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Thornton CS, Waddell BJ, Congly SE, Svishchuk J, Somayaji R, Fatovich L, Isaac D, Doucette K, Fonseca K, Drews SJ, Borlang J, Osiowy C, Parkins MD. Porcine-derived pancreatic enzyme replacement therapy may be linked to chronic hepatitis E virus infection in cystic fibrosis lung transplant recipients. Gut 2024; 73:1702-1711. [PMID: 38621922 PMCID: PMC11420761 DOI: 10.1136/gutjnl-2023-330602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES In high-income countries hepatitis E virus (HEV) is an uncommonly diagnosed porcine-derived zoonoses. After identifying disproportionate chronic HEV infections in persons with cystic fibrosis (pwCF) postlung transplant, we sought to understand its epidemiology and potential drivers. DESIGN All pwCF post-transplant attending our regional CF centre were screened for HEV. HEV prevalence was compared against non-transplanted pwCF and with all persons screened for suspected HEV infection from 2016 to 2022 in Alberta, Canada. Those with chronic HEV infection underwent genomic sequencing and phylogenetic analysis. Owing to their swine derivation, independently sourced pancreatic enzyme replacement therapy (PERT) capsules were screened for HEV. RESULTS HEV seropositivity was similar between transplanted and non-transplanted pwCF (6/29 (21%) vs 16/83 (19%); p=0.89). Relative to all other Albertans investigated for HEV as a cause of hepatitis (n=115/1079, 10.7%), pwCF had a twofold higher seropositivity relative risk and this was four times higher than the Canadian average. Only three chronic HEV infection cases were identified in all of Alberta, all in CF lung transplant recipients (n=3/29, 10.3%). Phylogenetics confirmed cases were unrelated porcine-derived HEV genotype 3a. Ninety-one per cent of pwCF were taking PERT (median 8760 capsules/person/year). HEV RNA was detected by RT-qPCR in 44% (47/107) of PERT capsules, and sequences clustered with chronic HEV cases. CONCLUSION PwCF had disproportionate rates of HEV seropositivity, regardless of transplant status. Chronic HEV infection was evident only in CF transplant recipients. HEV may represent a significant risk for pwCF, particularly post-transplant. Studies to assess HEV incidence and prevalence in pwCF, and potential role of PERT are required.
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Affiliation(s)
- Christina S Thornton
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Barbara J Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julianna Svishchuk
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Linda Fatovich
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Debra Isaac
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Fonseca
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Drews
- Canadian Blood Services, Edmonton, Alberta, Canada
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jamie Borlang
- Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Carla Osiowy
- Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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2
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Ramsey ML, Galante GJ. Pancreas and pancreatitis: Exocrine pancreatic insufficiency. Pediatr Pulmonol 2024; 59 Suppl 1:S44-S52. [PMID: 39105352 DOI: 10.1002/ppul.27013] [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: 08/23/2023] [Revised: 03/23/2024] [Accepted: 04/04/2024] [Indexed: 08/07/2024]
Abstract
Exocrine pancreatic insufficiency (EPI) is highly prevalent among individuals with cystic fibrosis (CF). Individuals diagnosed with EPI are often labeled as having "pancreas insufficient cystic fibrosis (PI-CF)" while those with normal exocrine function are labeled as "pancreas sufficient CF (PS-CF)." This diagnosis of EPI relies on clinical and laboratory features and management involves consumption of pancreas enzyme replacement therapy. In this review, we discuss the nuances of diagnosis and management of EPI in CF. We also present emerging evidence on the effects of CFTR modulating agents on the management of EPI, and speculate that these medications may lead to greater heterogeneity in management of EPI in CF moving forward.
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Affiliation(s)
- Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Gary J Galante
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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3
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Fabricius D, Knieling T, Zurmuehl N, Makedon L, Freihorst J, Schmidt H, Bode S. Changes in vitamins and trace elements after initiation of highly effective CFTR modulator therapy in children and adults with cystic fibrosis - a real-life insight. Mol Cell Pediatr 2024; 11:4. [PMID: 38717689 PMCID: PMC11078909 DOI: 10.1186/s40348-024-00178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/01/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Highly-effective CFTR-modulator therapy with elexa-/teza-/ivacaftor (ETI) has led to improvements in pulmonary outcomes, sweat chloride, body mass index (BMI) and quality of life in people with cystic fibrosis (CF). Improved uptake of fat-soluble vitamins and micronutrients has been reported for CFTR-modulators but data regarding ETI therapy is lacking. METHODS This single-center retrospective study evaluated forced expiratory volume in one second (FEV-1), sweat chloride, BMI, transaminases (AST, ALT), bilirubin, vitamins A, D, E, zinc and selenium in children and adults eligible for ETI. Parameters were assessed before and up to one year after initiation of ETI. RESULTS 58 patients (median age m = 28 years, SD ± 11.6 years, 51.7% female14 < 18 years old) were included. FEV-1 and sweat chloride improved significantly after ETI. There were no changes in BMI or AST. ALT was increased significantly after 4 weeks of ETI but returned to normal levels in further course. Bilirubin levels remained elevated after ETI. Vitamin A was significantly higher 12 months after ETI. No changes were found for vitamins D, E, zinc and selenium. CONCLUSIONS This study adds to the evidence that improvements of some fat-soluble vitamin levels can be found after ETI. No changes regarding micronutrients were noted. Individualized follow-up and supplementation are recommended.
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Affiliation(s)
- Dorit Fabricius
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Tina Knieling
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Noelle Zurmuehl
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Leandra Makedon
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Joachim Freihorst
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Hanna Schmidt
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany
| | - Sebastian Bode
- Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm University, Eythstrasse 24, 89075, Ulm, Germany.
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4
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Green DM, Lahiri T, Raraigh KS, Ruiz F, Spano J, Antos N, Bonitz L, Christon L, Gregoire-Bottex M, Hale JE, Langfelder-Schwind E, La Parra Perez Á, Maguiness K, Massie J, McElroy-Barker E, McGarry ME, Mercier A, Munck A, Oliver KE, Self S, Singh K, Smiley M, Snodgrass S, Tluczek A, Tuley P, Lomas P, Wong E, Hempstead SE, Faro A, Ren CL. Cystic Fibrosis Foundation Evidence-Based Guideline for the Management of CRMS/CFSPID. Pediatrics 2024; 153:e2023064657. [PMID: 38577740 DOI: 10.1542/peds.2023-064657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
A multidisciplinary committee developed evidence-based guidelines for the management of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen-positive, inconclusive diagnosis (CRMS/CFSPID). A total of 24 patient, intervention, comparison, and outcome questions were generated based on surveys sent to people with CRMS/CFSPID and clinicians caring for these individuals, previous recommendations, and expert committee input. Four a priori working groups (genetic testing, monitoring, treatment, and psychosocial/communication issues) were used to provide structure to the committee. A systematic review of the evidence was conducted, and found numerous case series and cohort studies, but no randomized clinical trials. A total of 30 recommendations were graded using the US Preventive Services Task Force methodology. Recommendations that received ≥80% consensus among the entire committee were approved. The resulting recommendations were of moderate to low certainty for the majority of the statements because of the low quality of the evidence. Highlights of the recommendations include thorough evaluation with genetic sequencing, deletion/duplication analysis if <2 disease-causing variants were noted in newborn screening; repeat sweat testing until at least age 8 but limiting further laboratory testing, including microbiology, radiology, and pulmonary function testing; minimal use of medications, which when suggested, should lead to shared decision-making with families; and providing communication with emphasis on social determinants of health and shared decision-making to minimize barriers which may affect processing and understanding of this complex designation. Future research will be needed regarding medication use, antibiotic therapy, and the use of chest imaging for monitoring the development of lung disease.
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Affiliation(s)
- Deanna M Green
- Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Thomas Lahiri
- University of Vermont Children's Hospital, Burlington, Vermont
| | - Karen S Raraigh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jacquelyn Spano
- Stanford University School of Medicine, Stanford, California
| | - Nicholas Antos
- Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Lynn Bonitz
- Cohen Children's Medical Center of NY/Northwell Health, New Hyde Park, New York
| | - Lillian Christon
- Medical University of South Carolina, Charleston, South Carolina
| | - Myrtha Gregoire-Bottex
- Advanced Pediatric Pulmonology, Pllc, Miramar, Florida
- Memorial Health Network, Hollywood, Florida
| | - Jaime E Hale
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | | | - Álvaro La Parra Perez
- John B. Goddard School of Business and Economics, Weber State University, Ogden, Utah
| | - Karen Maguiness
- Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John Massie
- University of Melbourne Murdoch Childrens Research Institute, Melbourne, Australia
| | | | - Meghan E McGarry
- University of California San Francisco, San Francisco, California
| | - Angelique Mercier
- Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Anne Munck
- Hospital Necker Enfants malades, AP-HP, Paris, France
| | | | - Staci Self
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Singh
- University of California, Irvine, Orange, California Miller Children's and Women's Hospital, Long Beach, California
| | | | | | | | | | - Paula Lomas
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Elise Wong
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Albert Faro
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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5
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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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6
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Hocquigny A, Hugerot H, Ghanem R, Haute T, Laurent V, Cogulet V, Montier T. Mucoactive drugs and multiple applications in pulmonary disease therapy. Eur J Pharm Biopharm 2024; 194:110-117. [PMID: 38048888 DOI: 10.1016/j.ejpb.2023.12.001] [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: 09/07/2023] [Revised: 11/19/2023] [Accepted: 12/01/2023] [Indexed: 12/06/2023]
Abstract
Mucus is a complex polymeric hydrogel that serves as a critical defense in several organs. In the lungs, it provides a formidable barrier against inhaled particles such as microorganisms. In addition, mucus is essential for normal lung physiology, as it promotes immune tolerance and facilitates a normal commensal pulmonary microbiome. Hypersecretion of airway mucus is a characteristic of numerous respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD) and Cystic Fibrosis (CF), and creates pulmonary obstruction, limiting the effectiveness of inhaled therapies. Due to those alterations, therapeutic strategies must be optimal to limit airway obstruction and restore pulmonary function. Mucoactive drugs are common therapeutic options and are classified into different groups depending on their modes of action, i.e., expectorants, mucokinetics, mucoregulators and mucolytics. This review focuses on mucoactive drugs and their modes of action. A special focus will be made on two challenging pulmonary pathologies: COPD and CF, and on their clinical studies conducted with mucoactive drugs.
