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Kaur H, Kasapoglu M, Yadavalli R, Nawaz S, Althwanay A, AlEdani EM, Yu AK. Inflammatory Bowel Disease and Its Association With Perinuclear Antineutrophil Cytoplasmic Antibodies: A Systematic Review. Cureus 2024; 16:e57872. [PMID: 38725759 PMCID: PMC11079720 DOI: 10.7759/cureus.57872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
An idiopathic condition known as inflammatory bowel disease (IBD) is characterized by a dysregulated immune response to the intestinal flora of the host. It falls into one of two primary categories: ulcerative colitis or Crohn's disease. A wide range of disorders, both clinically and genetically, can cause IBD. The purpose of this thorough analysis is to determine the significance and reliability of the correlation between perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) and IBD, as well as the implications of this correlation for the diagnosis and treatment of IBD. Ten pertinent studies were identified from a starting pool of 20 articles in this systematic review, which was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. These studies addressed treatment, complications, limitations, and outcome in addition to the presence or lack of p-ANCA in patients with IBD. In conclusion, p-ANCA is more strongly linked to inflammatory bowel illness than Crohn's disease, primarily ulcerative colitis. Some evidence suggests that there is a decrease in p-ANCA to some extent with medical or surgical interventions, but the exact intervention is not yet clear. There is less evidence suggesting that the medical or surgical treatments used in patients with IBD cause an increase or decrease in p-ANCA.
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Affiliation(s)
- Harleen Kaur
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Malik Kasapoglu
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rajesh Yadavalli
- Department of Internal Medicine, Rajiv Gandhi Institute of Medical Sciences, Adilabad, IND
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sarosh Nawaz
- Department of Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abdulaziz Althwanay
- Department of Dermatology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Esraa M AlEdani
- Department of Dermatology and Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Department of Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Pehrsson M, Domislovic V, Alexdottir MS, Brinar M, Karsdal MA, Barisic A, Krznaric Z, Mortensen JH. Blood-Based Biomarkers Reflecting Protease 3 and MMP-12 Catalyzed Elastin Degradation as Potential Noninvasive Surrogate Markers of Endoscopic and Clinical Disease in Inflammatory Bowel Disease. J Clin Med 2023; 13:21. [PMID: 38202027 PMCID: PMC10779348 DOI: 10.3390/jcm13010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Chronic inflammation in inflammatory bowel disease (IBD) triggers significant extracellular matrix remodeling, including elastin remodeling, leading to severe clinical complications. Novel methods to assess intestinal tissue destruction may act as surrogate markers of endoscopic disease activity, relieving patients of invasive endoscopy. We explored the noninvasive blood-based biomarkers ELP-3 and ELM-12, measuring elastin degradation in IBD. In a study involving 104 Crohn's disease (CD), 39 ulcerative colitis (UC), and 29 healthy donors, we assessed these biomarkers' association with endoscopic and clinical disease activity using ELISA. Patients were evaluated based on the SES-CD and CDAI for CD patients and modified MES and partial Mayo for UC patients. ELP-3 and ELM-12 were elevated in patients with IBD. Discerning CD patients in endoscopic remission and mild from moderate to severe, ELP-3 provided an AUC of 0.69 and ELM-12 an AUC of 0.73. The ELP-3 biomarker was associated with UC patients and provided the highest diagnostic power of 0.87 for remission vs. active clinical disease. The data suggest an association of ELP-3 with active CD and ELM-12 with endoscopic remission in CD patients. Additionally, ELP-3 could identify UC patients with active clinical disease from patients in remission. The noninvasive biomarkers ELP-3 and ELM-12 could be potential surrogate biomarkers of elastin degradation and endoscopic and clinical disease markers.
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Affiliation(s)
- Martin Pehrsson
- Biomarkers and Research, Nordic Bioscience A/S, 2730 Herlev, Denmark; (M.S.A.); (M.A.K.); (J.H.M.)
| | - Viktor Domislovic
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia; (V.D.); (M.B.); (Z.K.)
| | | | - Marko Brinar
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia; (V.D.); (M.B.); (Z.K.)
| | - Morten Asser Karsdal
- Biomarkers and Research, Nordic Bioscience A/S, 2730 Herlev, Denmark; (M.S.A.); (M.A.K.); (J.H.M.)
| | - Ana Barisic
- Center for Clinical Nutrition, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Zeljko Krznaric
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia; (V.D.); (M.B.); (Z.K.)
| | - Joachim Høg Mortensen
- Biomarkers and Research, Nordic Bioscience A/S, 2730 Herlev, Denmark; (M.S.A.); (M.A.K.); (J.H.M.)
