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McDonald CM, Reid EK, Pohl JF, Yuzyuk TK, Padula LM, Vavrina K, Altman K. Cystic fibrosis and fat malabsorption: Pathophysiology of the cystic fibrosis gastrointestinal tract and the impact of highly effective CFTR modulator therapy. Nutr Clin Pract 2024; 39 Suppl 1:S57-S77. [PMID: 38429959 DOI: 10.1002/ncp.11122] [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: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Cystic fibrosis (CF) is a progressive, genetic, multi-organ disease affecting the respiratory, digestive, endocrine, and reproductive systems. CF can affect any aspect of the gastrointestinal (GI) tract, including the esophagus, stomach, small intestine, colon, pancreas, liver, and gall bladder. GI pathophysiology associated with CF results from CF membrane conductance regulator (CFTR) dysfunction. The majority of people with CF (pwCF) experience exocrine pancreatic insufficiency resulting in malabsorption of nutrients and malnutrition. Additionally, other factors can cause or worsen fat malabsorption, including the potential for short gut syndrome with a history of meconium ileus, hepatobiliary diseases, and disrupted intraluminal factors, such as inadequate bile salts, abnormal pH, intestinal microbiome changes, and small intestinal bacterial overgrowth. Signs and symptoms associated with fat malabsorption, such as abdominal pain, bloating, malodorous flatus, gastroesophageal reflux, nausea, anorexia, steatorrhea, constipation, and distal intestinal obstruction syndrome, are seen in pwCF despite the use of pancreatic enzyme replacement therapy. Given the association of poor nutrition status with lung function decline and increased mortality, aggressive nutrition support is essential in CF care to optimize growth in children and to achieve and maintain a healthy body mass index in adults. The introduction of highly effective CFTR modulator therapy and other advances in CF care have profoundly changed the course of CF management. However, GI symptoms in some pwCF may persist. The use of current knowledge of the pathophysiology of the CF GI tract as well as appropriate, individualized management of GI symptoms continue to be integral components of care for pwCF.
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Affiliation(s)
| | - Elizabeth K Reid
- Cystic Fibrosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John F Pohl
- Pediatric Gastroenterology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Tatiana K Yuzyuk
- Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- ARUP Institute for Clinical & Experimental Pathology, Salt Lake City, Utah, USA
| | - Laura M Padula
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kay Vavrina
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York, New York, USA
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Yuzyuk T, McDonald CM, Zuromski LM, De Biase I, Johnson L, Williams N, Meihls S, Asfour F. Improvement of lipid and lipoprotein profiles in children and adolescents with cystic fibrosis on CFTR modulator therapy. J Cyst Fibros 2023; 22:1027-1035. [PMID: 37453889 DOI: 10.1016/j.jcf.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Association of a high-fat diet with increased risks of cardiovascular disease (CVD) and type 2 diabetes, has prompted evaluation of lipids in people with CF (pwCF). However, most evidence on dyslipidemia was published before CF transmembrane conductance regulator (CFTR) modulators became a standard of care. The main goal of this study was to investigate the effect of CFTR modulator therapies on lipid and lipoprotein profiles in children and adolescents with CF. METHODS Blood samples were collected from 153 pwCF (10.1 ± 4.7 years of age) and 60 age-matched controls. Most pwCF were pancreatic insufficient on pancreatic enzyme replacement therapy. By the end of the study, 65% of CF participants were on CFTR modulator therapy for >1 month. The results of traditional and advanced lipid testing in pwCF were correlated with clinical and dietary information. RESULTS Total cholesterol and low-density lipoprotein (LDL) cholesterol were significantly lower in pwCF compared to non-CF participants. Those not receiving CFTR modulators also had significantly lower high-density lipoprotein (HDL) cholesterol and HDL particle number than controls. Individuals with CF on modulator therapy had significantly higher concentrations of anti-atherogenic HDL cholesterol and HDL particles along with lower levels of atherogenic large very-low density lipoprotein (VLDL) particles, total and small LDL particles, and triglycerides compared to those without CFTR modulator therapy. CONCLUSION CFTR modulator therapy has a beneficial effect on dyslipidemia in CF. It remains to be seen if these positive changes translate into decreased CVD risk later in life given the increasing life expectancy in CF.
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Affiliation(s)
- Tatiana Yuzyuk
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA; ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA.
