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Walsh K, Kiosa A, Olupot-Olupot P, Alaroker F, Okiror W, Nakuya M, Tssenyondo T, Aromut D, Okalebo BC, Muhindo R, Mpoya A, George EC, Frost GS, Maitland K. Legume-supplemented feed for children hospitalised with severe malnutrition: a phase II trial. Br J Nutr 2024:1-10. [PMID: 38831516 DOI: 10.1017/s0007114524000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Children hospitalised with severe malnutrition have high mortality and readmission rates post-discharge. Current milk-based formulations target restoring ponderal growth but not the modification of gut barrier integrity or microbiome which increases the risk of gram-negative sepsis and poor outcomes. We propose that legume-based feeds rich in fermentable carbohydrates will promote better gut health and improve overall outcomes. We conducted an open-label phase II trial at Mbale and Soroti Regional Referral Hospitals, Uganda, involving 160 children aged 6 months to 5 years with severe malnutrition (mid-upper arm circumference (MUAC) < 11·5 cm and/or nutritional oedema). Children were randomised to a lactose-free, chickpea-enriched legume paste feed (LF) (n 80) v. WHO standard F75/F100 feeds (n 80). Co-primary outcomes were change in MUAC and mortality to day 90. Secondary outcomes included weight gain (> 5 g/kg/d), de novo development of diarrhoea, time to diarrhoea and oedema resolution. Day 90 MUAC increase was marginally lower in LF v. WHO arm (1·1 cm (interquartile range (IQR) 1·1) v. 1·4 cm (IQR 1·40), P = 0·09); day 90 mortality was similar (11/80 (13·8 %) v. 12/80 (15 %), respectively, OR 0·91 (95 % CI 0·40, 2·07), P = 0·83). There were no differences in any of the other secondary outcomes. Owing to initial poor palatability of the LF, ten children switched to WHO feeds. Per-protocol analysis indicated a trend to lower day 90 mortality and readmission rates in the LF (6/60 (10 %) and 2/60(3 %)) v. WHO feeds (12/71(17·5 %) and 4/71(6 %)). Further refinement of LF and clinical trials are warranted, given the poor outcomes in children with severe malnutrition.
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Affiliation(s)
- Kevin Walsh
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, 6th Floor Commonwealth Building, Hammersmith Campus, DuCane Road, LondonW12, UK
- Department of Nutritional Sciences, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College, LondonSE1 9NH, UK
| | - Akglinta Kiosa
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, 6th Floor Commonwealth Building, Hammersmith Campus, DuCane Road, LondonW12, UK
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
| | - Florence Alaroker
- Soroti Regional Referral Hospital, Hospital Road, PO Box 289, Soroti, Uganda
| | - William Okiror
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
| | - Margaret Nakuya
- Soroti Regional Referral Hospital, Hospital Road, PO Box 289, Soroti, Uganda
| | - Tonny Tssenyondo
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
| | - Denis Aromut
- Soroti Regional Referral Hospital, Hospital Road, PO Box 289, Soroti, Uganda
| | - Bernard Charles Okalebo
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
| | - Ayub Mpoya
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London, London, UK
| | - Gary S Frost
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, 6th Floor Commonwealth Building, Hammersmith Campus, DuCane Road, LondonW12, UK
| | - Kathryn Maitland
- Mbale Clinical Research Institute, Busitema University Faculty of Health Sciences, Mbale Campus, Palissa Road, PO Box 1966, Mbale, Uganda
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Imperial College, Department of Infectious Disease and Institute of Global Health and Innovation, Faculty of Medicine, Imperial College, London, UK
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Kiosia A, Dagbasi A, Berkley JA, Wilding JPH, Prendergast AJ, Li JV, Swann J, Mathers JC, Kerac M, Morrison D, Drake L, Briend A, Maitland K, Frost G. The double burden of malnutrition in individuals: Identifying key challenges and re-thinking research focus. NUTR BULL 2024; 49:132-145. [PMID: 38576109 DOI: 10.1111/nbu.12670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/28/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
The 'double burden of malnutrition' is a global health challenge that increasingly affects populations in both low- and middle-income countries (LMICs). This phenomenon refers to the coexistence of undernutrition and overweight or obesity, as well as other diet-related non-communicable diseases, in the same population, household or even individual. While noteworthy progress has been made in reducing undernutrition in some parts of the world, in many of these areas, the prevalence of overweight and obesity is increasing, particularly in urban areas, resulting in greater numbers of people who were undernourished in childhood and have overweight or obesity in adulthood. This creates a complex and challenging situation for research experts and policymakers who must simultaneously address the public health burdens of undernutrition and overweight/obesity. This review identifies key challenges and limitations in the current research on the double burden of malnutrition in individuals, including the need for a more comprehensive and nuanced understanding of the drivers of malnutrition, the importance of context-specific interventions and the need for greater attention to the food environment and food systems. We advocate for the re-evaluation of research strategies and focus, with a greater emphasis on multidisciplinary and systems approaches and greater attention to the synergistic relationship between the biological, environmental, commercial and socio-economic determinants of malnutrition. Addressing these key challenges can enable us to better comprehend and tackle the multifaceted and dynamic issues of the double burden of malnutrition, particularly in individuals and work towards more effective and sustainable solutions.
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Affiliation(s)
- Agklinta Kiosia
- Section of Nutrition, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Health Data Research Global, HDR UK, London, UK
| | - Aygul Dagbasi
- Section of Nutrition, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - James A Berkley
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Clinical Sciences Centre, Aintree University Hospital, Liverpool, UK
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jia V Li
- Section of Nutrition, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Jon Swann
- School of Human Development and Health, University of Southampton Faculty of Medicine, Southampton, UK
| | - John C Mathers
- Human Nutrition & Exercise Research Centre, Centre for Healthier Lives, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Douglas Morrison
- Scottish Universities Environmental Research Centre, East Kilbride, UK
| | - Lesley Drake
- Partnership for Child Development, School of Public Health, Imperial College London, London, UK
| | - Andre Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Kathryn Maitland
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Surgery and Cancer, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Gary Frost
- Section of Nutrition, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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Ehsan L, Coomes D, Kelly P, Greene AR, Ali SA, Mulenga C, Denno DM, VanBuskirk K, Raghib MF, Mahfuz M, Moore SR, Hossain MS, Ahmed T, Sullivan PB, Moskaluk CA, Syed S. Duodenal quantitative mucosal morphometry in children with environmental enteric dysfunction: a cross-sectional multi-country analysis. Am J Clin Nutr 2024:S0002-9165(24)00450-7. [PMID: 38685382 DOI: 10.1016/j.ajcnut.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 03/08/2024] [Accepted: 04/24/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED), a chronic inflammatory condition of the small intestine, is an important driver of childhood malnutrition globally. Quantifying intestinal morphology in EED allows for exploration of its association with functional and disease outcomes. OBJECTIVE We sought to define morphometric characteristics of childhood EED and determine whether morphology features were associated with disease pathophysiology. METHODS Morphometric measurements and histology were assessed on duodenal biopsy slides for this cross-sectional study from children with EED in Bangladesh, Pakistan, and Zambia (n=69), and those with no pathologic abnormality (NPA; n=8) or celiac disease (n=18) in North America. Immunohistochemistry was also conducted on 46, 8, and 18 biopsy slides, respectively. Linear mixed-effects regression models were used to reveal morphometric differences between EED compared to NPA or celiac disease, and identify associations between morphometry and histology or immunohistochemistry amongst children with EED. RESULTS In duodenal biopsies, median EED villus height (248 μm), crypt depth (299 μm), and villus:crypt (V:C) ratio (0.9) values ranged between those of NPA (396 μm villus height; 246 μm crypt depth; 1.6 V:C ratio) and celiac disease (208 μm villus height; 365 μm crypt depth; 0.5 V:C ratio). Among EED biopsy slides, morphometric assessments were not associated with histologic parameters or immunohistochemical markers, other than pathologist determined subjective semi-quantitative villus architecture. CONCLUSIONS Morphometric analysis of duodenal biopsy slides across geographies identified morphologic features of EED, specifically short villi, elongated crypts, and a smaller V:C ratio relative to NPA slides; although not as severe as in celiac slides. Morphometry did not explain other EED features, suggesting that EED histopathologic processes may be operating independently of morphology. While acknowledging the challenges with obtaining relevant tissue, these data form the basis for further assessments of the role of morphometry in EED.
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Affiliation(s)
- Lubaina Ehsan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA; Department of Pediatric and Adolescent Medicine, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, MI, USA
| | - David Coomes
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK; Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Adam R Greene
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Chola Mulenga
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Muhammad Faraz Raghib
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Mustafa Mahfuz
- Nutritional and Clinical services Division, International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Sean R Moore
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - M Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Peter B Sullivan
- Department of Paediatrics, Children's Hospital, University of Oxford, Oxford, UK
| | | | - Sana Syed
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA; School of Data Science, University of Virginia, Charlottesville, VA, USA.
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Chandwe K, Bwakura-Dangarembizi M, Amadi B, Tawodzera G, Ngosa D, Dzikiti A, Chulu N, Makuyana R, Zyambo K, Mutasa K, Mulenga C, Besa E, Sturgeon JP, Mudzingwa S, Simunyola B, Kazhila L, Zyambo M, Sonkwe H, Mutasa B, Chipunza M, Sauramba V, Langhaug L, Mudenda V, Murch SH, Hill S, Playford RJ, VanBuskirk K, Prendergast AJ, Kelly P. Malnutrition enteropathy in Zambian and Zimbabwean children with severe acute malnutrition: A multi-arm randomized phase II trial. Nat Commun 2024; 15:2910. [PMID: 38632262 PMCID: PMC11024201 DOI: 10.1038/s41467-024-45528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/26/2024] [Indexed: 04/19/2024] Open
Abstract
Malnutrition underlies almost half of all child deaths globally. Severe Acute Malnutrition (SAM) carries unacceptable mortality, particularly if accompanied by infection or medical complications, including enteropathy. We evaluated four interventions for malnutrition enteropathy in a multi-centre phase II multi-arm trial in Zambia and Zimbabwe and completed in 2021. The purpose of this trial was to identify therapies which could be taken forward into phase III trials. Children of either sex were eligible for inclusion if aged 6-59 months and hospitalised with SAM (using WHO definitions: WLZ <-3, and/or MUAC <11.5 cm, and/or bilateral pedal oedema), with written, informed consent from the primary caregiver. We randomised 125 children hospitalised with complicated SAM to 14 days treatment with (i) bovine colostrum (n = 25), (ii) N-acetyl glucosamine (n = 24), (iii) subcutaneous teduglutide (n = 26), (iv) budesonide (n = 25) or (v) standard care only (n = 25). The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin, α1-antitrypsin). Laboratory assessments, but not treatments, were blinded. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P < 0.10. Of 143 children screened, 125 were randomised. Teduglutide reduced the primary endpoint of biomarkers of mucosal damage (effect size -0.89 (90% CI: -1.69,-0.10) P = 0.07), while colostrum (-0.58 (-1.4, 0.23) P = 0.24), N-acetyl glucosamine (-0.20 (-1.01, 0.60) P = 0.67), and budesonide (-0.50 (-1.33, 0.33) P = 0.32) had no significant effect. All interventions proved safe. This work suggests that treatment of enteropathy may be beneficial in children with complicated malnutrition. The trial was registered at ClinicalTrials.gov with the identifier NCT03716115.
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Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Gertrude Tawodzera
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Anesu Dzikiti
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Nivea Chulu
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Robert Makuyana
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Chola Mulenga
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK
| | - Shepherd Mudzingwa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Bwalya Simunyola
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Lydia Kazhila
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Masuzyo Zyambo
- Department of Anaesthesia, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Hazel Sonkwe
- Department of Anaesthesia, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Miyoba Chipunza
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Virginia Sauramba
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Lisa Langhaug
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Victor Mudenda
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | | | - Susan Hill
- Great Ormond Street Hospital, London, UK
| | - Raymond J Playford
- University of West London, Ealing, London, UK
- University College Cork, College Road, Cork, Ireland
| | - Kelley VanBuskirk
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia.
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK.
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Ribeiro SA, Braga EL, Queiroga ML, Clementino MA, Fonseca XM, Belém MO, Magalhães LM, de Sousa JK, de Freitas TM, Veras HN, de Aquino CC, Santos AD, de Moura FR, Dos Santos AA, Havt A, Maciel BL, Lima AA. A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier. J Nutr 2024; 154:1232-1251. [PMID: 38346539 PMCID: PMC11347815 DOI: 10.1016/j.tjnut.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children. OBJECTIVES To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study. METHODS We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7. RESULTS The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period. CONCLUSIONS The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.
