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Bar N, Abdelgani S, Lal S, Deutsch L. A look inside the gut as a clue to nutritional status. Curr Opin Clin Nutr Metab Care 2024; 27:443-450. [PMID: 38837038 DOI: 10.1097/mco.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW Malabsorption and malnutrition are common gastrointestinal manifestations clinicians face, requiring diagnostic workup for effective diagnosis and management of the underlying cause. This review discusses recent advances in diagnostic approaches to malabsorption and maldigestion of macronutrients - lipids, proteins, and carbohydrates. We highlight underrecognized causes, available testing modalities, and ongoing diagnostic unmet needs. RECENT FINDINGS Innovations in the diagnostic landscape are enhancing our understanding of malabsorption syndromes. Stool collection and handling is uncomfortable and commonly avoided. The objective quantification of stool lipids, bile acids, and gut enzymes is therefore underused in the diagnosis and management of common disorders such as exocrine pancreatic insufficiency, bile acid diarrhea, protein-losing enteropathy, and more. We review the recent advancements in spot quantification of stool fat and bile acid content, endoscopic imaging techniques such as endocytoscopy, confocal laser endomicroscopy, and optical coherence tomography and the future place in clinical practice. SUMMARY Malabsorption and maldigestion represent significant challenges in clinical nutrition and gastroenterology. Through the integration of advanced diagnostic techniques, clinicians will be better equipped to tailor therapy and monitor treatment response, ultimately improving patient health outcomes. This review underscores the critical role of innovative diagnostic tools in accurately detecting and effectively managing gastrointestinal disorders linked to nutritional status.
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Affiliation(s)
- Nir Bar
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Siham Abdelgani
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford
- Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Liat Deutsch
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Farhan S, Holtan SG. Graft-versus-host disease: teaching old drugs new tricks at less cost. Front Immunol 2023; 14:1225748. [PMID: 37600820 PMCID: PMC10435076 DOI: 10.3389/fimmu.2023.1225748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic stem cell transplantation (SCT). Currently, more patients can receive SCT. This is attributed to the use of reduced intensity regimens and the use of different GVHD prophylaxis that breaks the barrier of human leukocyte antigen, allowing an increase in the donor pool. Once an area with relatively few clinical trial options, there has been an increase in interest in GVHD prophylaxis and treatment, which has led to many US Food and Drug Administration (FDA) approvals. Although there is considerable excitement over novel therapies, many patients may not have access to them due to geographical or other resource constraints. In this review article, we summarize the latest evidence on how we can continue to repurpose drugs for GVHD prophylaxis and treatment. Drugs covered by our review include those that have been FDA approved for other uses for at least 15 years (since 2008); thus, they are likely to have generic equivalents available now or in the near future.
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Affiliation(s)
- Shatha Farhan
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, United States
| | - Shernan G. Holtan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, United States
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Limpert R, Pan P, Wang LS, Chen X. From support to therapy: rethinking the role of nutrition in acute graft-versus-host disease. Front Immunol 2023; 14:1192084. [PMID: 37359550 PMCID: PMC10285162 DOI: 10.3389/fimmu.2023.1192084] [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: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Allogeneic Hematopoietic stem cell transplantation (HSCT) offers a potential cure for patients with hematologic malignancies. Unfortunately, graft-versus-host disease (GVHD) remains a major obstacle to the greater success of this treatment. Despite intensive research efforts over the past several decades, GVHD is still a major cause of morbidity and mortality in patients receiving allogeneic HSCT. The genetic disparity between donor and recipient is the primary factor that dictates the extent of alloimmune response and the severity of acute GVHD (aGVHD). However, some nongenetic factors are also actively involved in GVHD pathogenesis. Thus, identifying host factors that can be readily modified to reduce GVHD risk is of important clinical significance. We are particularly interested in the potential role of nutrition, as a nongenetic factor, in the etiology and management of aGVHD. In this article, we summarize recent findings regarding how different routes of nutritional support and various dietary factors affect aGVHD. Since diet is one of the most important factors that shape gut microbiota, we also provide evidence for a potential link between certain nutrients and gut microbiota in recipients of allogeneic HSCT. We propose a shifting role of nutrition from support to therapy in GVHD by targeting gut microbiota.
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Pan P, Atkinson SN, Taylor B, Zhu H, Zhou D, Flejsierowicz P, Wang LS, Morse M, Liu C, Gunsolus IL, Chen X. Retinoic Acid Signaling Modulates Recipient Gut Barrier Integrity and Microbiota After Allogeneic Hematopoietic Stem Cell Transplantation in Mice. Front Immunol 2021; 12:749002. [PMID: 34759928 PMCID: PMC8573259 DOI: 10.3389/fimmu.2021.749002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Graft-versus-host disease (GVHD) remains a major complication after allogeneic hematopoietic stem cell transplantation (HSCT). An impaired intestinal epithelial barrier is an important component of GVHD pathogenesis. However, contributing host factors that modulate mucosal barrier integrity during GVHD are poorly defined. We hypothesized that vitamin A and retinoic acid (RA) exert positive impacts on maintaining intestinal barrier function after HSCT, thus preventing or dampening GVHD severity. Unexpectedly, we found that exogenous RA increased intestinal permeability of recipient mice after allogeneic HSCT. Serum bacterial endotoxin levels were significantly higher in GVHD mice fed a vitamin A-high (VAH) diet compared to those fed a vitamin A-normal (VAN) diet, indicating a more compromised intestinal barrier function. Furthermore, VAH mice showed more severe lung GVHD with increased donor T cell infiltration in this tissue and died significantly faster than VAN recipients. 16S rRNA sequencing of fecal samples revealed significant differences in the diversity and composition of gut microbiota between VAN and VAH transplant recipients. Collectively, we show that retinoic acid signaling may negatively impact intestinal barrier function during GVHD. Mild vitamin A supplementation is associated with increased lung GVHD and more profound gut dysbiosis. Micronutrients such as vitamin A could modulate complications of allogeneic HSCT, which may be mediated by shaping gut microbiota.