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Affiliation(s)
| | - Hélène Hugerot
- CHU de Brest, Pharmacie hospitalière, Brest, 5 avenue du Maréchal Foch, France
| | - Rosy Ghanem
- Univ Brest, INSERM, EFS, UMR 1078, GGB, F-29200 Brest, France; CHU de Brest, Service de Génétique Médicale et de Biologie de la Reproduction, 29200 Brest, France
| | - Tanguy Haute
- Univ Brest, INSERM, EFS, UMR 1078, GGB, F-29200 Brest, France
| | - Véronique Laurent
- CHU de Brest, Pharmacie hospitalière, Brest, 5 avenue du Maréchal Foch, France
| | - Virginie Cogulet
- CHU de Brest, Pharmacie hospitalière, Brest, 5 avenue du Maréchal Foch, France
| | - Tristan Montier
- Univ Brest, INSERM, EFS, UMR 1078, GGB, F-29200 Brest, France; CHU de Brest, Service de Génétique Médicale et de Biologie de la Reproduction, 29200 Brest, France; CHU de Brest, Centre de Référence des Maladies Rares Maladies Neuromusculaires, 29200, Brest France.
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7
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Yuzyuk TN, Nelson HA, Johnson LM. Inherited causes of exocrine pancreatic insufficiency in pediatric patients: clinical presentation and laboratory testing. Crit Rev Clin Lab Sci 2023:1-16. [PMID: 36876586 DOI: 10.1080/10408363.2023.2179968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Pediatric patients with exocrine pancreatic insufficiency (EPI) have symptoms that include abdominal pain, weight loss or poor weight gain, malnutrition, and steatorrhea. This condition can be present at birth or develop during childhood for certain genetic disorders. Cystic fibrosis (CF) is the most prevalent disorder in which patients are screened for EPI; other disorders also are associated with pancreatic dysfunction, such as hereditary pancreatitis, Pearson syndrome, and Shwachman-Diamond syndrome. Understanding the clinical presentation and proposed pathophysiology of the pancreatic dysfunction of these disorders aids in diagnosis and treatment. Testing pancreatic function is challenging. Directly testing aspirates produced from the pancreas after stimulation is considered the gold standard, but the procedures are not standardized or widely available. Instead, indirect tests are often used in diagnosis and monitoring. Although indirect tests are more widely available and easier to perform, they have inherent limitations due to a lack of sensitivity and/or specificity for EPI.
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Affiliation(s)
- Tatiana N Yuzyuk
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Lisa M Johnson
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA
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8
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Freswick PN, Reid EK, Mascarenhas MR. Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis. Nutrients 2022; 14:nu14071341. [PMID: 35405954 PMCID: PMC9003370 DOI: 10.3390/nu14071341] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
While typically considered a pulmonary disease, cystic fibrosis patients develop significant nutritional complications and comorbidities, especially those who are pancreatic insufficient. Clinicians must have a high suspicion for cystic fibrosis among patients with clinical symptoms of pancreatic insufficiency, and pancreatic enzymatic replacement therapy (PERT) must be urgently initiated. PERT presents a myriad of considerations for patients and their supporting dieticians and clinicians, including types of administration, therapy failures, and complications.
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Affiliation(s)
- Peter N. Freswick
- Helen DeVos Children’s Hospital, Grand Rapids, MI 49503, USA
- Correspondence:
| | - Elizabeth K. Reid
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
| | - Maria R. Mascarenhas
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
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9
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Davies JC, Wainwright CE, Sawicki GS, Higgins MN, Campbell D, Harris C, Panorchan P, Haseltine E, Tian S, Rosenfeld M. Ivacaftor in Infants Aged 4 to <12 Months with Cystic Fibrosis and a Gating Mutation. Results of a Two-Part Phase 3 Clinical Trial. Am J Respir Crit Care Med 2021; 203:585-593. [PMID: 33023304 PMCID: PMC7924576 DOI: 10.1164/rccm.202008-3177oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: We previously reported that ivacaftor was safe and well tolerated in cohorts aged 12 to <24 months with cystic fibrosis and gating mutations in the ARRIVAL study; here, we report results for cohorts aged 4 to <12 months. Objectives: To evaluate the safety, pharmacokinetics, and pharmacodynamics of ivacaftor in infants aged 4 to <12 months with one or more gating mutations. Methods: ARRIVAL is a single-arm phase 3 study. Infants received 25 mg or 50 mg ivacaftor every 12 hours on the basis of age and weight for 4 days in part A and 24 weeks in part B. Measurements and Main Results: Primary endpoints were safety (parts A and B) and pharmacokinetics (part A). Secondary/tertiary endpoints (part B) included pharmacokinetics and changes in sweat chloride levels, growth, and markers of pancreatic function. Twenty-five infants received ivacaftor, 12 in part A and 17 in part B (four infants participated in both parts). Pharmacokinetics was consistent with that in older groups. Most adverse events were mild or moderate. In part B, cough was the most common adverse event (n = 10 [58.8%]). Five infants (part A, n = 1 [8.3%]; part B, n = 4 [23.5%]) had serious adverse events, all of which were considered to be not or unlikely related to ivacaftor. No deaths or treatment discontinuations occurred. One infant (5.9%) experienced an alanine transaminase elevation >3 to ≤5× the upper limit of normal at Week 24. No other adverse trends in laboratory tests, vital signs, or ECG parameters were reported. Sweat chloride concentrations and measures of pancreatic obstruction improved. Conclusions: This study of ivacaftor in the first year of life supports treating the underlying cause of cystic fibrosis in children aged ≥4 months with one or more gating mutations. Clinical trial registered with clinicaltrials.gov (NCT02725567).
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Affiliation(s)
- Jane C Davies
- National Heart & Lung Institute, Imperial College London and Royal Brompton Hospital, London, United Kingdom
| | - Claire E Wainwright
- Queensland Children's Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Gregory S Sawicki
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark N Higgins
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts; and
| | - Daniel Campbell
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts; and
| | | | - Paul Panorchan
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts; and
| | - Eric Haseltine
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts; and
| | - Simon Tian
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts; and
| | - Margaret Rosenfeld
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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10
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CFTR Modulator Therapy with Lumacaftor/Ivacaftor Alters Plasma Concentrations of Lipid-Soluble Vitamins A and E in Patients with Cystic Fibrosis. Antioxidants (Basel) 2021; 10:antiox10030483. [PMID: 33808590 PMCID: PMC8003491 DOI: 10.3390/antiox10030483] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Cystic fibrosis (CF), caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, leads to impaired pancreatic function and therefore reduced intestinal absorption of lipids and fat-soluble vitamins especially in patients with CF developing pancreatic insufficiency (PI). Previous studies showed that CFTR modulator therapy with lumacaftor-ivacaftor (LUM/IVA) in Phe508del-homozygous patients with CF results in improvement of pulmonary disease and thriving. However, the effects of LUM/IVA on plasma concentration of the lipid soluble vitamins A and E remain unknown. OBJECTIVES To investigate the course of plasma vitamin A and E in patients with CF under LUM/IVA therapy. METHODS Data from annual follow-up examinations of patients with CF were obtained to assess clinical outcomes including pulmonary function status, body mass index (BMI), and clinical chemistry as well as fat-soluble vitamins in Phe508del-homozygous CF patients before initiation and during LUM/IVA therapy. RESULTS Patients with CF receiving LUM/IVA improved substantially, including improvement in pulmonary inflammation, associated with a decrease in blood immunoglobulin G (IgG) from 9.4 to 8.2 g/L after two years (p < 0.001). During the same time, plasma vitamin A increased significantly from 1.2 to 1.6 µmol/L (p < 0.05), however, levels above the upper limit of normal were not detected in any of the patients. In contrast, plasma vitamin E as vitamin E/cholesterol ratio decreased moderately over the same time from 6.2 to 5.5 µmol/L (p < 0.01). CONCLUSIONS CFTR modulator therapy with LUM/IVA alters concentrations of vitamins A and vitamin E in plasma. The increase of vitamin A must be monitored critically to avoid hypervitaminosis A in patients with CF.
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11
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Barben J, Castellani C, Munck A, Davies JC, de Winter-de Groot KM, Gartner S, Kashirskaya N, Linnane B, Mayell SJ, McColley S, Ooi CY, Proesmans M, Ren CL, Salinas D, Sands D, Sermet-Gaudelus I, Sommerburg O, Southern KW. Updated guidance on the management of children with cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen positive, inconclusive diagnosis (CRMS/CFSPID). J Cyst Fibros 2020; 20:810-819. [PMID: 33257262 DOI: 10.1016/j.jcf.2020.11.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/30/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
Over the past two decades there has been considerable progress with the evaluation and management of infants with an inconclusive diagnosis following Newborn Screening (NBS) for cystic Fibrosis (CF). In addition, we have an increasing amount of evidence on which to base guidance on the management of these infants and, importantly, we have a consistent designation being used across the globe of CRMS/CFSPID. There is still work to be undertaken and research questions to answer, but these infants now receive more consistent and appropriate care pathways than previously. It is clear that the majority of these infants remain healthy, do not convert to a diagnosis of CF in childhood, and advice on management should reflect this. However, it is also clear that some will convert to a CF diagnosis and monitoring of these infants should facilitate their early recognition. Those infants that do not convert to a CF diagnosis have some potential of developing a CFTR-RD later in life. At present, it is not possible to quantify this risk, but families need to be provided with clear information of what to look out for. This paper contains a number of changes from previous guidance in light of developing evidence, but the major change is the recommendation of a detailed assessment of the child with CRMS/CFSPID in the sixth year of age, including respiratory function assessment and imaging. With these data, the CF team can discuss future care arrangements with the family and come to a shared decision on the best way forward, which may include discharge to primary care with appropriate information. Information is key for these families, and we recommend consideration of a further appointment when the individual is a young adult to directly communicate the implications of the CRMS/CFSPID designation.
