn screening: what works best, two-tier predefined CFTR mutation panels or second-tier CFTR panel followed by third-tier sequencing? Genet Med 2017; 19:1159-1163. [PMID: 28471435 DOI: 10.1038/gim.2017.32] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 02/06/2017] [Accepted: 02/09/2017] [Indexed: 01/08/2023] Open
Abstract
PurposeThe purpose of this study was to model the performance of several known two-tier, predefined mutation panels and three-tier algorithms for cystic fibrosis (CF) screening utilizing the ethnically diverse California population.MethodsThe cystic fibrosis transmembrane conductance regulator (CFTR) mutations identified among the 317 CF cases in California screened between 12 August 2008 and 18 December 2012 were used to compare the expected CF detection rates for several two- and three-tier screening approaches, including the current California approach, which consists of a population-specific 40-mutation panel followed by third-tier sequencing when indicated.ResultsThe data show that the strategy of using third-tier sequencing improves CF detection following an initial elevated immunoreactive trypsinogen and detection of only one mutation on a second-tier panel.ConclusionIn a diverse population, the use of a second-tier panel followed by third-tier CFTR gene sequencing provides a better detection rate for CF, compared with the use of a second-tier approach alone, and is an effective way to minimize the referrals of CF carriers for sweat testing. Restricting screening to a second-tier testing to predefined mutation panels, even broad ones, results in some missed CF cases and demonstrates the limited utility of this approach in states that have diverse multiethnic populations.
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10
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Hayeems RZ, Miller FA, Barg CJ, Bombard Y, Carroll JC, Tam K, Kerr E, Chakraborty P, Potter BK, Patton S, Bytautas JP, Taylor L, Davies C, Milburn J, Price A, Gonska T, Keenan K, Ratjen F, Guttmann A. Psychosocial Response to Uncertain Newborn Screening Results for Cystic Fibrosis. J Pediatr 2017; 184:165-171.e1. [PMID: 28279431 DOI: 10.1016/j.jpeds.2017.01.049] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 12/15/2016] [Accepted: 01/19/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To explore the psychosocial implications of diagnostic uncertainty that result from inconclusive results generated by newborn bloodspot screening (NBS) for cystic fibrosis (CF). STUDY DESIGN Using a mixed methods prospective cohort study of children who received NBS for CF, we compared psychosocial outcomes of parents whose children who received persistently inconclusive results with those whose children received true positive or screen-negative results. RESULTS Mothers of infants who received inconclusive results (n = 17), diagnoses of CF (n = 15), and screen-negative results (n = 411) were surveyed; 23 parent interviews were completed. Compared with mothers of infants with true positive/screen-negative results, mothers of infants with inconclusive results reported greater perceived uncertainty (P < .006) but no differences in anxiety or vulnerability (P > .05). Qualitatively, parents valued being connected to experts but struggled with the meaning of an uncertain diagnosis, worried about their infant's health-related vulnerability, and had mixed views about surveillance. CONCLUSION Inconclusive CF NBS results were not associated with anxiety or vulnerability but led to health-related uncertainty and qualitative concerns. Findings should be considered alongside efforts to optimize protocols for CF screening and surveillance. Educational and psychosocial supports are warranted for these families.
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Affiliation(s)
- Robin Z Hayeems
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Fiona A Miller
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Carolyn J Barg
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Yvonne Bombard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - June C Carroll
- Department of Family and Community Medicine, Mount Sinai Hospital, Sinai Health System, University of Toronto, Toronto, Canada
| | - Karen Tam
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Kerr
- Department of Psychology, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Pranesh Chakraborty
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Beth K Potter
- School of Epidemiology, Public Health & Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sarah Patton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jessica P Bytautas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Louise Taylor
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Christine Davies
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Jennifer Milburn
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - April Price
- Department of Pediatric Respirology, Children's Hospital of Western Ontario, London, Canada
| | - Tanja Gonska
- Division of Gastroenterology, Department of Pediatrics The Hospital for Sick Children, Toronto, Canada; Physiology and Experimental Medicine, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Katherine Keenan
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Felix Ratjen
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; Health System Planning & Evaluation Research Program, Institute for Clinical Evaluative Sciences, Toronto, Canada
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11
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Sermet-Gaudelus I, Brouard J, Audrézet MP, Couderc Kohen L, Weiss L, Wizla N, Vrielynck S, LLerena K, Le Bourgeois M, Deneuville E, Remus N, Nguyen-Khoa T, Raynal C, Roussey M, Girodon E. [Management of infants whose diagnosis is inconclusive at neonatal screening for cystic fibrosis]. Arch Pediatr 2017; 24:401-414. [PMID: 28258861 DOI: 10.1016/j.arcped.2017.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
Neonatal screening for cystic fibrosis (CF) may detect infants with elevated immunoreactive trypsinogen (IRT) levels but with inconclusive sweat tests and/or DNA results. This includes cases associating (1) either the presence of at most one CF-causing mutation and sweat chloride values between 30 and 59mmol/L or (2) two CFTR mutations with at least one of unknown pathogenicity and a sweat chloride below 60mmol/L. This encompasses different clinical situations whose progression cannot be predicted. These cases require redoing the sweat test at 12 months and if possible at 6 and 24 months of life. This must be associated with extended genotyping. CFTR functional explorations can also help by investigating CFTR dysfunction. These infants must be initially evaluated in dedicated CF centers including bacteriological sputum analysis, chest radiology and fecal elastase dosage. A home practitioner must be informed of the specificity of follow-up. These infants will be reviewed in the CF center at 3, 6 and 12 months and every year. Any CF-related symptom requires reevaluation of the diagnosis. These guidelines were established by the "neonatal screening and difficult diagnoses" working group of the French CF Society. They aim to standardize management of infants with unclear diagnosis in French CF centers.