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Affiliation(s)
- Pan Pan
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Samantha N. Atkinson
- Center for Microbiome Research, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian Taylor
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Haojie Zhu
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Dian Zhou
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Philip Flejsierowicz
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Li-Shu Wang
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Morse
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Chen Liu
- Department of Pathology, Yale University School of Medicine, New Haven, CT, United States
| | - Ian L. Gunsolus
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Xiao Chen
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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Soto JR, Anthias C, Madrigal A, Snowden JA. Insights Into the Role of Vitamin D as a Biomarker in Stem Cell Transplantation. Front Immunol 2020; 11:966. [PMID: 32582151 PMCID: PMC7295104 DOI: 10.3389/fimmu.2020.00966] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 12/19/2022] Open
Abstract
Vitamin D was discovered 100 years ago and since then multiple studies have consistently proved its effect on bone health and mineral metabolism. Further research has also explored its so-called "non-classical" biological effects, encompassing immune regulation and control of cell proliferation and differentiation. Vitamin D downregulates pro-inflammatory immune cells and subsequently their cytokine production, while enhancing the anti-inflammatory subsets, thus mediating inflammation and fostering a more tolerogenic environment. Its biological action is exerted through the vitamin D receptor, a nuclear receptor that mediates gene transcription and is expressed in most cells from the innate and adaptive immunity. Owing to its immune-modulatory properties, its role in cancer pathophysiology, hematology disorders and stem cell transplantation has also been investigated. Vitamin D deficiency causes immune imbalance and cytokine dysregulation, contributing to some autoimmune diseases. In the hematopoietic stem cell transplant setting this could lead to complications such as acute and chronic graft-versus-host disease, ultimately impacting transplant outcomes. Other factors have also been linked to this, including specific polymorphisms of the vitamin D receptor in both stem cell donors and recipients. Nevertheless, studies thus far have shown conflicting results and the use of vitamin D or its receptor as biomarkers has not been validated yet, therefore there are no evidence-based consensus guidelines to guide clinicians in their day-to-day practice. To gain more insight in this topic, we have reviewed the existent literature and gathered the current evidence. This is an overview of the role of serum vitamin D and its receptor as biomarkers for clinical outcomes in patients undergoing hematopoietic stem cell transplantation. Further prospective studies with larger cohorts are warranted to validate the viability of using serum vitamin D, and its receptor, as biomarkers in potential stem cell donors and patients, to identify those at risk of post-transplant complications and enable early therapeutic interventions.
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Affiliation(s)
- Jose Ros Soto
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
| | - Chloe Anthias
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Alejandro Madrigal
- Anthony Nolan Research Institute, Royal Free Hospital and University College London, London, United Kingdom
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Flamann C, Peter K, Kreutz M, Bruns H. Regulation of the Immune Balance During Allogeneic Hematopoietic Stem Cell Transplantation by Vitamin D. Front Immunol 2019; 10:2586. [PMID: 31749811 PMCID: PMC6848223 DOI: 10.3389/fimmu.2019.02586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022] Open
Abstract
One of the most promising therapeutic approaches for numerous hematological malignancies represents the allogeneic hematopoietic stem cell transplantation (allo-HSCT). One major complication is the development of the life-threatening graft-vs.-host disease (GvHD) which limits beneficial effects of graft-vs.-leukemia (GvL) responses during allo-HSCT. Strengthening GvL effects without induction of severe GvHD is essential to decrease the relapse rate after allo-HSCT. An interesting player in this context is vitamin D3 since it has modulatory capacity in both preventing GvHD and boosting GvL responses. Current studies claim that vitamin D3 induces an immunosuppressive environment by dendritic cell (DC)-dependent generation of regulatory T cells (Tregs). Since vitamin D3 is known to support the antimicrobial defense by re-establishing the physical barrier as well as releasing defensins and antimicrobial peptides, it might also improve graft-vs.-infection (GvI) effects in patients. Beyond that, alloreactive T cells might be attenuated by vitamin D3-mediated inhibition of proliferation and activation. Despite the inhibitory effects of vitamin D3 on T cells, anti-tumor responses of GvL might be reinforced by vitamin D3-triggered phagocytic activity and antibody-based immunotherapy. Therefore, vitamin D3 treatment does not only lead to a shift from a pro-inflammatory toward a tolerogenic state but also promotes tumoricidal activity of immune cells. In this review we focus on vitamin D3 and its immunomodulatory effects by enhancing anti-tumor activity while alleviating harmful allogeneic responses in order to restore the immune balance.
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Affiliation(s)
- Cindy Flamann
- Department of Internal Medicine 5, Hematology/Oncology, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Katrin Peter
- Department of Internal Medicine III - Hematology and Internal Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Marina Kreutz
- Department of Internal Medicine III - Hematology and Internal Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Heiko Bruns
- Department of Internal Medicine 5, Hematology/Oncology, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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