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Glucocorticoids Improve Enteral Feeding Tolerance in Pediatric Short Bowel Syndrome With Chronic Intestinal Inflammation. J Pediatr Gastroenterol Nutr 2021; 73:17-22. [PMID: 33534364 DOI: 10.1097/mpg.0000000000003058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES A group of short bowel syndrome (SBS) patients developed chronic intestinal inflammation while struggling weaning off parenteral nutrition (PN). They did not respond to standard management of SBS and food allergy. We treated them with glucocorticoids and described the outcome. METHODS Our study is a retrospective descriptive study. We reviewed records from the intestinal rehabilitation program from 2006 to 2017. We identified 15 patients whose lab values, pathology results, and clinic notes were reviewed. RESULTS We had more patients (n = 10) with diagnosis of gastroschisis, and more female patients (n = 9). Seven patients weaned off PN with median treatment duration of 5 months, 5 of which remained on budesonide for significant period of time (median: 7.5 months). One of these 7 patients relapsed, as the patient resumed glucocorticoids because of recurrence of chronic intestinal inflammation. Six of 15 children had significant eosinophils in their initial biopsy, 5 of these children weaned off PN whereas 1 child's gastrointestinal (GI) bleeding stopped. Four patients were not able to decrease PN calorie. Two of these patients' GI bleeding stopped, the other 2 had normalized histology. CONCLUSIONS For SBS children with histologically confirmed chronic intestinal inflammation, glucocorticoids may help promote enteral feeding tolerance. Glucocorticoids regimen should be chosen individually. Patients are more likely to respond if initial histology has significant eosinophilic infiltration. Patients may need to remain on glucocorticoids for over 6 months.
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Goulet OJ, Cai W, Seo JM. Lipid Emulsion Use in Pediatric Patients Requiring Long-Term Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S55-S67. [PMID: 32049395 DOI: 10.1002/jpen.1762] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022]
Abstract
The ability to deliver nutrients via parenteral nutrition (PN) has markedly improved the prognosis of infants and children with intestinal failure. Technical refinements and advances in knowledge have led to the development of highly sophisticated PN solutions that are tailored to meet the needs of pediatric patients. However, children who require long-term PN have an increased risk of complications such as catheter-related sepsis, liver disease, and bone disease. Although the pathogenesis of intestinal failure associated liver disease (IFALD) is multifactorial, studies have identified a possible link between the dose of lipid emulsions based on soybean oil and cholestasis, shown to occur with a significantly higher frequency in patients receiving >1 g lipids/kg/d. Potential contributing factors include oxidative stress, high ω-6 polyunsaturated fatty acid (PUFA) and phytosterol content, and relatively low α-tocopherol levels. Lipid emulsions containing fish oil offer potential advantages compared with traditional emulsions with a high soybean oil content, such as decreased ω-6 and increased ω-3 PUFA concentrations, high concentrations of α-tocopherol, and reduced phytosterol content. Studies in PN-dependent children at risk for IFALD have shown that lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with pure soybean oil emulsions. This review summarizes evidence regarding the role of lipid emulsions in the management of pediatric patients with intestinal failure requiring long-term PN, with a particular focus on the prevention and treatment of IFALD.