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Affiliation(s)
- I Sermet-Gaudelus
- Centre de ressources et de compétences en mucoviscidose, hôpital Necker-Enfants Malades, 149, rue de Sévres, 75015 Paris, France; Inserm U 1151, Paris, France.
| | - J Brouard
- Centre de ressources et de compétences en mucoviscidose, hôpital de la Côte-de-Nacre, 14033 Caen, France
| | - M-P Audrézet
- Laboratoire de génétique moléculaire, CHRU de Brest, 29609 Brest, France
| | - L Couderc Kohen
- Centre de ressources et de compétences en mucoviscidose, hôpital Charles-Nicolle, 76000 Rouen, France
| | - L Weiss
- Centre de ressources et de compétences en mucoviscidose, hôpital de Hautepierre, 67200 Strasbourg, France
| | - N Wizla
- Centre de ressources et de compétences en mucoviscidose, hôpital Jeanne-de-Flandres, 59000 Lille, France
| | - S Vrielynck
- Centre de ressources et de compétences en mucoviscidose, hôpital Mère-Enfant, 69677 Lyon, France
| | - K LLerena
- Centre de ressources et de compétences en mucoviscidose, CHU, 38700 Grenoble, France
| | - M Le Bourgeois
- Centre de ressources et de compétences en mucoviscidose, hôpital Necker-Enfants Malades, 149, rue de Sévres, 75015 Paris, France
| | - E Deneuville
- Centre de ressources et de compétences en mucoviscidose, CHU, 35000 Rennes, France
| | - N Remus
- Centre de ressources et de compétences en mucoviscidose, hôpital InterCommunal de Créteil, 94000 Créteil, France
| | - T Nguyen-Khoa
- Centre de ressources et de compétences en mucoviscidose, hôpital Necker-Enfants Malades, 149, rue de Sévres, 75015 Paris, France
| | - C Raynal
- Institut de génétique moléculaire, UMR 5535, 34293 Montpellier, France
| | - M Roussey
- Association française pour le dépistage et la prévention des handicaps de l'enfant, 75015 Paris, France
| | - E Girodon
- Laboratoire de génétique moléculaire, hôpital Cochin, 75014 Paris, France
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12
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Coffey MJ, Whitaker V, Gentin N, Junek R, Shalhoub C, Nightingale S, Hilton J, Wiley V, Wilcken B, Gaskin KJ, Ooi CY. Differences in Outcomes between Early and Late Diagnosis of Cystic Fibrosis in the Newborn Screening Era. J Pediatr 2017; 181:137-145.e1. [PMID: 27837951 DOI: 10.1016/j.jpeds.2016.10.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To evaluate children with cystic fibrosis (CF) who had a late diagnosis of CF (LD-CF) despite newborn screening (NBS) and compare their clinical outcomes with children diagnosed after a positive NBS (NBS-CF). STUDY DESIGN A retrospective review of patients with LD-CF in New South Wales, Australia, from 1988 to 2010 was performed. LD-CF was defined as NBS-negative (negative immunoreactive trypsinogen or no F508del) or NBS-positive but discharged following sweat chloride < 60 mmol/L. Cases of LD-CF were each matched 1:2 with patients with NBS-CF for age, sex, hospital, and exocrine pancreatic status. RESULTS A total of 45 LD-CF cases were identified (39 NBS-negative and 6 NBS-positive) with 90 NBS-CF matched controls. Median age (IQR) of diagnosis for LD-CF and NBS-CF was 1.35 (0.4-2.8) and 0.12 (0.03-0.2) years, respectively (P <.0001). Estimated incidence of LD-CF was 1 in 45 000 live births. Compared with NBS-CF, LD-CF had more respiratory manifestations at time of diagnosis (66% vs 4%; P <.0001), a higher rate of hospital admission per year for respiratory illness (0.49 vs 0.2; P = .0004), worse lung function (forced expiratory volume in 1 second percentage of predicted, 0.88 vs 0.97; P = .007), and higher rates of chronic colonization with Pseudomonas aeruginosa (47% vs 24%; P = .01). The LD-CF cohort also appeared to be shorter than NBS-CF controls (mean height z-score -0.65 vs -0.03; P = .02). CONCLUSIONS LD-CF, despite NBS, seems to be associated with worse health before diagnosis and worse later growth and respiratory outcomes, thus providing further support for NBS programs for CF.
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Affiliation(s)
- Michael J Coffey
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Viola Whitaker
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Natalie Gentin
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of General Pediatrics, Sydney Children's Hospital Randwick, Sydney, Australia
| | - Rosie Junek
- The Children's Hospital at Westmead, Sydney, Australia
| | - Carolyn Shalhoub
- Department of Medical Genetics, Sydney Children's Hospital Randwick, Sydney, Australia
| | - Scott Nightingale
- GrowUpWell Priority Research Centre, University of Newcastle, Newcastle, Australia; Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, Australia
| | - Jodi Hilton
- University of Newcastle, Newcastle, Australia; Department of Respiratory Medicine, John Hunter Children's Hospital, Newcastle, Australia
| | - Veronica Wiley
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Bridget Wilcken
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Kevin J Gaskin
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Chee Y Ooi
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Gastroenterology, Sydney Children's Hospital Randwick, Sydney, Australia.
