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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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Yuzyuk T, McDonald CM, Zuromski LM, De Biase I, Johnson L, Williams N, Meihls S, Asfour F. Improvement of lipid and lipoprotein profiles in children and adolescents with cystic fibrosis on CFTR modulator therapy. J Cyst Fibros 2023; 22:1027-1035. [PMID: 37453889 DOI: 10.1016/j.jcf.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Association of a high-fat diet with increased risks of cardiovascular disease (CVD) and type 2 diabetes, has prompted evaluation of lipids in people with CF (pwCF). However, most evidence on dyslipidemia was published before CF transmembrane conductance regulator (CFTR) modulators became a standard of care. The main goal of this study was to investigate the effect of CFTR modulator therapies on lipid and lipoprotein profiles in children and adolescents with CF. METHODS Blood samples were collected from 153 pwCF (10.1 ± 4.7 years of age) and 60 age-matched controls. Most pwCF were pancreatic insufficient on pancreatic enzyme replacement therapy. By the end of the study, 65% of CF participants were on CFTR modulator therapy for >1 month. The results of traditional and advanced lipid testing in pwCF were correlated with clinical and dietary information. RESULTS Total cholesterol and low-density lipoprotein (LDL) cholesterol were significantly lower in pwCF compared to non-CF participants. Those not receiving CFTR modulators also had significantly lower high-density lipoprotein (HDL) cholesterol and HDL particle number than controls. Individuals with CF on modulator therapy had significantly higher concentrations of anti-atherogenic HDL cholesterol and HDL particles along with lower levels of atherogenic large very-low density lipoprotein (VLDL) particles, total and small LDL particles, and triglycerides compared to those without CFTR modulator therapy. CONCLUSION CFTR modulator therapy has a beneficial effect on dyslipidemia in CF. It remains to be seen if these positive changes translate into decreased CVD risk later in life given the increasing life expectancy in CF.
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Affiliation(s)
- Tatiana Yuzyuk
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA; ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA.
| | | | - Lauren M Zuromski
- ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA
| | - Irene De Biase
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA; ARUP Institute of Clinical & Experimental Pathology, Salt Lake City, UT, USA
| | | | - Nicole Williams
- Cystic Fibrosis Clinic, Primary Children's Hospital, Salt Lake City, UT
| | - Suzanne Meihls
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Fadi Asfour
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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A fat lot of good: Balance and trends in fat intake in children with cystic fibrosis. J Cyst Fibros 2012; 11:154-7. [DOI: 10.1016/j.jcf.2011.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 10/24/2011] [Accepted: 10/25/2011] [Indexed: 11/22/2022]
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Vij N. Linoleic acid supplement in cystic fibrosis: friend or foe? Am J Physiol Lung Cell Mol Physiol 2010; 299:L597-8. [PMID: 20709729 DOI: 10.1152/ajplung.00257.2010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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GEORGIOPOULOU VV, DENKER A, BISHOP KL, BROWN JM, HIRSH B, WOLFENDEN L, SPERLING L. Metabolic abnormalities in adults with cystic fibrosis. Respirology 2010; 15:823-9. [DOI: 10.1111/j.1440-1843.2010.01771.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Guerrera IC, Astarita G, Jais JP, Sands D, Nowakowska A, Colas J, Sermet-Gaudelus I, Schuerenberg M, Piomelli D, Edelman A, Ollero M. A novel lipidomic strategy reveals plasma phospholipid signatures associated with respiratory disease severity in cystic fibrosis patients. PLoS One 2009; 4:e7735. [PMID: 19893743 PMCID: PMC2768907 DOI: 10.1371/journal.pone.0007735] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 10/14/2009] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to search for lipid signatures in blood plasma from cystic fibrosis (CF) patients using a novel MALDI-TOF-ClinProTools strategy, initially developed for protein analysis, and thin layer chromatography coupled to MALDI-TOF (TLC-MALDI). Samples from 33 CF patients and 18 healthy children were subjected to organic extraction and column chromatography separation of lipid classes. Extracts were analyzed by MALDI-TOF, ion signatures were compared by the ClinProTools software and by parallel statistical analyses. Relevant peaks were identified by LC-MSn. The ensemble of analyses provided 11 and 4 peaks differentially displayed in CF vs healthy and in mild vs severe patients respectively. Ten ions were significantly decreased in all patients, corresponding to 4 lysophosphatidylcholine (18:0, 18:2, 20:3, and 20:5) and 6 phosphatidylcholine (36:5, O-38:0, 38:4, 38:5, 38:6, and P-40:1) species. One sphingolipid, SM(d18:0), was significantly increased in all patients. Four PC forms (36:3, 36:5, 38:5, and 38:6) were consistently downregulated in severe vs mild patients. These observations were confirmed by TLC-MALDI. These results suggest that plasma phospholipid signatures may be able to discriminate mild and severe forms of CF, and show for the first time MALDI-TOF-ClinProTools as a suitable methodology for the search of lipid markers in CF.