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Affiliation(s)
- Samilly A Ribeiro
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil.
| | - Enock Lr Braga
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Marcus L Queiroga
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Marco A Clementino
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Xhaulla Mqc Fonseca
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Mônica O Belém
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Lyvia Mvc Magalhães
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - José K de Sousa
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Thiago M de Freitas
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Herlice N Veras
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Cristiane C de Aquino
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Alan Dc Santos
- Núcleo de Estudos Químicos de Micromoléculas da Amazônia (NEQUIMA), Manaus, Brazil
| | - Flávio Rm de Moura
- Núcleo de Estudos Químicos de Micromoléculas da Amazônia (NEQUIMA), Manaus, Brazil
| | - Armênio A Dos Santos
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Alexandre Havt
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Bruna Ll Maciel
- Nutrition Postgraduation Program, Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Aldo Am Lima
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
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6
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Sturgeon JP, Tome J, Dumbura C, Majo FD, Ngosa D, Mutasa K, Zyambo K, Besa E, Chandwe K, Kapoma C, Mwapenya B, Nathoo KJ, Bourke CD, Ntozini R, Chasekwa B, Smuk M, Bwakura-Dangarembizi M, Amadi B, Kelly P, Prendergast AJ. Inflammation and epithelial repair predict mortality, hospital readmission, and growth recovery in complicated severe acute malnutrition. Sci Transl Med 2024; 16:eadh0673. [PMID: 38416844 PMCID: PMC7615785 DOI: 10.1126/scitranslmed.adh0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/07/2024] [Indexed: 03/01/2024]
Abstract
Severe acute malnutrition (SAM) is the most high-risk form of undernutrition, particularly when children require hospitalization for complications. Complicated SAM is a multisystem disease with high inpatient and postdischarge mortality, especially in children with comorbidities such as HIV; however, the underlying pathogenesis of complicated SAM is poorly understood. Targeted multiplex biomarker analysis in children hospitalized with SAM (n = 264) was conducted on plasma samples, and inflammatory markers were assessed on stool samples taken at recruitment, discharge, and 12 to 24 and 48 weeks after discharge from three hospitals in Zimbabwe and Zambia. Compared with adequately nourished controls (n = 173), we found that at baseline, complicated SAM was characterized by systemic, endothelial, and intestinal inflammation, which was exacerbated by HIV infection. This persisted over 48 weeks despite nutritional recovery and was associated with children's outcomes. Baseline plasma concentrations of vascular endothelial growth factor, glucagon-like peptide-2, and intestinal fatty acid-binding protein were independently associated with lower mortality or hospital readmission over the following 48 weeks. Following principal components analysis of baseline biomarkers, higher scores of a component representing growth factors was associated with greater weight-for-height z score recovery and lower mortality or hospital readmission over the 48 weeks. Conversely, components representing higher gut and systemic inflammation were associated with higher mortality or hospital readmission. These findings highlight the interplay between inflammation, which damages tissues, and growth factors, which mediate endothelial and epithelial regeneration, and support further studies investigating interventions to reduce inflammation and promote epithelial repair as an approach to reducing mortality and improving nutritional recovery.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Benjamin Mwapenya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kusum J Nathoo
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Melanie Smuk
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Paul Kelly
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
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7
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Perlman M, Senger S, Verma S, Carey J, Faherty CS. A foundational approach to culture and analyze malnourished organoids. Gut Microbes 2023; 15:2248713. [PMID: 37724815 PMCID: PMC10512930 DOI: 10.1080/19490976.2023.2248713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/07/2023] [Indexed: 09/21/2023] Open
Abstract
The gastrointestinal (GI) epithelium plays a major role in nutrient absorption, barrier formation, and innate immunity. The development of organoid-based methodology has significantly impacted the study of the GI epithelium, particularly in the fields of mucosal biology, immunity, and host-microbe interactions. Various effects on the GI epithelium, such as genetics and nutrition, impact patients and alter disease states. Thus, incorporating these effects into organoid-based models will facilitate a better understanding of disease progression and offer opportunities to evaluate therapeutic candidates. One condition that has a significant effect on the GI epithelium is malnutrition, and studying the mechanistic impacts of malnutrition would enhance our understanding of several pathologies. Therefore, the goal of this study was to begin to develop methodology to generate viable malnourished organoids with accessible techniques and resources that can be used for a wide array of mechanistic studies. By selectively limiting distinct macronutrient components of organoid media, we were able to successfully culture and evaluate malnourished organoids. Genetic and protein-based analyses were used to validate the approach and confirm the presence of known biomarkers of malnutrition. Additionally, as proof-of-concept, we utilized malnourished organoid-derived monolayers to evaluate the effect of malnourishment on barrier formation and the ability of the bacterial pathogen Shigella flexneri to infect the GI epithelium. This work serves as the basis for new and exciting techniques to alter the nutritional state of organoids and investigate the related impacts on the GI epithelium.
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Affiliation(s)
- Meryl Perlman
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Stefania Senger
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA, USA
| | - Smriti Verma
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - James Carey
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA, USA
| | - Christina S. Faherty
- Mucosal Immunology and Biology Research Center, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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8
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Sturgeon JP, Njunge JM, Bourke CD, Gonzales GB, Robertson RC, Bwakura-Dangarembizi M, Berkley JA, Kelly P, Prendergast AJ. Inflammation: the driver of poor outcomes among children with severe acute malnutrition? Nutr Rev 2023; 81:1636-1652. [PMID: 36977352 PMCID: PMC10639108 DOI: 10.1093/nutrit/nuad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - James M Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ruairi C Robertson
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | | | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Paul Kelly
- is with the Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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9
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Martínez-Oca P, Alba C, Sánchez-Roncero A, Fernández-Marcelo T, Martín MÁ, Escrivá F, Rodríguez JM, Álvarez C, Fernández-Millán E. Maternal Diet Determines Milk Microbiome Composition and Offspring Gut Colonization in Wistar Rats. Nutrients 2023; 15:4322. [PMID: 37892398 PMCID: PMC10609248 DOI: 10.3390/nu15204322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Mother's milk contains a unique microbiome that plays a relevant role in offspring health. We hypothesize that maternal malnutrition during lactation might impact the microbial composition of milk and affect adequate offspring gut colonization, increasing the risk for later onset diseases. Then, Wistar rats were fed ad libitum (Control, C) food restriction (Undernourished, U) during gestation and lactation. After birth, offspring feces and milk stomach content were collected at lactating day (L)4, L14 and L18. The V3-V4 region of the bacterial 16S rRNA gene was sequenced to characterize bacterial communities. An analysis of beta diversity revealed significant disparities in microbial composition between groups of diet at L4 and L18 in both milk, and fecal samples. In total, 24 phyla were identified in milk and 18 were identified in feces, with Firmicutes, Proteobacteria, Actinobacteroidota and Bacteroidota collectively representing 96.1% and 97.4% of those identified, respectively. A higher abundance of Pasteurellaceae and Porphyromonas at L4, and of Gemella and Enterococcus at L18 were registered in milk samples from the U group. Lactobacillus was also significantly more abundant in fecal samples of the U group at L4. These microbial changes compromised the number and variety of milk-feces or feces-feces bacterial correlations. Moreover, increased offspring gut permeability and an altered expression of goblet cell markers TFF3 and KLF3 were observed in U pups. Our results suggest that altered microbial communication between mother and offspring through breastfeeding may explain, in part, the detrimental consequences of maternal malnutrition on offspring programming.
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Affiliation(s)
- Paula Martínez-Oca
- Instituto de Investigación en Ciencias de la Alimentación (CIAL), Campus de Excelencia Científica, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid (CSIC-UAM), 28049 Madrid, Spain;
| | - Claudio Alba
- Department of Nutrition and Food Science, Faculty of Veterinary Sciences, University Complutense of Madrid, 28040 Madrid, Spain; (C.A.); (J.M.R.)
| | - Alicia Sánchez-Roncero
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy, Complutense University of Madrid, 28040 Madrid, Spain; (A.S.-R.); (F.E.); (C.Á.)
| | - Tamara Fernández-Marcelo
- Centro de Investigación Biomédica en Red (CIBERDEM), ISCIII, 28029 Madrid, Spain; (T.F.-M.); (M.Á.M.)
| | - María Ángeles Martín
- Centro de Investigación Biomédica en Red (CIBERDEM), ISCIII, 28029 Madrid, Spain; (T.F.-M.); (M.Á.M.)
- Department of Metabolism and Nutrition, Institute of Food Science and Technology and Nutrition (ICTAN), Consejo Superior de Investigaciones Científicas (CSIC), 28040 Madrid, Spain
| | - Fernando Escrivá
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy, Complutense University of Madrid, 28040 Madrid, Spain; (A.S.-R.); (F.E.); (C.Á.)
- Centro de Investigación Biomédica en Red (CIBERDEM), ISCIII, 28029 Madrid, Spain; (T.F.-M.); (M.Á.M.)
| | - Juan Miguel Rodríguez
- Department of Nutrition and Food Science, Faculty of Veterinary Sciences, University Complutense of Madrid, 28040 Madrid, Spain; (C.A.); (J.M.R.)
| | - Carmen Álvarez
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy, Complutense University of Madrid, 28040 Madrid, Spain; (A.S.-R.); (F.E.); (C.Á.)
- Centro de Investigación Biomédica en Red (CIBERDEM), ISCIII, 28029 Madrid, Spain; (T.F.-M.); (M.Á.M.)
| | - Elisa Fernández-Millán
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy, Complutense University of Madrid, 28040 Madrid, Spain; (A.S.-R.); (F.E.); (C.Á.)
- Centro de Investigación Biomédica en Red (CIBERDEM), ISCIII, 28029 Madrid, Spain; (T.F.-M.); (M.Á.M.)
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10
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Ling C, Versloot CJ, Arvidsson Kvissberg ME, Hu G, Swain N, Horcas-Nieto JM, Miraglia E, Thind MK, Farooqui A, Gerding A, van Eunen K, Koster MH, Kloosterhuis NJ, Chi L, ChenMi Y, Langelaar-Makkinje M, Bourdon C, Swann J, Smit M, de Bruin A, Youssef SA, Feenstra M, van Dijk TH, Thedieck K, Jonker JW, Kim PK, Bakker BM, Bandsma RHJ. Rebalancing of mitochondrial homeostasis through an NAD +-SIRT1 pathway preserves intestinal barrier function in severe malnutrition. EBioMedicine 2023; 96:104809. [PMID: 37738832 PMCID: PMC10520344 DOI: 10.1016/j.ebiom.2023.104809] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND The intestine of children with severe malnutrition (SM) shows structural and functional changes that are linked to increased infection and mortality. SM dysregulates the tryptophan-kynurenine pathway, which may impact processes such as SIRT1- and mTORC1-mediated autophagy and mitochondrial homeostasis. Using a mouse and organoid model of SM, we studied the repercussions of these dysregulations on malnutrition enteropathy and the protective capacity of maintaining autophagy activity and mitochondrial health. METHODS SM was induced through feeding male weanling C57BL/6 mice a low protein diet (LPD) for 14-days. Mice were either treated with the NAD+-precursor, nicotinamide; an mTORC1-inhibitor, rapamycin; a SIRT1-activator, resveratrol; or SIRT1-inhibitor, EX-527. Malnutrition enteropathy was induced in enteric organoids through amino-acid deprivation. Features of and pathways to malnutrition enteropathy were examined, including paracellular permeability, nutrient absorption, and autophagic, mitochondrial, and reactive-oxygen-species (ROS) abnormalities. FINDINGS LPD-feeding and ensuing low-tryptophan availability led to villus atrophy, nutrient malabsorption, and intestinal barrier dysfunction. In LPD-fed mice, nicotinamide-supplementation was linked to SIRT1-mediated activation of mitophagy, which reduced damaged mitochondria, and improved intestinal barrier function. Inhibition of mTORC1 reduced intestinal barrier dysfunction and nutrient malabsorption. Findings were validated and extended using an organoid model, demonstrating that resolution of mitochondrial ROS resolved barrier dysfunction. INTERPRETATION Malnutrition enteropathy arises from a dysregulation of the SIRT1 and mTORC1 pathways, leading to disrupted autophagy, mitochondrial homeostasis, and ROS. Whether nicotinamide-supplementation in children with SM could ameliorate malnutrition enteropathy should be explored in clinical trials. FUNDING This work was supported by the Bill and Melinda Gates Foundation, the Sickkids Research Institute, the Canadian Institutes of Health Research, and the University Medical Center Groningen.
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Affiliation(s)
- Catriona Ling
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christian J Versloot
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Matilda E Arvidsson Kvissberg
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Guanlan Hu
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nathan Swain
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - José M Horcas-Nieto
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Emily Miraglia
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Biochemistry, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mehakpreet K Thind
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Amber Farooqui
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Albert Gerding
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands; Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Karen van Eunen
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Mirjam H Koster
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Niels J Kloosterhuis
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Lijun Chi
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - YueYing ChenMi
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Miriam Langelaar-Makkinje
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Celine Bourdon
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jonathan Swann
- Faculty of Medicine, School of Human Development and Health, University of Southampton, United Kingdom; Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, United Kingdom
| | - Marieke Smit
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Alain de Bruin
- Department of Biomolecular Health Sciences, Dutch Molecular Pathology Centre, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Sameh A Youssef
- Department of Biomolecular Health Sciences, Dutch Molecular Pathology Centre, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands; Janssen Pharmaceutica Research and Development, 2340, Beerse, Belgium
| | - Marjon Feenstra
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Theo H van Dijk
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Kathrin Thedieck
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands; Institute of Biochemistry and Center for Molecular Biosciences Innsbruck, University of Innsbruck, Innsbruck, Austria; Freiburg Materials Research Center (FMF), University Freiburg, Freiburg, Germany
| | - Johan W Jonker
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Peter K Kim
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Barbara M Bakker
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Robert H J Bandsma
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands; Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.
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11
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Weckman AM, McDonald CR, Ngai M, Richard-Greenblatt M, Leligdowicz A, Conroy AL, Kain KC, Namasopo S, Hawkes MT. Inflammatory profiles in febrile children with moderate and severe malnutrition presenting at-hospital in Uganda are associated with increased mortality. EBioMedicine 2023; 94:104721. [PMID: 37467665 PMCID: PMC10373657 DOI: 10.1016/j.ebiom.2023.104721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Children in Africa carry a disproportionate burden of malnutrition and infectious disease. Together, malnutrition and infection are major contributors to global child mortality; however, their collective impact on immune activation are not well described. METHODS This was a secondary analysis of a prospective cohort study of children hospitalized with acute febrile illness at a single centre in Uganda. We investigated the association between malnutrition (determined using the mid-upper arm circumference, MUAC), immune activation (as measured by inflammatory markers IL-6, IL-8, CXCL10, CHI3L1, sTNFR1, Cystatin C, granzyme B, and sTREM-1), and mortality. FINDINGS Of the 1850 children eligible for this secondary analysis, 71 (3.8%) and 145 (11.7%) presented with severe acute malnutrition (SAM, MUAC <115 mm) and moderate malnutrition (MUAC 115 to < 125 mm), respectively. SAM was associated with increased concentrations of CHI3L1, sTNFR1, Cystatin C, and sTREM-1, and decreased concentrations of CXCL10 and granzyme B, even after controlling for age, sex, and disease severity at presentation. There were 77 deaths (4.2%). SAM was associated with a 9.2-fold (95% CI 4.8-46), 17-fold (95% CI 3.9-74), and 13-fold (95% CI 3.5-52) increased odds of death in children with pneumonia, malaria, and diarrheal illness, respectively. Mediation analysis implicated sTREM-1 and CHI3L1 in the effect of SAM on mortality, suggesting that enhanced activation of these inflammatory pathways is associated with the increased mortality in undernourished children with pneumonia and malaria. INTERPRETATION Collectively, these data highlight systemic inflammation as a common pathway associated with malnutrition and infection that could be targeted to mitigate the burden of acute febrile illness in LMICs. FUNDING This work was supported in part by the Canadian Institutes of Health Research, and by kind donations from The Tesari Foundation and Kim Kertland. The funders had no role in design, analysis, or reporting of these studies.