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13
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Ren CL, Borowitz DS, Gonska T, Howenstine MS, Levy H, Massie J, Milla C, Munck A, Southern KW. Cystic Fibrosis Transmembrane Conductance Regulator-Related Metabolic Syndrome and Cystic Fibrosis Screen Positive, Inconclusive Diagnosis. J Pediatr 2017; 181S:S45-S51.e1. [PMID: 28129812 DOI: 10.1016/j.jpeds.2016.09.066] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE An unintended consequence of cystic fibrosis (CF) newborn screening (NBS) is the identification of infants with a positive NBS test but inconclusive diagnostic testing. These infants are classified as CF transmembrane conductance regulator-related metabolic syndrome (CRMS) in the US and CF screen positive, inconclusive diagnosis (CFSPID) in other countries. Diagnostic and management decisions of these infants are challenges for CF healthcare professionals and stressful situations for families. As CF NBS has become more widespread across the world, increased information about the epidemiology and outcomes of these infants is becoming available. These data were reviewed at the 2015 CF Foundation Diagnosis Consensus Conference, and a harmonized definition of CRMS and CFSPID was developed. STUDY DESIGN At the consensus conference, participants reviewed published and unpublished studies of CRMS/CFSPID and used a modified Delphi methodology to develop a harmonized approach to the definition of CRMS/CFSPID. RESULTS Several studies of CRMS/CFSPID from populations around the world have been published in the past year. Although the studies vary in the number of infants studied, study design, and outcome measures, there have been some consistent findings. CRMS/CFSPID occurs relatively frequently, with CF:CRMS that ranges from 3 to 5 cases of CF for every 1 case of CRMS/CFSPID in regions where gene sequencing is not used. The incidence varies by NBS protocol used, and in some regions more cases of CRMS/CFSPID are detected than cases of CF. The majority of individuals with CRMS/CFSPID do not develop CF disease or progress to a diagnosis of CF. However, between 10% and 20% of asymptomatic infants can develop clinical features concerning for CF, such as a respiratory culture positive for Pseudomonas aeruginosa. Most studies have only reported short-term outcomes in the first 1-3 years of life; the long-term outcomes of CRMS/CFSPID remain unknown. The European CF Society definition of CFSPID and the CF Foundation definition of CRMS differ only slightly, and the consensus conference was able to create a unified definition of CRMS/CFSPID. CONCLUSIONS CRMS/CFSPID is a relatively common outcome of CF NBS, and clinicians need to be prepared to counsel families whose NBS test falls into this classification. The vast majority of infants with CRMS/CFSPID will remain free from disease manifestations early in life. However, a small proportion may develop clinical features concerning for CF or demonstrate progression to a clinical phenotype compatible with a CF diagnosis, and their long-term outcomes are not known. A consistent international definition of CRMS/CFSPID will allow for better data collection for study of outcomes and result in improved patient care.
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Affiliation(s)
- Clement L Ren
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Drucy S Borowitz
- Clinical Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Tanja Gonska
- Division of Gastroenterology, Hepatology, and Nutrition, and Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle S Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Hara Levy
- Division of Pulmonary Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - John Massie
- Department of Respiratory Medicine, Royal Children's Hospital. and Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Carlos Milla
- Center for Excellence in Pulmonary Biology, Stanford University, Palo Alto, CA
| | - Anne Munck
- Centres de Ressources et de Compétences pour la Mucoviscidose, Hôpital Robert Debre, Paris, France
| | - Kevin W Southern
- Department for Women's and Children's Health, University of Liverpool, Institute in the Park, Alder Hey Children's Hospital, Liverpool, United Kingdom
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Shteinberg M, Downey DG, Beattie D, McCaughan J, Reid A, Stein N, Elborn JS. Lung function and disease severity in cystic fibrosis patients heterozygous for p.Arg117His. ERJ Open Res 2017; 3:00056-2016. [PMID: 28845426 PMCID: PMC5566269 DOI: 10.1183/23120541.00056-2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 01/19/2017] [Indexed: 01/20/2023] Open
Abstract
Expression of p.Arg117His cystic fibrosis (CF) transmembrane conductance regulator is influenced by a polythymidine (poly-T) tract and a thymidine-guanine (TG) repeat on intron 9, which vary in length and affect exon 10 skipping. We compared clinical characteristics and the rate of progression of lung disease of CF patients carrying the p.Arg117His mutation with different intron 9 varying sequences (poly-T) and mutation classes in trans. Data were collected from patients in Northern Ireland, UK, including diagnostic features, sweat chloride, nutritional status, sputum microbiology, CF-related complications and lung function. Poly-T and TG repeats were determined by PCR. Forced expiratory volume in 1 s (FEV1) decline was determined from linear regression of FEV1 measurements of patients over time. We identified 62 patients with p.Arg117His, 55 with a class I/II mutation in trans and six with p.Arg117His/p.Gly551Asp. 42 patients had 5T and 13 had 7T. All patients had 12 TG repeats. Patients with p.Arg117His-5T had greater lung function decline, sweat chloride concentrations, pancreatic insufficiency and prevalence of Pseudomonas aeruginosa infection compared with patients with p.Arg117His-7T. Lung function decline and disease severity in p.Arg117His is determined by the poly-T tract length and identity of the mutation in trans. Patients with p.Arg117His-5T and a second class I/II mutation have a severity similar to p.Phe508del homozygous patients, although lung function decline is delayed to an older age. There may be linkage disequilibrium between p.Arg117His and 12 TG repeats.