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Affiliation(s)
- Ida Chiara Guerrera
- Plateau Proteome Necker, Université Paris Descartes, IFR94, Paris, France
- INSERM, U845, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Giuseppe Astarita
- University of California Irvine, Irvine, California, United States of America
| | - Jean-Philippe Jais
- Université Paris Descartes, Service de Biostastistiques et Bioinformatique du CHU Necker-Enfants-Malades, Paris, France
| | | | | | - Julien Colas
- INSERM, U845, Université Paris Descartes, Faculté de Médecine, Paris, France
| | | | | | - Daniele Piomelli
- University of California Irvine, Irvine, California, United States of America
| | - Aleksander Edelman
- Plateau Proteome Necker, Université Paris Descartes, IFR94, Paris, France
- INSERM, U845, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Mario Ollero
- INSERM, U845, Université Paris Descartes, Faculté de Médecine, Paris, France
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Alves CDAD, Lima DS. Dislipidemia relacionada à fibrose cística. J Bras Pneumol 2008; 34:829-37. [DOI: 10.1590/s1806-37132008001000012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 03/03/2008] [Indexed: 11/22/2022] Open
Abstract
Esse artigo tem por objetivo rever o conhecimento atual sobre a fisiopatologia, o diagnóstico e a abordagem da dislipidemia relacionada à fibrose cística (DFC). A pesquisa bibliográfica utilizou os bancos de dados Medline e Literatura Latino-Americana e do Caribe em Ciências da Saúde (1987-2007), selecionando os artigos mais relevantes sobre o tema. A DFC é caracterizada por hipertrigliceridemia e/ou hipocolesterolemia e deficiência de ácidos graxos essenciais. Seus principais fatores de risco são: insuficiência pancreática, dieta rica em carboidratos, hepatopatias, estado inflamatório e corticoterapia. Não existem recomendações específicas sobre a triagem, que habitualmente é realizada a partir do diagnóstico e, em intervalos regulares, com maior freqüência, nos indivíduos pertencentes aos grupos de risco. O tratamento inclui: dieta balanceada, reposição de micronutrientes, vitaminas e fibras, além de exercício físico regular de acordo com a tolerância individual. Na grande maioria dos casos, a hipertrigliceridemia da DFC não atinge valores que indiquem o uso de hipolipemiantes. Conclui-se que existem poucos trabalhos na literatura sobre a freqüência, etiologia e manejo da DFC. A recomendações preventivas e terapêuticas para a hipertrigliceridemia são extrapoladas de diretrizes para indivíduos sem fibrose cística. Mais pesquisas são necessárias para investigar a associação da deficiência de ácidos graxos essenciais com a fisiopatologia da fibrose cística. Como a hipertrigliceridemia é um importante fator de risco para doença arterial coronariana, estudos prospectivos irão contribuir para o melhor entendimento da história natural dessa complicação bem como definir maneiras de preveni-la e tratá-la.