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Affiliation(s)
- Andrea M Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Melissa Richard-Greenblatt
- Public Health Ontario, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Aleksandra Leligdowicz
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University and Robarts Research Institute, Western University, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Kevin C Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada; Toronto General Hospital Research Institute, University Health Network, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada; Toronto General Research Institute, Toronto General Hospital, Toronto, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; School of Public Health, University of Alberta, Edmonton, AB, Canada; Distinguished Researcher, Stollery Science Lab, University of Alberta, Edmonton, AB, Canada; Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda; Women and Children's Research Institute, University of Alberta, Edmonton, AB, Canada.
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12
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Horowitz A, Chanez-Paredes SD, Haest X, Turner JR. Paracellular permeability and tight junction regulation in gut health and disease. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00766-3. [PMID: 37186118 PMCID: PMC10127193 DOI: 10.1038/s41575-023-00766-3] [Citation(s) in RCA: 103] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 05/17/2023]
Abstract
Epithelial tight junctions define the paracellular permeability of the intestinal barrier. Molecules can cross the tight junctions via two distinct size-selective and charge-selective paracellular pathways: the pore pathway and the leak pathway. These can be distinguished by their selectivities and differential regulation by immune cells. However, permeability increases measured in most studies are secondary to epithelial damage, which allows non-selective flux via the unrestricted pathway. Restoration of increased unrestricted pathway permeability requires mucosal healing. By contrast, tight junction barrier loss can be reversed by targeted interventions. Specific approaches are needed to restore pore pathway or leak pathway permeability increases. Recent studies have used preclinical disease models to demonstrate the potential of pore pathway or leak pathway barrier restoration in disease. In this Review, we focus on the two paracellular flux pathways that are dependent on the tight junction. We discuss the latest evidence that highlights tight junction components, structures and regulatory mechanisms, their impact on gut health and disease, and opportunities for therapeutic intervention.
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Affiliation(s)
- Arie Horowitz
- UNIROUEN, INSERM U1245, Normandy Centre for Genomic and Personalized Medicine, Normandie University, Rouen, France
| | - Sandra D Chanez-Paredes
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Xenia Haest
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold R Turner
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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13
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Abtahi S, Sailer A, Roland JT, Haest X, Chanez-Paredes SD, Ahmad K, Sadiq K, Iqbal NT, Ali SA, Turner JR. Intestinal Epithelial Digestive, Transport, and Barrier Protein Expression Is Increased in Environmental Enteric Dysfunction. J Transl Med 2023; 103:100036. [PMID: 36870290 PMCID: PMC10121737 DOI: 10.1016/j.labinv.2022.100036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/16/2022] [Indexed: 01/11/2023] Open
Abstract
Environmental enteric dysfunction (EED) is characterized by malabsorption and diarrhea that result in irreversible deficits in physical and intellectual growth. We sought to define the expression of transport and tight junction proteins by quantitative analysis of duodenal biopsies from patients with EED. Biopsies from Pakistani children with confirmed EED diagnoses were compared to those from age-matched North American healthy controls, patients with celiac disease, and patients with nonceliac disease with villous atrophy or intraepithelial lymphocytosis. Expression of brush border digestive and transport proteins and paracellular (tight junction) proteins was assessed by quantitative multiplex immunofluorescence microscopy. EED was characterized by partial villous atrophy and marked intraepithelial lymphocytosis. Epithelial proliferation and enteroendocrine, tuft, and Paneth cell numbers were unchanged, but there was significant goblet cell expansion in EED biopsies. Expression of proteins involved in nutrient and water absorption and that of the basolateral Cl- transport protein NKCC1 were also increased in EED. Finally, the barrier-forming tight junction protein claudin-4 (CLDN4) was significantly upregulated in EED, particularly within villous enterocytes. In contrast, expression of CFTR, CLDN2, CLDN15, JAM-A, occludin, ZO-1, and E-cadherin was unchanged. Upregulation of a barrier-forming tight junction protein and brush border and basolateral membrane proteins that support nutrient and water transport in EED is paradoxical, as their increased expression would be expected to be correlated with increased intestinal barrier function and enhanced absorption, respectively. These data suggest that EED activates adaptive intestinal epithelial responses to enhance nutrient absorption but that these changes are insufficient to restore health.
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Affiliation(s)
- Shabnam Abtahi
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne Sailer
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Joseph T Roland
- Epithelial Biology Center, Vanderbilt University Medical Center; Nashville, Tennessee
| | - Xenia Haest
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sandra D Chanez-Paredes
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kumail Ahmad
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Talat Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jerrold R Turner
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pathology, University of Chicago, Chicago, Illinois.
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14
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Besa E, Tembo MJ, Mulenga C, Mweetwa M, Choudhry N, Chandwe K, Storer C, Head R, Amadi B, Haritunians T, McGovern D, Kwenda G, Peiris M, Kelly P. Potential determinants of low circulating glucagon-like peptide 2 concentrations in Zambian children with non-responsive stunting. Exp Physiol 2023; 108:568-580. [PMID: 36744850 PMCID: PMC10103869 DOI: 10.1113/ep090492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Abstract
NEW FINDINGS What is the central question of this study? Non-responsive stunting is characterised by a progressive decline of circulating glucagon-like peptide 2: what are the possible causes of this decline? What is the main finding and its importance? In contrast with the established loss of Paneth and goblet cells in environmental enteropathy, there was no evidence of a parallel loss of enteroendocrine cells as seen by positive tissue staining for chromogranin A. Transcriptomic and genomic analyses showed evidence of genetic transcripts that could account for some of the variability seen in circulating glucagon-like peptide 2 values. ABSTRACT Nutrient sensing determines digestive and hormonal responses following nutrient ingestion. We have previously reported decreased levels of glucagon-like peptide 2 (GLP-2) in children with stunting. Here we demonstrate the presence of enteroendocrine cells in stunted children and explore potential pathways that may be involved in reduced circulating levels of GLP-2. At the time of performing diagnostic endoscopies for non-responsive stunted children, intestinal biopsies were collected for immunofluorescence staining of enteroendocrine cells and transcriptomic analysis. Circulating levels of GLP-2 were also measured and correlated with transcriptomic data. An exploratory genome-wide association study (GWAS) was conducted on DNA samples (n = 158) to assess genetic contribution to GLP-2 variability. Intestinal tissue sections collected from non-responsive stunted children stained positive for chromogranin A (88/89), alongside G-protein-coupled receptors G-protein receptor 119 (75/87), free fatty acid receptor 3 (76/89) and taste 1 receptor 1 (39/45). Transcriptomic analysis found three pathways correlated with circulating GLP-2: sugar metabolism, epithelial transport, and barrier function, which likely reflect downstream events following receptor-ligand interaction. GWAS analysis revealed potential genetic contributions to GLP-2 half-life and receptor binding. Enteroendocrine cell loss was not identified in stunted Zambian children as has been observed for goblet and Paneth cells. Transcriptomic analysis suggests that GLP-2 has pleiotrophic actions on the intestinal mucosa in malnutrition, but further work is needed to dissect pathways leading to perturbations in nutrient sensing.
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Affiliation(s)
- Ellen Besa
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Mizinga Jacqueline Tembo
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Chola Mulenga
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Monica Mweetwa
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Naheed Choudhry
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Chad Storer
- Genome Technology Access Center at McDonnell Genome InstituteWashington University in St LouisSt LouisMOUSA
| | - Richard Head
- Genome Technology Access Center at McDonnell Genome InstituteWashington University in St LouisSt LouisMOUSA
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
| | - Talin Haritunians
- Cedars‐Sinai Medical CenterInflammatory Bowel and Immunobiology Research InstituteLos AngelesCAUSA
| | - Dermot McGovern
- Cedars‐Sinai Medical CenterInflammatory Bowel and Immunobiology Research InstituteLos AngelesCAUSA
| | - Geoffrey Kwenda
- Department of Biomedical Sciences, School of Health SciencesUniversity of ZambiaLusakaZambia
| | - Madusha Peiris
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, School of MedicineUniversity of ZambiaLusakaZambia
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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15
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Horcas-Nieto JM, Versloot CJ, Langelaar-Makkinje M, Gerding A, Blokzijl T, Koster MH, Baanstra M, Martini IA, Coppes RP, Bourdon C, van Ijzendoorn SCD, Kim P, Bandsma RHJ, Bakker BM. Organoids as a model to study intestinal and liver dysfunction in severe malnutrition. Biochim Biophys Acta Mol Basis Dis 2023; 1869:166635. [PMID: 36581145 DOI: 10.1016/j.bbadis.2022.166635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Affiliation(s)
- José M Horcas-Nieto
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Christian J Versloot
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Miriam Langelaar-Makkinje
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Albert Gerding
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands; Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tjasso Blokzijl
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mirjam H Koster
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Mirjam Baanstra
- Department of Biomedical Sciences of Cell & Systems, Section Molecular Cell Biology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ingrid A Martini
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert P Coppes
- Department of Biomedical Sciences of Cell & Systems, Section Molecular Cell Biology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Céline Bourdon
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sven C D van Ijzendoorn
- Department of Biomedical Sciences of Cell & Systems, Section Molecular Cell Biology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Peter Kim
- Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Robert H J Bandsma
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands; Translational Medicine, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Barbara M Bakker
- Laboratory of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, the Netherlands.
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16
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Hossain MS, Begum SMKN, Rahman MM, Parvez M, Mazumder RN, Sarker SA, Hasan MM, Fahim SM, Gazi MA, Das S, Mahfuz M, Ahmed T. Environmental enteric dysfunction and small intestinal histomorphology of stunted children in Bangladesh. PLoS Negl Trop Dis 2023; 17:e0010472. [PMID: 36656867 PMCID: PMC9888706 DOI: 10.1371/journal.pntd.0010472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/31/2023] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
There is lack of information on the histological characteristics of the intestinal mucosa in Bangladeshi children. Collection of intestinal biopsy samples and assessment of the histomorphological features is considered to be the traditional gold standard for diagnosis of environmental enteric dysfunction (EED). The purpose of the study was to evaluate the intestinal histological characteristics of stunted children aged between 12-18 months with possible EED. 110 children with chronic malnutrition (52 stunted with length-for-age Z score, LAZ<-2 and 58 at risk of stunting with LAZ <-1 to -2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study protocol who underwent upper gastrointestinal (GI) endoscopy were selected for this study. To explore the association of EED with childhood stunting, upper GI endoscopy was done and the biopsy specimens were studied for histopathology. Villous height and crypt depth were measured and the presence and intensity of inflammatory infiltrates in the lamina propria was investigated. Bivariate analysis was performed to examine the relationship between stunting and histologic morphology. More than 90% children irrespective of nutritional status were diagnosed to have chronic non-specific duodenitis on histopathology. Half of the children from both groups had villous atrophy as well as crypt hyperplasia and lymphocytic infiltration was present in more than 90% children, irrespective of groups. However, no statistically significant difference was observed when compared between the groups. The prevalence of chronic non-specific duodenitis in Bangladeshi children, irrespective of nutritional status, was high. A significant number of these children had abnormal findings in intestinal histomorphology. Trial registration number: ClinicalTrials.gov ID: NCT02812615 Date of first registration: 24/06/2016. https://clinicaltrials.gov/ct2/results?cond=NCT02812615&term=&cntry=&state=&city=&dist.
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Affiliation(s)
- Md. Shabab Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | | | - M Masudur Rahman
- Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh
| | - Mashud Parvez
- Department of Pathology, Bangladesh Specialized Hospital, Dhaka, Bangladesh
| | - Ramendra Nath Mazumder
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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17
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Kummerlowe C, Mwakamui S, Hughes TK, Mulugeta N, Mudenda V, Besa E, Zyambo K, Shay JES, Fleming I, Vukovic M, Doran BA, Aicher TP, Wadsworth MH, Bramante JT, Uchida AM, Fardoos R, Asowata OE, Herbert N, Yilmaz ÖH, Kløverpris HN, Garber JJ, Ordovas-Montanes J, Gartner Z, Wallach T, Shalek AK, Kelly P. Single-cell profiling of environmental enteropathy reveals signatures of epithelial remodeling and immune activation. Sci Transl Med 2022; 14:eabi8633. [PMID: 36044598 PMCID: PMC9594855 DOI: 10.1126/scitranslmed.abi8633] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Environmental enteropathy (EE) is a subclinical condition of the small intestine that is highly prevalent in low- and middle-income countries. It is thought to be a key contributing factor to childhood malnutrition, growth stunting, and diminished oral vaccine responses. Although EE has been shown to be the by-product of a recurrent enteric infection, its full pathophysiology remains unclear. Here, we mapped the cellular and molecular correlates of EE by performing high-throughput, single-cell RNA-sequencing on 33 small intestinal biopsies from 11 adults with EE in Lusaka, Zambia (eight HIV-negative and three HIV-positive), six adults without EE in Boston, United States, and two adults in Durban, South Africa, which we complemented with published data from three additional individuals from the same clinical site. We analyzed previously defined bulk-transcriptomic signatures of reduced villus height and decreased microbial translocation in EE and showed that these signatures may be driven by an increased abundance of surface mucosal cells-a gastric-like subset previously implicated in epithelial repair in the gastrointestinal tract. In addition, we determined cell subsets whose fractional abundances associate with EE severity, small intestinal region, and HIV infection. Furthermore, by comparing duodenal EE samples with those from three control cohorts, we identified dysregulated WNT and MAPK signaling in the EE epithelium and increased proinflammatory cytokine gene expression in a T cell subset highly expressing a transcriptional signature of tissue-resident memory cells in the EE cohort. Together, our work elucidates epithelial and immune correlates of EE and nominates cellular and molecular targets for intervention.
