Fecal calprotectin and clinical disease activity in pediatric ulcerative colitis

Fecal Calprotectin Test Performed at Home: A Prospective Study of Pediatric Patients With Inflammatory Bowel Disease

OBJECTIVES

Measuring fecal calprotectin (FC) in a laboratory is time-consuming and that is why home tests have been developed. We studied the use of an FC home test in pediatric patients with inflammatory bowel disease (PIBD) in real-life settings.

METHODS

The patients were asked to perform the IBDoc FC home test monthly for 6 months and to report their clinical disease activity at testing. Clinical decision-making, however, was guided by routine FC enzyme-linked immunosorbent assay (ELISA) for patients with raised IBDoc values. Spare frozen samples were analyzed using ELISA and IBDoc in the laboratory. The participants completed a questionnaire about FC testing at the start and end of the study.

RESULTS

Of the 52 patients, 35 (67%) ages 5 to 18 years completed the study, and 197 home tests were performed. Of these, 15% failed, mainly because of technical reasons. Just under half of the patients (47%) considered home testing comparable or superior to routine testing. In contrast, the parents were unsatisfied (61%), mostly because the IBDoc results were significantly different from ELISA and they found the phone application difficult to handle but whenever the IBDoc was performed by a laboratory professional it was comparable with ELISA, suggesting that practical issues hampered home testing. Despite their reservations, more than 80% of parents felt that home testing would improve disease management.

CONCLUSIONS

PIBD patients and their families were interested in FC home monitoring and willing to adopt testing as a part of their disease management, but this approach requires thorough guidance.

Analytical evaluation of a fully automated immunoassay for faecal calprotectin in a paediatric setting

Introduction

Faecal calprotectin (FC) is a routinely used marker for identifying and monitoring children with inflammatory bowel disease (IBD). This non-invasive test is useful for screening children with gastrointestinal symptoms to avoid unnecessary invasive procedures. In this study, we validated for the first time the performance of a fully automated particle-enhanced turbidimetric immunoassay (PETIA) on the VITROS® 5600 analyzer for measurement of FC in symptomatic children and adolescents.

Materials and methods

For performance validation of the PETIA (fCAL® turbo, Bühlmann Laboratories, Switzerland) on the VITROS® 5600 analyzer (Ortho Clinical Diagnostics, USA) limit of quantitation (LoQ), linearity, precision data and calibration curve stability were defined. Additionally, 95 faecal samples were measured using the PETIA, an enzyme-linked immunosorbent assay (ELISA; fCAL®, Bühlmann Laboratories, Switzerland) and a semi-quantitative lateral flow assay (Quantum Blue Reader®, Bühlmann Laboratories, Switzerland) for agreement evaluation.

Results

The LoQ for calprotectin using PETIA on the VITROS® 5600 analyzer was 21 µg/g. The linearity range was 20 - 2100 µg/g and the precision study showed a total coefficient of variation (CV) between 2.3% and 8.9%. The calibration curve was stable for 4 weeks. Using the clinical samples quantifiable by PETIA, ELISA and the semi-quantitative lateral flow assay, Passing-Bablok regression analysis and Bland-Altman plots showed good agreement.

Conclusions

Due to good performance characteristics and agreement with established methods, the fully automated PETIA on the routine chemistry analyzer VITROS® 5600 is a new analytical option for the rapid determination of FC.

C4B gene influences intestinal microbiota through complement activation in patients with paediatric-onset inflammatory bowel disease

Complement C4 genes are linked to paediatric inflammatory bowel disease (PIBD), but the mechanisms have remained unclear. We examined the influence of C4B gene number on intestinal microbiota and in-vitro serum complement activation by intestinal microbes in PIBD patients. Complement C4A and C4B gene numbers were determined by genomic reverse transcription-polymerase chain reaction (RT-PCR) from 64 patients with PIBD (Crohn's disease or ulcerative colitis). The severity of the disease course was determined from faecal calprotectin levels. Intestinal microbiota was assessed using the HITChip microarray. Complement reactivity in patients was analysed by incubating their sera with Yersinia pseudotuberculosis and Akkermansia muciniphila and determining the levels of C3a and soluble terminal complement complex (SC5b-9) using enzyme immunoassays. The microbiota diversity was wider in patients with no C4B genes than in those with one or two C4B genes, irrespective of intestinal inflammation. C4B and total C4 gene numbers correlated positively with soluble terminal complement complex (TCC, SC5b-9) levels when patient serum samples were stimulated with bacteria. Our results suggest that the C4B gene number associates positively with inflammation in patients with PIBD. Multiple copies of the C4B gene may thus aggravate the IBD-associated dysbiosis through escalated complement reactivity towards the microbiota.