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Affiliation(s)
- Michal Shteinberg
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Belfast Health and Social Care Trust, Belfast, UK
- Pulmonology and CF Center, Carmel Medical Center and Rappaport Faculty of Medicine, Haifa, Israel
- Queen's University of Belfast, Belfast, UK
| | - Damian G. Downey
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Belfast Health and Social Care Trust, Belfast, UK
- Queen's University of Belfast, Belfast, UK
| | - Diane Beattie
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - John McCaughan
- Northern Ireland Regional Paediatric Cystic Fibrosis Centre, Royal Belfast Hospital for Sick Children, Belfast Health and Social Care Trust, Belfast, UK
| | - Alastair Reid
- Northern Ireland Regional Paediatric Cystic Fibrosis Centre, Royal Belfast Hospital for Sick Children, Belfast Health and Social Care Trust, Belfast, UK
| | - Nili Stein
- Pulmonology and CF Center, Carmel Medical Center and Rappaport Faculty of Medicine, Haifa, Israel
| | - J. Stuart Elborn
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Belfast Health and Social Care Trust, Belfast, UK
- Queen's University of Belfast, Belfast, UK
- Imperial College and Royal Brompton Hospital, London, UK
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15
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Raina MA, Khan MS, Malik SA, Raina AH, Makhdoomi MJ, Bhat JI, Mudassar S. Assessment of Correlation between Sweat Chloride Levels and Clinical Features of Cystic Fibrosis Patients. J Clin Diagn Res 2016; 10:BC01-BC06. [PMID: 28208841 DOI: 10.7860/jcdr/2016/21526.8951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/10/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Cystic Fibrosis (CF) is an autosomal recessive disorder and the incidence of this disease is undermined in Northern India. The distinguishable salty character of the sweat belonging to individuals suffering from CF makes sweat chloride estimation essential for diagnosis of CF disease. AIM The aim of this prospective study was to elucidate the relationship of sweat chloride levels with clinical features and pattern of CF. MATERIALS AND METHODS A total of 182 patients, with clinical features of CF were included in this study for quantitative measurement of sweat chloride. Sweat stimulation and collection involved pilocarpine iontophoresis based on the Gibson and Cooks methodology. The quantitative estimation of chloride was done by Schales and Schales method with some modifications. Cystic Fibrosis Trans Membrane Conductance Regulator (CFTR) mutation status was recorded in case of patients with borderline sweat chloride levels to correlate the results and for follow-up. RESULTS Out of 182 patients having clinical features consistent with CF, borderline and elevated sweat chloride levels were present in 9 (5%) and 41 (22.5%) subjects respectively. Elevated sweat chloride levels were significantly associated with wheeze, Failure To Thrive (FTT), history of CF in Siblings, product of Consanguineous Marriage (CM), digital clubbing and steatorrhoea on univariate analysis. On multivariate analysis only wheeze, FTT and steatorrhoea were found to be significantly associated with elevated sweat chloride levels (p<0.05). Among the nine borderline cases six cases were positive for at least two CFTR mutations and rest of the three cases were not having any mutation in CFTR gene. CONCLUSION The diagnosis is often delayed and the disease is advanced in most patients at the time of diagnosis. Sweat testing is a gold standard for diagnosis of CF patients as genetic mutation profile being heterozygous and unlikely to become diagnostic test.
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Affiliation(s)
- Manzoor A Raina
- Junior Research Fellow, Department of Clinical Biochemistry, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
| | - Mosin S Khan
- Senior Resident, Department of Clinical Biochemistry, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
| | - Showkat A Malik
- PhD Scholar, Department of Clinical Biochemistry, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
| | - Ab Hameed Raina
- Senior Resident, Department of Internal Medicine, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
| | - Mudassir J Makhdoomi
- Junior Research Fellow, Department of Clinical Biochemistry, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
| | - Javed I Bhat
- Assistant Professor, Department of Paediatrics, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jamu and Kashmir, India
| | - Syed Mudassar
- Professor and Head, Department of Clinical Biochemistry, Sher-I-Kashmir Institute of Medical Sciences , Soura, Srinagar, Jammu and Kashmir, India
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16
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Faria AG, Marson FAL, Gomez CCDS, Ribeiro MÂGDO, Morais LB, Servidoni MDF, Bertuzzo CS, Sakano E, Goto M, Paschoal IA, Pereira MC, Hessel G, Levy CE, Toro AADC, Peixoto AO, Simões MCR, Lomazi EA, Nogueira RJN, Ribeiro AF, Ribeiro JD. Quality of sweat test (ST) based on the proportion of sweat sodium (Na) and sweat chloride (Cl) as diagnostic parameter of cystic fibrosis: are we on the right way? Diagn Pathol 2016; 11:103. [PMID: 27784314 PMCID: PMC5080702 DOI: 10.1186/s13000-016-0555-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To assess the quality of sweat test (ST) based on the proportion of sweat sodium and sweat chloride as diagnostic parameter of cystic fibrosis (CF). METHODS A retrospective study of 5,721 sweat samples and subsequent descriptive analysis were carried out. The test was considered "of good quality" (correct) when: (i) sweat chloride was lower than 60 mEq/L, and sweat sodium was higher than sweat chloride; (ii) sweat chloride was higher than 60 mEq/L, and sweat sodium was lower than sweat chloride. RESULTS The study included 5,692/5,721 sweat samples of ST which had been requested due to clinical presentations compatible with CF and/or neonatal screenings with altered immunoreactive trypsinogen values. Considering the proportion of sweat sodium and sweat chloride as ST quality parameter, the test was performed correctly in 5,023/5,692 (88.2 %) sweat samples. The sweat chloride test results were grouped into four reference ranges for chloride (i) chloride < 30 mEq/L: 3,651/5,692 (64.1 %); (ii) chloride ≥ 30 mEq/L to < 40 mEq/L: 652/5,692 (11.5 %); (iii) ≥ 40 mEq/L to < 60 mEq/L: 673/5,692 (11.8 %); (iv) ≥ 60 mEq/L: 716/5,692 (12.6 %). In the comparative analysis, there was no association between ST quality and: (i) symptoms to indicate a ST [respiratory (p = 0.084), digestive (p = 0.753), nutritional (p = 0.824), and others (p = 0.136)], (ii) sweat weight (p = 0.416). However, there was a positive association with: (i) gender, (ii) results of ST (p < 0.001), (iii) chloride/sodium ratio (p < 0.001), (iv) subject's age at the time of ST [grouped according to category (p < 0.001) and numerical order (p < 0.001)]. For the subset of 169 patients with CF and two CFTR mutations Class I, II and/or III, in comparative analysis, there was a positive association with: (i) sweat chloride/sodium ratio (p < 0.001), (ii) sweat chloride values (p = 0.047), (iii) subject's age at the time of the ST grouped by numerical order (p = 0.001). CONCLUSIONS Considering that the quality of ST can be assessed by levels of sweat sodium and sweat chloride, an increasing number of low-quality tests could be observed in our sweat samples. The quality of the test was associated with important factors, such as gender, CF diagnosis, and subjects' age.