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Affiliation(s)
- Jürg Barben
- Paediatric Pulmonology & CF Centre, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland.
| | - Carlo Castellani
- Istituto Giannina Gaslini, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Anne Munck
- CF referent physician for the French Society of Newborn Screening, Hopital Necker Enfants-Malades, AP-HP, CF centre, Université Paris Descartes, France
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Karin M de Winter-de Groot
- Department of Paediatric Pulmonology & Allergology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Silvia Gartner
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Nataliya Kashirskaya
- Laboratory of genetic epidemiology, Research Centre for Medical Genetics, Moscow, Russian Federation
| | - Barry Linnane
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Sarah J Mayell
- Regional Paediatric CF Centre, Alder Hey Children's Hospital, Liverpool, UK
| | - Susanna McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Stanley Manne Children's Research Institute, Ann and Robert H Lurie Children's Hospital of Chicago, USA
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Australia; Department of Gastroenterology and Molecular and Integrative Cystic Fibrosis Research Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Marijke Proesmans
- Division of Woman and Child, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Clement L Ren
- Department of Pediatrics, Indiana University School of Medicine, Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, USA
| | - Danieli Salinas
- Department of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, USA
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Service de Pneumologie et Allergologie Pédiatriques Centre de Référence Maladies Rares, Mucoviscidose et maladies de CFTR, Hôpital Necker Enfants Malades Paris. Université de Paris. ERN Lung, France
| | - Olaf Sommerburg
- Paediatric Pulmonology, Allergology & CF Centre, Department of Paediatrics III, and Translational Lung Research Center, German Lung Research Center, University Hospital Heidelberg, Germany
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, UK
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12
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Abstract
PURPOSE OF REVIEW The pancreas is highly affected in cystic fibrosis, with complications occurring early in childhood. This review highlights recent research in exocrine pancreatic function in the era of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies and discusses how these are affecting pancreatitis and exocrine pancreatic insufficiency (EPI) in children. Additionally, new research into exocrine--endocrine interactions sheds light on how CFTR dysfunction in ductal cells may affect beta cells. RECENT FINDINGS Ivacaftor has disproved the hypothesis that EPI in children with cystic fibrosis is irreversible. Improvements in pancreatic function have increased pancreatitis episodes in some children and reduced them in others. Imaging advances are providing complementary methods for exocrine pancreatic function testing. New research into the interplay between the exocrine and endocrine components of the pancreas are elucidating the intertwined and complex relationship between the exocrine and endocrine pancreas. SUMMARY Pancreatic complications contribute to the morbidity and mortality of children with cystic fibrosis. Increasing use of highly effective CFTR modulators will not only abrogate these but will also advance our understanding of pancreatic pathophysiology in cystic fibrosis. New frontiers into pancreatic gene therapy and exocrine--endocrine research will help provide new therapeutic opportunities for pancreatitis, EPI, and diabetes in cystic fibrosis.
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Affiliation(s)
- Zachary M Sellers
- Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Stanford, California, USA
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13
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Zybert K, Wozniacki L, Tomaszewska-Sobczyńska A, Wertheim-Tysarowska K, Czerska K, Ołtarzewski M, Sands D. Clinical characteristics of rare CFTR mutations causing cystic fibrosis in Polish population. Pediatr Pulmonol 2020; 55:2097-2107. [PMID: 32442342 DOI: 10.1002/ppul.24823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION More than 2000 mutations have been identified since the discovery of the CFTR gene in 1989. However, only 346 mutations have been classified as cystic fibrosis (CF)-causing mutations. Due to the increasing number of mutations and poor correlation between the genotype and phenotype, there is an urgent need to determine the mutations that are pathogenic, nonpathogenic, or lead to variable symptoms. AIM The aim of the study was to present the clinical characteristics of Polish patients with rare and novel CFTR mutations, with an attempt to determine the pathogenicity status of those variants. MATERIALS AND METHODS The group included 13 patients born between September 2006 and May 2019, who underwent CF newborn screening and in whom two CFTR mutations, including at least one rare or a novel mutation, were identified. RESULTS We identified 13 patients with mutations in both alleles of the CFTR gene, one of which was at least rare in Polish population (R289NfsX17, I618RfsX2, T682KfsX40, S1347PfsX13, W356X, E33X, dup.16,17A) or was a mutation of unknown clinical consequences (H199R, L468P, A1217E, Q359R, T1036I, W1282R). None of them were described in the CFTR2 database. In all examined patients, sweat tests were elevated. The diagnosed patients presented with a wide spectrum of clinical symptoms. Broad clinical characteristics and test results are presented. CONCLUSION Pathogenic mutations are H199R, L468P, A1217E, Q359R, T1036I, W1282R, R289NfsX17, I618RfsX2, T682KfsX40, S1347PfsX13, W356X, E33X, dup.16,17A. Every patient with a mutation of unknown clinical consequences in one CFTR allele requires attentive follow-up.
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Affiliation(s)
- Katarzyna Zybert
- Department of Cystic Fibrosis, Institute of Mother and Child, Warsaw, Poland.,Warsaw Cystic Fibrosis Centre, Dziekanow Lesny Paediatric Hospital, Lomianki, Poland
| | - Lukasz Wozniacki
- Department of Cystic Fibrosis, Institute of Mother and Child, Warsaw, Poland.,Warsaw Cystic Fibrosis Centre, Dziekanow Lesny Paediatric Hospital, Lomianki, Poland
| | - Agnieszka Tomaszewska-Sobczyńska
- MedGen Medical Centre, Warsaw, Poland.,Department of Screening and Metabolic Diagnostics, Institute of Mother and Child, Warsaw, Poland
| | | | | | - Mariusz Ołtarzewski
- Department of Screening and Metabolic Diagnostics, Institute of Mother and Child, Warsaw, Poland
| | - Dorota Sands
- Department of Cystic Fibrosis, Institute of Mother and Child, Warsaw, Poland.,Warsaw Cystic Fibrosis Centre, Dziekanow Lesny Paediatric Hospital, Lomianki, Poland
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14
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Diagnosis of Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Altman K, McDonald CM, Michel SH, Maguiness K. Nutrition in cystic fibrosis: From the past to the present and into the future. Pediatr Pulmonol 2019; 54 Suppl 3:S56-S73. [PMID: 31715089 DOI: 10.1002/ppul.24521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022]
Abstract
Nutritional management is an integral part of multidisciplinary care for persons with cystic fibrosis. This review will look at how nutrition care has evolved over time. In addition, we will look at how some newer therapies impact nutrition care.
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Affiliation(s)
- Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, New York Presbyterian/Columbia University Medical Center, New York, New York, United States
| | | | - Suzanne H Michel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Karen Maguiness
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
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16
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van de Peppel IP, Bodewes FAJA, Verkade HJ, Jonker JW. Bile acid homeostasis in gastrointestinal and metabolic complications of cystic fibrosis. J Cyst Fibros 2018; 18:313-320. [PMID: 30201330 DOI: 10.1016/j.jcf.2018.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
With the improved treatment of the pulmonary complications of cystic fibrosis (CF), gastrointestinal problems have become more important in the morbidity in CF. A hallmark of the gastrointestinal phenotype of CF, apart from pancreatic insufficiency, is a disruption of bile acid homeostasis. Bile acid homeostasis is important for many gastrointestinal processes including fat absorption, inflammation, microbial composition, as well as regulation of whole body energy metabolism. This review describes the impairment of bile acid homeostasis in CF, its possible consequences for gastrointestinal and metabolic complications and its potential as a target for therapy.
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Affiliation(s)
- Ivo P van de Peppel
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands; Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Frank A J A Bodewes
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Henkjan J Verkade
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands; Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Johan W Jonker
- Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands.
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17
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Engjom T, Kavaliauskiene G, Tjora E, Erchinger F, Wathle G, Lærum BN, Njølstad PR, Frøkjær JB, Gilja OH, Dimcevski G, Haldorsen IS. Sonographic pancreas echogenicity in cystic fibrosis compared to exocrine pancreatic function and pancreas fat content at Dixon-MRI. PLoS One 2018; 13:e0201019. [PMID: 30048483 PMCID: PMC6062060 DOI: 10.1371/journal.pone.0201019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 07/06/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Fatty infiltration of the pancreas is a dominating feature in cystic fibrosis (CF). We evaluate the association between pancreatic fat content assessed by Dixon magnetic resonance imaging (MRI), pancreatic echogenicity at ultrasonography (US) and exocrine function in CF patients and healthy controls (HC). MATERIAL AND METHODS Transabdominal US, pancreatic Dixon-MRI and diffusion-weighted imaging (DWI) were performed in 21 CF patients and 15 HCs. Exocrine function was assessed by endoscopic secretin test and fecal elastase. RESULTS CF patients were grouped according to exocrine pancreatic function as subjects with normal (CFS: n = 11) or reduced (CFI: n = 10) function. Among CFI 90% (9/10) had visual hyperechogenicity. CFI also had increased echo-level values (p<0.05 vs others). All CFI (10/10) had markedly increased pancreatic fat content estimated by MRI compared to sufficient groups, p<0.001). Among CFS patients and HC, 27% (3/11) and 33% (5/15), respectively, had hyperechoic pancreas. However, all these had low pancreatic fat-content at MRI compared to CFI. In CFI, pancreatic fat content was correlated to ADC (r = -0.93, p<0.001). CONCLUSION Pancreas insufficient CF patients exhibit severe pancreatic fatty-infiltration at MRI and hyperechoic pancreas at US. Pancreas hyperechogenicity in pancreatic sufficient subjects does not co-exist with fatty infiltration at MRI. MRI evaluates pancreatic fatty infiltration more accurately than US and fat infiltration estimated by MRI outperforms sonographic hyper-echogenicity as a marker for exocrine pancreatic failure in CF.
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Affiliation(s)
- Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Erling Tjora
- Pediatric Department, Haukeland University Hospital,Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Friedemann Erchinger
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Voss Hospital, Voss, Norway
| | - Gaute Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | | | - Pål Rasmus Njølstad
- Pediatric Department, Haukeland University Hospital,Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingfrid Salvesen Haldorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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18
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Eikani MS, Nugent M, Poursina A, Simpson P, Levy H. Clinical course and significance of nontuberculous mycobacteria and its subtypes in cystic fibrosis. BMC Infect Dis 2018; 18:311. [PMID: 29980189 PMCID: PMC6035392 DOI: 10.1186/s12879-018-3200-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 06/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) infections in patients with cystic fibrosis (CF) is increasing globally. However, the related epidemiology, comorbidities, and clinical impact of NTM infection remains unclear in the progress of CF lung disease and patient survival. METHODS We performed a retrospective, case-control, cohort study (10 years), comparing NTM culture-positive CF patients (N = 28) to matched controls (N = 26). NTM positive patients were divided in to two groups of slow-growing (N = 17) and rapid- growing NTM (N = 8). Three patients were positive for both slow and rapid NTM. For independent group comparisons, a non-parametric Mann-Whitney test (Kruskal-Wallis test for more than two groups) was used to compare the continuous variables, and a Fisher's exact test was used for the categorical variables. Paired comparisons were performed using a Wilcoxon signed-rank test. RESULTS The prevalence of NTM isolation was 8%. The age at CF diagnosis was significantly lower in the slow-growing NTM group compared to the rapidly growing NTM group (P = 0.04). The median percent predicted forced expiratory flow of 25% - 75% (FEF25-75) was significantly higher before NTM acquisition in slow-growing (P = 0.013) and rapidly growing NTM group (P = 0.028). The slow-growing NTM group received significantly more penicillin/beta lactamase (P = 0.010) and rifampin (P = 0.042) following isolation. Macrolide use was significantly higher after isolation in both the slow-growing NTM (P = 0.018) and rapidly growing NTM groups (P = 0.042). CONCLUSIONS An earlier CF diagnosis was associated with a higher isolation of slow-growing NTM and greater antimicrobial use after infection. NTM acquisition is associated with a worsening of FEF25-75. Thus, both the early diagnosis and treatment of an NTM infection in patients with CF may positively impact lung function.