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Affiliation(s)
- Olivier J Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, National Reference Center for Rare Digestive Diseases, Hospital Necker-Enfants Malades, Paris-Descartes Medical School at the University of Sorbonne-Paris-Cité, Paris, France
| | - Wei Cai
- Department of Pediatric Surgery, Division of Pediatric Gastroenterology and Nutrition, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jeong-Meen Seo
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Courtney CM, Onufer EJ, McDonald KG, Steinberger AE, Sescleifer AM, Seiler KM, Tecos ME, Newberry RD, Warner BW. Small Bowel Resection Increases Paracellular Gut Barrier Permeability via Alterations of Tight Junction Complexes Mediated by Intestinal TLR4. J Surg Res 2021; 258:73-81. [PMID: 33002664 PMCID: PMC7937530 DOI: 10.1016/j.jss.2020.08.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/22/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Short bowel syndrome resulting from small bowel resection (SBR) is associated with significant morbidity and mortality. Many adverse sequelae including steatohepatitis and bacterial overgrowth are thought to be related to increased bacterial translocation, suggesting alterations in gut permeability. We hypothesized that after intestinal resection, the intestinal barrier is altered via toll-like receptor 4 (TLR4) signaling at the intestinal level. METHODS B6 and intestinal-specific TLR4 knockout (iTLR4 KO) mice underwent 50% SBR or sham operation. Transcellular permeability was evaluated by measuring goblet cell associated antigen passages via two-photon microscopy. Fluorimetry and electron microscopy evaluation of tight junctions (TJ) were used to assess paracellular permeability. In parallel experiments, single-cell RNA sequencing measured expression of intestinal integral TJ proteins. Western blot and immunohistochemistry confirmed the results of the single-cell RNA sequencing. RESULTS There were similar number of goblet cell associated antigen passages after both SBR and sham operation (4.5 versus 5.0, P > 0.05). Fluorescein isothiocyanate-dextran uptake into the serum after massive SBR was significantly increased compared with sham mice (2.13 ± 0.39 ng/μL versus 1.62 ± 0.23 ng/μL, P < 0.001). SBR mice demonstrated obscured TJ complexes on electron microscopy. Single-cell RNA sequencing revealed a decrease in TJ protein occludin (21%) after SBR (P < 0.05), confirmed with immunostaining and western blot analysis. The KO of iTLR4 mitigated the alterations in permeability after SBR. CONCLUSIONS Permeability after SBR is increased via changes at the paracellular level. However, these alterations were prevented in iTLR4 mice. These findings suggest potential protein targets for restoring the intestinal barrier and obviating the adverse sequelae of short bowel syndrome.
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Affiliation(s)
- Cathleen M Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Emily J Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Keely G McDonald
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Allie E Steinberger
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Anne M Sescleifer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Kristen M Seiler
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Maria E Tecos
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Rodney D Newberry
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Brad W Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri.
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Maselli KM, Gee K, Isani M, Fode A, Schall KA, Grikscheit TC. Broad-spectrum antibiotics alter the microbiome, increase intestinal fxr, and decrease hepatic steatosis in zebrafish short bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2020; 319:G212-G226. [PMID: 32597709 DOI: 10.1152/ajpgi.00119.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Short bowel syndrome (SBS) is associated with changes in the intestinal microbiome and marked local and systemic inflammation. There is also a late complication of SBS, intestinal failure associated liver disease (IFALD) in which hepatic steatosis progresses to cirrhosis. Most patients with SBS arrive at massive intestinal resection after a contaminating intraabdominal catastrophe and have a history of exposure to broad-spectrum antibiotics. We therefore investigated whether the administration of broad-spectrum antibiotics in conjunction with SBS in zebrafish (ZF) would replicate these systemic effects observed in humans to identify potentially druggable targets to aid in the management of SBS and resulting IFALD. In zebrafish with SBS, broad-spectrum antibiotics altered the microbiome, decreased inflammation, and reduced the development of hepatic steatosis. After two weeks of broad-spectrum antibiotics, these fish exhibited decreased alpha diversity, with less variation in microbial community composition between SBS and sham fish. Additionally, administration of broad-spectrum antibiotics was associated with decreased expression of intestinal toll-like receptor 4 (tlr4), increased expression of the intestinal gene encoding the Farnesoid X receptor (fxr), decreased expression of downstream hepatic cyp7a1, and decreased development of hepatic steatosis. SBS in zebrafish reproducibly results in increased epithelial surface area as occurs in human patients who demonstrate intestinal adaptation, but antibiotic administration in zebrafish with SBS reduced these gains with increased cell death in the intervillus pocket that contains stem/progenitor cells. These alternate states in SBS zebrafish might direct the development of future human therapies.NEW & NOTEWORTHY In a zebrafish model that replicates a common clinical scenario, systemic effects of the administration of broad-spectrum antibiotics in a zebrafish model of SBS identified two alternate states that led to the establishment of fat accumulation in the liver or its absence. Broad-spectrum antibiotics given to zebrafish with SBS over 2 wk altered the intestinal microbiome, decreased intestinal and hepatic inflammation, and decreased hepatic steatosis.
