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Roca M, Masip E, Colombo C, Boon M, Hulst JM, Garriga M, de Koning BAE, Bulfamante A, de Boeck K, Ribes-Koninckx C, Calvo-Lerma J. Long-term evaluation of faecal calprotectin levels in a European cohort of children with cystic fibrosis. Arch Dis Child 2024; 109:552-556. [PMID: 38123920 DOI: 10.1136/archdischild-2023-326221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Intestinal inflammation with contradictory data on faecal calprotectin (fCP) levels is documented in patients with cystic fibrosis (CF). The aim of this study was to longitudinally evaluate fCP in a cohort of children with CF and their relationship with clinical variables. DESIGN Prospective observational study to assess evolution of fCP levels, primary aimed at improving fat absorption. Along 1.5 years of follow-up (November 2016-May 2018) with four study visits pertaining to a pilot study (two of four) and to a clinical trial (two of four), the study outcomes were measured. SETTING Six European CF centres in the context of MyCyFAPP Project. SUBJECTS Children with CF and pancreatic insufficiency (2-18 years old). MAIN OUTCOME MEASUREMENTS fCP levels, pulmonary function (percentage of forced expiratory volume in 1 s (FEV1%)) and coefficient of fat absorption (CFA). Additionally, in the last two visits, gastrointestinal (GI) symptoms were evaluated through the PedsQL-GI Questionnaire. Linear mixed regression models were applied to assess association between fCP and FEV1, CFA and GI symptoms. RESULTS Twenty-nine children with CF and pancreatic insufficiency were included. fCP levels were inversely associated with total modified specific PedsQL-GI score (p=0.04) and positively associated with diarrhoea (p=0.03), but not with CFA. Along the four study visits, fCP significantly increased (from 62 to 256 µg/g) and pulmonary function decreased (from 97% to 87%), with a significant inverse association between the two study outcomes (p<0.001). CONCLUSIONS In children with CF, fCP levels are inversely associated with pulmonary function and thus the specificity of fCP as a marker of intestinal inflammation in paediatric patients with CF warrants further investigation.
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Affiliation(s)
- Maria Roca
- Health Research Institute La Fe, Valencia, Spain
| | - Etna Masip
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mieke Boon
- Department of Pediatrics, KU Leuven Hospital, Leuven, Belgium
| | - Jessie M Hulst
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Anna Bulfamante
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Kris de Boeck
- Department of Pediatrics, KU Leuven Hospital, Leuven, Belgium
| | | | - Joaquim Calvo-Lerma
- Health Research Institute La Fe, Valencia, Spain
- Universitat de València, Valencia, Spain
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Tacelli M, Arcidiacono PG, Capurso G. Exocrine pancreatic insufficiency: more compromise than precision. Hepatobiliary Surg Nutr 2024; 13:523-526. [PMID: 38911206 PMCID: PMC11190531 DOI: 10.21037/hbsn-24-92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/15/2024] [Indexed: 06/25/2024]
Affiliation(s)
- Matteo Tacelli
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Chadwick C, Lehman H, Luebbert S, Abdul-Aziz R, Borowitz D. Autoimmunity in people with cystic fibrosis. J Cyst Fibros 2023; 22:969-979. [PMID: 36966037 DOI: 10.1016/j.jcf.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/27/2023]
Abstract
Cystic fibrosis (CF) clinicians may see patients who have difficult-to-manage symptoms that do not have a clear CF-related etiology, such as unusual gastrointestinal (GI) complaints, vasculitis, or arthritis. Alterations in immunity, inflammation and intraluminal dysbiosis create a milieu that may lead to autoimmunity, and the CF transmembrane regulator protein may have a direct role as well. While autoantibodies and other autoimmune markers may develop, these may or may not lead to organ involvement, therefore they are helpful but not sufficient to establish an autoimmune diagnosis. Autoimmune involvement of the GI tract is the best-established association. Next steps to understand autoimmunity in CF should include a more in-depth assessment of the community perspective on its impact. In addition, bringing together specialists in various fields including, but not limited to, pulmonology, gastroenterology, immunology, and rheumatology, would lead to cross-dissemination and help define the path forward in basic science and clinical practice.