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Affiliation(s)
- Conner Kummerlowe
- Program in Computational and Systems Biology, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Simutanyi Mwakamui
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine; Lusaka, Zambia
| | - Travis K. Hughes
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Nolawit Mulugeta
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Victor Mudenda
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine; Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine; Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine; Lusaka, Zambia
| | - Jessica E. S. Shay
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital; Boston, MA, 02114, USA
| | - Ira Fleming
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Marko Vukovic
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Ben A. Doran
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital; Boston, MA 02115, USA
| | - Toby P. Aicher
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | - Marc H. Wadsworth
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
| | | | - Amiko M. Uchida
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital; Boston, MA 02115, USA
- Cancer Immunology and Virology, Dana Farber Cancer Institute; Boston, MA, 02115, USA
- Department of Medicine, Harvard Medical School; Boston MA, 02115, USA
| | - Rabiah Fardoos
- Africa Health Research Institute, Durban, 4001, South Africa
| | | | | | - Ömer H. Yilmaz
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Department of Pathology, MGH, Harvard Medical School, Boston, MA, 02115, USA
| | | | - John J. Garber
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital; Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School; Boston MA, 02115, USA
| | - Jose Ordovas-Montanes
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital; Boston, MA 02115, USA
- Program in Immunology, Harvard Medical School; Boston, MA, 02115, USA
- Harvard Stem Cell Institute; Cambridge, MA, 02138, USA
| | - Zev Gartner
- University of California San Francisco; San Francisco, CA, 94185 USA
| | - Thomas Wallach
- SUNY Downstate Health Sciences University; Department of Pediatrics, Brooklyn, NY, 11203, USA
| | - Alex K. Shalek
- Program in Computational and Systems Biology, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology; Cambridge, MA, 02139, USA
- Ragon Institute of MGH, MIT, and Harvard; Cambridge, MA, 02139, USA
- Broad Institute of MIT and Harvard; Cambridge, MA, 02142, USA
- Department of Pathology, MGH, Harvard Medical School, Boston, MA, 02115, USA
- Program in Immunology, Harvard Medical School; Boston, MA, 02115, USA
| | - Paul Kelly
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital; Boston, MA, 02114, USA
- Blizard Institute, Queen Mary University of London; London E1 2AT, United Kingdom
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18
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Patterson GT, Osorio EY, Peniche A, Dann SM, Cordova E, Preidis GA, Suh JH, Ito I, Saldarriaga OA, Loeffelholz M, Ajami NJ, Travi BL, Melby PC. Pathologic Inflammation in Malnutrition Is Driven by Proinflammatory Intestinal Microbiota, Large Intestine Barrier Dysfunction, and Translocation of Bacterial Lipopolysaccharide. Front Immunol 2022; 13:846155. [PMID: 35720380 PMCID: PMC9204284 DOI: 10.3389/fimmu.2022.846155] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Acute malnutrition, or wasting, is implicated in over half of all deaths in children under five and increases risk of infectious disease. Studies in humans and preclinical models have demonstrated that malnutrition is linked to an immature intestinal microbiota characterized by increased prevalence of Enterobacteriaceae. Observational studies in children with moderate acute malnutrition (MAM) have also observed heightened systemic inflammation and increased circulating bacterial lipopolysaccharides (LPS; endotoxin). However, the mechanisms that underpin the systemic inflammatory state and endotoxemia, and their pathophysiological consequences, remain uncertain. Understanding these pathophysiological mechanisms is necessary to design targeted treatments that will improve the unacceptable rate of failure or relapse that plague current approaches. Here we use a mouse model of MAM to investigate the mechanisms that promote inflammation in the malnourished host. We found that mice with MAM exhibited increased systemic inflammation at baseline, increased translocation of bacteria and bacterial LPS, and an exaggerated response to inflammatory stimuli. An exaggerated response to bacterial LPS was associated with increased acute weight loss. Remarkably, intestinal inflammation and barrier dysfunction was found in the cecum and colon. The cecum showed a dysbiotic microbiota with expansion of Gammaproteobacteria and some Firmicutes, and contraction of Bacteroidetes. These changes were paralleled by an increase in fecal LPS bioactivity. The inflammatory phenotype and weight loss was modulated by oral administration of non-absorbable antibiotics that altered the proportion of cecal Gammaproteobacteria. We propose that the heightened inflammation of acute malnutrition is the result of changes in the intestinal microbiota, intestinal barrier dysfunction in the cecum and colon, and increased systemic exposure to LPS.
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Affiliation(s)
- Grace T Patterson
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Elvia Y Osorio
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Alex Peniche
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Sara M Dann
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Erika Cordova
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Geoffrey A Preidis
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ji Ho Suh
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ichiaki Ito
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Omar A Saldarriaga
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Michael Loeffelholz
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Nadim J Ajami
- The Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Bruno L Travi
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Peter C Melby
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
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19
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Zyambo K, Hodges P, Chandwe K, Chisenga CC, Mayimbo S, Amadi B, Kelly P, Kayamba V. Selenium status in adults and children in Lusaka, Zambia. Heliyon 2022; 8:e09782. [PMID: 35800716 PMCID: PMC9253361 DOI: 10.1016/j.heliyon.2022.e09782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/14/2022] [Accepted: 06/20/2022] [Indexed: 10/26/2022] Open
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20
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Barratt MJ, Nuzhat S, Ahsan K, Frese SA, Arzamasov AA, Sarker SA, Islam MM, Palit P, Islam MR, Hibberd MC, Nakshatri S, Cowardin CA, Guruge JL, Byrne AE, Venkatesh S, Sundaresan V, Henrick B, Duar RM, Mitchell RD, Casaburi G, Prambs J, Flannery R, Mahfuz M, Rodionov DA, Osterman AL, Kyle D, Ahmed T, Gordon JI. Bifidobacterium infantis treatment promotes weight gain in Bangladeshi infants with severe acute malnutrition. Sci Transl Med 2022; 14:eabk1107. [PMID: 35417188 PMCID: PMC9516695 DOI: 10.1126/scitranslmed.abk1107] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Disrupted development of the gut microbiota is a contributing cause of childhood malnutrition. Bifidobacterium longum subspecies infantis is a prominent early colonizer of the infant gut that consumes human milk oligosaccharides (HMOs). We found that the absolute abundance of Bifidobacterium infantis is lower in 3- to 24-month-old Bangladeshi infants with severe acute malnutrition (SAM) compared to their healthy age-matched counterparts. A single-blind, placebo-controlled trial (SYNERGIE) was conducted in 2- to 6-month-old Bangladeshi infants with SAM. A commercial U.S. donor-derived B. infantis strain (EVC001) was administered daily with or without the HMO lacto-N-neotetraose for 28 days. This intervention increased fecal B. infantis abundance in infants with SAM, although to levels still 10- to 100-fold lower than in untreated healthy controls. EVC001 treatment promoted weight gain that was associated with reduced intestinal inflammation markers in infants with SAM. We cultured fecal B. infantis strains from Bangladeshi infants and colonized gnotobiotic mice with these cultured strains. The gnotobiotic mice were fed a diet representative of that consumed by 6-month-old Bangladeshi infants, with or without HMO supplementation. One B. infantis strain, Bg_2D9, expressing two gene clusters involved in uptake and utilization of N-glycans and plant-derived polysaccharides, exhibited superior fitness over EVC001. The fitness advantage of Bg_2D9 was confirmed in a gnotobiotic mouse model of mother-to-infant gut microbiota transmission where dams received a pretreatment fecal community from a SAM infant in the SYNERGIE trial. Whether Bg_2D9 is superior to EVC001 for treating malnourished infants who consume a diet with limited breastmilk requires further clinical testing.
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Affiliation(s)
- Michael J. Barratt
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Sharika Nuzhat
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Kazi Ahsan
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Steven A. Frese
- Evolve BioSystems, Inc., Davis, CA 95618 USA
- Department of Food Science and Technology, University of Nebraska, Lincoln, NE 68588 USA
| | - Aleksandr A. Arzamasov
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
| | - Shafiqul Alam Sarker
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - M. Munirul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Parag Palit
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Md Ridwan Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Matthew C. Hibberd
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Swetha Nakshatri
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Carrie A. Cowardin
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Janaki L. Guruge
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Alexandra E. Byrne
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Siddarth Venkatesh
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Vinaik Sundaresan
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Bethany Henrick
- Evolve BioSystems, Inc., Davis, CA 95618 USA
- Department of Food Science and Technology, University of Nebraska, Lincoln, NE 68588 USA
| | | | | | | | | | | | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Dmitry A. Rodionov
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
- A.A. Kharkevich Institute for Information Transmission Problems, Russian Academy of Sciences, Moscow 127994 Russia
| | - Andrei L. Osterman
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
| | - David Kyle
- Evolve BioSystems, Inc., Davis, CA 95618 USA
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Jeffrey I. Gordon
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
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Chandwe K, Zyambo K, Mulenga C, Haritunians T, Amadi B, Kosek M, Heimburger DC, McGovern D, Kelly P. Histo-Blood Group Antigens, Enteropathogen Carriage and Environmental Enteropathy in Stunted Zambian Children. J Pediatr Gastroenterol Nutr 2022; 74:529-534. [PMID: 34724448 PMCID: PMC9046470 DOI: 10.1097/mpg.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Stunting, the most common form of childhood undernutrition, is associated with environmental enteropathy (EE). Enteric infections are believed to play a role in the pathophysiology of EE and stunting though the exact mechanism remains undetermined. The FUT2 (secretor) and FUT3 (Lewis) genes have been shown to be associated with some symptomatic enteric infections in both children and adults. These genes are responsible for the presence of histo-blood group antigens (HBGAs) in various secretions and epithelial surfaces.We evaluated whether the secretor and Lewis status influences asymptomatic enteric infections and thus EE severity on duodenal biopsies of stunted children. METHODS In this case-control study, we used saliva samples to determine the secretor and Lewis status of stunted children (cases, n = 113) enrolled in a nutritional rehabilitation program and from their well-nourished counterparts (controls, n = 42). Where available, saliva was also collected from the mothers. Baseline stool samples were used to detect asymptomatic enteropathogen carriage. Duodenal biopsies were collected from a subgroup of stunted children (n = 77) who had an upper gastrointestinal endoscopy done as part of the evaluation process for their non-response to nutritional therapy. RESULTS The proportion of secretors was similar between the cases and the controls (82% vs 81%, P = 0.81). The stunted children had significantly higher rates of carrying multiple enteropathogens, but this was not associated with their secretor status nor that of their mothers. The secretor status was also not associated with mucosal morphometry of duodenal biopsies. CONCLUSION This case-control analysis in Zambian children does not support the hypothesis that fucosylation status determines asymptomatic enteropathogen carriage in stunting.
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Affiliation(s)
- Kanta Chandwe
- University of Zambia School of Medicine, Lusaka, Zambia
- Tropical Gastroenterology & Nutrition group, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition group, Lusaka, Zambia
| | - Chola Mulenga
- Tropical Gastroenterology & Nutrition group, Lusaka, Zambia
| | - Talin Haritunians
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Beatrice Amadi
- University of Zambia School of Medicine, Lusaka, Zambia
- Tropical Gastroenterology & Nutrition group, Lusaka, Zambia
| | | | - Douglas C. Heimburger
- University of Zambia School of Medicine, Lusaka, Zambia
- Vanderbilt University Medical Center
| | - Dermot McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, Lusaka, Zambia
- Queen Mary University of London, London, UK
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22
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Lee DU, Fan GH, Hastie DJ, Addonizio EA, Prakasam VN, Ahern RR, Seog KJ, Karagozian R. The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals. J Clin Gastroenterol 2022; 56:349-359. [PMID: 33769393 DOI: 10.1097/mcg.0000000000001528] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/06/2021] [Indexed: 01/13/2023]
Abstract
GOALS We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States. BACKGROUND Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes. STUDY 2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints. RESULTS After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44). CONCLUSION This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.
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Affiliation(s)
- David U Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Washington Street, Boston, MA
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23
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Mulenga C, Sviben S, Chandwe K, Amadi B, Kayamba V, Fitzpatrick JAJ, Mudenda V, Kelly P. Epithelial Abnormalities in the Small Intestine of Zambian Children With Stunting. Front Med (Lausanne) 2022; 9:849677. [PMID: 35372420 PMCID: PMC8966729 DOI: 10.3389/fmed.2022.849677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/22/2022] [Indexed: 01/17/2023] Open
Abstract
Background Environmental enteropathy (EE) contributes to impaired linear growth (stunting), in millions of children worldwide. We have previously reported that confocal laser endomicroscopy (CLE) shows fluorescein leaking from blood to gut lumen in vivo in adults and children with EE. We set out to identify epithelial lesions which might explain this phenomenon in Zambian children with stunting non-responsive to nutritional support. Methods We performed confocal laser endomicroscopy (CLE) in 75 children and collected intestinal biopsies for histology in 91 children. CLE videos were evaluated, employing the Watson score to determine severity of leakiness. Morphometry was carried out on well-orientated mucosa and 3 biopsies were examined by electron microscopy. Results Confocal laser endomicroscopy demonstrated substantial leakage from circulation to gut lumen in 73 (97%) children. Histology consistently showed characteristic changes of EE: villus blunting, lamina propria and epithelial inflammation, and depletion of secretory cells (Paneth cells and goblet cells). Epithelial abnormalities included marked variability in epithelial height, disorganised and shortened microvilli, dilated intercellular spaces, pseudostratification, formation of synechiae between epithelium on adjacent villi, crypt destruction, and abundant destructive lesions which may correspond to the microerosions identified on CLE. Conclusion Epithelial abnormalities were almost universal in Zambian children with non-responsive stunting, including epithelial microerosions, cell-cell adhesion anomalies, and defects in secretory cells which may all contribute to impairment of mucosal barrier function and microbial translocation.
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Affiliation(s)
- Chola Mulenga
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sanja Sviben
- Washington University Center for Cellular Imaging, Washington University School of Medicine, St. Louis, MO, United States
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Violet Kayamba
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - James A. J. Fitzpatrick
- Washington University Center for Cellular Imaging, Washington University School of Medicine, St. Louis, MO, United States
- Departments of Cell Biology & Physiology and Neuroscience, Washington University School of Medicine, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Victor Mudenda
- Department of Pathology and Microbiology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
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Hodges P, Tembo M, Kelly P. Intestinal Biopsies for the Evaluation of Environmental Enteropathy and Environmental Enteric Dysfunction. J Infect Dis 2021; 224:S856-S863. [PMID: 34273148 PMCID: PMC8687084 DOI: 10.1093/infdis/jiab372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Environmental enteric dysfunction (EED) is a syndrome characterized by impairments of digestion and absorption and intestinal barrier failure in people living in insanitary or tropical environments. There is substantial evidence that it contributes to impaired linear growth of millions of children in low- and middle-income countries, to slowed neurocognitive development, and to diminished responses to oral vaccines. It represents the functional consequences of environmental enteropathy, an asymptomatic inflammatory disorder of the mucosa, and there is considerable overlap with the enteropathy observed in severe clinical malnutrition. The majority of studies of EED have employed functional tests based on lactulose permeation to define the presence of abnormal leak in the gut. However, where intestinal biopsies can safely be collected the opportunity then arises to study the underlying enteropathy in cellular and molecular detail, as well as to measure important functional elements such as enzyme expression. The purpose of this narrative review is to summarize the current understanding of environmental enteropathy obtained from small intestinal biopsies, and prospects for future work. We review histology, electron microscopy, transcription and protein expression, physiological measures, and the microbiome. We conclude that while noninvasive biomarkers of enteropathy and intestinal dysfunction permit large-scale studies of unquestionable value, intestinal biopsies are still required to investigate pathophysiology in depth.