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Affiliation(s)
- Maxine S Eikani
- Novant Health Pediatric Pulmonology, Novant Health Hemby Children's Hospital, Charlotte, NC, USA
| | - Melodee Nugent
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Arash Poursina
- Piedmont Medical Center Infectious Disease, Piedmont Medical Center, Rock Hill, SC, USA
| | - Pippa Simpson
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hara Levy
- Division of Pulmonary, MedicineNorthwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA. .,Department of Pediatrics, Section of Pulmonary Medicine, Human Molecular Genetics Program, Stanley Manne Children's Research Institute, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL, USA.
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19
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Rosenfeld M, Wainwright CE, Higgins M, Wang LT, McKee C, Campbell D, Tian S, Schneider J, Cunningham S, Davies JC. Ivacaftor treatment of cystic fibrosis in children aged 12 to <24 months and with a CFTR gating mutation (ARRIVAL): a phase 3 single-arm study. THE LANCET RESPIRATORY MEDICINE 2018; 6:545-553. [PMID: 29886024 DOI: 10.1016/s2213-2600(18)30202-9] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/01/2018] [Accepted: 05/04/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ivacaftor is generally safe and effective in patients aged 2 years and older who have cystic fibrosis and specific CFTR mutations. We assessed its use in children aged 12 to <24 months. METHODS The ARRIVAL study is a phase 3, single-arm, two-part, multicentre study. Eligible children were aged 12 to <24 months at enrolment and had a confirmed diagnosis of cystic fibrosis and a CFTR gating mutation on at least one allele and could participate in one or both parts of the study. Children received 50 mg (bodyweight 7 to <14 kg) or 75 mg (bodyweight ≥14 to <25 kg) ivacaftor orally every 12 h. In study part A, children received ivacaftor for 3 days plus one morning. In study part B, children received 24 weeks of treatment. Children were enrolled into part A at seven sites in Australia (one site), the UK (one), and the USA (five) and into part B at 13 sites in Australia (two sites), Canada (one), the UK (three), and the USA (seven). Primary endpoints were pharmacokinetics (part A) and safety (parts A and B) in children who received at least one dose of ivacaftor. Secondary endpoints in part B were pharmacokinetics in children who received at least one dose of ivacaftor and absolute change from baseline in sweat chloride concentration. We also explored changes in growth parameters and markers of pancreatic function. This study is registered with ClinicalTrials.gov, number NCT02725567. FINDINGS Children aged 12 to <24 months were enrolled between Aug 25, 2016, and Nov 1, 2017. Seven children were enrolled in part A, of whom five received 50 mg and two received 75 mg ivacaftor. All completed treatment. Of 19 children enrolled in part B, including one from part A, all received 50 mg ivacaftor and 18 completed treatment (one withdrew because of difficulty with blood draws). All children received at least one dose of ivacaftor. Pharmacokinetics indicated exposure was similar to that in children aged 2 to <6 years and adults. No children discontinued because of adverse events or safety findings. In part A, three (43%) of seven children had treatment-emergent adverse events, all of which were mild and deemed not to be or unlikely to be related to ivacaftor. By 24 weeks in part B, treatment-emergent adverse events had been reported in 18 (95%) of 19 children, of which most were mild or moderate and the most frequent was cough (14 [74%] children). Two children in part B had four serious adverse events: one had constipation (possibly related to ivacaftor), distal intestinal obstruction syndrome, and eczema herpeticum, and one had persistent cough, all needing hospital admission. In five (28%) of 18 children aspartate or alanine aminotransferase concentrations rose to more than three times the upper limit of normal (to more than eight times in two children with concurrent infections). At week 24, the mean absolute change from baseline in sweat chloride concentration was -73·5 (SD 17·5) mmol/L. Growth parameters for age were normal at baseline and at week 24. At week 24, concentrations of faecal elastase-1 had increased and concentrations of immunoreactive trypsinogen had decreased from baseline. Mean serum lipase and amylase were raised at baseline and rapidly decreased after treatment was started. INTERPRETATION Ivacaftor was generally safe and well tolerated in children aged 12 to <24 months for up to 24 weeks and was associated with rapid and sustained reductions in sweat chloride concentrations. Improvements in biomarkers of pancreatic function suggest that ivacaftor preserves exocrine pancreatic function if started early. The study is continuing in infants younger than 12 months. FUNDING Vertex Pharmaceuticals Incorporated.
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Affiliation(s)
- Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire E Wainwright
- Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital and Child Health Research Centre, University of Queensland, South Brisbane, QLD, Australia
| | | | | | | | | | | | | | - Steve Cunningham
- University of Edinburgh MRC Centre for Inflammation Research, Royal Hospital for Sick Children and University of Edinburgh, Edinburgh, UK
| | - Jane C Davies
- Cystic Fibrosis and Chronic Lung Infection, National Heart & Lung Institute, Imperial College London & Royal Brompton Hospital, London, UK.
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20
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Kent DS, Remer T, Blumenthal C, Hunt S, Simonds S, Egert S, Gaskin KJ. 13C-Mixed Triglyceride Breath Test and Fecal Elastase as an Indirect Pancreatic Function Test in Cystic Fibrosis Infants. J Pediatr Gastroenterol Nutr 2018; 66:811-815. [PMID: 29432279 DOI: 10.1097/mpg.0000000000001905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The 'gold standard' test for the indirect determination of pancreatic function status in infants with cystic fibrosis (CF), the 72-hour fecal fat excretion test, is likely to become obsolete in the near future. Alternative indirect pancreatic function tests with sufficient sensitivity and specificity to determine pancreatic phenotype need further evaluation in CF infants. OBJECTIVE Evaluation of the clinical utility of both the noninvasive, nonradioactive C-mixed triglyceride (MTG) breath test and fecal elastase-1 (FE1) in comparison with the 72-hour fecal fat assessment in infants with CF. METHODS C-MTG breath test and the monoclonal and polyclonal FE1 assessment in stool was compared with the 72-hour fecal fat assessment in 24 infants with CF. Oral pancreatic enzyme substitution (PERT; if already commenced) was stopped before the tests. RESULTS Sensitivity rates between 82% and 100% for CF patients with pancreatic insufficiency assessed by both the C-MTG breath test and the FE1 tests proved to be high and promising. The C-MTG breath test (31%-38%) as well as both FE1 tests assessed by the monoclonal (46%-54%) and the polyclonal (45%) ELISA kits, however, showed unacceptably low-sensitivity rates for the detection of pancreatic-sufficient CF patients in the present study. CONCLUSIONS The C-MTG breath test with nondispersive infrared spectroscopy (NDIRS) technique, as well as both FE1 tests, are not alternatives to the fecal fat balance test for the evaluation of pancreatic function in CF infants during the first year of life.
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Affiliation(s)
- Dorothea Stark Kent
- James Fairfax Institute of Paediatric Nutrition, University of Sydney, Sydney, Australia
| | - Thomas Remer
- University of Bonn, IEL-Nutritional Epidemiology, DONALD Study, Dortmund, Germany
| | - Caron Blumenthal
- James Fairfax Institute of Paediatric Nutrition, University of Sydney, Sydney, Australia.,Storr Liver Unit and Department of Nutrition and Dietetics, Westmead Hospital, Westmead, New South Wales
| | - Sharon Hunt
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Sharon Simonds
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Sarah Egert
- University of Bonn, IEL-Nutritional Physiology, Bonn, Germany
| | - Kevin J Gaskin
- James Fairfax Institute of Paediatric Nutrition, University of Sydney, Sydney, Australia
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21
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Engjom T, Tjora E, Wathle G, Erchinger F, Lærum BN, Gilja OH, Haldorsen IS, Dimcevski G. Secretin-stimulated ultrasound estimation of pancreatic secretion in cystic fibrosis validated by magnetic resonance imaging. Eur Radiol 2018; 28:1495-1503. [PMID: 29134356 PMCID: PMC5834563 DOI: 10.1007/s00330-017-5115-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 08/07/2017] [Accepted: 10/02/2017] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Secretin-stimulated magnetic resonance imaging (s-MRI) is the best validated radiological modality assessing pancreatic secretion. The purpose of this study was to compare volume output measures from secretin-stimulated transabdominal ultrasonography (s-US) to s-MRI for the diagnosis of exocrine pancreatic failure in cystic fibrosis (CF). METHODS We performed transabdominal ultrasonography and MRI before and at timed intervals during 15 minutes after secretin stimulation in 21 CF patients and 13 healthy controls. To clearly identify the subjects with reduced exocrine pancreatic function, we classified CF patients as pancreas-sufficient or -insufficient by secretin-stimulated endoscopic short test and faecal elastase. RESULTS Pancreas-insufficient CF patients had reduced pancreatic secretions compared to pancreas-sufficient subjects based on both imaging modalities (p < 0.001). Volume output estimates assessed by s-US correlated to that of s-MRI (r = 0.56-0.62; p < 0.001). Both s-US (AUC: 0.88) and s-MRI (AUC: 0.99) demonstrated good diagnostic accuracy for exocrine pancreatic failure. CONCLUSIONS Pancreatic volume-output estimated by s-US corresponds well to exocrine pancreatic function in CF patients and yields comparable results to that of s-MRI. s-US provides a simple and feasible tool in the assessment of pancreatic secretion. KEY POINTS • Cystic fibrosis patients with affected pancreas have reduced pancreatic secretions. • Secretin-stimulated sonography is a simple and feasible method to assess pancreatic output. • Secretin-simulated MRI is a more precise method to assess pancreatic secretions. • The sonographic and MRI methods yielded comparable pancreatic secretory output estimates.