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Affiliation(s)
| | - Heather Lehman
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | | | - Rabheh Abdul-Aziz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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Borowitz D, Aronoff N, Cummings LC, Maqbool A, Mulberg AE. Coefficient of Fat Absorption to Measure the Efficacy of Pancreatic Enzyme Replacement Therapy in People With Cystic Fibrosis: Gold Standard or Coal Standard? Pancreas 2022; 51:310-318. [PMID: 35695742 PMCID: PMC9257055 DOI: 10.1097/mpa.0000000000002016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/02/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We sought data on the validity, reliability, responsiveness, and feasibility of the coefficient of fat absorption (CFA) as a measure of pancreatic enzyme replacement therapy (PERT) efficacy in people with cystic fibrosis (pwCF) and reviewed the literature for alternative measures. METHODS We searched PubMed for the Medical Subject Heading cystic fibrosis and the key words cystic fibrosis, fat absorption, CFA, and fecal fat imbalance; historical articles; and citations in bibliographies. RESULTS The lower the CFA, the greater its variability; thus, it is less variable in healthy individuals who have higher CFA than pwCF. In addition, the test-retest values for CFA are more variable in pwCF than the general population. There is no correlation between CFA and body mass index or PERT dose but CFA is related to gastrointestinal signs and symptoms. Research-quality CFA studies are expensive, time consuming, and odious to pwCF and research staff. Sparse stool tests, breath tests, and blood tests of fat absorption have been studied as potential alternatives to CFA to measure PERT efficacy. CONCLUSIONS Based on the evidence, we conclude that CFA as a measure of the efficacy of PERT is more of a "coal standard" than a gold standard; developing suitable alternatives should be a priority.
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Affiliation(s)
- Drucy Borowitz
- From the Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences
| | - Nell Aronoff
- University Libraries, University at Buffalo, Buffalo, NY
| | - Linda C. Cummings
- Department of Internal Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Asim Maqbool
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Calvo-Lerma J, Roca M, Boon M, Colombo C, de Koning B, Fornés-Ferrer V, Masip E, Garriga M, Bulfamante A, Asensio-Grau A, Andrés A, de Boeck K, Hulst J, Ribes-Koninckx C. Association between faecal pH and fat absorption in children with cystic fibrosis on a controlled diet and enzyme supplements dose. Pediatr Res 2021; 89:205-210. [PMID: 32247283 DOI: 10.1038/s41390-020-0860-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/31/2019] [Accepted: 02/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite treatment with pancreatic enzyme replacement therapy (PERT), patients with cystic fibrosis (CF) can still suffer from fat malabsorption. A cause could be low intestinal pH disabling PERT. The aim of this study was to assess the association between faecal pH (as intestinal pH surrogate) and coefficient of fat absorption (CFA). Additionally, faecal free fatty acids (FFAs) were quantified to determine the amount of digested, but unabsorbed fat. METHODS In a 24-h pilot study, CF patients followed a standardised diet with fixed PERT doses, corresponding to theoretical optimal doses determined by an in vitro digestion model. Study variables were faecal pH, fat and FFA excretion, CFA and transit time. Linear mixed regression models were applied to explore associations. RESULTS In 43 patients, median (1st, 3rd quartile) faecal pH and CFA were 6.1% (5.8, 6.4) and 90% (84, 94), and they were positively associated (p < 0.001). An inverse relationship was found between faecal pH and total fat excretion (p < 0.01), as well as total FFA (p = 0.048). Higher faecal pH was associated with longer intestinal transit time (p = 0.049) and the use of proton pump inhibitors (p = 0.009). CONCLUSIONS Although the clinical significance of faecal pH is not fully defined, its usefulness as a surrogate biomarker for intestinal pH should be further explored. IMPACT Faecal pH is a physiological parameter that may be related to intestinal pH and may provide important physiopathological information on CF-related pancreatic insufficiency. Faecal pH is correlated with fat absorption, and this may explain why pancreatic enzyme replacement therapy is not effective in all patients with malabsorption related to CF. Use of proton pump inhibitors is associated to higher values of faecal pH. Faecal pH could be used as a surrogate biomarker to routinely monitor the efficacy of pancreatic enzyme replacement therapy in clinical practice. Strategies to increase intestinal pH in children with cystic fibrosis should be targeted.
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Affiliation(s)
- Joaquim Calvo-Lerma
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain. .,Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain.
| | - Maria Roca
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
| | - Mieke Boon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals, 3000, Leuven, Belgium
| | - Carla Colombo
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122, Milan, Italy
| | - Barbara de Koning
- Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Etna Masip
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
| | - Maria Garriga
- Hospital Universitario Ramón y Cajal, 28034, Madrid, Spain
| | - Anna Bulfamante
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122, Milan, Italy
| | - Andrea Asensio-Grau
- Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain
| | - Ana Andrés
- Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain
| | - Kris de Boeck
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals, 3000, Leuven, Belgium
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Carmen Ribes-Koninckx
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
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Boon M, Calvo-Lerma J, Claes I, Havermans T, Asseiceira I, Bulfamante A, Garriga M, Masip E, van Schijndel BAM, Fornes V, Barreto C, Colombo C, Crespo P, Vicente S, Janssens H, Hulst J, Witters P, Nobili R, Pereira L, Ruperto M, Van der Wiel E, Mainz JG, De Boeck K, Ribes-Koninckx C. Use of a mobile application for self-management of pancreatic enzyme replacement therapy is associated with improved gastro-intestinal related quality of life in children with Cystic Fibrosis. J Cyst Fibros 2020; 19:562-568. [PMID: 32335023 DOI: 10.1016/j.jcf.2020.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency (PI), leading to fat malabsorption, malnutrition, abdominal discomfort and impaired growth. Pancreatic enzyme replacement therapy (PERT) is effective, but evidence based guidelines for dose adjustment are lacking. A mobile app for self-management of PERT was developed in the context of the HORIZON 2020 project MyCyFAPP. It contains an algorithm to calculate individual PERT-doses for optimal fat digestion, based on in vitro and in vivo studies carried out in the same project. In addition, the app includes a symptoms diary, educational material, and it is linked to a web tool allowing health care professionals to evaluate patient's data and provide feedback. METHODS A 6-month open label prospective multicenter interventional clinical trial was performed to assess effects of using the app on gastro-intestinal related quality of life (GI QOL), measured by the CF-PedsQL-GI (shortened, CF specific version of the Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Module). RESULTS One hundred and seventy-one patients with CF and PI between 2 and 18 years were recruited at 6 European CF centers. Self-reported CF-PedsQL-GI improved significantly from month 0 (M0) (84.3, 76.4-90.3) to month 6 (M6) (89.4, 80.35-93.5) (p< 0.0001). Similar improvements were reported by parents. Lower baseline CF-PedsQL-GI was associated with a greater improvement at M6 (p < 0.001). CONCLUSIONS The results suggest that the MyCyFAPP may improve GI QOL for children with CF. This tool may help patients to improve self-management of PERT, especially those with considerable GI symptoms.