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Affiliation(s)
- Alethéa Guimarães Faria
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fernando Augusto Lima Marson
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Department of Medical Genetics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Tessália Vieira de Camargo, 126, Barão Geraldo, Cidade Universitária Zeferino Vaz, CEP: 13083-887 Campinas, São Paulo Brazil
| | | | - Maria Ângela Gonçalves de Oliveira Ribeiro
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Lucas Brioschi Morais
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maria de Fátima Servidoni
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carmen Sílvia Bertuzzo
- Department of Medical Genetics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Eulália Sakano
- Department of Otorhinolaryngology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maura Goto
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Ilma Aparecida Paschoal
- Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Mônica Corso Pereira
- Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gabriel Hessel
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carlos Emílio Levy
- Department of Clinical Pathology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | | | | | | | | | | | - José Dirceu Ribeiro
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
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Machogu E, Ren CL. Novel insights into the diagnostic and therapeutic challenges of the CFTR metabolic syndrome/CF screen positive indeterminate diagnosis. Pediatr Pulmonol 2016; 51:S45-S48. [PMID: 27662103 DOI: 10.1002/ppul.23478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/01/2016] [Accepted: 05/02/2016] [Indexed: 11/09/2022]
Abstract
The growth of cystic fibrosis newborn screening (CF NBS) has led to an increased number of infants with a positive NBS test but inconclusive CF diagnostic testing. In the USA this condition is called CFTR related metabolic syndrome (CRMS), while in Europe the term CF screen positive, inconclusive diagnosis (CFSPID) is used. Recent advances in CF genetics and epidemiologic studies of CRMS/CFSPID have provided new insights into the prevalence and outcomes associated with this condition. Pediatr Pulmonol. 2016;51:S45-S48. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Evans Machogu
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Clement L Ren
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
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Groves T, Robinson P, Fitzgerald DA. Question 7: For an infant with an equivocal sweat chloride following newborn screening, how likely is a diagnosis of cystic fibrosis? Paediatr Respir Rev 2016; 20:48-50. [PMID: 26724140 DOI: 10.1016/j.prrv.2015.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Tyler Groves
- University of Sydney, Discipline of Paediatrics and Child Health, University of Sydney; Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney.
| | - Paul Robinson
- University of Sydney, Discipline of Paediatrics and Child Health, University of Sydney; Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney
| | - Dominic A Fitzgerald
- University of Sydney, Discipline of Paediatrics and Child Health, University of Sydney; Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney
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20
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Abstract
Cystic fibrosis (CF) is the most common autosomal-recessive disease in white persons. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the CF Foundation and international CF societies; networks of CF care centers; and the worldwide community of care providers, researchers, and patients and families. There are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival.
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Affiliation(s)
- Don B. Sanders
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aliza Fink
- Epidemiology, Cystic Fibrosis Foundation, Bethesda, Maryland
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Abstract
The diagnosis of cystic fibrosis (CF) has evolved over the past decade as newborn screening has become universal in the United States and elsewhere. The heterogeneity of phenotypes associated with CF transmembrane conductance regulator (CFTR) dysfunction and mutations in the CFTR gene has become clearer, ranging from classic pancreatic-insufficient CF to manifestations in only 1 organ system to indeterminate diagnoses identified by newborn screening. The tools available for diagnosis have also expanded. This article reviews the newest diagnostic criteria for CF, newborn screening, prenatal screening and diagnosis, and indeterminate diagnoses in newborn-screened infants and symptomatic adults.
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Newborn screening for cystic fibrosis. THE LANCET RESPIRATORY MEDICINE 2016; 4:653-661. [PMID: 27053341 DOI: 10.1016/s2213-2600(16)00053-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/23/2016] [Accepted: 01/28/2016] [Indexed: 01/16/2023]
Abstract
Since the late 1970s when the potential of the immunoreactive trypsinogen assay for early identification of infants with cystic fibrosis was first recognised, the performance of newborn blood spot screening (NBS) has been continually assessed and its use has gradually expanded. NBS for cystic fibrosis is a cost-effective strategy and, if standards of care are fully implemented and robust management pathways are in place, has a positive effect on clinical outcomes. In the past decade, NBS has undergone rapid expansion and an unprecedented number of infants with cystic fibrosis have access to early diagnosis and care. Cystic fibrosis NBS has now moved on from the development phase and is entering an era of consolidation. In the future, research should focus on the rationalisation and optimisation of existing programmes, with particular attention to bioethical implications such as unwanted detection of carriers and inconclusive diagnoses.
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Levy H, Nugent M, Schneck K, Stachiw-Hietpas D, Laxova A, Lakser O, Rock M, Dahmer MK, Biller J, Nasr SZ, Baker M, McColley SA, Simpson P, Farrell PM. Refining the continuum of CFTR-associated disorders in the era of newborn screening. Clin Genet 2016; 89:539-49. [PMID: 26671754 DOI: 10.1111/cge.12711] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/25/2015] [Accepted: 12/06/2015] [Indexed: 02/01/2023]
Abstract
Clinical heterogeneity in cystic fibrosis (CF) often causes diagnostic uncertainty in infants without symptoms and in older patients with milder phenotypes. We performed a cross-sectional evaluation of a comprehensive set of clinical and laboratory descriptors in a physician-defined cohort (N = 376; Children's Hospital of Wisconsin and the American Family Children's Hospital CF centers in Milwaukee and Madison, WI, USA) to determine the robustness of categorizing CF (N = 300), cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (N = 19), and CFTR-related (CRMS) metabolic syndrome (N = 57) according to current consensus guidelines. Outcome measures included patient demographics, clinical measures, sweat chloride levels, CFTR genotype, age at diagnosis, airway microbiology, pancreatic function, infection, and nutritional status. The CF cohort had a significantly higher median sweat chloride level (105 mmol/l) than CFTR-related disorder patients (43 mmol/l) and CFTR-related metabolic syndrome patients (35 mmol/l; p ≤ 0.001). Patient groups significantly differed in pancreatic sufficiency, immunoreactive trypsinogen levels, sweat chloride values, genotype, and positive Pseudomonas aeruginosa cultures (p ≤ 0.001). An automated classification algorithm using recursive partitioning demonstrated concordance between physician diagnoses and consensus guidelines. Our analysis suggests that integrating clinical information with sweat chloride levels, CFTR genotype, and pancreatic sufficiency provides a context for continued longitudinal monitoring of patients for personalized and effective treatment.