Clinical Use of Infliximab Trough Levels and Antibodies to Infliximab in Pediatric Patients With Inflammatory Bowel Disease

OBJECTIVES

Optimizing infliximab (IFX) treatment in pediatric patients with inflammatory bowel disease (IBD) by using serum infliximab (S-IFX) trough levels and antibodies to IFX is recommended. There is need for studies assessing this strategy in clinical practice.

METHODS

We retrospectively identified all pediatric patients with IBD (n = 146, median age 14.8 years) treated with IFX at our tertiary referral center from 2003 to 2014. All were analyzed for IFX trough levels (S-IFX, n = 475), and IFX antibody (IFX-Ab, n = 219) titers were included. Both were analyzed using enzyme-linked immunosorbent assay. We correlated these parameters with concurrently analyzed fecal calprotectin levels and the treatment outcome.

RESULTS

If IFX had no efficacy, or a loss of response occurred, 40 of 64 (63%) had trough levels <2.0 mg/L, with negative IFX-Ab in 37 of 59 (63%). If the S-IFX was very low (<0.2 mg/L), 4 of 36 still had negative IFX-Ab. Concurrent azathioprine therapy did not relate to IFX-Ab. Fecal calprotectin was significantly lower in patients with clinical remission or ongoing therapy compared with those with subsequent loss of efficacy: medians 95 μg/g (33-308) and 670 μg/g (264-1473), P < 0.0001. The S-IFX median was substantially higher in patients with either remission or ongoing therapy, compared with those with no or loss of efficacy: 3.7 mg/L (1.8-5.4) and 1.2 mg/L (0.03-4.4, P = 0.01), respectively.

CONCLUSIONS

Measuring IFX trough levels and fecal calprotectin has a potential impact on the treatment strategies and should be included in clinical routine. Low IFX trough levels associate with increased antibodies to IFX in most, but not in all cases.

Fecal calprotectin in juvenile idiopathic arthritis patients related to drug use

BACKGROUND

Patients with juvenile idiopathic arthritis (JIA) on non-steroidal anti- inflammatory drugs (NSAIDs) may experience abdominal pain. In adults, NSAID use has been linked to an increase in fecal calprotectin (FC) levels, a surrogate marker for gut inflammation. In JIA, data on gut inflammation related to drug use is scarce.

METHODS

JIA patients followed up at the outpatient pediatric rheumatology clinic in Children's Hospital, Helsinki University Hospital, Helsinki, Finland were routinely assessed for FC if they complained about abdominal pain, had an elevated erythrocyte sedimentation rate (ESR) or used NSAIDs on a daily basis. The FC levels were related to the presence of abdominal pain, to ESR, and to the presence of HLA-B27.

RESULTS

Of the total group of 90 patients (median age 9.1 years; 45 JIA patients with disease modifying anti-rheumatic drugs (DMARDs), 25 without DMARD medication, and 20 arthralgia patients as controls), approximately 50% used NSAIDs, of whom 40% complained about abdominal pain. In patients with abdominal pain, one-third had elevated FC values (>100 μg/g). The FC values, for the most part, declined along with the discontinuation or reduction of NSAIDs and after intensifying the DMARD medication, where after the pain disappeared. In patients with an elevated ESR, the FC values and ESR normalized in parallel. The presence of HLA-B27 was not associated with FC levels.

CONCLUSION

In patients with JIA and abdominal pain, it may be useful to determine the FC when evaluating the need for further gastrointestinal examinations.

Assessment of disease activity in pediatric ulcerative colitis

To date, we encounter more and more pediatric patients with ulcerative colitis (UC). For yet unclear reasons, UC in pediatric patients seems to be a more aggressive and extensive disease than in their adult counterparts. In the majority of pediatric patients, the disease presents as pancolitis. The severity of the disease is reflected in the high use of corticosteroids and immunosuppressants and a high rate of surgery for medically refractory patients. The means by which to assess disease activity or to accurately predict its course are far from optimal. This review summarizes the current knowledge on the means for assessing UC activity in children. Research for developing new tools by which to monitor and forecast disease activity, are needed in all areas including invasive endoscopy, clinical evaluation, and treatment follow-up.