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Affiliation(s)
- Phoebe Hodges
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
- Queen Mary University of London, London, United Kingdom
| | - Mizinga Tembo
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
- Queen Mary University of London, London, United Kingdom
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Tamlyn E, Das D. Anorexia and Starvation Related Duodenal Villous Atrophy in an Adult Patient. Cureus 2021; 13:e18536. [PMID: 34765335 PMCID: PMC8575289 DOI: 10.7759/cureus.18536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/30/2022] Open
Abstract
Coeliac disease is the most well-known cause of villous atrophy in duodenal biopsies. Other well recognised causes of villous atrophy include infection with Giardiaduodenalis and HIV, peptic duodenitis, drug-induced enteropathy, common variable immunodeficiency, Crohn’s disease, Whipple’s disease, small intestinal bacterial overgrowth, eosinophilic gastroenteritis, tropical or collagenous sprue and autoimmune enteropathy. While mucosal adaptation due to malnutrition, leading to villous atrophy, has been reported in paediatric populations in Africa and South America, in hibernating animals and animal models of experimental starvation, there is very little literature on adult human subjects. We report a case of a 76-year-old gentleman, presenting with chronic metabolic acidosis and anorexia who was found to have villous atrophy on duodenal biopsy, in the absence of any evidence of coeliac disease or other non-coeliac enteropathy. The nutritional state improved with correction of the underlying metabolic abnormality, and serial endoscopic assessment showed improvement in the villous atrophy. We discuss the relationship between malnutrition and villous atrophy, and suggest a potential workup for non-coeliac villous atrophy.
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Affiliation(s)
- Ethan Tamlyn
- Gastroenterology, Leicester Medical School, Leicester, GBR
| | - Debashish Das
- Gastroenterology, Kettering General Hospital, NHS Foundation Trust, Kettering, GBR
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26
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Hodges P, Kelly P, Kayamba V. Helicobacter pylori infection and hypochlorhydria in Zambian adults and children: A secondary data analysis. PLoS One 2021; 16:e0256487. [PMID: 34449790 PMCID: PMC8396721 DOI: 10.1371/journal.pone.0256487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background Hypochlorhydria (gastric pH >4) increases susceptibility to diarrhoea, iron deficiency, and gastric cancer. We sought to clarify the prevalence of this condition and its predisposing factors in Zambia by pooling data from previous studies conducted in hospital and community settings. Methods Gastric pH was measured in participants from five separate studies by collecting gastric aspirate from fasted adults and children under 3 years of age undergoing gastroscopy. Gastric pH was correlated with serological testing for Human Immunodeficiency Virus (HIV) and Helicobacter pylori (H. pylori) infections. Results We studied 597 individuals (487 adults and 110 children). Hypochlorhydria was present in 53% of adults and 31% of children. HIV infection was detected in 41% of adults and 11% of children. H. pylori serology was available for 366 individuals: 93% of adults and 6% of children were seropositive. In univariate analysis, hypochlorhydria was significantly associated with HIV seropositivity (OR 1.7; 95% CI 1.2–2.4; p = 0.004) and H. pylori antibody seropositivity (OR 4.9; 95% CI 2.8–8.6; p<0.0001), and with advancing age in HIV negative individuals (p = 0.0001). In multivariable analysis, only H. pylori was associated with hypochlorhydria (OR 4.0; 95% CI 2.2–7.2; p<0.0001) while excluding possible exposure to proton pump inhibitors. Conclusions Hypochlorhydria is common in our population, with H. pylori being the dominant factor. Only young HIV seronegative individuals had a low prevalence of hypochlorhydria. This may have implications for the risk of other health conditions including gastric cancer.
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Affiliation(s)
- Phoebe Hodges
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Violet Kayamba
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
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27
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Gene expression profiles compared in environmental and malnutrition enteropathy in Zambian children and adults. EBioMedicine 2021; 70:103509. [PMID: 34333236 PMCID: PMC8346547 DOI: 10.1016/j.ebiom.2021.103509] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/11/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Environmental enteropathy (EE) contributes to growth failure in millions of children worldwide, but its relationship to clinical malnutrition has not been elucidated. We used RNA sequencing to compare duodenal biopsies from adults and children with EE, and from children with severe acute malnutrition (SAM), to define key features of these malnutrition-related enteropathies. METHODS RNA was extracted and sequenced from biopsies of children with SAM in hospital (n=27), children with non-responsive stunting in the community (n=30), and adults living in the same community (n=37) using an identical sequencing and analysis pipeline. Two biopsies each were profiled and differentially expressed genes (DEGs) were computed from the comparisons of the three groups. DEG lists from these comparisons were then subjected to analysis with CompBio software to assemble a holistic view of the biological landscape and IPA software to interrogate canonical pathways. FINDINGS Dysregulation was identified in goblet cell/mucin production and xenobiotic metabolism/detoxification for both cohorts of children, versus adults. Within the SAM cohort, substantially greater induction of immune response and barrier function, including NADPH oxidases was noted, concordant with broadly reduced expression of genes associated with the brush border and intestinal structure/transport/absorption. Interestingly, down regulation of genes associated with the hypothalamic-pituitary-adrenal axis was selectively observed within the cohort of children with stunting. INTERPRETATION Gene expression profiles in environmental enteropathy and severe acute malnutrition have similarities, but SAM has several distinct transcriptional features. The intestinal capacity to metabolise drugs and toxins in malnourished children requires further study. FUNDING Bill & Melinda Gates Foundation (OPP1066118).
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Parenti M, McClorry S, Maga EA, Slupsky CM. Metabolomic changes in severe acute malnutrition suggest hepatic oxidative stress: a secondary analysis. Nutr Res 2021; 91:44-56. [PMID: 34134040 PMCID: PMC8311294 DOI: 10.1016/j.nutres.2021.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 03/09/2021] [Accepted: 05/11/2021] [Indexed: 11/25/2022]
Abstract
Severe acute malnutrition (SAM), due to poor energy and/or protein intake, is associated with poor growth, depressed immune function, and long-term impacts on metabolic function. As the liver is a major metabolic organ and malnutrition poses metabolic stress, we hypothesize that SAM will be associated with alterations in the hepatic metabolome reflective of oxidative stress, gluconeogenesis, and ketogenesis. Thus, the purpose of this secondary analysis was to understand how SAM alters hepatic metabolism using a piglet model. Weanling piglets were feed either a reference (REF) or protein-energy deficient diet (MAL) for 5 weeks. After dietary treatment MAL piglets were severely underweight (weight-for-age Z-score of -3.29, Welch's t test, P = .0007), moderately wasted (weight-for-length Z-score of-2.49, Welch's t test, P = .003), and tended toward higher hepatic triglyceride content (Welch's t test, P = .07). Hematologic and blood biochemical measurements were assessed at baseline and after dietary treatment. The hepatic metabolome was investigated using 1H-NMR spectroscopy. Hepatic concentrations of betaine, cysteine, and glutathione tended to be lower in MAL (Welch's t test with FDR correction, P < .1), while inosine, lactate, and methionine sulfoxide concentrations were higher in MAL (inosine: P = .0448, lactate: P = .0258, methionine sulfoxide: P = .0337). These changes suggest that SAM is associated with elevated hepatic oxidative stress, increased gluconeogenesis, and alterations in 1-carbon metabolism.
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Affiliation(s)
- Mariana Parenti
- Department of Nutrition, University of California, Davis, USA
| | | | - Elizabeth A Maga
- Department of Animal Science, University of California, Davis, USA
| | - Carolyn M Slupsky
- Department of Nutrition, University of California, Davis, USA; Department of Food Science and Technology, University of California, Davis, USA.
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29
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Thompson AJ, Bourke CD, Robertson RC, Shivakumar N, Edwards CA, Preston T, Holmes E, Kelly P, Frost G, Morrison DJ. Understanding the role of the gut in undernutrition: what can technology tell us? Gut 2021; 70:gutjnl-2020-323609. [PMID: 34103403 PMCID: PMC8292602 DOI: 10.1136/gutjnl-2020-323609] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/04/2021] [Indexed: 12/22/2022]
Abstract
Gut function remains largely underinvestigated in undernutrition, despite its critical role in essential nutrient digestion, absorption and assimilation. In areas of high enteropathogen burden, alterations in gut barrier function and subsequent inflammatory effects are observable but remain poorly characterised. Environmental enteropathy (EE)-a condition that affects both gut morphology and function and is characterised by blunted villi, inflammation and increased permeability-is thought to play a role in impaired linear growth (stunting) and severe acute malnutrition. However, the lack of tools to quantitatively characterise gut functional capacity has hampered both our understanding of gut pathogenesis in undernutrition and evaluation of gut-targeted therapies to accelerate nutritional recovery. Here we survey the technology landscape for potential solutions to improve assessment of gut function, focussing on devices that could be deployed at point-of-care in low-income and middle-income countries (LMICs). We assess the potential for technological innovation to assess gut morphology, function, barrier integrity and immune response in undernutrition, and highlight the approaches that are currently most suitable for deployment and development. This article focuses on EE and undernutrition in LMICs, but many of these technologies may also become useful in monitoring of other gut pathologies.
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Affiliation(s)
- Alex J Thompson
- Hamlyn Centre for Robotic Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Claire D Bourke
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Ruairi C Robertson
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Nirupama Shivakumar
- Division of Nutrition, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | - Tom Preston
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
| | - Elaine Holmes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Gary Frost
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Douglas J Morrison
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
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Syed S, Ehsan L, Shrivastava A, Sengupta S, Khan M, Kowsari K, Guleria S, Sali R, Kant K, Kang SJ, Sadiq K, Iqbal NT, Cheng L, Moskaluk CA, Kelly P, Amadi BC, Ali SA, Moore SR, Brown DE. Artificial Intelligence-based Analytics for Diagnosis of Small Bowel Enteropathies and Black Box Feature Detection. J Pediatr Gastroenterol Nutr 2021; 72:833-841. [PMID: 33534362 PMCID: PMC8767179 DOI: 10.1097/mpg.0000000000003057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Striking histopathological overlap between distinct but related conditions poses a disease diagnostic challenge. There is a major clinical need to develop computational methods enabling clinicians to translate heterogeneous biomedical images into accurate and quantitative diagnostics. This need is particularly salient with small bowel enteropathies; environmental enteropathy (EE) and celiac disease (CD). We built upon our preliminary analysis by developing an artificial intelligence (AI)-based image analysis platform utilizing deep learning convolutional neural networks (CNNs) for these enteropathies. METHODS Data for the secondary analysis was obtained from three primary studies at different sites. The image analysis platform for EE and CD was developed using CNNs including one with multizoom architecture. Gradient-weighted class activation mappings (Grad-CAMs) were used to visualize the models' decision-making process for classifying each disease. A team of medical experts simultaneously reviewed the stain color normalized images done for bias reduction and Grad-CAMs to confirm structural preservation and biomedical relevance, respectively. RESULTS Four hundred and sixty-one high-resolution biopsy images from 150 children were acquired. Median age (interquartile range) was 37.5 (19.0-121.5) months with a roughly equal sex distribution; 77 males (51.3%). ResNet50 and shallow CNN demonstrated 98% and 96% case-detection accuracy, respectively, which increased to 98.3% with an ensemble. Grad-CAMs demonstrated models' ability to learn different microscopic morphological features for EE, CD, and controls. CONCLUSIONS Our AI-based image analysis platform demonstrated high classification accuracy for small bowel enteropathies which was capable of identifying biologically relevant microscopic features and emulating human pathologist decision-making process. Grad-CAMs illuminated the otherwise "black box" of deep learning in medicine, allowing for increased physician confidence in adopting these new technologies in clinical practice.
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Affiliation(s)
- Sana Syed
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lubaina Ehsan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Aman Shrivastava
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Saurav Sengupta
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Marium Khan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kamran Kowsari
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
- University of California Los Angeles, Los Angeles, CA, USA
| | - Shan Guleria
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Rasoul Sali
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| | - Karan Kant
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Sung-Jun Kang
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lin Cheng
- Pathology Department, Rush University Medical Center, Chicago, IL, USA
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Beatrice C. Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - S. Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Donald E. Brown
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
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Kelly P. Starvation and Its Effects on the Gut. Adv Nutr 2021; 12:897-903. [PMID: 33271592 PMCID: PMC8166558 DOI: 10.1093/advances/nmaa135] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/09/2020] [Accepted: 09/21/2020] [Indexed: 12/20/2022] Open
Abstract
There is growing awareness that intestinal dysfunction determines the clinical outcomes of situations as diverse as undernourished children in urban tropical slums and undernourished surgical patients in intensive care units. As experimental starvation in humans has only rarely been studied, and largely not using current biomedical research tools, we must draw inference from disparate clinical and experimental observations as to the derangements present in the starved gut. There is good evidence of intestinal atrophy and achlorhydria in starvation and severe undernutrition. Historical reports from concentration camps and conflict settings consistently reported a noncontagious phenomenon called "hunger diarrhea," but in settings where starved individuals are isolated from others (prisoners on hunger strike, anorexia nervosa) diarrhea is not a feature. Changes in intestinal permeability and absorption have been infrequently studied in experimental starvation; available data suggest that short-term starvation reduces sugar absorption but not permeability. Severe acute malnutrition in children is associated with severe changes in the intestinal mucosa. Experimental animal models may help explain some observations in humans. Starved rats develop a hypersecretory state and intestinal barrier defects. Starved pigs demonstrate prolongation of rotavirus diarrhea and reproduce some of the absorptive and barrier defects observed in malnourished children. However, there remains much to be learned about the effects of starvation on the gut. Given the high prevalence of undernutrition in hospitals and disadvantaged communities, the lack of attention to the interaction between undernutrition and gastrointestinal damage is surprising and needs to be corrected. Current sophisticated cellular and molecular techniques now provide the opportunity to create fresh understanding of gastrointestinal changes in pure undernutrition, using volunteer studies and samples from anorexia nervosa.