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Affiliation(s)
- H Levy
- Children's Research Institute, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Pulmonary and Sleep Medicine, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - M Nugent
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - K Schneck
- Children's Research Institute, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - D Stachiw-Hietpas
- Genetics Center, Children's Hospital and Health System of Wisconsin, Milwaukee, WI, USA
| | - A Laxova
- Department of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - O Lakser
- Department of Pediatrics, Section of Pulmonary Medicine, Lurie's Children's Hospital and Northwestern University, Chicago, IL, USA
| | - M Rock
- Department of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - M K Dahmer
- Children's Research Institute, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - J Biller
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - S Z Nasr
- Division of Pediatric Pulmonary Medicine, University of Michigan, Ann Arbor, MI, USA
| | - M Baker
- Wisconsin State Lab of Hygiene, Madison, WI, USA.,Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - S A McColley
- Department of Pediatrics, Section of Pulmonary Medicine, Lurie's Children's Hospital and Northwestern University, Chicago, IL, USA
| | - P Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - P M Farrell
- Department of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Abstract
Cystic Fibrosis (CF) is a rare, multisystem disease leading to significant morbidity and mortality. CF is caused by defects in the cystic fibrosis transmembrane conductance regulator protein (CFTR), a chloride and bicarbonate transporter. Early diagnosis and access to therapies provides benefits in nutrition, pulmonary health, and cognitive ability. Several screening and diagnostic tests are available to support a diagnosis. We discuss the characteristics of screening and diagnostic tests for CF and guideline-based algorithms using these tools to establish a diagnosis. We discuss classification and management of common "diagnostic dilemmas," including the CFTR-related metabolic syndrome and other CFTR-associated diseases.
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Affiliation(s)
- John Brewington
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J P Clancy
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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25
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Cystic Fibrosis Screen Positive, Inconclusive Diagnosis (CFSPID): A new designation and management recommendations for infants with an inconclusive diagnosis following newborn screening. J Cyst Fibros 2015; 14:706-13. [DOI: 10.1016/j.jcf.2015.01.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/29/2014] [Accepted: 01/08/2015] [Indexed: 11/24/2022]
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27
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Levy H, Farrell PM. New challenges in the diagnosis and management of cystic fibrosis. J Pediatr 2015; 166:1337-41. [PMID: 26008169 PMCID: PMC4477509 DOI: 10.1016/j.jpeds.2015.03.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/19/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Hara Levy
- Division of Pulmonary Medicine, Department of Pediatrics, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center, Madison, Wisconsin
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28
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Groves T, Robinson P, Wiley V, Fitzgerald DA. Long-term outcomes of children with intermediate sweat chloride values in infancy. J Pediatr 2015; 166:1469-74.e1-3. [PMID: 25812778 DOI: 10.1016/j.jpeds.2015.01.052] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 01/15/2015] [Accepted: 01/28/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the clinical course of children who have intermediate sweat chloride values on initial screening for cystic fibrosis (CF). STUDY DESIGN We performed a retrospective review of children with intermediate sweat chloride values (raised immunoreactive trypsinogen/1 copy of p.F508del CF mutation on newborn screening (NBS)/sweat chloride value of 30-59 mmol/L) presenting to The Children's Hospital at Westmead over 15 years. Patients with an intermediate sweat chloride evolving to a formal diagnosis of CF (termed "delayed CF") were matched (2:1) with NBS positive patients with CF (termed "NBS positive CF"). Clinical outcomes were compared. RESULTS Fourteen of 29 (48%, 95% CI 0.3-0.66) patients with intermediate sweat chloride value evolved to a diagnosis of CF and were matched with 28 NBS positive patients with CF. Delayed CF had less pancreatic insufficiency (OR 0.06, 95% CI 0.01-0.44, P = .006), less colonization with nonmucoid Pseudomonas aeruginosa (OR 0.04, 95% CI 0.01-0.38, P = .005), milder obstructive lung disease (forced expiratory volume in 1 second/forced vital capacity ratio), and overall disease severity (Shwachman scores) at 10 years (mean difference 5.93, 95% CI 0.39-11.46, P = .04; mean difference 4.72, 95% CI 0.9-8.53, P = .015, respectively). Nutritional outcomes were better at 2 years for delayed CF but did not persist to later ages. CONCLUSIONS In this cohort, approximately one-half of infants with intermediate sweat chloride value were later diagnosed with CF. The clinical course of delayed CF was milder in some aspects compared with NBS positive CF. These results emphasize the importance of ongoing follow-up of infants with intermediate sweat chloride values.