| | | | - Lauren M Zuromski
- ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA
| | - Irene De Biase
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA; ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA
| | | | - Nicole Williams
- Cystic Fibrosis Clinic, Primary Children's Hospital, Salt Lake City, UT
| | - Suzanne Meihls
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Fadi Asfour
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Burgel PR, Burnet E, Regard L, Martin C. The Changing Epidemiology of Cystic Fibrosis: The Implications for Adult Care. Chest 2023; 163:89-99. [PMID: 35850286 DOI: 10.1016/j.chest.2022.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 01/13/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease in which mutations in the gene encoding for the CF transmembrane conductance regulator protein result in a multisystem disease dominated by digestive and respiratory manifestations. In the mid-20th century, CF caused death within the first years of life. Over the past decades, advances in disease management, which includes systematic neonatal screening, multidisciplinary symptomatic CF care, lung transplantation and, more recently, highly effective CF transmembrane conductance regulator modulators, have transformed the prognosis of people with CF markedly. In most countries with well-established CF care, adults now outnumber children, and life expectancy is expected to increase further, narrowing the survival gap with the general population. However, marked differences in the prognosis of CF exist not only among high-, low-, and middle-income countries but also among high-income countries, based on the presence and quality of a specialized CF care provision network. Current evidence suggests that differences in patient clinical status and survival could be attributable not only to intrinsic disease severity but also to disparities in access to high-quality specialized care. Because CF is generally a progressive disease, adults with CF often show increased pulmonary severity and complications and increased occurrence of comorbidities, which highlights the need for specialized adult CF centers. This article seeks to describe the evolution of CF demography over the past decades, predict future trends, and anticipate the future provision of adult CF care.
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Affiliation(s)
- Pierre-Régis Burgel
- Université de Paris, Institut Cochin, Inserm, Paris, France; Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France; ERN-Lung CF Network, Frankfurt, Germany.
| | - Espérie Burnet
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Lucile Regard
- Université de Paris, Institut Cochin, Inserm, Paris, France; Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France; ERN-Lung CF Network, Frankfurt, Germany
| | - Clémence Martin
- Université de Paris, Institut Cochin, Inserm, Paris, France; Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France; ERN-Lung CF Network, Frankfurt, Germany
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Potter KJ, Bonhoure A, Boudreau V, Tremblay F, Lavoie A, Carricart M, Senior PA, Rabasa-Lhoret R. Marginal association of fasting blood glucose with the risk of cystic fibrosis-related diabetes. ANNALES D'ENDOCRINOLOGIE 2022; 84:265-271. [PMID: 36332698 DOI: 10.1016/j.ando.2022.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Cystic fibrosis-related diabetes (CFRD) may be diagnosed by fasting blood glucose ≥ 7.0 mmol/L and/or glucose ≥ 11.1 mmol/L following oral glucose tolerance test (OGTT). We compared the role of fasting and stimulated glucose for diagnosis of CFRD. METHODS We performed a cross-sectional review of the prevalence of fasting glycemic abnormalities and Kaplan-Meier survival analysis of risk of progression to CFRD according to baseline fasting glucose in the prospective Montreal Cystic Fibrosis Cohort. RESULTS Isolated fasting hyperglycemia was detected in only 8% of participants at study onset. Eighty percent of subjects had isolated post-challenge hyperglycemia on their first OGTT meeting criteria for CFRD. Kaplan Meier survival analysis demonstrated that impaired fasting glucose (IFG) alone is not a risk factor for CFRD. Subjects with combined IFG and impaired glucose tolerance at baseline (IGT) had the highest risk of progression to CFRD. CONCLUSION Post-prandial elevations in blood glucose are more common at diagnosis of CFRD. While IGT is a significant risk factor for CFRD, IFG alone is uncommon and does not increase the risk of CFRD. Patients with both IGT and IFG have the highest risk of CFRD.
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Affiliation(s)
- Kathryn J Potter
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Department of Endocrinology, University of Alberta, Edmonton, Alberta, Canada
| | - Anne Bonhoure
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Valérie Boudreau
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - François Tremblay
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Annick Lavoie
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Maité Carricart
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Peter A Senior
- Department of Endocrinology, University of Alberta, Edmonton, Alberta, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada; Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
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Ciochina M, Balaban DV, Manucu G, Jinga M, Gheorghe C. The Impact of Pancreatic Exocrine Diseases on the β-Cell and Glucose Metabolism-A Review with Currently Available Evidence. Biomolecules 2022; 12:biom12050618. [PMID: 35625546 PMCID: PMC9139037 DOI: 10.3390/biom12050618] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 02/07/2023] Open
Abstract
Pancreatic exocrine and endocrine dysfunctions often come together in the course of pancreatic diseases as interdependent manifestations of the same organ. However, the mechanisms underlying the bidirectional connection of the exocrine and endocrine pancreas are not fully understood. In this review, we aimed to synthetize the current knowledge regarding the effects of several exocrine pancreatic pathologies on the homeostasis of β-cells, with a special interest in the predisposition toward diabetes mellitus (DM). We focused on the following pancreatic exocrine diseases: chronic pancreatitis, acute pancreatitis, cystic fibrosis, pancreatic cancer, pancreatic resections, and autoimmune pancreatitis. We discuss the pathophysiologic mechanisms behind the impact on β-cell function and evolution into DM, as well as the associated risk factors in progression to DM, and we describe the most relevant and statistically significant findings in the literature. An early and correct diagnosis of DM in the setting of pancreatic exocrine disorders is of paramount importance for anticipating the disease's course and its therapeutical needs.
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Affiliation(s)
- Marina Ciochina
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Correspondence:
| | - Daniel Vasile Balaban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - George Manucu
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Mariana Jinga
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Cristian Gheorghe
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
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