Biological Variation of Chloride and Sodium in Sweat Obtained by Pilocarpine Iontophoresis in Adults: How Sure are You About Sweat Test Results?

Diagnosing Cystic Fibrosis in the 21st Century-A Complex and Challenging Task

Cystic fibrosis (CF) is a chronic and potentially life-threatening condition, wherein timely diagnosis assumes paramount significance for the prompt initiation of therapeutic interventions, thereby ameliorating pulmonary function, addressing nutritional deficits, averting complications, mitigating morbidity, and ultimately enhancing the quality of life and extending longevity. This review aims to amalgamate existing knowledge to provide a comprehensive appraisal of contemporary diagnostic modalities pertinent to CF in the 21st century. Deliberations encompass discrete delineations of each diagnostic modality and the elucidation of potential diagnostic quandaries encountered in select instances, as well as the delineation of genotype-phenotype correlations germane to genetic counseling endeavors. The synthesis underscores that, notwithstanding the availability and strides in diagnostic methodologies, including genetic assays, the sweat test (ST) retains its position as the preeminent diagnostic standard for CF, serving as a robust surrogate for CFTR functionality. Prospective clinical investigations in the realm of CF should be orchestrated with the objective of discerning novel diagnostic modalities endowed with heightened specificity and sensitivity.

Soft, skin-interfaced sweat stickers for cystic fibrosis diagnosis and management

The concentration of chloride in sweat remains the most robust biomarker for confirmatory diagnosis of cystic fibrosis (CF), a common life-shortening genetic disorder. Early diagnosis via quantitative assessment of sweat chloride allows prompt initiation of care and is critically important to extend life expectancy and improve quality of life. The collection and analysis of sweat using conventional wrist-strapped devices and iontophoresis can be cumbersome, particularly for infants with fragile skin, who often have insufficient sweat production. Here, we introduce a soft, epidermal microfluidic device ("sweat sticker") designed for the simple and rapid collection and analysis of sweat. Intimate, conformal coupling with the skin supports nearly perfect efficiency in sweat collection without leakage. Real-time image analysis of chloride reagents allows for quantitative assessment of chloride concentrations using a smartphone camera, without requiring extraction of sweat or external analysis. Clinical validation studies involving patients with CF and healthy subjects, across a spectrum of age groups, support clinical equivalence compared to existing device platforms in terms of accuracy and demonstrate meaningful reductions in rates of leakage. The wearable microfluidic technologies and smartphone-based analytics reported here establish the foundation for diagnosis of CF outside of clinical settings.

A thermal activated and differential self-calibrated flexible epidermal biomicrofluidic device for wearable accurate blood glucose monitoring

This paper reports a flexible electronics-based epidermal biomicrofluidics technique for clinical continuous blood glucose monitoring, overcoming the drawback of the present wearables, unreliable measurements. A thermal activation method is proposed to improve the efficiency of transdermal interstitial fluid (ISF) extraction, enabling extraction with a low current density to notably reduce skin irritation. An Na⁺ sensor and a correction model are proposed to eliminate the effect of individual differences, which leads to fluctuations in the amount of ISF extraction. An electrochemical sensor with a 3D nanostructured working electrode surface is designed to enable precise in situ glucose measurement. A differential structure is proposed to eliminate the effect of passive perspiration, which leads to inaccurate blood glucose prediction. Fabrications of the epidermal biomicrofluidic device including formation of flexible electrodes, nanomaterial modification, and enzyme immobilization are fully realized by inkjet printing to enable facile manufacturing with low cost, which benefits practical production.

The Dynamic Response of Sweat Chloride to Changes in Exercise Load Measured by a Wearable Sweat Sensor

Wearable sensors enable the monitoring of an individual’s sweat composition in real time. In this work, we recorded real-time sweat chloride concentration for 12 healthy subjects in three different protocols involving step changes in exercise load and compared the results to laboratory-based analysis. The sensor results reflected the changes in exercise load in real time. On increasing the exercise load from 100 W to 200 W the sweat chloride concentration increased from 12.0 ± 5.9 to 31.4 ± 16 mM (mean ± SD). On decreasing the load from 200 W to 100 W, the sweat chloride concentration decreased from 27.7 ± 10.5 to 14.8 ± 8.1 mM. The half-time associated with the change in sweat chloride, defined as the time at which the concentration reached half of the overall change, was about 6 minutes. While the changes in sweat chloride were statistically significant, there was no correlation with changes in sweat rate or other physiological parameters, which we attribute to intra-individual variation (SD = 1.6–8.1 mM). The response to exercise-induced sweating was significantly different to chemically-induced sweating where the sweat chloride concentration was almost independent of sweat rate. We speculate that this difference is related to changes in the open probability of the CFTR channel during exercise, resulting in a decrease in reabsorption efficiency at higher sweat rates.