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Affiliation(s)
- Kathryn M Maselli
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kristin Gee
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California
| | - Mubina Isani
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California
| | - Alexa Fode
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kathy A Schall
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tracy C Grikscheit
- Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California.,Department of Surgery, Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California.,Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Unay-Demirel O, Ignak S, Orug T, Yuksel M. Presepsin Levels in Experimental Sepsis and Massive Bowel Resection Models in Rats. In Vivo 2019; 34:155-161. [PMID: 31882474 DOI: 10.21873/invivo.11756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIM Presepsin is a useful biomarker for diagnosing sepsis. This study aimed to investigate the relationship between oxidative stress and presepsin levels in animal models. MATERIALS AND METHODS Sprague-Dawley rats were used for cecal ligation and puncture (CLP) and to generate massive bowel resection (MBR) models. Trunk blood was collected for analysis of presepsin. Liver and intestinal tissue samples were taken to determine oxidative stress parameters. RESULTS Presepsin levels in MBR and CLP sepsis models were higher than those in control groups. Reactive oxygen and nitrogen species (RONS) and malondialdehyde levels were increased in the liver and small intestine of rats in both models, whereas glutathione levels were decreased. CONCLUSION Presepsin levels and RONS may be released by the same mechanism which is closely associated with the progression of sepsis and inflammation in both CLP and MBR models.
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Affiliation(s)
- Ozlem Unay-Demirel
- Department of Biochemistry, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Seyda Ignak
- Department of Medical Biology, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Taner Orug
- Department of Surgery, Medicana Hospital, Istanbul, Turkey
| | - Meral Yuksel
- Department of Medical Laboratory Techniques, Vocational School of Health Services, Marmara University, Istanbul, Turkey
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Lin S, Stoll B, Robinson J, Pastor JJ, Marini JC, Ipharraguerre IR, Hartmann B, Holst JJ, Cruz S, Lau P, Olutoye O, Fang Z, Burrin DG. Differential action of TGR5 agonists on GLP-2 secretion and promotion of intestinal adaptation in a piglet short bowel model. Am J Physiol Gastrointest Liver Physiol 2019; 316:G641-G652. [PMID: 30920308 PMCID: PMC6580240 DOI: 10.1152/ajpgi.00360.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/14/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023]
Abstract
Enteroendocrine L cells and glucagon-like peptide 2 (GLP-2) secretion are activated in the intestinal adaptation process following bowel resection in patients with short bowel syndrome. We hypothesized that enteral activation of Takeda G protein-coupled receptor 5 (TGR5), expressed in enteroendocrine L cells, could augment endogenous GLP-2 secretion and the intestinal adaptation response. Our aim was to assess the efficacy of different TGR5 agonists to stimulate GLP-2 secretion and intestinal adaptation in a piglet short-bowel model. In study 1, parenterally fed neonatal pigs (n = 6/group) were gavaged with vehicle, olive extract (OE; 10 or 50 mg/kg), or ursolic acid (UA; 10 mg/kg), and plasma GLP-2 was measured for 6 h. In study 2, neonatal pigs (n = 6-8/group) were subjected to transection or 80% mid-small intestine resection and, after 2 days, assigned to treatments for 10 days as follows: 1) transection + vehicle (sham), 2) resection + vehicle (SBS), 3) resection + 30 mg UA (SBS + UA), and 4) resection + 180 mg/kg OE (SBS + OE). We measured plasma GLP-2, intestinal histology, cell proliferation, and gene expression, as well as whole body citrulline-arginine kinetics and bile acid profiles. In study 1, GLP-2 secretion was increased by UA and tended to be increased by OE. In study 2, SBS alone, but not additional treatment with either TGR5 agonist, resulted in increased mucosal thickness and crypt cell proliferation in remnant jejunum and ileum sections. SBS increased biliary and ileal concentration of bile acids and expression of inflammatory and farnesoid X receptor target genes, but these measures were suppressed by UA treatment. In conclusion, UA is an effective oral GLP-2 secretagogue in parenterally fed pigs but is not capable of augmenting GLP-2 secretion or the intestinal adaptation response after massive small bowel resection. NEW & NOTEWORTHY Therapeutic activation of endogenous glucagon-like peptide 2 (GLP-2) secretion is a promising strategy to improve intestinal adaptation in patients with short bowel syndrome. This study in neonatal pigs showed that oral supplementation with a selective Takeda G protein-coupled receptor 5 (TGR5) agonist is an effective approach to increase GLP-2 secretion. The results warrant further study to establish a more potent oral TGR5 agonist that can effectively improve intestinal adaptation in pediatric patients with SBS.