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Affiliation(s)
- Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, London, United Kingdom; and Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
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Shivakumar N, Sivadas A, Devi S, Jahoor F, McLaughlin J, Smith CP, Kurpad AV, Mukhopadhyay A. Gut microbiota profiles of young South Indian children: Child sex-specific relations with growth. PLoS One 2021; 16:e0251803. [PMID: 33989353 PMCID: PMC8121364 DOI: 10.1371/journal.pone.0251803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022] Open
Abstract
Gut microbiota has been implicated as a modifier of childhood growth. Here, 16S rRNA sequencing-based fecal microbiota profiles of 18–24 month old Indian children were evaluated (n = 41), in relation to their anthropometric parameters, intestinal permeability, body composition and total energy expenditure. Pathway analyses were conducted to assess microbial functions related to stunting, underweight and wasting. The fecal microbiota was enriched in Prevotella 9, Bifidobacterium and Escherichia-Shigella. Weight, weight-for-age Z-scores (WAZ) and weight-for-length Z-scores (WLZ), along with age, acted as covariates of microbiota variation specifically in boys (n = 23). Bifidobacterium longum subsp longum abundance was positively associated with WAZ while Bifidobacterium bifidum and Bifidobacterium breve abundances were negatively associated with age. The lipopolysaccharide biosynthesis pathway was upregulated in stunted (n = 16) and wasted (n = 8) children. Findings from this study indicate that child sex may be a critical modifier of the role of gut microbiota on childhood growth.
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Affiliation(s)
- Nirupama Shivakumar
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Ambily Sivadas
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Sarita Devi
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Farook Jahoor
- Department of Pediatrics, USDA/Agricultural Research Service Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas, United States of America
| | - John McLaughlin
- Faculty of Biology, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Medicine & Health, Manchester Academic Health Sciences Centre, University of Manchester, Clinical Sciences Building, Salford Royal Hospital, Salford, United Kingdom
| | - Craig P. Smith
- Faculty of Biology, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Medicine & Health, Manchester Academic Health Sciences Centre, University of Manchester, Clinical Sciences Building, Salford Royal Hospital, Salford, United Kingdom
| | - Anura V. Kurpad
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
- Department of Physiology, St. John’s Medical College, St. John’s National Academy of Health Sciences, Bangalore, India
| | - Arpita Mukhopadhyay
- Division of Nutrition, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, India
- * E-mail:
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Balamtekin N, Erdal H, Gençkardeşler E, Arslan M. Reliability of anti-tissue transglutaminase antibodies in children with malnutrition. Scand J Gastroenterol 2021; 56:378-381. [PMID: 33590788 DOI: 10.1080/00365521.2021.1882554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Serological markers are used in the diagnosis of celiac disease. Among these, the most widely used are tissue transglutaminase antibodies (anti-TG2 antibodies). It has been suggested that the mechanisms that are set in motion by malnutrition cause the tight connections between enterocytes to expand, which allows gluten-derived peptides to pass through the epithelium. This causes the production of anti-TG2 antibodies without the presence of celiac disease. METHODS The patients who were examined for malnutrition and had their anti-TG2 antibody levels measured at the same time, were accepted into the study. The patients who were investigated for suspected celiac disease, showed no signs of malnutrition, and had their anti-TG2 antibody levels measured were accepted into a control group. RESULTS The study population consisted of 126 children with mild malnutrition (54.8% female, 7.44 ± 5.38 years); 89 children with moderate malnutrition (54.8% female, 7.62 ± 5.43 years), and a control group of 200 children (53.2% female, 7.72 ± 5.05 years). According to the results, anti-TG2 IgG levels were significantly higher among patients in the mild and moderate malnutrition groups compared to patients in the control group (p = .02 and p = .01, respectively). However, there was no significant difference between the mild and moderate malnutrition groups (p > .05). CONCLUSIONS Malnutrition does not affect anti-TG2 IgA levels in children. However, anti-TG2 IgG levels increase in children suffering from malnutrition. When examining celiac disease, especially in people with a background IgA deficiency, doctors should consider whether malnutrition may be the cause of the increase in serum anti-TG2 IgG levels without celiac disease.
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Affiliation(s)
- Necati Balamtekin
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Harun Erdal
- Department of Internal Medicine, Division of Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Emira Gençkardeşler
- Department of Pediatrics, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Melike Arslan
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
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Noble CCA, Sturgeon JP, Bwakura-Dangarembizi M, Kelly P, Amadi B, Prendergast AJ. Postdischarge interventions for children hospitalized with severe acute malnutrition: a systematic review and meta-analysis. Am J Clin Nutr 2021; 113:574-585. [PMID: 33517377 PMCID: PMC7948836 DOI: 10.1093/ajcn/nqaa359] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/06/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Children hospitalized with severe acute malnutrition (SAM) have poor long-term outcomes following discharge, with high rates of mortality, morbidity, and impaired neurodevelopment. There is currently minimal guidance on how to support children with SAM following discharge from inpatient treatment. OBJECTIVES This systematic review and meta-analysis aimed to examine whether postdischarge interventions can improve outcomes in children recovering from complicated SAM. METHODS Systematic searches of 4 databases were undertaken to identify studies of interventions delivered completely or partially after hospital discharge in children aged 6-59 mo, following inpatient treatment of SAM. The main outcome of interest was mortality. Random-effects meta-analysis was undertaken where ≥2 studies were sufficiently similar in intervention and outcome. RESULTS Ten studies fulfilled the inclusion criteria, recruiting 39-1781 participants in 7 countries between 1975 and 2015. Studies evaluated provision of zinc (2 studies), probiotics or synbiotics (2 studies), antibiotics (1 study), pancreatic enzymes (1 study), and psychosocial stimulation (4 studies). Six studies had unclear or high risk of bias in ≥2 domains. Compared with standard care, pancreatic enzyme supplementation reduced inpatient mortality (37.8% compared with 18.6%, P < 0.05). In meta-analysis there was some evidence that prebiotics or synbiotics reduced mortality (RR: 0.72; 95% CI: 0.51, 1.00; P = 0.049). Psychosocial stimulation reduced mortality in meta-analysis of the 2 trials reporting deaths (RR: 0.36; 95% CI: 0.15, 0.87), and improved neurodevelopmental scores in ≥1 domain in all studies. There was no evidence that zinc reduced mortality in the single study reporting deaths. Antibiotics reduced infectious morbidity but did not reduce mortality. CONCLUSIONS Several biological and psychosocial interventions show promise in improving outcomes in children following hospitalization for SAM and require further exploration in larger randomized mortality trials. This study was registered with PROSPERO as CRD42018111342 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=111342).
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Affiliation(s)
- Christie C A Noble
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan P Sturgeon
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Paul Kelly
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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The contribution of environmental enteropathy to the global problem of micronutrient deficiency. Proc Nutr Soc 2021; 80:303-310. [PMID: 33663621 DOI: 10.1017/s0029665121000549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent.
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Hossain MS, Begum SMKN, Rahman MM, Mazumder RN, Parvez M, Gazi MA, Hasan MM, Fahim SM, Das S, Mahfuz M, Sarker SA, Ahmed T. Alterations in the histological features of the intestinal mucosa in malnourished adults of Bangladesh. Sci Rep 2021; 11:2355. [PMID: 33504937 PMCID: PMC7840936 DOI: 10.1038/s41598-021-82079-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 12/20/2022] Open
Abstract
There is paucity of knowledge on the histological features of the intestinal mucosa in malnourished adults of Bangladesh. The purpose of the study was to explore the histological features of the intestinal mucosa in malnourished adults of Bangladesh and to compare the findings with their well-nourished counterparts. 64 adults (37 malnourished with body mass index, BMI < 18.5 kg/m2 and 27 controls with BMI > 18.5 kg/m2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study, who underwent upper-gastrointestinal endoscopy, were selected for this study. With a view to address the association of environmental enteric dysfunction (EED) with malnutrition, upper-gastrointestinal endoscopy was performed and mucosal biopsies from the distal duodenum were studied for histopathology. Villous height, crypt depth, and presence of inflammatory infiltrates in lamina propria were investigated. Bivariate analysis was performed to quantify the relation between malnutrition and the histological features. About 95% adults, irrespective of nutritional status, were diagnosed to have chronic non-specific duodenitis on histopathology. Malnourished adults suffered significantly more from chronic active duodenitis compared to their well-nourished counterparts (p = 0.003). Malnourished adults also had significantly higher frequency of subtotal villous atrophy, crypt hyperplasia and marked cellular infiltration in the lamina propria than the healthy controls (p < 0.05).
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Affiliation(s)
- Md Shabab Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | | | - M Masudur Rahman
- Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, 1212, Bangladesh
| | - Ramendra Nath Mazumder
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mashud Parvez
- Department of Pathology, Bangladesh Specialized Hospital, Dhaka, 1207, Bangladesh
| | - Md Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Md Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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Choudhry N, Scott F, Edgar M, Sanger GJ, Kelly P. Reversal of Pathogen-Induced Barrier Defects in Intestinal Epithelial Cells by Contra-pathogenicity Agents. Dig Dis Sci 2021; 66:88-104. [PMID: 32034605 DOI: 10.1007/s10620-020-06121-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 01/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Environmental enteropathy (EE) is associated with stunting, impairment of responses to oral vaccines, and other adverse health consequences in young children throughout the developing world. EE is characterized by chronic low-grade intestinal inflammation and disrupted epithelial barrier integrity, partly resulting from dysregulation of tight junction proteins, observed in other enteropathies such as celiac disease. During EE, this dysregulation of tight junction expression amplifies translocation of pathogenic bacteria across the intestinal mucosa. AIMS The aim was to determine whether enteropathogen-mediated epithelial barrier failure can be ameliorated using contra-pathogenicity therapies. METHODS Intestinal epithelial barrier damage was assessed in Caco-2 cells incubated with three important enteropathogens identified in EE patients: Enteropathogenic Escherichia coli (EPEC), Citrobacter rodentium (C. rodentium), and Cryptosporidium parvum (C. parvum). Potential therapeutic molecules were tested to detect effects on transepithelial resistance (TER), bacterial translocation (BT), claudin-4 expression, and regulation of the inflammatory cytokine response. RESULTS All three enteropathogens compared to uninfected cells, reduced TER (EPEC; p < 0.0001, C. rodentium; p < 0.0001, C. parvum; p < 0.0007), reduced claudin-4 expression, and permitted BT (EPEC; p < 0.0001, C. rodentium; p < 0.0001, C. parvum; p < 0.0003) through the monolayer. Zinc, colostrum, epidermal growth factor, trefoil factor 3, resistin-like molecule-β, hydrocortisone, and the myosin light chain kinase inhibitor ML7 (Hexahydro-1-[(5-iodo-1-naphthalenyl)sulfonyl]-1H-1,4-diazepine hydrochloride); ML7) improved TER (up to 70%) and decreased BT (as much as 96%). Only zinc demonstrated modest antimicrobial activity. CONCLUSION The enteropathogens impaired intestinal-epithelial barrier integrity with dysregulation of claudin-4 and increased bacterial translocation. Enteropathogen-mediated damage was reduced using contra-pathogenicity agents which mitigated the effects of pathogens without direct antimicrobial activity.
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Affiliation(s)
- Naheed Choudhry
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK.
| | - Flora Scott
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
| | - Meghan Edgar
- Gastroenterology Drug Discovery Unit, Takeda California, Inc., 10410 Science Center Drive, San Diego, CA, 92121, USA
| | - Gareth J Sanger
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
- Gastroenterology Drug Discovery Unit, Takeda California, Inc., 10410 Science Center Drive, San Diego, CA, 92121, USA
| | - Paul Kelly
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
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Selimoglu MA, Kansu A, Aydogdu S, Sarioglu AA, Erdogan S, Dalgic B, Yuce A, Cullu Cokugras F. Nutritional Support in Malnourished Children With Compromised Gastrointestinal Function: Utility of Peptide-Based Enteral Therapy. Front Pediatr 2021; 9:610275. [PMID: 34164352 PMCID: PMC8215107 DOI: 10.3389/fped.2021.610275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 05/07/2021] [Indexed: 12/20/2022] Open
Abstract
This review focuses on nutritional support in malnourished children with compromised gastrointestinal function addressing the interplay between malnutrition and gastrointestinal dysfunction, and the specific role of peptide-based enteral therapy in pediatric malnutrition. Malnutrition is associated with impaired gut functions such as increased intestinal permeability, malabsorption, and diarrhea, while pre-existing functional gastrointestinal disorders may also lead to malnutrition. Presence of compromised gastrointestinal function in malnourished children is critical given that alterations such as malabsorption and increased intestinal permeability directly interfere with efficacy of nutritional support and recovery from malnutrition. Appropriate nutritional intervention is the key step in the management of malnutrition, while alterations in gastrointestinal functions in malnourished children are likely even in those with mild degree malnutrition. Therefore, nutritional therapy in children with compromised gastrointestinal function is considered to involve gut-protective interventions that address the overlapping and interacting effects of diarrhea, enteropathy and malnutrition to improve child survival and developmental potential in the long-term. Peptide-based enteral formulas seem to have clinical applications in malnourished children with compromised gastrointestinal function, given their association with improved gastrointestinal tolerance and absorption, better nitrogen retention/ balance, reduced diarrhea and bacterial translocation, enhanced fat absorption, and maintained/restored gut integrity as compared with free amino acid or whole-protein formulas.