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Chen AH, Innis SM, Davidson AGF, James SJ. Phosphatidylcholine and lysophosphatidylcholine excretion is increased in children with cystic fibrosis and is associated with plasma homocysteine, S-adenosylhomocysteine, and S-adenosylmethionine. Am J Clin Nutr 2005; 81:686-91. [PMID: 15755840 DOI: 10.1093/ajcn/81.3.686] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hepatic steatosis and fat malabsorption are common in cystic fibrosis (CF). Choline deficiency results in decreased phosphatidylcholine synthesis through the cytidine diphosphocholine-choline pathway and hepatic steatosis and in increased synthesis of phosphatidylcholine from phosphatidylethanolamine using methyl groups from S-adenosylmethionine. The intestinal absorption of phosphatidylcholine in CF is unknown. OBJECTIVES The objective was to determine whether excretion of choline phosphoglyceride (phosphatidylcholine and lysophosphatidylcholine) is increased in CF and whether loss of fecal choline phosphoglyceride is associated with altered plasma methionine cycle metabolites. DESIGN A cross-sectional study involved 53 children with CF and 18 control children without CF. Blood was collected from all participants. A subset of 18 children with CF and 8 control children provided 72-h fecal samples and 5-d food records. RESULTS Fat absorption was significantly lower (x+/- SEM: 86.2 +/- 1.6% and 94.1 +/- 1.2%) and excretion of fecal fat (12.9 +/- 1.7 and 3.9 +/- 0.7 g/d), phospholipid (median: 130 and 47.7 mg/d), phosphatidylcholine (19.6 and 2.1 mg/d), and lysophosphatidylcholine (60.3 and 16.9 mg/d) was significantly higher in children with CF than in control children, respectively (P < 0.05). Choline phosphoglyceride excretion was positively correlated with plasma homocysteine and S-adenosylhomocysteine and inversely related with plasma methionine (P < 0.05). CONCLUSIONS Choline phosphoglyceride excretion is increased in children with CF and is associated with decreased plasma methionine and increased homocysteine and S-adenosylhomocysteine. These findings suggest choline depletion and an increased choline synthesis by S-adenosylmethionine-dependent methylation in CF, as well as a metabolic link between phosphatidylcholine metabolism and the methionine-homocysteine cycle in humans.
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Affiliation(s)
- Alice H Chen
- Department of Paediatrics and the Nutrition Research Program, University of British Columbia, Vancouver, Canada
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Figueroa V, Milla C, Parks EJ, Schwarzenberg SJ, Moran A. Abnormal lipid concentrations in cystic fibrosis. Am J Clin Nutr 2002; 75:1005-11. [PMID: 12036806 DOI: 10.1093/ajcn/75.6.1005] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Concentrations of cholesterol and triacylglycerol are commonly believed to be low in persons with cystic fibrosis and thus not of concern. OBJECTIVE The goal was to determine whether concentrations of cholesterol and triacylglycerol are related to glucose tolerance or nutritional status in patients with cystic fibrosis. DESIGN Fasting lipid profiles were measured in 192 patients ( +/- SD age: 21 +/- 11 y) in conjunction with an oral-glucose-tolerance test. RESULTS Cystic fibrosis patients in all age groups had higher triacylglycerol (1.51 +/- 0.95 mmol/L) and lower cholesterol (3.57 +/- 0.96 mmol/L) concentrations than US population means. Thirty patients (16%) had hypertriglyceridemia (3.22 +/- 1.22 mmol/L), and 8 patients (4%) had elevated cholesterol (6.05 +/- 1.32 mmol/L). In most cases, hypertriglyceridemia was isolated; only 3 subjects had elevation of both cholesterol and triacylglycerol. Lipid concentrations were not related to body mass index, weight, glucose tolerance, the areas under the curve for glucose or insulin, or glycated hemoglobin. Lipid concentrations also did not correlate with cystic fibrosis genotype, use of systemic steroids, blood pressure, liver enzymes, C-reactive protein, or pulmonary function. CONCLUSIONS Isolated hypertriglyceridemia appears to be common in cystic fibrosis, whereas cholesterol concentrations are generally low. Hypertriglyceridemia may be related to chronic low-grade inflammation or to a dietary macronutrient imbalance with excessive simple carbohydrate absorption relative to fat absorption. Whether it is associated with a risk of cardiovascular disease in this population is uncertain, but the clinical significance of triacylglycerol elevation may become important as survival improves.
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Affiliation(s)
- Veronica Figueroa
- Divisions of Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis 55455, USA
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