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Andalucía C, Martínez-Prat L, Bentow C, Aure MA, Horn MP, Mahler M. Clinical Validity of Anti-Proteinase 3 Antibodies in Patients with Inflammatory Bowel Disease: A Short Meta-Analysis. Diagnostics (Basel) 2023; 13:3682. [PMID: 38132266 PMCID: PMC10742424 DOI: 10.3390/diagnostics13243682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA) directed to proteinase 3 (PR3) represent highly established markers for patients with ANCA-associated vasculitis (AAV). PR3-ANCA have also demonstrated utility in the management of inflammatory bowel disease (IBD). More specifically, PR3-ANCA discriminate individuals with ulcerative colitis (UC) from Crohn's disease (CD) patients and are associated with disease severity, activity, and treatment non-response. Here, we aim to summarize the current data on the diagnostic utility of PR3-ANCA in IBD. A structured, systematic literature review, including three electronic databases, was conducted on June 6th, 2023, to identify studies assessing the diagnostic accuracy of the QUANTA Flash® PR3 assay in UC vs. CD patients. Electronic searches were supplemented by hand searching. A hierarchical, bivariate, mixed-effect meta-analysis was conducted using the metandi function, as per the Cochrane collaboration recommendations. Study quality was assessed using the QUADAS-2 tool, which considers the risk of bias and applicability. Six out of a hundred and eleven citations met the inclusion criteria and reported QUANTA Flash® PR3 diagnostic accuracy in UC vs. CD (UC, n = 667, CD, n = 682 patients). The sensitivity/specificity point estimate for UC was 34.9%/95.9%. This resulted in a Diagnostic Odds Ratio (DOR) of 12.6. The risk of bias was low in the index test and reference standard domains. Four of the six studies (67%) showed an unclear risk of bias in patient selection and in flow and timing domains. All studies had low concerns about applicability in all the domains. PR3-ANCA measured with the QUANTA Flash® PR3 assay represent novel diagnostic markers in IBD and enables discrimination between UC and CD.
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Affiliation(s)
- Carmen Andalucía
- Research and Development, Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA 92121, USA; (C.A.); (L.M.-P.); (C.B.); (M.A.A.)
| | - Laura Martínez-Prat
- Research and Development, Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA 92121, USA; (C.A.); (L.M.-P.); (C.B.); (M.A.A.)
| | - Chelsea Bentow
- Research and Development, Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA 92121, USA; (C.A.); (L.M.-P.); (C.B.); (M.A.A.)
| | - Mary Ann Aure
- Research and Development, Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA 92121, USA; (C.A.); (L.M.-P.); (C.B.); (M.A.A.)
| | - Michael P. Horn
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Michael Mahler
- Research and Development, Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA 92121, USA; (C.A.); (L.M.-P.); (C.B.); (M.A.A.)
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Gravina AG, Dallio M, Romeo M, Pellegrino R, Stiuso P, Lama S, Grieco P, Merlino F, Panarese I, Marino FZ, Sangineto M, Romano M, Federico A. The urotensin-II receptor: A marker for staging and steroid outcome prediction in ulcerative colitis. Eur J Clin Invest 2023; 53:e13972. [PMID: 36807243 DOI: 10.1111/eci.13972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Urotensin-II receptor- (UTR) related pathway exerts a key-role in promoting inflammation. The aim was to assess the relationship between UTR expression and clinical, endoscopic and biochemical severity of ulcerative colitis (UC), exploring its predictivity of intravenous (iv) steroid administration therapeutic outcome. METHODS One-hundred patients with first diagnosis of UC and 44 healthy subjects were enrolled. UTR expression was assessed by qPCR, Western Blot (WB) and immunohistochemistry (IHC). Clinical, endoscopic and histological activity of UC were evaluated by using Truelove and Witts (T&W) severity index, Mayo Endoscopic Score (MES), and Truelove and Richards Index (TRI). The partial and full Mayo scores (PMS and FMS) were assessed to stage the disease. RESULTS The UTR expression, resulted higher in the lesioned mucosa of UC patients in comparison to healthy subjects (p < .0001 all). Direct relationship between UTR (mRNA and protein) expression and disease severity assessment (T&W, PMS, MES and TRI) was highlighted (p < .0001 all). UTR expression resulted also higher in the 72 patients requiring iv steroids administration compared to those who underwent alternative medications, (p < .0001). The 32 steroid-non-responders showed an increased UTR expression (WB, IHC and qPCR from lesioned mucosa), compared to 40 steroid-responders (p: .0002, .0001, p < .0001 respectively). The predictive role of UTR expression (p < .05) on the negative iv steroids administration therapeutic outcome was highlighted and ROC curves identified the thresholds expressing the better predictive performance. CONCLUSIONS UTR represents a promising inflammatory marker related to clinical, endoscopic, and histological disease activity as well as a predictive marker of steroid administration therapeutic outcome in the UC context.