Progress in the treatment and outcome of pediatric inflammatory bowel disease patients

INTRODUCTION

The number of pediatric patients with inflammatory bowel disease (IBD), namely Crohn´s disease, ulcerative colitis and unclassified colitis, has rapidly increased in Western countries. Areas covered: This review discusses how the treatment of pediatric IBD patients has improved,with attention given to therapeutic quality and cost. The literature search covers Medline-PubMed and the Cochrane Library, with February 2016 as the last search dates. Similarly to what has been the trend in the management of adult IBD, pediatric IBD therapy has become more active than before. High use of immunosuppressants and the availability of biological therapeutic agents has helped to control the extensive and aggressive course of pediatric IBD. Full disease control at an early phase has advantages such as preserving normal child growth and development, maintaining overall good health and quality of life, as well as decreasing the psychosocial burden of the disease. Expert commentary: A key research direction is to tailor treatment modalities according to anticipated individual phenotype and disease course. Another is to reduce healthcare costs by decreasing the so-far high rate of surgery of pediatric IBD patients, and, instead, to develop a more active approach to treatment than before.

Correlation Between Concentrations of Fecal Calprotectin and Outcomes of Patients With Ulcerative Colitis in a Phase 2 Trial

BACKGROUND & AIMS

Accurate biomarkers of disease activity and therapeutic response can be valuable for clinical trials. We performed a post hoc analysis of data from a phase 2 trial to assess the relationship between the concentration of fecal calprotectin (FCP) and clinical and endoscopic outcomes of patients with moderate to severe ulcerative colitis receiving tofacitinib.

METHODS

In a double-blind, placebo-controlled, phase 2 trial, 194 patients were assigned randomly to groups given tofacitinib (0.5, 3, 10, or 15 mg twice daily) or placebo. Clinical and endoscopic outcomes were assessed at week 8 using the Mayo scoring system. Receiver operating characteristics were used to evaluate the relationships between FCP concentration and clinical and endoscopic outcomes, and to determine the FCP cut-off concentration that correlated with patient outcome.

RESULTS

Week 8 median concentrations of FCP were significantly lower in responders than in nonresponders (P < .001): clinical response, 156 vs 725 mg/kg; clinical remission, 64 vs 617 mg/kg; endoscopic remission, 44 vs 489 mg/kg; and mucosal healing, 127 vs 753 mg/kg. Area-under-the-curve values for FCP receiver operating characteristic models were 0.80 for clinical remission, 0.81 for endoscopic remission, and 0.78 for mucosal healing. An FCP cut-off value of 150 mg/kg achieved the highest summation of sensitivity and specificity for clinical remission (0.68 and 0.79, respectively; κ coefficient, 0.44) and endoscopic remission (0.79 and 0.75, respectively; κ coefficient, 0.38).

CONCLUSIONS

Concentrations of FCP correlate with clinical and endoscopic outcomes of patients with moderate to severe ulcerative colitis receiving tofacitinib, although at an individual level the agreement was moderate. FCP concentration with a cut-off value of 150 mg/kg had only fair to good accuracy in classifying clinical and endoscopic outcomes in a clinical trial. ClinicalTrials.gov no: NCT00787202.

Fecal calprotectin and its correlation with inflammatory markers and endoscopy in patients from India with inflammatory bowel disease

INTRODUCTION

In clinical practice, endoscopic findings are often used for assessing disease activity in inflammatory bowel disease (IBD). In recent years, blood and stool markers are being increasingly used for this purpose. Among them, the fecal calprotectin (FC) level is probably the most favored. Data on the reliability of FC are lacking from countries like India, where gut infections are common.

OBJECTIVE

The aims of this study were to compare the FC level with the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) as non-invasive markers of IBD and, in patients with ulcerative colitis (UC), and to study its correlation with disease extent, clinical activity, and endoscopic severity.

METHODS

Records of patients with IBD who had tests for FC, ESR and CRP and colonoscopy done within a 2-week period, between 2012 and 2014, were retrieved. Sixty-three patients (UC 32, Crohn's disease [CD] 31) were included for analysis. ESR, CRP and FC were compared to endoscopy to assess inflammation.