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Affiliation(s)
- Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway.
| | - Erling Tjora
- Pediatric Department, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, 5021, Bergen, Norway
| | - Gaute Wathle
- Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Friedemann Erchinger
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Voss Hospital, Sjukehusvegen 16, 5740, Voss, Norway
| | - Birger N Lærum
- Department of Clinical Science, University of Bergen, 5021, Bergen, Norway
| | - Odd H Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Ingfrid Salvesen Haldorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway
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22
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Pancreatic Enzyme Replacement Therapy Use in Infants With Cystic Fibrosis Diagnosed by Newborn Screening. J Pediatr Gastroenterol Nutr 2018; 66:657-663. [PMID: 29176494 PMCID: PMC5866181 DOI: 10.1097/mpg.0000000000001829] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study is to describe pancreatic enzyme practices during the first year of life in infants with cystic fibrosis (CF) and evaluate associations between dosing and outcomes, including growth and gastrointestinal (GI) symptoms. METHODS We analyzed data from a subset of infants who were in a prospective cohort study conducted at 28 US CF centers. Anthropometric measurements and medications were recorded at each visit. Diaries with infant diet, pancreatic enzyme replacement therapy (PERT) dosing, stool frequency and consistency, and pain were completed by a parent/guardian for 3 days before each visit. RESULTS Two hundred and thirty-one infants were enrolled in the main study; 205 of these met criteria for pancreatic insufficiency (PI). PERT dose between birth and 6 months was on average 1882 LU/kg per meal (range: 492-3727) and was similar between 6 and 12 months (mean: 1842 LU/kg per mean, range: 313-3612). PERT dose had a weak, negative association with weight z score at 3 and 6 months (r = -0.16, 95% confidence interval [CI] -0.29 to -0.02 and r = -0.18, 95% CI -0.31 to -0.04, respectively) but not at 12 months. There was not a clear relationship between PERT dosing and number of stools per day, stool consistency or pain. One hundred and forty-four infants (70%) were placed on acid suppression medication. Weight z score mean was 0.37 higher in infants using proton pump inhibitors (PPIs) exclusively versus those using histamine-2 blockers exclusively (95% CI -0.02 to 0.76, P = 0.06). CONCLUSIONS We did not observe that centers with a higher PERT dosing strategy yielded greater clinical benefit than dosing at the lower end of the recommended range.
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Ayoub F, Trillo-Alvarez C, Morelli G, Lascano J. Risk factors for hepatic steatosis in adults with cystic fibrosis: Similarities to non-alcoholic fatty liver disease. World J Hepatol 2018; 10:34-40. [PMID: 29399276 PMCID: PMC5787682 DOI: 10.4254/wjh.v10.i1.34] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical, biochemical and imaging characteristics of adult cystic fibrosis (CF) patients with hepatic steatosis as compared to normal CF controls.
METHODS We performed a retrospective review of adult CF patients in an academic outpatient setting during 2016. Baseline characteristics, genetic mutation analysis as well as laboratory values were collected. Abdominal imaging (ultrasound, computed tomography, magnetic resonance) was used to determine presence of hepatic steatosis. We compare patients with hepatic steatosis to normal controls.
RESULTS Data was collected on 114 patients meeting inclusion criteria. Seventeen patients (14.9%) were found to have hepatic steatosis on imaging. Being overweight (BMI > 25) (P = 0.019) and having a higher ppFEV1 (75 vs 53, P = 0.037) were significantly associated with hepatic steatosis. Patients with hepatic steatosis had a significantly higher median alanine aminotransferase level (27 vs 19, P = 0.048). None of the hepatic steatosis patients had frank CF liver disease, cirrhosis or portal hypertension. We found no significant association with pancreatic insufficiency or CF related diabetes.
CONCLUSION Hepatic steatosis appears to be a clinically and phenotypically distinct entity from CF liver disease. The lack of association with malnourishment and the significant association with higher BMI and higher ppFEV1 demonstrate similarities with non-alcoholic fatty liver disease. Long term prospective studies are needed to ascertain whether CF hepatic steatosis progresses to fibrosis and cirrhosis.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Cesar Trillo-Alvarez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Jorge Lascano
- Department of Medicine, Adult Cystic Fibrosis Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
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Singh VK, Schwarzenberg SJ. Pancreatic insufficiency in Cystic Fibrosis. J Cyst Fibros 2017; 16 Suppl 2:S70-S78. [DOI: 10.1016/j.jcf.2017.06.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022]
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Athanazio RA, Silva Filho LVRFD, Vergara AA, Ribeiro AF, Riedi CA, Procianoy EDFA, Adde FV, Reis FJC, Ribeiro JD, Torres LA, Fuccio MBD, Epifanio M, Firmida MDC, Damaceno N, Ludwig-Neto N, Maróstica PJC, Rached SZ, Melo SFDO. Brazilian guidelines for the diagnosis and treatment of cystic fibrosis. ACTA ACUST UNITED AC 2017; 43:219-245. [PMID: 28746534 PMCID: PMC5687954 DOI: 10.1590/s1806-37562017000000065] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder characterized by dysfunction of the CFTR gene. It is a multisystem disease that most often affects White individuals. In recent decades, various advances in the diagnosis and treatment of CF have drastically changed the scenario, resulting in a significant increase in survival and quality of life. In Brazil, the current neonatal screening program for CF has broad coverage, and most of the Brazilian states have referral centers for the follow-up of individuals with the disease. Previously, CF was limited to the pediatric age group. However, an increase in the number of adult CF patients has been observed, because of the greater number of individuals being diagnosed with atypical forms (with milder phenotypic expression) and because of the increase in life expectancy provided by the new treatments. However, there is still great heterogeneity among the different regions of Brazil in terms of the access of CF patients to diagnostic and therapeutic methods. The objective of these guidelines was to aggregate the main scientific evidence to guide the management of these patients. A group of 18 CF specialists devised 82 relevant clinical questions, divided into five categories: characteristics of a referral center; diagnosis; treatment of respiratory disease; gastrointestinal and nutritional treatment; and other aspects. Various professionals working in the area of CF in Brazil were invited to answer the questions devised by the coordinators. We used the PubMed database to search the available literature based on keywords, in order to find the best answers to these questions.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Andrade Vergara
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | | | - Fabíola Villac Adde
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francisco José Caldeira Reis
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - José Dirceu Ribeiro
- . Hospital de Clínicas, Universidade Estadual de Campinas, Campinas (SP) Brasil
| | - Lídia Alice Torres
- . Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcelo Bicalho de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - Matias Epifanio
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | | | - Neiva Damaceno
- . Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo (SP) Brasil
| | - Norberto Ludwig-Neto
- . Hospital Infantil Joana de Gusmão, Florianópolis (SC) Brasil.,. Serviço de Fibrose Cística e Triagem Neonatal para Fibrose Cística, Secretaria Estadual de Saúde de Santa Catarina, Florianópolis (SC) Brasil
| | - Paulo José Cauduro Maróstica
- . Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Universidade Federal do Rio Grande do Sul Porto Alegre (RS) Brasil
| | - Samia Zahi Rached
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Trout AT, Wallihan DB, Serai S, Abu-El-Haija M. Secretin-Enhanced Magnetic Resonance Cholangiopancreatography for Assessing Pancreatic Secretory Function in Children. J Pediatr 2017; 188:186-191. [PMID: 28693787 DOI: 10.1016/j.jpeds.2017.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/08/2017] [Accepted: 06/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the accuracy and interrater reproducibility of measurements of pancreatic secretory function by magnetic resonance cholangiopancreatography in response to secretin administration and to describe our experience using the technique to noninvasively assess pancreatic secretory function in a pediatric population. STUDY DESIGN In the accuracy study, phantoms with varying fluid volume (47-206 mL) were imaged using the clinical quantification sequence. Fluid volume was measured by image segmentation (ImageJ). Measurement accuracy was expressed in terms of error (absolute and percent) relative to known fluid volume. In the reproducibility study and clinical experience, 31 patients with suspected pancreatic disease underwent 33 secretin-enhanced magnetic resonance cholangiopancreatography exams. Two-dimensional T2-weighted, fat-saturated single shot fast spin echo sequences were acquired before and after secretin injection (0.2 µg/kg, max 16 µg). Secreted fluid volume (postsecretin minus presecretin) was independently measured by 2 blinded reviewers. Between reviewer measurement reproducibility was assessed based on correlation (Spearman) and bias (Bland-Altman analysis). RESULTS For the accuracy study, fluid volumes were measured with mean volume errors of -0.3 to +12.5 mL (percent error -0.03% to +9.0%). For the reproducibility study, the mean secreted fluid volumes measured by reviewer 1 and reviewer 2 were 79.1 ± 54.3 mL (range 5.5-215.4) and 77.2 ± 47.1 mL (range 6.7-198.1 mL), respectively. Measured secreted fluid volumes were very strongly correlated (r = 0.922) between reviewers with a bias of only 1.9 mL (95% limits of agreement -40.5 to 44.2). CONCLUSIONS Measurement of fluid volume by magnetic resonance imaging is highly accurate with <10% (<13 mL) error in measured volume. Measurements of pancreatic secreted fluid volume in response to secretin by magnetic resonance cholangiopancreatography are highly reproducible with a bias of <2 mL between reviewers.
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Affiliation(s)
- Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | | | - Suraj Serai
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Naehrig* S, Chao* CM, Naehrlich L. Cystic Fibrosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:564-574. [PMID: 28855057 PMCID: PMC5596161 DOI: 10.3238/arztebl.2017.0564] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 10/09/2016] [Accepted: 05/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Universal screening of newborn babies for cystic fibrosis was launched in Germany on 1 September 2016. Here we present up-to-date information on the diagnosis, treatment, and prognosis of this disease. METHODS This article is based on relevant publications retrieved by a selective search in PubMed, along with guidelines from Germany and abroad and systematic reviews. RESULTS Cystic fibrosis is caused by a gene mutation leading to dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. It affects multiple organ systems-the lungs, pancreas, upper airways, liver, intestine, and reproductive organs-to varying degrees. Its incidence among newborn babies in Germany is between 1 in 3300 and 1 in 4800. Its diagnosis requires both clinical evidence (positive newborn screening, sibling[s] with cystic fibrosis, clinical signs) and the demonstration of CFTR dysfunction by an elevated chloride concentration in sweat, and/or two disease-causing mutations, and/or abnormal electrophysiological findings (nasal potential difference measurement, intestinal short-circuit current measurement). Patients should be cared for by specialized cystic fibrosis centers in close cooperation with their primary care physicians. The median life span of patients with this disease has risen steadily to the current value of 40 years. Aside from symptomatic treatment, the first mutation- specific treatments have recently become available. CONCLUSION Early diagnosis and optimized treatment prolong the lives of persons with cystic fibrosis and improve their quality of life. Causally directed treatment for all patients and their effects on the course of disease are now central issues for further research.