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Affiliation(s)
| | - Marcello Dallio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Romeo
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Raffaele Pellegrino
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Stiuso
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stefania Lama
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Grieco
- Department of Pharmacy, University of Naples "Federico II", Naples, Italy
| | - Francesco Merlino
- Department of Pharmacy, University of Naples "Federico II", Naples, Italy
| | - Iacopo Panarese
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Federica Zito Marino
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Moris Sangineto
- University Center for Research and Treatment of Liver Diseases (C.U.R.E.), Liver Unit, University of Foggia, Foggia, Italy
| | - Marco Romano
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro Federico
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Vieujean S, Louis E. Precision medicine and drug optimization in adult inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231173331. [PMID: 37197397 PMCID: PMC10184262 DOI: 10.1177/17562848231173331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/16/2023] [Indexed: 05/19/2023] Open
Abstract
Inflammatory bowel diseases (IBD) encompass two main entities including ulcerative colitis and Crohn's disease. Although having a common global pathophysiological mechanism, IBD patients are characterized by a significant interindividual heterogeneity and may differ by their disease type, disease locations, disease behaviours, disease manifestations, disease course as well as treatment needs. Indeed, although the therapeutic armamentarium for these diseases has expanded rapidly in recent years, a proportion of patients remains with a suboptimal response to medical treatment due to primary non-response, secondary loss of response or intolerance to currently available drugs. Identifying, prior to treatment initiation, which patients are likely to respond to a specific drug would improve the disease management, avoid unnecessary side effects and reduce the healthcare expenses. Precision medicine classifies individuals into subpopulations according to clinical and molecular characteristics with the objective to tailor preventative and therapeutic interventions to the characteristics of each patient. Interventions would thus be performed only on those who will benefit, sparing side effects and expense for those who will not. This review aims to summarize clinical factors, biomarkers (genetic, transcriptomic, proteomic, metabolic, radiomic or from the microbiota) and tools that could predict disease progression to guide towards a step-up or top-down strategy. Predictive factors of response or non-response to treatment will then be reviewed, followed by a discussion about the optimal dose of drug required for patients. The time at which these treatments should be administered (or rather can be stopped in case of a deep remission or in the aftermath of a surgery) will also be addressed. IBD remain biologically complex, with multifactorial etiopathology, clinical heterogeneity as well as temporal and therapeutic variabilities, which makes precision medicine especially challenging in this area. Although applied for many years in oncology, it remains an unmet medical need in IBD.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
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PR3-ANCAs Detected by Third-Generation ELISA Predicts Severe Disease and Poor Survival in Primary Sclerosing Cholangitis. Diagnostics (Basel) 2022; 12:diagnostics12112682. [PMID: 36359524 PMCID: PMC9689935 DOI: 10.3390/diagnostics12112682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/21/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
A highly sensitive detection of anti-neutrophil cytoplasmic antibodies to serine proteinase-3 (PR3-ANCAs) aids in the serological diagnosis of autoimmune liver disorders and the prediction of severity in primary sclerosing cholangitis (PSC). Here, we evaluate a novel third-generation ELISA for the detection of PR3-ANCAs. In total, 309 patients with PSC, 51 with primary biliary cholangitis (PBC), and 120 healthy blood donors (BD) were analyzed. For the survival analysis in PSC, the outcome was defined as liver-transplantation-free survival during the follow-up. Positive PR3-ANCA levels were found in 74/309 (24.0%) of patients with PSC. No BDs and one patient with PBC demonstrated PR3-ANCA positivity. PR3-ANCAs were revealed as independent predictors for a poor PSC outcome (study endpoint: liver transplantation/death, log-rank test, p = 0.02). PR3-ANCA positivity, lower albumin levels, and higher bilirubin concentrations were independent risks of a poor survival (Cox proportional-hazards regression analysis, p < 0.05). The Mayo risk score for PSC was associated with PR3-ANCA positivity (p = 0.01) and the disease severity assessed with a model of end-stage liver disease (MELD) and extended MELD-Na (p < 0.05). PR3-ANCAs detected by a third-generation ELISA are diagnostic and prognostic markers for PSC. Their wider use could help to identify patients who are at-risk of a more severe disease.