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Affiliation(s)
- Mukadder Ayse Selimoglu
- Department of Pediatric Gastroenterology, Atasehir and Bahcelievler Memorial Hospitals, Istanbul, Turkey
| | - Aydan Kansu
- Department of Pediatric Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Sema Aydogdu
- Department of Pediatric Gastroenterology, Ege University Faculty of Medicine, Izmir, Turkey
| | | | | | - Buket Dalgic
- Department of Pediatric Gastroenterology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Aysel Yuce
- Department of Pediatric Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Fugen Cullu Cokugras
- Department of Pediatric Gastroenterology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Amadi B, Zyambo K, Chandwe K, Besa E, Mulenga C, Mwakamui S, Siyumbwa S, Croft S, Banda R, Chipunza M, Chifunda K, Kazhila L, VanBuskirk K, Kelly P. Adaptation of the small intestine to microbial enteropathogens in Zambian children with stunting. Nat Microbiol 2021; 6:445-454. [PMID: 33589804 PMCID: PMC8007472 DOI: 10.1038/s41564-020-00849-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/10/2020] [Indexed: 01/30/2023]
Abstract
Environmental enteropathy is a major contributor to growth faltering in millions of children in Africa and South Asia. We carried out a longitudinal, observational and interventional study in Lusaka, Zambia, of 297 children with stunting (aged 2-17 months at recruitment) and 46 control children who had good growth (aged 1-5 months at recruitment). Control children contributed data only at baseline. Children were provided with nutritional supplementation of daily cornmeal-soy blend, an egg and a micronutrient sprinkle, and were followed up to 24 months of age. Children whose growth did not improve over 4-6 months of nutritional supplementation were classified as having non-responsive stunting. We monitored microbial translocation from the gut lumen to the bloodstream in the cohort with non-responsive stunting (n = 108) by measuring circulating lipopolysaccharide (LPS), LPS-binding protein and soluble CD14 at baseline and when non-response was declared. We found that microbial translocation decreased with increasing age, such that LPS declined in 81 (75%) of 108 children with non-responsive stunting, despite sustained pathogen pressure and ongoing intestinal epithelial damage. We used confocal laser endomicroscopy and found that mucosal leakiness also declined with age. However, expression of brush border enzyme, nutrient transporter and mucosal barrier genes in intestinal biopsies did not change with age or correlate with biomarkers of microbial translocation. We propose that environmental enteropathy arises through adaptation to pathogen-mediated epithelial damage. Although environmental enteropathy reduces microbial translocation, it does so at the cost of impaired growth. The reduced epithelial surface area imposed by villus blunting may explain these findings.
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Affiliation(s)
- Beatrice Amadi
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanekwa Zyambo
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanta Chandwe
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Ellen Besa
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Chola Mulenga
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Simutanyi Mwakamui
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Stepfanie Siyumbwa
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sophie Croft
- grid.4868.20000 0001 2171 1133Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rose Banda
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Miyoba Chipunza
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kapula Chifunda
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Lydia Kazhila
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kelley VanBuskirk
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- grid.12984.360000 0000 8914 5257Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia ,grid.4868.20000 0001 2171 1133Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Chandwe K, Amadi B, Chipunza M, Zyambo M, Kelly P. Safety and Ethics in Endoscopic Studies in Children: Evidence From the BEECH Study in Zambia. J Trop Pediatr 2020; 67:5981785. [PMID: 33188430 PMCID: PMC7948385 DOI: 10.1093/tropej/fmaa074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Environmental enteropathy is an example of a poorly-understood intestinal disorder affecting millions of children worldwide, characterized by malabsorption and stunting. Although there is increasing interest in non-invasive means of assessing intestinal structure and function, the potential value of intestinal biopsy for histology, immunostaining, RNA sequencing and epigenetic work means that endoscopic biopsy remains extremely valuable. We here report our experience in the BEECH (Biomarkers of Environmental Enteropathy in CHildren) study of stunting in Zambia, in the belief that it may help address the knowledge gap regarding the safety of endoscopic biopsy in vulnerable young children. METHODS We report our experience of safety in 119 children undergoing endoscopic biopsy in the BEECH study in Lusaka Children's Hospital, Lusaka, and discuss ethical considerations in this light. RESULTS Upper gastrointestinal endoscopy was performed on children with stunting (length-for-age z score -2 or less) not responsive to nutritional interventions. Conscious sedation was provided by anaesthetists. Of 119 children, 5 (4%) developed transient desaturation, but no serious adverse events were experienced; no clinical, demographic or anaesthetic characteristics were identified as predictive of desaturation. Two children derived clinically useful information from the endoscopy, one life-saving. Of 105 lactase tests, 59 (54%) showed hypolactasia. DISCUSSION Children with stunting underwent endoscopy safely, and some derived clinical benefit. Safety and the possibility of clinical benefit are usually felt to be preconditions for the ethical justification for endoscopy for research in children, and we believe that these conditions were met in this study.
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Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Correspondence: Kanta Chandwe, MMed. Paeds. Tropical Gastroenterology & Nutrition Group (TROPGAN), University of Zambia, School of Medicine. Lusaka 10101, ZAMBIA. Tel: +260-966-806-816. E-mail:
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Miyoba Chipunza
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Masuzyo Zyambo
- Department of Anaesthesia, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Barts & The London School of Medicine, Queen Mary University of London, London E1 2AT, UK
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Arndt MB, Cantera JL, Mercer LD, Kalnoky M, White HN, Bizilj G, Boyle DS, de Hostos EL, Choy RKM. Validation of the Micronutrient and Environmental Enteric Dysfunction Assessment Tool and evaluation of biomarker risk factors for growth faltering and vaccine failure in young Malian children. PLoS Negl Trop Dis 2020; 14:e0008711. [PMID: 32997666 PMCID: PMC7549819 DOI: 10.1371/journal.pntd.0008711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/12/2020] [Accepted: 08/13/2020] [Indexed: 12/31/2022] Open
Abstract
Environmental enteric dysfunction (EED) is an intestinal disorder common among children in low-resource settings and is associated with increased risk of growth stunting, cognitive deficits, and reduced oral vaccine immunogenicity. The Micronutrient and EED Assessment Tool (MEEDAT) is a multiplexed immunoassay that measures biomarkers previously associated with child growth faltering and/or oral vaccine immunogenicity: intestinal fatty acid–binding protein (I-FABP), soluble CD14 (sCD14), insulin-like growth factor 1 (IGF-1), and fibroblast growth factor 21 (FGF21). MEEDAT also measures systemic inflammation (α1-acid glycoprotein, C-reactive protein), ferritin, soluble transferrin receptor, retinol binding protein 4, thyroglobulin, and Plasmodium falciparum antigenemia (histidine-rich protein 2). The performance of MEEDAT was compared with commercially available enzyme-linked immunosorbent assays (ELISAs) using 300 specimens from Malian infant clinical trial participants. Regression methods were used to test if MEEDAT biomarkers were associated with seroconversion to meningococcal A conjugate vaccine (MenAV), yellow fever vaccine (YFV), and pentavalent rotavirus vaccine (PRV) after 28 days, or with growth faltering over 12 weeks. The Pearson correlations between the MEEDAT and ELISA results were 0.97, 0.86, 0.80, and 0.97 for serum I-FABP, sCD14, IGF-1, and FGF21, respectively. There were significant associations between I-FABP concentration and the probability of PRV IgG seroconversion and between IGF-1 concentration and the probability of YFV seroconversion. In multivariable models neither association remained significant, however there was a significant negative association between AGP concentration and YFV seroconversion. GLP-2 and sCD14 concentrations were significantly negatively associated with 12-week change in weight-for-age z-score and weight-for-height z-score in multivariable models. MEEDAT performed well in comparison to commercially-available ELISAs for the measurement of four analytes for EED and growth hormone resistance. Adoption of MEEDAT in low-resource settings could help accelerate the identification of interventions that prevent or treat child stunting and interventions that boost the immunogenicity of child vaccinations. Environmental enteric dysfunction (EED) is an intestinal disorder common among children in low-resource settings and has been associated with increased risk of growth stunting, cognitive deficits, and reduced oral vaccine immunogenicity. A key challenge to identifying children with EED at highest risk of morbid sequelae is the lack of validated predictive biomarkers. Ongoing clinical studies are testing and validating EED biomarkers in child populations at risk for stunting, yet testing multiple biomarkers commonly requires specialized equipment, complex methods, resources, and considerable effort. The Micronutrient and EED Assessment Tool (MEEDAT) is a multiplexed immunoassay that measures biomarkers associated with child growth faltering and oral vaccine immunogenicity, and biomarkers indicative of systemic inflammation and micronutrient deficiencies. The performance of MEEDAT was well-correlated with commercial monoplex assays in specimens from children living in a low-resource setting in the present study. MEEDAT biomarkers were associated with growth outcomes and seroconversion in response to several vaccines. MEEDAT has the potential to reduce the time and cost of evaluating impact of interventions targeting EED.
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Affiliation(s)
- Michael B. Arndt
- PATH, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, United States of America
- * E-mail:
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Liu TC, VanBuskirk K, Ali SA, Kelly MP, Holtz LR, Yilmaz OH, Sadiq K, Iqbal N, Amadi B, Syed S, Ahmed T, Moore S, Ndao IM, Isaacs MH, Pfeifer JD, Atlas H, Tarr PI, Denno DM, Moskaluk CA. A novel histological index for evaluation of environmental enteric dysfunction identifies geographic-specific features of enteropathy among children with suboptimal growth. PLoS Negl Trop Dis 2020; 14:e0007975. [PMID: 31929525 PMCID: PMC6980693 DOI: 10.1371/journal.pntd.0007975] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/24/2020] [Accepted: 12/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background A major limitation to understanding the etiopathogenesis of environmental enteric dysfunction (EED) is the lack of a comprehensive, reproducible histologic framework for characterizing the small bowel lesions. We hypothesized that the development of such a system will identify unique histology features for EED, and that some features might correlate with clinical severity. Methods Duodenal endoscopic biopsies from two cohorts where EED is prevalent (Pakistan, Zambia) and North American children with and without gluten sensitive enteropathy (GSE) were processed for routine hematoxylin & eosin (H&E) staining, and scanned to produce whole slide images (WSIs) which we shared among study pathologists via a secure web browser-based platform. A semi-quantitative scoring index composed of 11 parameters encompassing tissue injury and response patterns commonly observed in routine clinical practice was constructed by three gastrointestinal pathologists, with input from EED experts. The pathologists then read the WSIs using the EED histology index, and inter-observer reliability was assessed. The histology index was further used to identify within- and between-child variations as well as features common across and unique to each cohort, and those that correlated with host phenotype. Results Eight of the 11 histologic scoring parameters showed useful degrees of variation. The overall concordance across all parameters was 96% weighted agreement, kappa 0.70, and Gwet’s AC 0.93. Zambian and Pakistani tissues shared some histologic features with GSE, but most features were distinct, particularly abundance of intraepithelial lymphocytes in the Pakistani cohort, and marked villous destruction and loss of secretory cell lineages in the Zambian cohort. Conclusions We propose the first EED histology index for interpreting duodenal biopsies. This index should be useful in future clinical and translational studies of this widespread, poorly understood, and highly consequential disorder, which might be caused by multiple contributing processes, in different regions of the world. The study of EED has been limited by the lack of a rigorously tested, reproducible histology index that can provide insight to the pathogenesis of this entity. In this study we report the first duodenal histology index that was developed using an unbiased approach, with excellent inter-observer reproducibility, for the study of EED. The EED histology index readily identified histologic features that are common or unique to cohorts of distinct geographic locations. Incorporating the histology index into future clinical studies will provide useful insight into the pathogenesis and for intervention strategy development.
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Affiliation(s)
- Ta-Chiang Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Kelley VanBuskirk
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Syed A. Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - M. Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Lori R. Holtz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Omer H. Yilmaz
- The David H. Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sana Syed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Sean Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - I. Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Michael H. Isaacs
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - John D. Pfeifer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Hannah Atlas
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States of America
| | - Phillip I. Tarr
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Donna M. Denno
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States of America
| | - Christopher A. Moskaluk
- Department of Pathology, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
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Kelly P, Bell L, Amadi B, Bwakura-Dangarembizi M, VanBuskirk K, Chandwe K, Chipunza M, Ngosa D, Chulu N, Hill S, Murch S, Playford R, Prendergast A. TAME trial: a multi-arm phase II randomised trial of four novel interventions for malnutrition enteropathy in Zambia and Zimbabwe - a study protocol. BMJ Open 2019; 9:e027548. [PMID: 31727642 PMCID: PMC6887014 DOI: 10.1136/bmjopen-2018-027548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Severe acute malnutrition (SAM) in children in many countries still carries unacceptably high mortality, especially when complicated by secondary infection or metabolic derangements. New therapies are urgently needed and we have identified mucosal healing in the intestine as a potential target for novel treatment approaches. METHODS AND ANALYSIS The TAME trial (Therapeutic Approaches for Malnutrition Enteropathy) will evaluate four novel treatments in an efficient multi-arm single-blind phase II design. In three hospitals in Zambia and Zimbabwe, 225 children with SAM will be randomised to one of these treatments or to standard care, once their inpatient treatment has reached the point of transition from stabilisation to increased nutritional intake. The four interventions are budesonide, bovine colostrum or N-acetyl glucosamine given orally or via nasogastric tube, or teduglutide given by subcutaneous injection. The primary endpoint will be a composite score of faecal inflammatory markers, and a range of secondary endpoints include clinical and laboratory endpoints. Treatments will be given daily for 14 days, and evaluation of the major endpoints will be at 14 to 18 days, with a final clinical evaluation at 28 days. In a subset of children in Zambia, endoscopic biopsies will be used to evaluate the effect of interventions in detail. ETHICS AND DISSEMINATION The study has been approved by the University of Zambia Biomedical Research Ethics Committee (006-09-17, dated 9th July, 2018), and the Joint Research Ethics Committee of the University of Zimbabwe (24th July, 2019). Caregivers will provide written informed consent for each participant. Findings will be disseminated through peer-reviewed journals, conference presentations and to caregivers at face-to-face meetings. TRIAL REGISTRATION NUMBER NCT03716115; Pre-results.
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Affiliation(s)
- Paul Kelly
- Barts and The London School of Medicine, Queen Mary University of London, London, UK
- University of Zambia School of Medicine, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lauren Bell
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Mutsa Bwakura-Dangarembizi
- Department of Paediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Kanta Chandwe
- University of Zambia School of Medicine, Lusaka, Zambia
| | | | | | - Nivea Chulu
- University of Zambia School of Medicine, Lusaka, Zambia
| | - Susan Hill
- Great Ormond Street Hospital, London, UK
| | - Simon Murch
- University Hospital Coventry & Warwickshire, Coventry, UK
| | - Raymond Playford
- Barts and The London School of Medicine, Queen Mary University of London, London, UK
| | - Andrew Prendergast
- Barts and The London School of Medicine, Queen Mary University of London, London, UK
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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Salameh E, Morel FB, Zeilani M, Déchelotte P, Marion-Letellier R. Animal Models of Undernutrition and Enteropathy as Tools for Assessment of Nutritional Intervention. Nutrients 2019; 11:nu11092233. [PMID: 31527523 PMCID: PMC6770013 DOI: 10.3390/nu11092233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/24/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
: Undernutrition is a major public health problem leading to 1 in 5 of all deaths in children under 5 years. Undernutrition leads to growth stunting and/or wasting and is often associated with environmental enteric dysfunction (EED). EED mechanisms leading to growth failure include intestinal hyperpermeability, villus blunting, malabsorption and gut inflammation. As non-invasive methods for investigating gut function in undernourished children are limited, pre-clinical models are relevant to elucidating the pathophysiological processes involved in undernutrition and EED, and to identifying novel therapeutic strategies. In many published models, undernutrition was induced using protein or micronutrient deficient diets, but these experimental models were not associated with EED. Enteropathy models mainly used gastrointestinal injury triggers. These models are presented in this review. We found only a few studies investigating the combination of undernutrition and enteropathy. This highlights the need for further developments to establish an experimental model reproducing the impact of undernutrition and enteropathy on growth, intestinal hyperpermeability and inflammation, that could be suitable for preclinical evaluation of innovative therapeutic intervention.