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Affiliation(s)
- Susanne Naehrig*
- *Joint and equal first authors
- Medizinische Klinik V (Pneumology), LMU University of Munich, Pneumology, Medizinische Klinik Innenstadt, University of Munich
| | - Cho-Ming Chao*
- *Joint and equal first authors
- Department of Pediatrics, Justus-Liebig-University Gießen
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Gießen
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Yi Y, Norris AW, Wang K, Sun X, Uc A, Moran A, Engelhardt JF, Ode KL. Abnormal Glucose Tolerance in Infants and Young Children with Cystic Fibrosis. Am J Respir Crit Care Med 2017; 194:974-980. [PMID: 27447840 DOI: 10.1164/rccm.201512-2518oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE In cystic fibrosis, abnormal glucose tolerance is associated with decreased lung function and worsened outcomes. Translational evidence indicates that abnormal glucose tolerance may begin in early life. OBJECTIVES To determine whether very young children with cystic fibrosis have increased abnormal glucose tolerance prevalence compared with control subjects. The secondary objective was to compare area under the curve for glucose and insulin in children with cystic fibrosis with control subjects. METHODS This is a prospective multicenter study in children ages 3 months to 5 years with and without cystic fibrosis. MEASUREMENTS AND MAIN RESULTS Oral glucose tolerance testing with glucose, insulin, and C-peptide was sampled at 0, 10, 30, 60, 90, and 120 minutes. Twenty-three children with cystic fibrosis and nine control subjects had complete data. All control subjects had normal glucose tolerance. Nine of 23 subjects with cystic fibrosis had abnormal glucose tolerance (39%; P = 0.03). Of those, two met criteria for cystic fibrosis-related diabetes, two indeterminate glycemia, and six impaired glucose tolerance. Children with cystic fibrosis failed to exhibit the normal increase in area under the curve insulin with age observed in control subjects (P < 0.01), despite increased area under the curve glucose (P = 0.02). CONCLUSIONS Abnormal glucose tolerance is notably prevalent among young children with cystic fibrosis. Children with cystic fibrosis lack the normal increase in insulin secretion that occurs in early childhood despite increased glucose. These findings demonstrate that glycemic abnormalities begin very early in cystic fibrosis, possibly because of insufficient insulin secretion.
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Affiliation(s)
- Yaling Yi
- 1 Department of Anatomy and Cell Biology
| | - Andrew W Norris
- 2 Department of Pediatrics.,3 Fraternal Order of Eagles Diabetes Research Center, and
| | - Kai Wang
- 4 Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa; and
| | | | | | - Antoinette Moran
- 5 Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - John F Engelhardt
- 1 Department of Anatomy and Cell Biology.,3 Fraternal Order of Eagles Diabetes Research Center, and
| | - Katie Larson Ode
- 2 Department of Pediatrics.,3 Fraternal Order of Eagles Diabetes Research Center, and
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Stuhltests in der pädiatrischen Gastroenterologie. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0316-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Leung DH, Heltshe SL, Borowitz D, Gelfond D, Kloster M, Heubi JE, Stalvey M, Ramsey BW. Effects of Diagnosis by Newborn Screening for Cystic Fibrosis on Weight and Length in the First Year of Life. JAMA Pediatr 2017; 171:546-554. [PMID: 28437538 PMCID: PMC5731827 DOI: 10.1001/jamapediatrics.2017.0206] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Since the implementation of universal newborn screening (NBS) for cystic fibrosis (CF), the timing and magnitude of growth deficiency or its association with correlates of disease among infants with CF who underwent NBS has not been well described. OBJECTIVE To examine incremental weight gain, linear growth, and clinical features in the first year of life among infants with CF who underwent NBS. DESIGN, SETTING, AND PARTICIPANTS The Baby Observational and Nutrition Study (BONUS), a multicenter, longitudinal, observational cohort study, was conducted during regular CF clinic visits in the first 12 months of life at 28 US Cystic Fibrosis Foundation-accredited Care Centers from January 7, 2012, through May 31, 2015. Participants included 231 infants younger than 3.5 months who underwent NBS and had confirmed CF, with a gestational age of at least 35 weeks, birth weight of at least 2.5 kg, and toleration of full oral feeds. Of these, 222 infants (96.1%) had follow-up beyond 6 months of age and 215 (93.1%) completed 12 months of follow-up. EXPOSURE Cystic fibrosis. MAIN OUTCOME AND MEASURES Attained weight and length for age and World Health Organization normative z scores at ages 1 to 6 and 8, 10, and 12 months (defined a priori). RESULTS Of the 231 infants enrolled, 110 infants (47.6%) were female and 121 (52.4%) were male, with a mean (SD) age of 2.58 (0.69) months. BONUS infants had lower than mean birth weights (mean z score, -0.15; 95% CI, -0.27 to -0.04) and higher birth lengths (mean z score, 0.44; 95% CI, 0.26 to 0.62). They achieved normal weight by 12 months, a significant improvement over a prescreening cohort of newborns with CF from 20 years before the contemporary cohort (mean z score increase, 0.57; 95% CI, 0.37-0.77). However, length was lower than the mean at 12 months (mean z score, -0.56; 95% CI, -0.70 to -0.42). Only 30 infants (13.6%) were at less than the 10th percentile of weight for age, whereas 53 (23.9%) were at less than the 10th percentile of length for age at more than half their visits. Male sex, pancreatic insufficiency, meconium ileus, histamine blocker use, and respiratory Pseudomonas aeruginosa infection were associated with lower weight or length during the first year. Insulinlike growth factor 1 levels were significantly lower among low-length infants. Persistently low-weight infants consumed significantly more calories, and weight and length z scores were negatively correlated with caloric intake. CONCLUSIONS AND RELEVANCE Since initiation of universal NBS for CF, significant improvement has occurred in nutritional status, with normalization of weight in the first year of life. However, length stunting remains common.
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Affiliation(s)
- Daniel H. Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Sonya L. Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Drucy Borowitz
- Department of Pediatrics, University of Buffalo, Buffalo, New YorkCystic Fibrosis Foundation, Bethesda, Maryland
| | - Daniel Gelfond
- Division of Gastroenterology/Nutrition, Department of Pediatrics, University of Rochester, Rochester, New York
| | - Margaret Kloster
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - James E. Heubi
- Division of Gastroenterology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael Stalvey
- Department of Pediatrics, University of Alabama at Birmingham
| | - Bonnie W. Ramsey
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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Farrell PM, White TB, Howenstine MS, Munck A, Parad RB, Rosenfeld M, Sommerburg O, Accurso FJ, Davies JC, Rock MJ, Sanders DB, Wilschanski M, Sermet-Gaudelus I, Blau H, Gartner S, McColley SA. Diagnosis of Cystic Fibrosis in Screened Populations. J Pediatr 2017; 181S:S33-S44.e2. [PMID: 28129810 DOI: 10.1016/j.jpeds.2016.09.065] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cystic fibrosis (CF) can be difficult to diagnose, even when newborn screening (NBS) tests yield positive results. This challenge is exacerbated by the multitude of NBS protocols, misunderstandings about screening vs diagnostic tests, and the lack of guidelines for presumptive diagnoses. There is also confusion regarding the designation of age at diagnosis. STUDY DESIGN To improve diagnosis and achieve standardization in definitions worldwide, the CF Foundation convened a committee of 32 experts with a mission to develop clear and actionable consensus guidelines on diagnosis of CF with an emphasis on screened populations, especially the newborn population. A comprehensive literature review was performed with emphasis on relevant articles published during the past decade. RESULTS After reviewing the common screening protocols and outcome scenarios, 14 of 27 consensus statements were drafted that apply to screened populations. These were approved by 80% or more of the participants. CONCLUSIONS It is recommended that all diagnoses be established by demonstrating dysfunction of the CF transmembrane conductance regulator (CFTR) channel, initially with a sweat chloride test and, when needed, potentially with newer methods assessing membrane transport directly, such as intestinal current measurements. Even in babies with 2 CF-causing mutations detected via NBS, diagnosis must be confirmed by demonstrating CFTR dysfunction. The committee also recommends that the latest classifications identified in the Clinical and Functional Translation of CFTR project [http://www.cftr2.org/index.php] should be used to aid with CF diagnosis. Finally, to avoid delays in treatment, we provide guidelines for presumptive diagnoses and recommend how to determine the age of diagnosis.
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Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Michelle S Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Anne Munck
- Centres de Ressources et de Compétences pour la Mucoviscidose, Hôpital Robert Debre, Paris, France
| | - Richard B Parad
- Department of Pediatric and Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | - Frank J Accurso
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jane C Davies
- Pediatric Respirology and Experimental Medicine, Imperial College London and Pediatric Respiratory Medicine, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Michael J Rock
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Don B Sanders
- Department of Pediatrics, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Hôpital Necker Enfants Malades, Centres de Ressources et de Compétences pour la Mucoviscidose, Paris, France
| | - Hannah Blau
- Sackler Faculty of Medicine, Graub Cystic Fibrosis Center, Pulmonary Institute Schneider Children's Medical Center of Israel, Petah Tikva, Tel Aviv University, Tel Aviv, Israel
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Abstract
Cystic fibrosis (CF) is the most common autosomal-recessive disease in white persons. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the CF Foundation and international CF societies; networks of CF care centers; and the worldwide community of care providers, researchers, and patients and families. There are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival.
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Affiliation(s)
- Don B. Sanders
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aliza Fink
- Epidemiology, Cystic Fibrosis Foundation, Bethesda, Maryland
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Lavelle GM, White MM, Browne N, McElvaney NG, Reeves EP. Animal Models of Cystic Fibrosis Pathology: Phenotypic Parallels and Divergences. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5258727. [PMID: 27340661 PMCID: PMC4908263 DOI: 10.1155/2016/5258727] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/08/2016] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The resultant characteristic ion transport defect results in decreased mucociliary clearance, bacterial colonisation, and chronic neutrophil-dominated inflammation. Much knowledge surrounding the pathophysiology of the disease has been gained through the generation of animal models, despite inherent limitations in each. The failure of certain mouse models to recapitulate the phenotypic manifestations of human disease has initiated the generation of larger animals in which to study CF, including the pig and the ferret. This review will summarise the basic phenotypes of three animal models and describe the contributions of such animal studies to our current understanding of CF.