RESULTS

Patients with UC had higher levels of FC than those with ileocolonic CD (median FC 800 mcg/g vs. 619 mcg/g, respectively; p = 0.04). FC levels correlated with CRP (r = 0.4, p < 0.001) but not with ESR (r = 0.21, p = 0.09). In patients with UC with endoscopic evidence of inflammation, more (86.9 %) had FC > 200 mcg/g (cut-off for disease activity in our laboratory) than had ESR >20 mm in the first hour (60.6 %) or positive CRP (65.6 %) (< 0.01); FC levels increased with increasing endoscopic Mayo score (p = 0.001) and Truelove-Witt's clinical severity score (p = 0.006), but did not correlate with disease extent (p = 0.7). The best FC cut-off level to identify 'active UC' (Mayo grade 2 or more) was 800 mcg/g.

CONCLUSION

Fecal calprotectin level correlates with CRP but not with ESR. In patients with UC with inflammation, FC > 200 mcg/g is more often positive than raised ESR or CRP; it also correlates with clinical and endoscopic activity but not with disease extent. FC level > 800 mcg/g can be used to differentiate active from inactive UC.

Disproportionate rise in Clostridium difficile-associated hospitalizations among US youth with inflammatory bowel disease, 1997-2011

OBJECTIVES

Our aim was to characterize the temporal changes in burden that Clostridium difficile infection (CDI) added to the hospital care of children and young adults with inflammatory bowel disease (IBD) in the United States.

METHODS

Retrospective analysis of annual, nationally representative samples of children and young adults with IBD.

RESULTS

There was a 5-fold increase in IBD hospitalizations with CDI from 1997 to 2011 (P for trend <0.01). During the same period, IBD hospitalizations without CDI increased 2-fold (P for trend <0.01). Mean length of stay for IBD hospitalizations with CDI was consistently longer than that for hospitalizations without CDI and did not significantly change over time (P for trend = 0.47). CDI-related total hospital days in the United States rose from 1702 to 10,194 days per million individuals per year from 1997 to 2011 (P for trend <0.01). Children and young adults hospitalized with CDI had a significantly lower odds of colectomy (0.31) compared with those without CDI. Total charges for CDI-related hospitalizations among children and young adults in the United States rose from $8.7 million in 1997 to $68.2 million in 2011.

CONCLUSIONS

A widening gap in burden has opened between IBD hospitalizations with and without CDI during the last decade and a half. CDI-related hospitalizations are associated with disproportionately longer lengths of stay, more hospital days, and more charges than hospitalizations without CDI over time. Further work within health systems, hospitals, and practices can help us better understand this enlarging gap to improve clinical care for this vulnerable population.

Outcome measures for clinical trials in paediatric IBD: an evidence-based, expert-driven practical statement paper of the paediatric ECCO committee

OBJECTIVE

Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials.

DESIGN

The Paediatric European Crohn's and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement.

RESULTS

Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8-12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn's Disease Activity Index in Crohn's disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn's disease), faecal calprotectin, quality of life scales, and a patient-reported outcome.

CONCLUSIONS

It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal.

Fecal calprotectin in diagnosis and clinical assessment of inflammatory bowel disease

The fecal neutrophil-derived biomarker calprotectin has several features of an ideal noninvasive test for detecting intestinal inflammation: it is simple, reliable, and low in cost. Its utility in differentiating inflammatory bowel diseases (IBDs) from functional conditions such as irritable bowel syndrome is well documented. Fecal calprotectin (FC) correlates closely with endoscopic activity of IBD. Emerging evidence suggest its usefulness in serial monitoring of disease activity and of therapy success in IBD. A low FC concentration predicts persistence of clinical remission especially in non-symptomatic ulcerative colitis and Crohn's colitis. Here, an overview is given to the current role of FC in diagnosis and clinical assessment of IBD.

Skin reactions during anti-TNFα therapy for pediatric inflammatory bowel disease: a 2-year prospective study

BACKGROUND

Although the development of therapy-related skin reactions is common along with an increase in the number of adult patients receiving anti-TNFα, there are few studies on pediatric inflammatory bowel disease; hence, this prospective study focuses on skin reactions related to infliximab therapy.

METHODS

All pediatric patients with inflammatory bowel disease undergoing infliximab therapy were prospectively screened for the presence of skin manifestations at the time of each infusion between March 1, 2011 and March 31, 2011 at Children's Hospital, Helsinki, Finland. Blood inflammatory markers and fecal calprotectin levels were measured at the time of infusions.