Out-of-clinic measurement of sweat chloride using a wearable sensor during low-intensity exercise

Wearable sensors have the potential to enable measurement of sweat chloride outside the clinic. Here we assess the feasibility of mild exercise as an alternative to pilocarpine iontophoresis for sweat generation. The results from this proof-of-concept study suggest that mild exercise could be a feasible approach to obtain reliable measurements of sweat chloride concentration within 20-30 min using a wearable sensor.

Fluid-permeable enzymatic lactate sensors for micro-volume specimen

Sensing of lactate in perspiration provides a way to monitor health and control exercise. The volume of perspiration is miniscule, and the efficient collection of perspiration is desired for its effective sensing. We developed mesh-type enzymatic electrodes fabricated on textile meshes and integrated the meshes into an enzymatic biofuel cell. We tested them as self-powered lactate sensors for a small volume of lactate solution. A fluid-permeable enzymatic anode was fabricated based on an insulating textile mesh that was coated with carbon nanotubes (CNTs) and lactate oxidase. The anode was further coated with polyurethane to increase the linear range by limiting the diffusion of lactate while maintaining the advantages of the original textile mesh, such as flexibility, stretchability, and permeability. Permeability of the mesh-type lactate-oxidizing anode allowed a vertically stacked structure of the anode and a previously developed air-breathing cathode. This resulted in a small overall device size (1 cm2). The mesh-type sensor was tested using a small flow rate of lactate solution, and a moderate linearity of amperometric response for a wide concentration range (5 to ≥20 mM) was confirmed. The fluid-permeable anode and enzymatic biofuel cell show the potential of the sensor for continuous monitoring of lactate in perspiration on skin.

Intra-individual biological variation in sweat chloride concentrations in CF, CFTR dysfunction, and healthy pediatric subjects

BACKGROUND

The sweat test is one of the main diagnostic tools used in newborn screening programs and as a confirmatory test, in case of suspect of Cystic Fibrosis (CF). Since sweat chloride (Cl) concentration is also considered an appropriate parameter to explore the efficacy of CFTR modulators in clinical trials, it is crucial to evaluate the biological variability of this test in healthy and pathological conditions. The aim of this pilot study was to determine the intra-individual biological variability of sweat Cl, both in healthy individuals and CF patients and to assess its correlation with diet, season, and menstrual cycle.

METHODS

Thirty-five out of 36 selected subjects (6-18 years) were enrolled by 2 CF care centers and assigned to 3 cohorts: CF, CFTR-related disorder (CFTR-RD) and healthy volunteers. Each participant was subjected to eight sweat tests in different conditions and time of the year. Data were analyzed using linear mixed effects models for repeated measures, taking also into account intra-individual correlations.

RESULTS

We observed a high intra-individual variability of sweat Cl, with the lowest mean CV% values among CF patients (20.21 in CF, 29.74 in CFTR-RD, and 31.15 in healthy subjects). Gender and diet had no influence on sweat Cl variability, nor had pubertal age and menstrual phase.

CONCLUSION

Results of this pilot study confirmed that sweat Cl variability is high in CF patients, although non-CF individuals displayed even higher mean CV% values. Season significantly influenced sweat test values only in CF patients, likely due to changes in their hydration status.

Analytical and biological variation in repeated sweat chloride concentrations in clinical trials for CFTR modulator therapy

BACKGROUND

Using sweat chloride as a biomarker for CFTR modifying drugs requires knowledge of analytical and biological variation.

METHODS

979 sweat chloride concentrations from 128 subjects enrolled in the placebo arm of 2 multicenter, investigational drug trials were analyzed to determine coefficients of variation (CV) as well as reference change value (RCV) and index of individuality (II).

RESULTS

For these populations, calculated values for the two studies were: analytical variation (3.9, 4.1%); within-subject variation (4.4, 6.0%); between-subject variation (8.9, 7.0%); RCV (13.7, 17.0%) and II (0.7, 1.0). Sweat chloride variation was not affected by sex, collection site or sample weight; but was slightly affected by age in one of the two studies.

CONCLUSION

Through determination of analytical as well as between- and within-subject variation, and with a larger sample size, our data allows improved estimates of the RCV and II, and can contribute to future trials of CFTR modulators and inform the design and interpretation of n of 1 trials in both research and clinical settings.