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Affiliation(s)
- Gillian M. Lavelle
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
| | - Michelle M. White
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
| | - Niall Browne
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
| | - Noel G. McElvaney
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
| | - Emer P. Reeves
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland
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Salinas DB, Sosnay PR, Azen C, Young S, Raraigh KS, Keens TG, Kharrazi M. Benign and Deleterious Cystic Fibrosis Transmembrane Conductance Regulator Mutations Identified by Sequencing in Positive Cystic Fibrosis Newborn Screen Children from California. PLoS One 2016; 11:e0155624. [PMID: 27214204 PMCID: PMC4877015 DOI: 10.1371/journal.pone.0155624] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/02/2016] [Indexed: 12/19/2022] Open
Abstract
Background Of the 2007 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutations, 202 have been assigned disease liability. California’s racially diverse population, along with CFTR sequencing as part of newborn screening model, provides the opportunity to examine the phenotypes of children with uncategorized mutations to help inform disease liability and penetrance. Methods We conducted a retrospective cohort study based on children screened from 2007 to 2011 and followed for two to six years. Newborns that screened positive were divided into three genotype groups: those with two CF-causing mutations (CF-C); those with one mutation of varying clinic consequence (VCC); and those with one mutation of unknown disease liability (Unknown). Sweat chloride tests, pancreatic sufficiency status, and Pseudomonas aeruginosa colonization were compared. Results Children with two CF-causing mutations had a classical CF phenotype, while 5% of VCC (4/78) and 11% of Unknown (27/244) met diagnostic criteria of CF. Children carrying Unknown mutations 2215insG with D836Y, and T1036N had early and classical CF phenotype, while others carrying 1525-42G>A, L320V, L967S, R170H, and 296+28A>G had a benign clinical presentation, suggesting that these are non-CF causing. Conclusions While most infants with VCC and Unknown CFTR mutations do not meet diagnostic criteria for CF, a small proportion do. These findings highlight the range of genotypes and phenotypes in the first few years of life following CF newborn screening when CFTR sequencing is performed.
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Affiliation(s)
- Danieli B. Salinas
- Department of Pediatrics, Division of Pediatric Pulmonology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
- * E-mail:
| | - Patrick R. Sosnay
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and McKusick-Nathans Institute of Medical Genetics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Colleen Azen
- Department of Biostatistics, Southern California Clinical and Translational Science Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Suzanne Young
- The Sequoia Foundation, La Jolla, California, United States of America
| | - Karen S. Raraigh
- McKusick-Nathans Institute of Medical Genetics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Thomas G. Keens
- Department of Pediatrics, Division of Pediatric Pulmonology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Martin Kharrazi
- Division of Environmental and Occupational Disease Control, Environmental Health Investigations Branch, Environmental Epidemiology Section, California Department of Public Health, Richmond, California, United States of America
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Toward quality improvement in cystic fibrosis newborn screening: Progress and continuing challenges. J Cyst Fibros 2016; 15:267-9. [PMID: 27172835 DOI: 10.1016/j.jcf.2016.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yi Y, Sun X, Gibson-Corley K, Xie W, Liang B, He N, Tyler SR, Uc A, Philipson LH, Wang K, Hara M, Ode KL, Norris AW, Engelhardt JF. A Transient Metabolic Recovery from Early Life Glucose Intolerance in Cystic Fibrosis Ferrets Occurs During Pancreatic Remodeling. Endocrinology 2016; 157:1852-65. [PMID: 26862997 PMCID: PMC4870869 DOI: 10.1210/en.2015-1935] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cystic fibrosis (CF)-related diabetes in humans is intimately related to exocrine pancreatic insufficiency, yet little is known about how these 2 disease processes simultaneously evolve in CF. In this context, we examined CF ferrets during the evolution of exocrine pancreatic disease. At 1 month of age, CF ferrets experienced a glycemic crisis with spontaneous diabetic-level hyperglycemia. This occurred during a spike in pancreatic inflammation that was preceded by pancreatic fibrosis and loss of β-cell mass. Surprisingly, there was spontaneous normalization of glucose levels at 2-3 months, with intermediate hyperglycemia thereafter. Mixed meal tolerance was impaired at all ages, but glucose intolerance was not detected until 4 months. Insulin secretion in response to hyperglycemic clamp and to arginine was impaired. Insulin sensitivity, measured by euglycemic hyperinsulinemic clamp, was normal. Pancreatic inflammation rapidly diminished after 2 months of age during a period where β-cell mass rose and gene expression of islet hormones, peroxisome proliferator-activated receptor-γ, and adiponectin increased. We conclude that active CF exocrine pancreatic inflammation adversely affects β-cells but is followed by islet resurgence. We predict that very young humans with CF may experience a transient glycemic crisis and postulate that pancreatic inflammatory to adipogenic remodeling may facilitate islet adaptation in CF.
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Affiliation(s)
- Yaling Yi
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Xingshen Sun
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Katherine Gibson-Corley
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Weiliang Xie
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Bo Liang
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Nan He
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Scott R Tyler
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Aliye Uc
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Louis H Philipson
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Kai Wang
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Manami Hara
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Katie Larson Ode
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Andrew W Norris
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - John F Engelhardt
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
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Barben J, Rueegg CS, Jurca M, Spalinger J, Kuehni CE. Measurement of fecal elastase improves performance of newborn screening for cystic fibrosis. J Cyst Fibros 2016; 15:313-7. [DOI: 10.1016/j.jcf.2015.12.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 12/31/2022]
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VanDevanter DR, Kahle JS, O’Sullivan AK, Sikirica S, Hodgkins PS. Cystic fibrosis in young children: A review of disease manifestation, progression, and response to early treatment. J Cyst Fibros 2016; 15:147-57. [DOI: 10.1016/j.jcf.2015.09.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 12/31/2022]
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Abstract
Cystic Fibrosis (CF) is a rare, multisystem disease leading to significant morbidity and mortality. CF is caused by defects in the cystic fibrosis transmembrane conductance regulator protein (CFTR), a chloride and bicarbonate transporter. Early diagnosis and access to therapies provides benefits in nutrition, pulmonary health, and cognitive ability. Several screening and diagnostic tests are available to support a diagnosis. We discuss the characteristics of screening and diagnostic tests for CF and guideline-based algorithms using these tools to establish a diagnosis. We discuss classification and management of common "diagnostic dilemmas," including the CFTR-related metabolic syndrome and other CFTR-associated diseases.
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Affiliation(s)
- John Brewington
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J P Clancy
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Abstract
OBJECTIVE Short endoscopic secretin tests for exocrine pancreatic function are not properly evaluated in cystic fibrosis (CF). METHODS Patients with CF and healthy controls (HCs) underwent endoscopic collection of duodenal juice between 30 and 45 minutes after secretin stimulation. Duodenal juice was analyzed for HCO3 concentration and pancreatic enzyme activities. Stool was analyzed for fecal elastase. RESULTS Thirty-one patients with CF and 25 HCs were tested. Patients were classified as exocrine pancreatic sufficient (n = 13) or insufficient (n = 18). Both bicarbonate concentrations and enzyme activities in duodenal juice differentiated patients with CFI from patients with CFS and HC (P < 0.001). The population displays strong correlation between severe CF genotype in both alleles and pancreatic insufficient phenotype (P < 0.001). CONCLUSIONS Pancreatic exocrine insufficient CF patients could be differentiated from exocrine sufficient patients and HCs using short endoscopic secretin test.
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44
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Safety and efficacy of Creon® Micro in children with exocrine pancreatic insufficiency due to cystic fibrosis. J Cyst Fibros 2015; 14:275-81. [DOI: 10.1016/j.jcf.2014.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 07/08/2014] [Accepted: 07/09/2014] [Indexed: 01/31/2023]
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Bodewes FAJA, Verkade HJ, Taminiau JAJM, Borowitz D, Wilschanski M. Cystic fibrosis and the role of gastrointestinal outcome measures in the new era of therapeutic CFTR modulation. J Cyst Fibros 2015; 14:169-77. [PMID: 25677689 DOI: 10.1016/j.jcf.2015.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 01/01/2023]
Abstract
With the development of new drugs that directly affect CFTR protein function, clinical trials are being designed or initiated for a growing number of patients with cystic fibrosis. The currently available and accepted clinical endpoints, FEV1 and BMI, have limitations. The aim of this report is to draw attention to the need and the ample possibilities for the development and validation of relevant gastrointestinal clinical endpoints for scientific evaluation of CFTR modulation treatment, particularly in young children and infants. The gastrointestinal tract offers very good opportunities to measure CFTR protein function and systematically evaluate CF related clinical outcomes based on the principal clinical gastrointestinal manifestations of CF: intestinal pH, intestinal transit time, intestinal bile salt malabsorption, intestinal inflammation, exocrine pancreatic function and intestinal fat malabsorption. We present a descriptive analysis of a variety of gastrointestinal outcome measures for clinical relevance, reliability, validity, responsiveness to interventions, feasibility in particular in young children and the availability of reference values.
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Affiliation(s)
- Frank A J A Bodewes
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center, Groningen, The Netherlands.
| | - Henkjan J Verkade
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | | | - Drucy Borowitz
- Department of Pediatrics, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Women and Children's Hospital of Buffalo, Buffalo, NY, United States
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Goepp J, Fowler E, McBride T, Landis D. Frequency of abnormal fecal biomarkers in irritable bowel syndrome. Glob Adv Health Med 2014; 3:9-15. [PMID: 24891989 PMCID: PMC4030610 DOI: 10.7453/gahmj.2013.099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PRIMARY STUDY OBJECTIVE Determine the frequency of abnormal fecal biomarker test results in patients with 13 irritable bowel syndrome (IBS)-related ICD-9 (International Statistical Classification of Diseases and Related Health Problems) codes. STUDY DESIGN Quantitative review of de-identified records from patients in whom IBS was a possible diagnosis. METHODS Records were selected for analysis if they included any of 13 IBS-related diagnostic codes and laboratory test results of fecal testing for all biomarkers of interest. Data collection was restricted to one 12-month period. Frequency distributions were calculated to identify rates of abnormal results for each biomarker within the total number of tests conducted in the eligible population. RESULTS Two thousand, two hundred fifty-six records were included in the study, of which 1867 (82.8%) included at least one abnormal value. Quantitative stool culture for beneficial bacteria (Lactobacillus and Bifidobacterium) indicated low growth suggestive of intestinal dysbiosis in 73.1% of records, followed by abnormally elevated eosinophil protein X (suggestive of food allergy) in 14.3%, elevated calprotectin (suggestive of inflammation) in 12.1%, detection of parasites in 7.5%, and low pancreatic elastase (suggestive of exocrine pancreatic insufficiency) in 7.1%. CONCLUSIONS Abnormal fecal biomarkers are prevalent in patients with diagnoses suggestive of IBS. Abnormal fecal biomarker testing, if confirmed in additional independent clinical trials, could substantially reduce the economic costs associated with diagnosis and management of IBS.