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Affiliation(s)
- Emmeline Salameh
- UniRouen, Inserm UMR 1073 Nutrition, Inflammation and Gut-Brain Axis, Normandie University, 76183 Rouen, France.
- Nutriset SAS, 76770 Malaunay, France.
| | | | | | - Pierre Déchelotte
- UniRouen, Inserm UMR 1073 Nutrition, Inflammation and Gut-Brain Axis, Normandie University, 76183 Rouen, France.
- Department of Nutrition, Rouen University Hospital, 76183 Rouen, France.
| | - Rachel Marion-Letellier
- UniRouen, Inserm UMR 1073 Nutrition, Inflammation and Gut-Brain Axis, Normandie University, 76183 Rouen, France.
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Hossain MS, Das S, Gazi MA, Alam MA, Haque NMS, Mahfuz M, Ahmed T, Damman CJ. Association of faecal pH with childhood stunting: Results from a cross-sectional study. BMJ Paediatr Open 2019; 3:e000549. [PMID: 31646200 PMCID: PMC6782033 DOI: 10.1136/bmjpo-2019-000549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Gut microbiota plays an important role in the growth of children. The gut of children with optimum growth is enriched in certain species, especially Bifidobacteria and Clostridia. Bifidobacteria and commensal Clostridia both contribute to formation of acidic stool, and an elevated faecal pH indicates reduction of these species in the gut. The purpose of the study was to investigate the association of faecal pH with childhood stunting. METHODS In this cross-sectional study, 100 children with length-for-age Z score (LAZ) <-1 aged between 12 and 18 months were enrolled from the ongoing Bangladesh Environmental Enteric Dysfunction study conducted in Dhaka, Bangladesh. LAZ was measured by anthropometry and data on factors affecting linear growth were recorded. Faecal pH measurement was done using pH metre on freshly collected non-diarrhoeal faecal samples following standard procedure. Multiple quantile regression was done to quantify the relation between faecal pH and LAZ scores. RESULTS The mean LAZ and faecal pH of the children were -2.12±0.80 and 5.84±1.11, respectively. Pearson correlation analysis showed a statistically significant negative correlation between stool pH and the LAZ scores (p<0.01). After inclusion of other factors affecting linear growth into the regression model, a statistically significant inverse association was observed between faecal pH and LAZ score (p<0.01). CONCLUSION Elevated faecal pH was found to have a significant association with stunted growth. As an indicator of gut microbiota status, faecal pH might have emerged as a possible indirect determinant of childhood stunting. TRIAL REGISTRATION NUMBER NCT02812615.
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Affiliation(s)
- Md. Shabab Hossain
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Md. Amran Gazi
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Md. Ashraful Alam
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Nur Muhammad Shahedul Haque
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Chris J Damman
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
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Correlates of Gut Function in Children Hospitalized for Severe Acute Malnutrition, a Cross-sectional Study in Uganda. J Pediatr Gastroenterol Nutr 2019; 69:292-298. [PMID: 31169661 DOI: 10.1097/mpg.0000000000002381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Children with severe acute malnutrition (SAM) may have impaired intestinal function, which can result in malabsorption, diarrhoea, and poor growth. This study evaluated the gut function of children with SAM using fecal and blood biomarkers and assessed their correlates. METHODS A cross-sectional study, nested in a randomized trial (www.isrctn.com, ISRCTN 16454889), was conducted at Mulago hospital, Uganda among subgroups of 400 children with complicated SAM and 30 community controls. Gut function was evaluated by 5 biomarkers: plasma citrulline, fecal myeloperoxidase and fecal neopterin, bacterially derived 16S rRNA gene and internal transcribed Spacer region (ITS) specific for Candida spp. in blood. RESULTS Compared with controls, children with SAM had lower median plasma citrulline (5.14 vs 27.4 μmol/L, P < 0.001), higher median fecal myeloperoxidase (18083 vs 7482 ng/mL, P = 0.001), and fecal neopterin (541 vs 210 nmol/L, P < 0.001). A higher blood concentration of 16S rRNA gene copy numbers was observed among children with SAM (95 vs 28 copies/μl, P = 0.05), whereas there was no difference in the blood concentration of Candida-specific ITS fragment.Among those with SAM, plasma citrulline was lower in children with edema, diarrhoea, dermatosis, and plasma C-reactive protein (CRP) >10 mg/L. Fecal neopterin was positively correlated with symptoms of fever and cough whereas it was negatively correlated with mid-upper arm circumference (MUAC), weight-for-height z score (WHZ), edema, and dermatosis. CONCLUSIONS Children with complicated SAM seem to have impaired gut function characterized by reduced enterocyte mass, intestinal inflammation, and increased bacterial translocation.
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Bourke CD, Jones KDJ, Prendergast AJ. Current Understanding of Innate Immune Cell Dysfunction in Childhood Undernutrition. Front Immunol 2019; 10:1728. [PMID: 31417545 PMCID: PMC6681674 DOI: 10.3389/fimmu.2019.01728] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
Undernutrition affects millions of children in low- and middle-income countries (LMIC) and underlies almost half of all deaths among children under 5 years old. The growth deficits that characterize childhood undernutrition (stunting and wasting) result from simultaneous underlying defects in multiple physiological processes, and current treatment regimens do not completely normalize these pathways. Most deaths among undernourished children are due to infections, indicating that their anti-pathogen immune responses are impaired. Defects in the body's first-line-of-defense against pathogens, the innate immune system, is a plausible yet understudied pathway that could contribute to this increased infection risk. In this review, we discuss the evidence for innate immune cell dysfunction from cohort studies of childhood undernutrition in LMIC, highlighting knowledge gaps in almost all innate immune cell types. We supplement these gaps with insights from relevant experimental models and make recommendations for how human and animal studies could be improved. A better understanding of innate immune function could inform future tractable immune-targeted interventions for childhood undernutrition to reduce mortality and improve long-term health, growth and development.
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Affiliation(s)
- Claire D Bourke
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kelsey D J Jones
- Kennedy Institute for Rheumatology, University of Oxford, Oxford, United Kingdom.,Department of Paediatric Gastroenterology & Nutrition, University of Oxford NHS Foundation Trust, Oxford, United Kingdom
| | - Andrew J Prendergast
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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Chama M, Amadi BC, Chandwe K, Zyambo K, Besa E, Shaikh N, Ndao IM, Tarr PI, Storer C, Head R, Kelly P. Transcriptomic analysis of enteropathy in Zambian children with severe acute malnutrition. EBioMedicine 2019; 45:456-463. [PMID: 31229436 PMCID: PMC6642221 DOI: 10.1016/j.ebiom.2019.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Children with severe acute malnutrition (SAM), with or without diarrhoea, often have enteropathy, but there are few molecular data to guide development of new therapies. We set out to determine whether SAM enteropathy is characterised by specific transcriptional changes which might improve understanding or help identify new treatments. METHODS We collected intestinal biopsies from children with SAM and persistent diarrhoea. mRNA was extracted from biopsies, sequenced, and subjected to a progressive set of complementary analytical approaches: NOIseq, Gene Set Enrichment Analysis (GSEA), and correlation analysis of phenotypic data with gene expression. FINDINGS Transcriptomic profiles were generated for biopsy sets from 27 children of both sexes, under 2 years of age, of whom one-third were HIV-infected. NOIseq analysis, constructed from phenotypic group extremes, revealed 66 differentially expressed genes (DEGs) out of 21,386 mapped to the reference genome. These DEGs include genes for mucins and mucus integrity, antimicrobial defence, nutrient absorption, C-X-C chemokines, proteases and anti-proteases. Phenotype - expression correlation analysis identified 1221 genes related to villus height, including increased cell cycling gene expression in more severe enteropathy. Amino acid transporters and ZIP zinc transporters were specifically increased in severe enteropathy, but transcripts for xenobiotic metabolising enzymes were reduced. INTERPRETATION Transcriptomic analysis of this rare collection of intestinal biopsies identified multiple novel elements of pathology, including specific alterations in nutrient transporters. Changes in xenobiotic metabolism in the gut may alter drug disposition. Both NOIseq and GSEA identified gene clusters similar to those differentially expressed in pediatric Crohn's disease but to a much lesser degree than those identified in coeliac disease. FUND: Bill & Melinda Gates Foundation OPP1066118. The funding agency had no role in study design, data collection, data analysis, interpretation, or writing of the report.
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Affiliation(s)
- Mubanga Chama
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Beatrice C Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Nurmohammad Shaikh
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - I Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Philip I Tarr
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Chad Storer
- Department of Genetics, Washington University School of Medicine, St Louis, MO, United States
| | - Richard Head
- Department of Genetics, Washington University School of Medicine, St Louis, MO, United States
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, UK.
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Syed S, Al-Boni M, Khan MN, Sadiq K, Iqbal NT, Moskaluk CA, Kelly P, Amadi B, Ali SA, Moore SR, Brown DE. Assessment of Machine Learning Detection of Environmental Enteropathy and Celiac Disease in Children. JAMA Netw Open 2019; 2:e195822. [PMID: 31199451 PMCID: PMC6575155 DOI: 10.1001/jamanetworkopen.2019.5822] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Importance Duodenal biopsies from children with enteropathies associated with undernutrition, such as environmental enteropathy (EE) and celiac disease (CD), display significant histopathological overlap. Objective To develop a convolutional neural network (CNN) to enhance the detection of pathologic morphological features in diseased vs healthy duodenal tissue. Design, Setting, and Participants In this prospective diagnostic study, a CNN consisting of 4 convolutions, 1 fully connected layer, and 1 softmax layer was trained on duodenal biopsy images. Data were provided by 3 sites: Aga Khan University Hospital, Karachi, Pakistan; University Teaching Hospital, Lusaka, Zambia; and University of Virginia, Charlottesville. Duodenal biopsy slides from 102 children (10 with EE from Aga Khan University Hospital, 16 with EE from University Teaching Hospital, 34 with CD from University of Virginia, and 42 with no disease from University of Virginia) were converted into 3118 images. The CNN was designed and analyzed at the University of Virginia. The data were collected, prepared, and analyzed between November 2017 and February 2018. Main Outcomes and Measures Classification accuracy of the CNN per image and per case and incorrect classification rate identified by aggregated 10-fold cross-validation confusion/error matrices of CNN models. Results Overall, 102 children participated in this study, with a median (interquartile range) age of 31.0 (20.3-75.5) months and a roughly equal sex distribution, with 53 boys (51.9%). The model demonstrated 93.4% case-detection accuracy and had a false-negative rate of 2.4%. Confusion metrics indicated most incorrect classifications were between patients with CD and healthy patients. Feature map activations were visualized and learned distinctive patterns, including microlevel features in duodenal tissues, such as alterations in secretory cell populations. Conclusions and Relevance A machine learning-based histopathological analysis model demonstrating 93.4% classification accuracy was developed for identifying and differentiating between duodenal biopsies from children with EE and CD. The combination of the CNN with a deconvolutional network enabled feature recognition and highlighted secretory cells' role in the model's ability to differentiate between these histologically similar diseases.
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Affiliation(s)
- Sana Syed
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mohammad Al-Boni
- Systems and Information Engineering, University of Virginia, Charlottesville
| | - Marium N. Khan
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - S. Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Donald E. Brown
- Data Science Institute, University of Virginia, Charlottesville
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50
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Njunge JM, Gwela A, Kibinge NK, Ngari M, Nyamako L, Nyatichi E, Thitiri J, Gonzales GB, Bandsma RHJ, Walson JL, Gitau EN, Berkley JA. Biomarkers of post-discharge mortality among children with complicated severe acute malnutrition. Sci Rep 2019; 9:5981. [PMID: 30979939 PMCID: PMC6461700 DOI: 10.1038/s41598-019-42436-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 04/01/2019] [Indexed: 12/22/2022] Open
Abstract
High mortality after discharge from hospital following acute illness has been observed among children with Severe Acute Malnutrition (SAM). However, mechanisms that may be amenable to intervention to reduce risk are unknown. We performed a nested case-control study among HIV-uninfected children aged 2-59 months treated for complicated SAM according to WHO recommendations at four Kenyan hospitals. Blood was drawn from 1778 children when clinically judged stable before discharge from hospital. Cases were children who died within 60 days. Controls were randomly selected children who survived for one year without readmission to hospital. Untargeted proteomics, total protein, cytokines and chemokines, and leptin were assayed in plasma and corresponding biological processes determined. Among 121 cases and 120 controls, increased levels of calprotectin, von Willebrand factor, angiotensinogen, IL8, IL15, IP10, TNFα, and decreased levels of leptin, heparin cofactor 2, and serum paraoxonase were associated with mortality after adjusting for possible confounders. Acute phase responses, cellular responses to lipopolysaccharide, neutrophil responses to bacteria, and endothelial responses were enriched among cases. Among apparently clinically stable children with SAM, a sepsis-like profile is associated with subsequent death. This may be due to ongoing bacterial infection, translocated bacterial products or deranged immune response during nutritional recovery.
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Affiliation(s)
- James M Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Agnes Gwela
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Moses Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lydia Nyamako
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emily Nyatichi
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gerard Bryan Gonzales
- Department of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Inflammation Research Centre, Flemish Institute for Biotechnology, Ghent, Belgium
| | - Robert H J Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Departments of Global Health, Medicine, Paediatrics and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Evelyn N Gitau
- African Population and Health Research Centre, Nairobi, Kenya
| | - James A Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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