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Affiliation(s)
- Tyler Groves
- Sydney Medical School, University of Sydney, New South Wales, Australia; Department of Respiratory Medicine, The Children's Hospital at Westmead, New South Wales, Australia.
| | - Paul Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, New South Wales, Australia; Discipline of Pediatrics and Child Health, Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Veronica Wiley
- Discipline of Pediatrics and Child Health, Sydney Medical School, University of Sydney, New South Wales, Australia; New South Wales Newborn Screening Program, The Children's Hospital at Westmead, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, New South Wales, Australia; Discipline of Pediatrics and Child Health, Sydney Medical School, University of Sydney, New South Wales, Australia
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Abstract
Cystic fibrosis is an autosomal recessive, monogenetic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The gene defect was first described 25 years ago and much progress has been made since then in our understanding of how CFTR mutations cause disease and how this can be addressed therapeutically. CFTR is a transmembrane protein that transports ions across the surface of epithelial cells. CFTR dysfunction affects many organs; however, lung disease is responsible for the vast majority of morbidity and mortality in patients with cystic fibrosis. Prenatal diagnostics, newborn screening and new treatment algorithms are changing the incidence and the prevalence of the disease. Until recently, the standard of care in cystic fibrosis treatment focused on preventing and treating complications of the disease; now, novel treatment strategies directly targeting the ion channel abnormality are becoming available and it will be important to evaluate how these treatments affect disease progression and the quality of life of patients. In this Primer, we summarize the current knowledge, and provide an outlook on how cystic fibrosis clinical care and research will be affected by new knowledge and therapeutic options in the near future. For an illustrated summary of this Primer, visit: http://go.nature.com/4VrefN.
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Improving newborn screening for cystic fibrosis using next-generation sequencing technology: a technical feasibility study. Genet Med 2015; 18:231-8. [PMID: 25674778 DOI: 10.1038/gim.2014.209] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 12/22/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Many regions have implemented newborn screening (NBS) for cystic fibrosis (CF) using a limited panel of cystic fibrosis transmembrane regulator (CFTR) mutations after immunoreactive trypsinogen (IRT) analysis. We sought to assess the feasibility of further improving the screening using next-generation sequencing (NGS) technology. METHODS An NGS assay was used to detect 162 CFTR mutations/variants characterized by the CFTR2 project. We used 67 dried blood spots (DBSs) containing 48 distinct CFTR mutations to validate the assay. NGS assay was retrospectively performed on 165 CF screen-positive samples with one CFTR mutation. RESULTS The NGS assay was successfully performed using DNA isolated from DBSs, and it correctly detected all CFTR mutations in the validation. Among 165 screen-positive infants with one CFTR mutation, no additional disease-causing mutation was identified in 151 samples consistent with normal sweat tests. Five infants had a CF-causing mutation that was not included in this panel, and nine with two CF-causing mutations were identified. CONCLUSION The NGS assay was 100% concordant with traditional methods. Retrospective analysis results indicate an IRT/NGS screening algorithm would enable high sensitivity, better specificity and positive predictive value (PPV). This study lays the foundation for prospective studies and for introducing NGS in NBS laboratories.
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Ren CL, Parad R, Borowitz D. Indeterminate cystic fibrosis newborn screening results. Pediatr Pulmonol 2015; 50:209-10. [PMID: 24760681 DOI: 10.1002/ppul.23055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/17/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Clement L Ren
- Department of Pediatrics, University of Rochester, Rochester, New York
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Massie J, Gillam L. Uncertain diagnosis after newborn screening for cystic fibrosis: An ethics-based approach to a clinical dilemma. Pediatr Pulmonol 2014; 49:1-7. [PMID: 24166986 DOI: 10.1002/ppul.22933] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 08/18/2013] [Indexed: 11/05/2022]
Abstract
There is uncertainty about the diagnosis of cystic fibrosis after newborn screening (NBS) for some babies, either because of an intermediate sweat chloride test or inconclusive gene mutation analysis. There is considerable difficulty knowing how best to manage these babies, some of whom will develop cystic fibrosis, but many not. This article offers an ethics-based approach to this clinical dilemma that should be helpful to clinicians managing the baby with an uncertain diagnosis of cystic fibrosis after NBS.
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Affiliation(s)
- John Massie
- Department of Respiratory Medicine, Royal Children's Hospital, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Children's Bioethics Centre, Royal Children's Hospital, Parkville, Victoria, Australia
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Kawoosa MS, Bhat MA, Ali SW, Hafeez I, Shastri S. Clinical and mutation profile of children with cystic fibrosis in Jammu and Kashmir. Indian Pediatr 2013; 51:185-9. [PMID: 24277965 DOI: 10.1007/s13312-014-0381-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 09/05/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the clinical and mutation profiles of children with cystic fibrosis in Jammu and Kashmir. METHODS One hundred consecutive patients presenting with one or more phenotypic features suggestive of cystic fibrosis (CF) were screened by quantitative sweat chloride testing. For patients with positive/equivocal test result on two occasions, CFTR gene mutation analysis was done by polymerase chain reaction. RESULTS Of the 100 patients, 18 (10 females) were diagnosed to have CF at a median age of 10.5 y (IQR 4.75-15.25 y) while the median age at the onset of symptoms was 12 mo (IQR 4-63 mo) with a delay in diagnosis by 102.4±80.5 months. Clinical features at presentation included failure to thrive (94.4%), chronic cough (78%), recurrent pneumonia (61%), persistent pneumonia (11%), and chronic diarrhea (50%). Positive sweat chloride (>60 meq/L) was seen in 14 (14%) patients and 4 (4%) patients had equivocal (40-60 meq/L) value on two different occasions. Mutational analysis done in 15 patients showed DeltaF508 mutation in 20% (3/15) patients in homozygous form and in 13% (2/15) patients in heterozygous form. Intron 19 mutation 3849+10kb C>T was found in 40% (6/15) in heterozygous form. One (6.6%) patient had DeltaF508 and 3849+10kbC>T mutations in compound heterozygous form. Patients with equivocal sweat chloride and 3849+10kbC>T mutation had delayed onset of pulmonary involvement. CONCLUSION 3849 +10kbC>T mutation appears to be common in children with cystic fibrosis in Jammu and Kashmir followed by DeltaF508, although the data are quite limited. Although presentation is delayed and sweat chloride is in the equivocal range, severe lung involvement may occur in these patients.