RESULTS

During the study period, 84 children with inflammatory bowel disease (Crohn's n = 64) received infliximab infusions (the median duration of therapy 12.2 mo). Almost every other patient (n = 40; 47.6%) presented chronic skin reactions, 23% with lesions considered severe. Most commonly, the patient's ear lobes and scalp were affected with psoriasis-like manifestations, followed by their eyelids, perioral and pubic area, trunk, and the extremities. However, an HLA-Cw*0602 genotype associating with psoriasis was rare. Interestingly, most patients with skin reactions had a low degree of intestinal inflammation based on their fecal calprotectin levels (median level, 133 μg/g versus 589 in unaffected patients; P < 0.016). Seven patients (8.3% of all patients but 17% of those with skin lesions) discontinued the given therapy due to a skin reaction.

CONCLUSIONS

Skin reactions are common during maintenance therapy with infliximab in pediatric patients. For most patients, skin reactions seem to correlate with a low level of intestinal inflammation. Although potentially harsh, skin lesions mostly allow continuation of infliximab.

Comparison of three tests for faecal calprotectin in children and young adults: a retrospective monocentric study

OBJECTIVE

Faecal calprotectin is used as a sensitive marker for gastrointestinal mucosal inflammation. We compared the performance of three different assays in a large cohort of symptomatic paediatric patients.

DESIGN

Retrospective monocentric study.

SETTING

Inpatients and outpatients of a tertiary referral centre for paediatric gastroenterology.

PARTICIPANTS

304 symptomatic patients (163 males, aged 2-20 years) with active inflammatory bowel disease (IBD/A, n=130), IBD in clinical remission (IBD/R, n=62), other intestinal diseases (n=45) and controls without identified intestinal disease (n=67).

INTERVENTIONS

Calprotectin was measured in homogenised faecal samples with three tests (A: EliA Calprotectin, Phadia AB, Sweden; B: PhiCal, Calpro AS, Norway; C: EK-Cal, Bühlmann Laboratories, Switzerland).

OUTCOMES

Concordance between tests was calculated using Kendall's τ coefficient.

RESULTS

IBD/A and controls were correctly classified as 97.7%/82.1% (A), 97.7%/85.1% (B) and 98.4%/62.7% (C; not significant). Test C tended to have higher calprotectin values with a lower specificity compared to tests A and B. The concordance between two tests was 0.835 for tests A and B, 0.782 for tests A and C and 0.765 for tests B and C.

CONCLUSIONS

All three tests are very sensitive for detecting mucosal inflammation, but major differences exist between specificity and absolute values. It is highly advisable to use the test of the same manufacturer for follow-up and to monitor for disease activity.

Fecal calprotectin, MMP-9, and human beta-defensin-2 levels in pediatric inflammatory bowel disease

PURPOSE

Fecal MMP-9 and human beta-defensin-2 (HBD-2)levels, potential markers of intestinal inflammation, are in sufficiently explored in pediatric inflammatory bowel disease(IBD). The aim was to study fecal MMP-9 and HBD-2 in pediatric IBD to compare their performance to calprotectin and to study whether they would provide additional value in categorizing patients according to their disease subtype.

METHODS

Fecal calprotectin, MMP-9, and HBD-2 levels were measured with ELISA in 110 pediatric patients with IBD(Crohn’s disease, n = 68; ulcerative colitis (UC), n = 27; unclassified, n = 15; median age, 14). To compare the performance of the fecal markers, the area under the receiver operating characteristics curve (±95 % CI) was used. In addition,the best cut-off values of each measure to differentiate IBD patients and controls (n = 27 presenting with diarrhea, abdominal pain, and/or anemia) were derived by maximizing sensitivity and specificity.

RESULTS

Of the fecal markers studied, calprotectin performed best for separation of IBD and non-IBD patients with the are a under curve (AUC) of 0.944 (95 % CI, 0.907 to 0.981). For MMP-9, AUC was 0.837 (95% CI, 0.766 to 0.909), the levels being significantly higher in active IBD and in UC compared with Crohn’s disease (p = 0.0013), but categorization of these patient groups did not take place. HBD-2 did not categorize any of the studied groups.

CONCLUSIONS

Calprotectin was the best fecal marker in pediatric IBD, but MMP-9 showed almost comparable performance in UC, suggesting applicability as a surrogate marker of inflammation. Fecal HBD-2 did not bring information to the disease characteristics of pediatric IBD patients.