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Affiliation(s)
- M Boon
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium.
| | - J Calvo-Lerma
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - I Claes
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - T Havermans
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - I Asseiceira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - A Bulfamante
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Garriga
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Masip
- Gastroenterology and Pediatric cystic Fibrosis Unit, La Fe Hospital, Valencia, Spain
| | - B A M van Schijndel
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - V Fornes
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - C Barreto
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - C Colombo
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - P Crespo
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - S Vicente
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - H Janssens
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J Hulst
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - P Witters
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - R Nobili
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - L Pereira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - M Ruperto
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Van der Wiel
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Germany; Cystic Fibrosis Center Brandenburg Medical School (MHB), University, Brandenburg an der Havel, Germany
| | - K De Boeck
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
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Boon M, Claes I, Havermans T, Fornés-Ferrer V, Calvo-Lerma J, Asseiceira I, Bulfamante A, Garriga M, Masip E, Woodcock S, Walet S, Barreto C, Colombo C, Crespo P, Van der Wiel E, Hulst J, Martinez-Barona S, Nobili R, Pereira L, Ruperto M, Vicente S, De Boeck K, Ribes-Koninckx C. Assessing gastro-intestinal related quality of life in cystic fibrosis: Validation of PedsQL GI in children and their parents. PLoS One 2019; 14:e0225004. [PMID: 31860639 PMCID: PMC6924691 DOI: 10.1371/journal.pone.0225004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/25/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency, leading to fat malabsorption, malnutrition and abdominal discomfort. Until recently, no specific tool was available for assessing gastro-intestinal related quality of life (GI QOL) in patients with CF. As the Horizon2020 project MyCyFAPP aims to improve GI QOL by using a newly designed mobile application, a sensitive and reliable outcome measure was needed. We aimed to study the applicability of the existing child-specific Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Scales and Module (PedsQL GI) in children with CF. METHODS A multicenter, prospective observational study was performed in 6 European centers to validate the PedsQL GI in children with CF during 3 months. RESULTS In total, 248 children and their parents were included. Within-patient variability of PedsQL GI was low (24.11), and there was reasonable agreement between children and parents (ICC 0.681). Nine of 14 subscales were informative (no ceiling effect). The PedsQL GI and the median scores for 4 subscales were significantly lower in patients compared to healthy controls. Positive associations were found between PedsQL GI and age (OR = 1.044, p = 0.004) and between PedsQL GI and BMI z-score (OR = 1.127, p = 0.036). PedsQL GI correlated with most CFQ-R subscales (r 0.268 to 0.623) and with a Visual Analogue Scale (r = 0.20). CONCLUSIONS PedsQL GI is a valid and applicable instrument to assess GI QOL in children with CF. Future research efforts should examine the responsiveness of the CF PedsQL GI to change in the context of clinical interventions and trials.
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Affiliation(s)
- Mieke Boon
- Cystic Fibrosis Center, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
- * E-mail:
| | - Ine Claes
- Cystic Fibrosis Center, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | - Trudy Havermans
- Cystic Fibrosis Center, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | | | | | - Inês Asseiceira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - Anna Bulfamante
- Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Etna Masip
- Instituto de Investigación Sanitaria La Fe de Valencia, Spain
| | - Sandra Woodcock
- Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Sylvia Walet
- Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Celeste Barreto
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - Carla Colombo
- Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Paula Crespo
- Instituto de Investigación Sanitaria La Fe de Valencia, Spain
| | - Els Van der Wiel
- Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Jessie Hulst
- Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | | | - Rita Nobili
- Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Luisa Pereira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - Mar Ruperto
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Kris De Boeck
- Cystic Fibrosis Center, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
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