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Affiliation(s)
- Sen Lin
- Institute of Animal Nutrition, Sichuan Agricultural University , Chengdu, Sichuan , People's Republic of China
| | - Barbara Stoll
- US Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center , Houston, Texas
| | - Jason Robinson
- US Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center , Houston, Texas
| | | | - Juan C Marini
- US Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center , Houston, Texas
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine , Houston, Texas
| | - Ignacio R Ipharraguerre
- Lucta S.A., Montornès del Vallès, Spain
- Institute of Human Nutrition and Food Science, University of Kiel , Kiel , Germany
| | - Bolette Hartmann
- Department of Biomedical Sciences and Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen , Copenhagen , Denmark
| | - Jens J Holst
- Department of Biomedical Sciences and Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen , Copenhagen , Denmark
| | - Stephanie Cruz
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital , Houston, Texas
| | - Patricio Lau
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital , Houston, Texas
| | - Oluyinka Olutoye
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital , Houston, Texas
| | - Zhengfeng Fang
- Institute of Animal Nutrition, Sichuan Agricultural University , Chengdu, Sichuan , People's Republic of China
| | - Douglas G Burrin
- US Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center , Houston, Texas
- Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas
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7
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Schall KA, Thornton ME, Isani M, Holoyda KA, Hou X, Lien CL, Grubbs BH, Grikscheit TC. Short bowel syndrome results in increased gene expression associated with proliferation, inflammation, bile acid synthesis and immune system activation: RNA sequencing a zebrafish SBS model. BMC Genomics 2017; 18:23. [PMID: 28118819 PMCID: PMC5264326 DOI: 10.1186/s12864-016-3433-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/19/2016] [Indexed: 01/19/2023] Open
Abstract
Background Much of the morbidity associated with short bowel syndrome (SBS) is attributed to effects of decreased enteral nutrition and administration of total parenteral nutrition (TPN). We hypothesized that acute SBS alone has significant effects on gene expression beyond epithelial proliferation, and tested this in a zebrafish SBS model. Methods In a model of SBS in zebrafish (laparotomy, proximal stoma, distal ligation, n = 29) or sham (laparotomy alone, n = 28) surgery, RNA-Seq was performed after 2 weeks. The proximal intestine was harvested and RNA isolated. The three samples from each group with the highest amount of RNA were spiked with external RNA controls consortium (ERCC) controls, sequenced and aligned to reference genome with gene ontology (GO) enrichment analysis performed. Gene expression of ctnnb1, ccnb1, ccnd1, cyp7a1a, dkk3, ifng1-2, igf2a, il1b, lef1, nos2b, saa1, stat3, tnfa and wnt5a were confirmed to be elevated in SBS by RT-qPCR. Results RNA-seq analysis identified 1346 significantly upregulated genes and 678 significantly downregulated genes in SBS zebrafish intestine compared to sham with Ingenuity analysis. The upregulated genes were involved in cell proliferation, acute phase response signaling, innate and adaptive immunity, bile acid regulation, production of nitric oxide and reactive oxygen species, cellular barrier and coagulation. The downregulated genes were involved in folate synthesis, gluconeogenesis, glycogenolysis, fatty-acid oxidation and activation and drug and steroid metabolism. RT-qPCR confirmed gene expression differences from RNA-Sequencing. Conclusion Changes of gene expression after 2 weeks of SBS indicate complex and extensive alterations of multiple pathways, some previously implicated as effects of TPN. The systemic sequelae of SBS alone are significant and indicate multiple targets for investigating future therapies. Electronic supplementary material The online version of this article (doi:10.1186/s12864-016-3433-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathy A Schall
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Matthew E Thornton
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Mubina Isani
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Kathleen A Holoyda
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Xiaogang Hou
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Ching-Ling Lien
- Division of Cardiothoracic Surgery, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Brendan H Grubbs
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Tracy C Grikscheit
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA, 90027, USA. .,Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 100, Los Angeles, CA, 90027, USA.