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Laass MW, Ziesmann J, de Laffolie J, Röber N, Conrad K. Anti-Proteinase 3 Antibodies as a Biomarker for Ulcerative Colitis and Primary Sclerosing Cholangitis in Children. J Pediatr Gastroenterol Nutr 2022; 74:463-470. [PMID: 35703948 DOI: 10.1097/mpg.0000000000003359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Anti-neutrophil cytoplasmic antibody (ANCA) directed against proteinase 3 (PR3) is a marker for granulomatosis with polyangiitis, but is also found in patients with inflammatory bowel disease (IBD), mainly ulcerative colitis (UC). The aim of our study was to investigate ANCA and PR3-ANCA in paediatric IBD. METHODS We tested 326 paediatric IBD patients and 164 controls for anti-Saccharomyces cerevisiae antibodies (ASCA), ANCA (indirect immunofluorescence, IIF) and PR3-ANCA (chemiluminescence immunoassay). We applied the Paris classification for paediatric IBD and documented liver manifestations such as primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH). RESULTS We found PR3-ANCA in 49/121 (40%) of UC, 20/187 (11%) of Crohn disease (CD) and 2/18 (11%) of IBD-unclassified (IBD-U) patients but in none of the controls. 54% UC and 12% CD patients were positive for ANCA (IIF). PR3-ANCA positive UC patients were characterised by more extensive disease (P = .070). Fourteen of 21 (67%) of UC patients with backwash ileitis were anti-PR3 ANCA-positive (P = .011). We diagnosed PSC or PSC/AIH in 19 UC and 3 IBD-U patients. Fifteen of 22 (68%) patients with PSC or PSC/AIH were anti-PR3-ANCA positive in contrast to 36 of 117 (32%) patients without PSC (P = .001). PR3-ANCA positive patients showed higher levels of gamma-glutamyl transferase, alanine transaminase and aspartate transferase (P < 0.001, 0.001, 0.006, respectively). Forty-seven percent of CD and 6% of UC patients were ASCA-IgA positive. PR3-ANCA-positive and -negative patients showed no significant differences concerning age at diagnosis, disease activity, need for drugs, and number of hospitalisations. CONCLUSIONS Our study provides data for PR3-ANCA as a potential serological marker for paediatric UC and PSC.
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Affiliation(s)
- Martin Walter Laass
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Josefine Ziesmann
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Immunology, Technische Universität Dresden, Dresden, Germany
- Department of Obstetrics, University College Hospital, London WC1E 6DB, United Kingdom
| | - Jan de Laffolie
- Department of General Paediatrics and Neonatology, University Children's Hospital, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Nadja Röber
- Institute of Immunology, Technische Universität Dresden, Dresden, Germany
| | - Karsten Conrad
- Institute of Immunology, Technische Universität Dresden, Dresden, Germany
- Association for the Advancement of Immune Diagnostics, 01219 Dresden, Germany
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Yang CW, Kao YC, Lin PC, Chien HY, Lin SC, Lee YH, Huang YL, Fang SB. Case Report: Proteinase 3 Antineutrophil Cytoplasmic Antibody-Associated Ulcerative Colitis Presenting as Recurrent Intestinal Pseudo-Obstruction in a Teenage Patient With in situ Proteinase 3 Immunohistochemical Staining. Front Pediatr 2022; 10:822491. [PMID: 35281249 PMCID: PMC8904890 DOI: 10.3389/fped.2022.822491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/24/2022] [Indexed: 12/05/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease with the colorectum as its major target organ. Involvement of the upper gastrointestinal tract in UC is rare and presents with nonspecific endoscopic and microscopic characteristics. Recent studies have demonstrated proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) to be a serological marker for differentiating UC from Crohn's disease in children and for detecting disease activity and nonresponse to steroid therapy and antitumor necrotizing factor-α agents. Herein, we report a 13-year-old female patient mainly presenting with recurrent bilious vomiting who was initially diagnosed with acute gastroenteritis. Intestinal pseudo-obstruction was confirmed through observation of a patent but segmentally dilated jejunum in the barium follow-through examination and other imaging; such obstruction can be attributed to backwash ileitis, superior mesenteric artery syndrome, ileus due to hypokalemia, or PR3-associated enteritis. Laboratory data revealed leukocytosis with neutrophil predominance and serum antinuclear antibody and PR3-ANCA positivity. Overlapping syndrome with autoimmune diseases was suspected. Pathology revealed a crypt abscess with aggregates of neutrophils consistent with UC but did not indicate vasculitis. The in situ immunohistochemical staining revealed PR3 density mainly in the colon and focally in the duodenum. To our knowledge, this is the first case report with in situ pathological evidence of PR3 in inflamed intestinal tissues in a patient with UC and with rare initial presentation of intestinal pseudo-obstruction-induced recurrent bilious vomiting. Whether the clinical features of the present case constitute overlap syndrome with other autoimmune disease or a disease variation of UC warrants further investigation. Notably, the patient's serum PR3-ANCA titers remained high in coincidence with increased disease activity and nonresponse to steroid therapy, but became lower after infliximab treatment. PR3-ANCA as a potential serum biomarker to aid in making differential diagnoses of UC in children, correlating disease activity, and predicting therapeutic responses was also reviewed.
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Affiliation(s)
- Ching-Wen Yang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chien Kao
- Department of Pathology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Pei-Chun Lin
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hsi-Yuan Chien
- Department of Gastroenterology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Gastroenterology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yu-Hsien Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yen-Lin Huang
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Shiuh-Bin Fang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Master Program in Clinical Genomics and Proteomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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