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Affiliation(s)
- Julius Goepp
- Lupine Creative Consulting, Inc, Rochester, New York (Dr Goepp), United States
| | - Elizabeth Fowler
- Genova Diagnostics, Asheville, North Carolina (Dr Fowler), United States
| | - Teresa McBride
- Genova Diagnostics, Asheville, North Carolina (Dr McBride), United States
| | - Darryl Landis
- Genova Diagnostics, Asheville, North Carolina (Dr Landis), United States
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Abstract
PURPOSE OF REVIEW The article reviews advances in gastrointestinal aspects of cystic fibrosis (CF) published in the literature over the past year, and highlights new and interesting research. RECENT FINDINGS Animal models can be used to understand the pathophysiology of gastrointestinal complications in CF. The CF mouse is useful for studying distal intestinal obstruction, dysmotility and dysbiosis, and the CF pig model has helped us better understand meconium ileus and pancreatic and hepatobiliary secretory problems. Studies in humans help elucidate the evolution of pancreatic insufficiency, how reflux may lead to lung disease, problems with intestinal dysmotility, mechanisms leading to pancreatitis and the increased prevalence of gastrointestinal cancer. Biomarkers are shedding light on CF-related liver disease. Rectal biopsies can help in diagnosis and in studying new drugs for CF. SUMMARY Gastrointestinal complications of CF are likely to be seen with increasing frequency as patients with CF lead longer lives. CF animal models and modern research techniques are providing new insights into extrapulmonary complications. CF clinicians should be familiar with diagnosis and management of common gastrointestinal complications and should build bridges with specialists so that referrals can be made when needed.
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Sun X, Olivier AK, Yi Y, Pope CE, Hayden HS, Liang B, Sui H, Zhou W, Hager KR, Zhang Y, Liu X, Yan Z, Fisher JT, Keiser NW, Song Y, Tyler SR, Goeken JA, Kinyon JM, Radey MC, Fligg D, Wang X, Xie W, Lynch TJ, Kaminsky PM, Brittnacher MJ, Miller SI, Parekh K, Meyerholz DK, Hoffman LR, Frana T, Stewart ZA, Engelhardt JF. Gastrointestinal pathology in juvenile and adult CFTR-knockout ferrets. THE AMERICAN JOURNAL OF PATHOLOGY 2014; 184:1309-22. [PMID: 24637292 PMCID: PMC4005986 DOI: 10.1016/j.ajpath.2014.01.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 02/07/2023]
Abstract
Cystic fibrosis (CF) is a multiorgan disease caused by loss of a functional cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel in many epithelia of the body. Here we report the pathology observed in the gastrointestinal organs of juvenile to adult CFTR-knockout ferrets. CF gastrointestinal manifestations included gastric ulceration, intestinal bacterial overgrowth with villous atrophy, and rectal prolapse. Metagenomic phylogenetic analysis of fecal microbiota by deep sequencing revealed considerable genotype-independent microbial diversity between animals, with the majority of taxa overlapping between CF and non-CF pairs. CF hepatic manifestations were variable, but included steatosis, necrosis, biliary hyperplasia, and biliary fibrosis. Gallbladder cystic mucosal hyperplasia was commonly found in 67% of CF animals. The majority of CF animals (85%) had pancreatic abnormalities, including extensive fibrosis, loss of exocrine pancreas, and islet disorganization. Interestingly, 2 of 13 CF animals retained predominantly normal pancreatic histology (84% to 94%) at time of death. Fecal elastase-1 levels from these CF animals were similar to non-CF controls, whereas all other CF animals evaluated were pancreatic insufficient (<2 μg elastase-1 per gram of feces). These findings suggest that genetic factors likely influence the extent of exocrine pancreas disease in CF ferrets and have implications for the etiology of pancreatic sufficiency in CF patients. In summary, these studies demonstrate that the CF ferret model develops gastrointestinal pathology similar to CF patients.
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Affiliation(s)
- Xingshen Sun
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | | | - Yaling Yi
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Christopher E Pope
- Department of Pediatrics, University of Washington, Seattle, Washington; Department of Microbiology, University of Washington, Seattle, Washington
| | - Hillary S Hayden
- Department of Microbiology, University of Washington, Seattle, Washington
| | - Bo Liang
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Hongshu Sui
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Weihong Zhou
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Kyle R Hager
- Department of Microbiology, University of Washington, Seattle, Washington
| | - Yulong Zhang
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Xiaoming Liu
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Ziying Yan
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - John T Fisher
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Nicholas W Keiser
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Yi Song
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Scott R Tyler
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - J Adam Goeken
- Department of Pathology, University of Iowa, Iowa City, Iowa
| | - Joann M Kinyon
- Department of Veterinary Diagnostic & Production Animal Medicine, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Matthew C Radey
- Department of Microbiology, University of Washington, Seattle, Washington
| | - Danielle Fligg
- Department of Veterinary Diagnostic & Production Animal Medicine, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Xiaoyan Wang
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Weiliang Xie
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Thomas J Lynch
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | - Paul M Kaminsky
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa
| | | | - Samuel I Miller
- Department of Microbiology, University of Washington, Seattle, Washington; Department of Genome Sciences, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Kalpaj Parekh
- Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa
| | | | - Lucas R Hoffman
- Department of Pediatrics, University of Washington, Seattle, Washington; Department of Microbiology, University of Washington, Seattle, Washington
| | - Timothy Frana
- Department of Veterinary Diagnostic & Production Animal Medicine, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Zoe A Stewart
- Department of Surgery, University of Iowa, Iowa City, Iowa
| | - John F Engelhardt
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, Iowa.
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del Campo R, Garriga M, Pérez-Aragón A, Guallarte P, Lamas A, Máiz L, Bayón C, Roy G, Cantón R, Zamora J, Baquero F, Suárez L. Improvement of digestive health and reduction in proteobacterial populations in the gut microbiota of cystic fibrosis patients using a Lactobacillus reuteri probiotic preparation: a double blind prospective study. J Cyst Fibros 2014; 13:716-22. [PMID: 24636808 DOI: 10.1016/j.jcf.2014.02.007] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/10/2014] [Accepted: 02/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although scientific knowledge about the benefits of probiotic use in cystis fibrosis (CF) is scarce, their expectative is promising. The aim of this work was to analyze the effect of a Lactobacillus reuteri probiotic preparation versus placebo in CF patients. METHODS A prospective, double blind, crossover and with placebo study was carried out in 30 CF patients from two Spanish hospitals. Patients were randomized in Group A (6 months of probiotic followed by 6 months of placebo) and Group B (6 months of placebo followed by 6 months of probiotic). GIQLI (gastrointestinal) and SF-12 (general) health tests were performed after probiotic and placebo intakes. Fat absorption coefficient, calprotectin, and inflammatory interleukin quantification were determined in fecal samples. Total fecal DNA was obtained and metagenomic 454-pyrosequencing was applied to analyze the microbiome composition. STATA v12 MP software was used for statistical analyses. RESULTS Statistically significant improvement in the gastrointestinal health and decrease of the calprotectin levels were demonstrated in patients after probiotic exposure, in comparison with placebo. All CF subjects reported good tolerance to L. reuteri without secondary effects. Metagenomic analysis showed an important dysbiosis in CF gut microbiota associated with a high concentration of Proteobacteria. Probiotic intake was followed by a reduction in the total bacterial density, mostly due to a considerable reduction in the γ-Proteobacteria phylum; and an important increase of the microbial diversity with a higher representation of Firmicutes. CONCLUSIONS Probiotics might ameliorate the dysbiosis of CF gut microbiota, characterized by a high density of Proteobacterial organisms. L. reuteri significantly decrease intestinal inflammation and increase digestive comfort.
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Affiliation(s)
- Rosa del Campo
- Department of Microbiology, Hospital Universitario Ramón y Cajal, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Spanish Network for the Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Spain.
| | - María Garriga
- Cystic Fibrosis Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ana Pérez-Aragón
- Department of Pediatrics, Virgen de las Nieves and San Cecilio University Hospitals, Granada, Spain
| | - Pilar Guallarte
- Department of Gastroenterology, Hospital Parc Tauli, Sabadell, Spain
| | - Adelaida Lamas
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Cystic Fibrosis Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Luis Máiz
- Cystic Fibrosis Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Carmen Bayón
- Deparment of Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Garbiñe Roy
- Department of Immunology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Rafael Cantón
- Department of Microbiology, Hospital Universitario Ramón y Cajal, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Spanish Network for the Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Spain
| | - Javier Zamora
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain; Center for Network Research in Epidemiology and Public Health (CIBERESP), Spain
| | - Fernando Baquero
- Department of Microbiology, Hospital Universitario Ramón y Cajal, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Center for Network Research in Epidemiology and Public Health (CIBERESP), Spain
| | - Lucrecia Suárez
- Cystic Fibrosis Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Abstract
Cystic fibrosis-related diabetes (CFRD) is the most common complication of cystic fibrosis. It is associated with significantly increased morbidity and mortality in adults and children. Adolescents with cystic fibrosis have a much higher prevalence of diabetes than any other similar age population. Glucose abnormalities that precede diabetes are even more common, especially in children younger than 10 years. The pathophysiology of glucose metabolic abnormalities is poorly understood, but insulin insufficiency is clearly the main component. Findings from animal studies have provided insight into the pathophysiology of CFRD, and imply that carbohydrate metabolic abnormalities might begin at much younger ages than was previously thought in patients with cystic fibrosis, and might be related to the basic cystic fibrosis chloride channel defect. In this Review we explore present knowledge of CFRD in children and adolescents, and new data that indicate that the pathophysiology of CFRD begins in very young patients.
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Affiliation(s)
- Katie L Ode
- Department of Pediatrics, University of Iowa Children's Hospital, University of Iowa, Iowa City, IA, USA.
| | - Antoinette Moran
- Department of Pediatrics, Amplatz Children's Hospital, University of Minnesota, Minneapolis, MN, USA
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