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Mokha JS, Davidovics ZH, Samela K, Emerick K. Effects of Ethanol Lock Therapy on Central Line Infections and Mechanical Problems in Children With Intestinal Failure. JPEN J Parenter Enteral Nutr 2016; 41:625-631. [DOI: 10.1177/0148607115625057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jasmeet S. Mokha
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Zev H. Davidovics
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Kate Samela
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Karan Emerick
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
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Mutanen A, Lohi J, Heikkilä P, Jalanko H, Pakarinen MP. Loss of ileum decreases serum fibroblast growth factor 19 in relation to liver inflammation and fibrosis in pediatric onset intestinal failure. J Hepatol 2015; 62:1391-7. [PMID: 25595885 DOI: 10.1016/j.jhep.2015.01.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/22/2014] [Accepted: 01/02/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The pathogenesis of intestinal failure (IF) associated liver disease (IFALD) is uncertain, we therefore investigated the role of FGF19 and pro-inflammatory cytokines has on this disease state. METHODS Serum FGF19, IL-6 and, TNF-α were measured in 52 IF patients at median age 6.0 years (IQR 2.2-13) after 10 months (4.1-39) on parenteral nutrition (PN). Thirty-nine patients underwent liver biopsies. RESULTS In IF patients, FGF19 concentrations were lower and those of IL-6 and TNF-α higher compared to healthy matched controls (p ⩽ 0.001 for all). FGF19 concentrations were further decreased in patients without a remaining ileum [37 pg/ml (IQR 30-68) vs. 74 (35-135) p=0.028], and correlated with remaining ileum length (r = 0.333, p = 0.018) and markers of cholesterol synthesis (r = -0.552 to -0.643, p < 0.001). Patients with histological portal inflammation [30 pg/ml (28-45) vs. 48 (33-100), p = 0.019] or fibrosis [35 pg/ml (30-66) vs. 99 (38-163), p = 0.013] had lower serum FGF19 concentrations than others. FGF19 negatively correlated with portal inflammation grade (r = -0.442, p = 0.005), serum TNF-α (r = -0.318, p = 0.025), METAVIR fibrosis stage (r = -0.441, p = 0.005) and APRI (r = -0.328, p = 0.028). IL-6 was higher during PN [6 pg/ml (2-31)] than after weaning off PN [2 pg/ml (1-5), p = 0.009], correlated weakly with cholestasis grade (r = 0.328, p = 0.044), and tended to associate with histological cholestasis [n = 5, 5 pg/ml (5-267) vs. n=34, 2 pg/ml (1-7), p = 0.058]. CONCLUSIONS In pediatric onset of IF, total or partial loss of ileum decreases serum FGF19 concentration corresponding to hepatic inflammation and fibrosis, along with increased cholesterol synthesis. In contrast, serum IL-6 increases during PN and may associate with concurrent cholestasis. These data suggests that FGF19 may contribute to the pathogenesis of IFALD.