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Affiliation(s)
- Masarat Sultana Kawoosa
- Department of Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India and *Department of Genetics, All India Institute of Medical Sciences, New Delhi, India. Correspondence to: Prof Mushtaq Ahmad Bhat, Department of Pediatrics, Sheri Kashmir Institute of Medical Sciences, Srinagar Kashmir, India.
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Leonardi S, Praticò AD, Rotolo N, Di Dio G, Lionetti E, La Rosa M. Early acute pancreatitis in a child with compound heterozygosis ∆F508/R1438W/Y1032C cystic fibrosis: a case report. J Med Case Rep 2013; 7:188. [PMID: 23883480 PMCID: PMC3750286 DOI: 10.1186/1752-1947-7-188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 06/11/2013] [Indexed: 11/14/2022] Open
Abstract
Introduction Recent studies suggest an important role of the cystic fibrosis transmembrane conductance regulator gene in the development of pancreatitis. It occurs approximately in 20% of patients with cystic fibrosis and almost exclusively in pancreatic sufficient people. Newborn screening and improved panels of deoxyribonucleic acid mutation analysis techniques are revealing more rare and nonclassical pictures of the disease, generally associated with pancreatic sufficiency and with an increased risk of developing pancreatitis. Mutations R1438 and Y1032 are considered rare mutations, and, when singularly associated with ∆F508, lead to a mild phenotype with pancreatic sufficiency and no detectable respiratory involvement. Case presentation We present the case of a Caucasian girl, aged six years, whose genotype was characterized by three different mutations ∆F508, R1438W and Y1032C, never reported, together, in the same patient. She presented with a positive immunoreactive trypsinogen screening, a borderline sweat test, and, in the first years, a favorable pulmonary course, and pancreatic sufficiency. At the age of six years, she presented with a sudden episode of acute abdominal pain, anorexia and fever. A diagnosis of pancreatitis was made after clinical and laboratory examinations. Venous rehydration, bowel rest and therapy with ursodeoxycholic acid resulted in complete remission. The treatment was successful, with normalization of her symptoms and laboratory parameters within four weeks. Conclusion There has been a vast expansion in the understanding of the wide range of phenotypes associated with cystic fibrosis transmembrane conductance regulator dysfunction since the discovery of the cystic fibrosis transmembrane conductance regulator gene. The genotype-phenotype correlation in pancreatitis is rare compared to other organ manifestations, since this is seen almost exclusively among pancreatic sufficient patients with cystic fibrosis. Our study supports that compound heterozygosis ∆F508-R1438W/Y1032C is a 'cystic fibrosis-causing genotype' characterized by an immunoreactive trypsinogen positive screening, abnormal sweat chloride testing, and pancreatic sufficiency, with an increased risk of acute pancreatitis at an early age.
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Affiliation(s)
- Salvatore Leonardi
- Department of Medical and Pediatric Science, Unit of Broncho-Pneumology and Cystic Fibrosis, University of Catania, Via Santa Sofia 78, Catania 95123, Italy.
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Abstract
The Clinical and Functional Translation of CFTR (CFTR2) project presents a novel approach to clinical and functional annotation of mutations identified in disease-causing genes. Phenotype and genotype information on approximately 40,000 cystic fibrosis (CF) patients were collected from registries and large clinics. The disease-liability of the 160 most frequently reported mutations was evaluated by means of a multistage process which involved clinical (sweat chloride average), functional (expression in cell-based systems) and epidemiological (mutation analysis in obligate heterozygotes) steps. The results of this analysis can be consulted in a dedicated website. Data originated by CFTR2 may be valuable in several facets of CF care, including diagnosis, newborn screening, carrier testing, genotype/phenotype correlation and mutation-specific therapeutics.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
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Birth prevalence of disorders detectable through newborn screening by race/ethnicity. Genet Med 2012; 14:937-45. [PMID: 22766612 DOI: 10.1038/gim.2012.76] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The purpose of this study was to describe the birth prevalence of genetic disorders among different racial/ethnic groups through population-based newborn screening data. METHODS Between 7 July 2005 and 6 July 2010 newborns in California were screened for selected metabolic, endocrine, hemoglobin, and cystic fibrosis disorders using a blood sample collected via heel stick. The race and ethnicity of each newborn was self-reported by the mother at the time of specimen collection. RESULTS Of 2,282,138 newborns screened, the overall disorder detection rate was 1 in 500 births. The disorder with the highest prevalence among all groups was primary congenital hypothyroidism (1 in 1,706 births). Birth prevalence for specific disorders varied widely among different racial/ethnic groups. CONCLUSION The California newborn screening data offer a unique opportunity to explore the birth prevalence of many genetic disorders across a wide spectrum of racial/ethnicity classifications. The data demonstrate that racial/ethnic subgroups of the California newborn population have very different patterns of heritable disease expression. Determining the birth prevalence of these disorders in California is a first step to understanding the short- and long-term medical and treatment needs faced by affected communities, especially those groups that are impacted by more severe disorders.
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Abstract
PURPOSE OF REVIEW Newborn screening for cystic fibrosis (CF) is now universal in the US and many other countries. The rapid expansion of screening has resulted in numerous publications identifying new challenges for healthcare providers. This review provides an overview of these publications and includes ideas on managing these challenges. RECENT FINDINGS Most CF newborn screening algorithms involve DNA mutation analysis. As screening has expanded, new challenges have been identified related to carrier detection and inconclusive diagnoses. Early descriptions of infants with CF-related metabolic syndrome (CRMS) indicate that the natural history of this condition cannot be predicted. Early identification has also provided an opportunity to better understand the pathophysiology of CF. However, few studies have been conducted in infants with CF to determine optimal therapy and recommendations are largely anecdotal. SUMMARY Newborn screening provides an opportunity to identify and begin treatment early in individuals with CF. Whereas a single, optimal approach to screening does not exist, all programs can benefit from new findings regarding sweat testing, carrier detection, early pathophysiology, and clinical outcomes.
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