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Affiliation(s)
- Annika Mutanen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.
| | - Jouko Lohi
- Department of Pathology, HUSLAB, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Päivi Heikkilä
- Department of Pathology, HUSLAB, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Breast milk is better than formula milk in preventing parenteral nutrition-associated liver disease in infants receiving prolonged parenteral nutrition. J Pediatr Gastroenterol Nutr 2013; 57:383-8. [PMID: 23689264 DOI: 10.1097/mpg.0b013e31829b68f3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Breast milk has been shown to be associated with greater success with regard to weaning children with intestinal failure off parenteral nutrition (PN). There are only a few studies investigating the role of breast milk in decreasing PN-associated liver disease (PNALD). The aim of our study was to determine whether breast milk is better than formula milk in preventing PNALD in infants receiving PN for >4 weeks. METHODS We conducted a retrospective analysis of newborns requiring prolonged parenteral nutrition. We divided the sample into 3 different groups (exclusive breast-feeding, exclusive formula-feeding, and mixed feeding. We compared baseline characteristics, feeding profiles and liver function tests, and liver enzymes among the 3 groups. RESULTS Among infants receiving PN for >4 weeks, we found that infants who were fed only breast milk were significantly less likely to develop PNALD (34.6%) compared with those who were fed only formula milk (72.7%; P = 0.008). The mean maximum conjugated bilirubin (P = 0.03) and the mean maximum aspartate aminotransferase were significantly lower in the breast-fed group (P = 0.04) compared with the formula-fed group. Among the mixed-feeding group, infants who received a higher percentage of breast milk showed a significant negative correlation with the mean maximum conjugated bilirubin. (Pearson correlation -0.517, P = 0.027). The mean number of days receiving PN and the average daily lipid intake in the 2 groups was not significantly different. CONCLUSIONS As a modality for early enteral nutrition, breast milk is protective against the development of PNALD in infants receiving PN for >4 weeks.
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Medeiros AC, Brígido ARD, Silva SM, Brito VR, Rocha KBF, Oliveira CN. The ileum as a determinant organ of the functional liver cell mass in rats. Acta Cir Bras 2013; 28:210-5. [DOI: 10.1590/s0102-86502013000300009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/24/2013] [Indexed: 11/21/2022] Open
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Jones BA, Hull MA, Richardson DS, Zurakowski D, Gura K, Fitzgibbons SC, Duro D, Lo CW, Duggan C, Jaksic T. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010; 45:1287-93. [PMID: 20620333 PMCID: PMC4547776 DOI: 10.1016/j.jpedsurg.2010.02.099] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 02/23/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine whether a regimen of 70% ethanol locks could reduce the rate of central venous catheter (CVC) infections in parenteral nutrition-dependent children with intestinal failure. METHODS We performed a retrospective review of 23 parenteral nutrition-dependent children in our multidisciplinary intestinal rehabilitation clinic who started ethanol lock therapy between September 2007 and June 2009. The treatment regimen consisted of a 70% ethanol lock instilled 3 times per week in each catheter lumen. The rate of CVC infections before and after initiation of ethanol lock therapy was compared using the Wilcoxon signed ranks test with significance set at P < .05. RESULTS The most common diagnoses leading to intestinal failure were necrotizing enterocolitis (26.1%), gastroschisis (21.7%), and intestinal atresia (14.3%). Ethanol locks were well tolerated with no reported adverse side effects. The infection rate decreased from 9.9 per 1000 catheter days prior to initiation of ethanol locks to 2.1 per 1000 catheter days during therapy (P = .03). CONCLUSIONS A regimen of ethanol lock therapy administered three days per week appears to be a safe and effective means of reducing the rate of CVC infections in parenteral nutrition-dependent children with intestinal failure.
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Affiliation(s)
- Brian A. Jones
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Department of Surgery, Children’s Hospital Boston and Harvard Medical School
| | - Melissa A. Hull
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Department of Surgery, Children’s Hospital Boston and Harvard Medical School
| | - Denise S. Richardson
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School
| | - David Zurakowski
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School
| | - Kathleen Gura
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Department of Pharmacy, Children’s Hospital Boston and Harvard Medical School
| | - Shimae C. Fitzgibbons
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Department of Surgery, Children’s Hospital Boston and Harvard Medical School
| | - Debora Duro
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School
| | - Clifford W. Lo
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School
| | - Christopher Duggan
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation (CAIR), Children’s Hospital Boston and Harvard Medical School,Department of Surgery, Children’s Hospital Boston and Harvard Medical School,Corresponding Author: Tom Jaksic, MD, PhD, Children’s Hospital Boston, 300 Longwood Ave., Department of Surgery, Fegan 3, Boston, MA 02115, Telephone: (617) 355-9600, Fax: (617) 730-0477,
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13
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Kaufman SS, Pehlivanova M, Fennelly EM, Rekhtman YM, Gondolesi GE, Little CA, Matsumoto CS, Fishbein TM. Predicting liver failure in parenteral nutrition-dependent short bowel syndrome of infancy. J Pediatr 2010; 156:580-5.e1. [PMID: 20097357 DOI: 10.1016/j.jpeds.2009.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 08/28/2009] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To test the hypothesis that early trends in common blood tests may delineate risks of liver failure (LF) in infants with parenteral nutrition-associated liver disease (PNALD) from short bowel syndrome and suggest criteria for transplant referral. STUDY DESIGN Total levels of bilirubin, gamma-glutamyl transferase, albumin, alanine aminotransferase, platelet count, and absolute neutrophil count were recorded every 3 months for 61 infants with PNALD who were being considered for intestinal transplant starting at age 3 months until death without transplant (n = 12), LF with transplant (n = 35), or liver recovery without transplant (n = 14). Probabilities of LF were determined with logistic regression. RESULTS Independent predictors of LF were, in descending order, total bilirubin level (odds ratio [OR] = 1.195), platelet count (OR = 0.992), and albumin level (OR = 0.248). Predicted probabilities of eventual LF varied from 36% to 38% at ages 3 to 6 months when the total bilirubin level was 6.0 mg/dL, platelet count was 220 x 10(3)/microL, and albumin level was 3.5 g/dL to 83% to 84% when the total bilirubin level was 11.7 mg/dL, platelet count was 168 x 10(3)/microL, and albumin level was 3.0 g/dL. CONCLUSIONS Transplant referral for a total bilirubin level of 6 mg/dL between 3 to 6 months of age is appropriate, because the probability of LF is at least 36%.
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Affiliation(s)
- Stuart S Kaufman
- Department of Pediatrics, Georgetown University School of Medicine, Institute of Transplantation, Georgetown University Hospital, Washington, DC 20007, USA.
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14
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Diamond IR, Pencharz PB, Wales PW. Omega-3 lipids for intestinal failure associated liver disease. Semin Pediatr Surg 2009; 18:239-45. [PMID: 19782305 DOI: 10.1053/j.sempedsurg.2009.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intestinal failure associated liver disease (IFALD) is one of the most common and devastating complications in infants with intestinal failure. Although multifactorial, its pathophysiology is clearly related to the administration of parenteral nutrition (PN), with a recent focus on the role of PN lipid emulsions. This paper will review the evidence for the use of omega-3 fatty acid PN lipid emulsions, which are proposed to have efficacy in the treatment of IFALD. Mechanisms explaining their effects will be considered as will future research directions.
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Affiliation(s)
- Ivan R Diamond
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
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15
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Martin CA, Perrone EE, Longshore SW, Toste P, Kathryn MD, Nair R, Guo J, Erwin CR, Warner BW. Intestinal resection induces angiogenesis within adapting intestinal villi. J Pediatr Surg 2009; 44:1077-82; discussion 1083. [PMID: 19524720 PMCID: PMC2697129 DOI: 10.1016/j.jpedsurg.2009.02.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 02/17/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE Adaptive growth of the intestinal mucosa in response to massive gut loss is fundamental for autonomy from parenteral nutrition. Although angiogenesis is essential for cellular proliferation in other tissues, its relevance to intestinal adaptation is unknown. We tested the hypothesis that resection-induced adaptation is associated with new blood vessel growth. METHODS Male C57Bl/6 mice underwent either a 50% small bowel resection or a sham (transection and reanastomosis) operation. After 1, 3, or 7 days, capillary density within the intestinal villi was measured using confocal microscopy. A messenger RNA reverse-transcriptase polymerase chain reaction (RT-PCR) array was used to determine angiogenic gene expression during adaptation. RESULTS Mice that underwent small bowel resection had a significantly increased capillary density compared to sham-operated mice at postoperative day 7. This morphological alteration was preceded by significant alterations in 5 candidate genes at postoperative day 3. CONCLUSION New vessel blood growth is observed in the adapting intestine after massive small bowel loss. This response appears to follow rather than initiate the adaptive alterations in mucosal morphology that are characteristic of adaptation. A better understanding of this progress and the signaling factors involved may improve therapeutic options for children with short gut syndrome.
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Affiliation(s)
- Colin A. Martin
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Erin E. Perrone
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
- Department of Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Shannon W. Longshore
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
- Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Paul Toste
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - MD Kathryn
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
| | - Rajalakshmi Nair
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
| | - Jun Guo
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
| | - Christopher R. Erwin
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
| | - Brad W. Warner
- Division of Pediatric Surgery, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, MO
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16
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Wiles A, Woodward JM. Recent advances in the management of intestinal failure-associated liver disease. Curr Opin Clin Nutr Metab Care 2009; 12:265-72. [PMID: 19339882 DOI: 10.1097/mco.0b013e328329e4ef] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize the current management of intestinal failure-associated liver disease (IFALD) by reviewing recent advances in our understanding of the condition and the effects of different therapeutic approaches. RECENT FINDINGS The importance of gastrointestinal length and continuity in the aetiology and treatment of IFALD has been demonstrated in both retrospective and interventional cohorts. A mechanism for the cholestatic effect of soy-based lipid has been described, and the clinical use of alternative lipid sources has demonstrated benefit. Prevention of IFALD has been shown with the use of erythromycin in neonates, and reversal of established IFALD has been demonstrated with isolated intestinal transplantation. SUMMARY A greater understanding of the mechanisms of IFALD has led to promising interventions to prevent and treat the condition. Other possible therapeutic targets require more formal evaluation, and further work is required to develop noninvasive tools for the assessment and prognosis of IFALD that will guide treatment and help in the selection of patients and timing of transplantation.
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Affiliation(s)
- Alan Wiles
- Department of Gastroenterology and Clinical Nutrition, Addenbrookes Hospital, Cambridge, UK
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17
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The Role of Endoscopic Ultrasound for Evaluating Portal Hypertension in Children Being Assessed for Intestinal Transplantation. Transplantation 2008; 86:1470-3. [DOI: 10.1097/tp.0b013e3181891d63] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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The rationale for the use of parenteral omega-3 lipids in children with short bowel syndrome and liver disease. Pediatr Surg Int 2008; 24:773-8. [PMID: 18504595 DOI: 10.1007/s00383-008-2174-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
Abstract
Parenteral nutrition associated liver disease (PNALD) is the major source of morbidity and mortality in children with short bowel syndrome (SBS). There is emerging evidence that omega-6 fatty acids (omega6FA) within the parenteral solution play a major role in PNALD and their effects may be reversed or ameliorated by substitution with omega-3 fatty acids (omega3FA). This paper reviews the mechanisms whereby omega3FAs may influence PNALD by improving bile flow, inhibiting steatosis, and having immunomodulatory effects. The early clinical experience with omega3FAs in SBS and PNALD is briefly reviewed and the implications of such, and future directions are considered.
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