Breath-Taking Perspectives and Preliminary Data toward Early Detection of Chronic Liver Diseases

Infection Diagnostics Enabled by Selective Adsorption of Breath-Based Biomarkers in Zr-Based Metal-Organic Frameworks

Exhaled breath contains trace levels of volatile organic compounds (VOCs) that can reveal information about metabolic processes or pathogens in the body. These molecules can be used for medical diagnosis, but capturing and accurately measuring them is a significant challenge in chemical separations. A highly selective nanoporous sorbent can be used to capture target molecules from a breath sample and preconcentrate them for use in a detector. In this work, we present a combined predictive modeling-experimental validation study in which five Zr-based metal-organic frameworks (MOFs) were identified and tested. These MOFs display good selectivity for a variety of VOCs known to be indicators of viral infections such as influenza and COVID-19. We first used molecular simulation to identify promising MOF candidates that were subsequently synthesized and tested for recovery of a variety of VOCs (toluene, propanal, butanone, octane, acetaldehyde) at concentrations of 20 ppm in humid nitrogen. We show that MOF-818, PCN-777, and UiO-66 have particularly good selectivity for the target molecules in the presence of humidity. These three MOFs each recover around 40-60% of the targets (with the exception of acetaldehyde) at up to 95% relative humidity. MOF-818 recovers 63% of butanone and 60% of toluene at 80% relative humidity. Recovery for acetaldehyde is lower across all MOFs at high humidity, but notably, MOF-808 recovers 90% of acetaldehyde at 60% humidity.

The potential of volatile organic compounds to diagnose primary sclerosing cholangitis

Background & Aims

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive inflammation and fibrosis of the bile ducts. PSC is a complex disease of largely unknown aetiology that is strongly associated with inflammatory bowel disease (IBD). Diagnosis, especially at an early stage, is difficult and to date there is no diagnostic biomarker. The present study aimed to assess the diagnostic potential of volatile organic compounds (VOCs) in exhaled breath to detect (early) PSC in an IBD population.

Methods

Breath samples were obtained from 16 patients with PSC alone, 47 with PSC and IBD, and 53 with IBD alone during outpatient clinic visits. Breath sampling was performed using the ReCIVA breath sampler and subsequently analysed by gas chromatography mass spectrometry. Random forest modelling was performed to find discriminatory VOCs and create a predictive model that was tested using an independent test set.

Results

The final model to discriminate patients with PSC, with or without IBD, from patients with IBD alone included twenty VOCs and achieved a sensitivity, specificity, and area under the receiver-operating curve on the test set of 77%, 83%, and 0.84 respectively. Three VOCs (isoprene, 2-octanone and undecane) together correlated significantly with the Amsterdam-Oxford score for PSC disease prognosis. A sensitivity analysis showed stable results across early-stage PSC, including in those with normal alkaline phosphatase levels, as well as further progressed PSC.

Conclusion

The present study demonstrates that exhaled breath can distinguish PSC cases from IBD and has potential as a non-invasive clinical breath test for (early) PSC.

Impact and implications

Primary sclerosing cholangitis is a complex chronic liver disease, which ultimately results in cirrhosis, liver failure, and death. Detection, especially in early disease stages, can be challenging, and therefore therapy typically starts when there is already some irreversible damage. The current study shows that metabolites in exhaled breath, so called volatile organic compounds, hold promise to non-invasively detect primary sclerosing cholangitis, including at early disease stages.

Progress and challenges of developing volatile metabolites from exhaled breath as a biomarker platform

BACKGROUND

The multitude of metabolites generated by physiological processes in the body can serve as valuable biomarkers for many clinical purposes. They can provide a window into relevant metabolic pathways for health and disease, as well as be candidate therapeutic targets. A subset of these metabolites generated in the human body are volatile, known as volatile organic compounds (VOCs), which can be detected in exhaled breath. These can diffuse from their point of origin throughout the body into the bloodstream and exchange into the air in the lungs. For this reason, breath VOC analysis has become a focus of biomedical research hoping to translate new useful biomarkers by taking advantage of the non-invasive nature of breath sampling, as well as the rapid rate of collection over short periods of time that can occur. Despite the promise of breath analysis as an additional platform for metabolomic analysis, no VOC breath biomarkers have successfully been implemented into a clinical setting as of the time of this review.

AIM OF REVIEW

This review aims to summarize the progress made to address the major methodological challenges, including standardization, that have historically limited the translation of breath VOC biomarkers into the clinic. We highlight what steps can be taken to improve these issues within new and ongoing breath research to promote the successful development of the VOCs in breath as a robust source of candidate biomarkers. We also highlight key recent papers across select fields, critically reviewing the progress made in the past few years to advance breath research.

KEY SCIENTIFIC CONCEPTS OF REVIEW

VOCs are a set of metabolites that can be sampled in exhaled breath to act as advantageous biomarkers in a variety of clinical contexts.

Breath biomarkers in Non-Carcinogenic diseases

The analysis of volatile organic compounds (VOCs) from human matrices like breath, perspiration, and urine has received increasing attention from academic and medical researchers worldwide. These biological-borne VOCs molecules have characteristics that can be directly related to physiologic and pathophysiologic metabolic processes. In this work, gathers a total of 292 analytes that have been identified as potential biomarkers for the diagnosis of various non-carcinogenic diseases. Herein we review the advances in VOCs with a focus on breath biomarkers and their potential role as minimally invasive tools to improve diagnosis prognosis and therapeutic monitoring.

Exogenous Volatile Organic Compound (EVOC®) Breath Testing Maximizes Classification Performance for Subjects with Cirrhosis and Reveals Signs of Portal Hypertension

Background: Cirrhosis detection in primary care relies on low-performing biomarkers. Consequently, up to 75% of subjects with cirrhosis receive their first diagnosis with decompensation when causal treatments are less effective at preserving liver function. We investigated an unprecedented approach to cirrhosis detection based on dynamic breath testing. Methods: We enrolled 29 subjects with cirrhosis (Child-Pugh A and B), and 29 controls. All subjects fasted overnight. Breath samples were taken using Breath Biopsy® before and at different time points after the administration of 100 mg limonene. Absolute limonene breath levels were measured using gas chromatography-mass spectrometry. Results: All subjects showed a >100-fold limonene spike in breath after administration compared to baseline. Limonene breath kinetics showed first-order decay in >90% of the participants, with higher bioavailability in the cirrhosis group. At the Youden index, baseline limonene levels showed classification performance with an area under the roc curve (AUROC) of 0.83 ± 0.012, sensitivity of 0.66 ± 0.09, and specificity of 0.83 ± 0.07. The best performing timepoint post-administration was 60 min, with an AUROC of 0.91, sensitivity of 0.83 ± 0.07, and specificity of 0.9 ± 0.06. In the cirrhosis group, limonene bioavailability showed a correlation with MELD and fibrosis indicators, and was associated with signs of portal hypertension. Conclusions: Dynamic limonene breath testing enhances diagnostic performance for cirrhosis compared to static testing. The correlation with disease severity suggests potential for monitoring therapeutic interventions. Given the non-invasive nature of breath collection, a dynamic limonene breath test could be implemented in primary care.

Dynamic Breath Limonene Sensing at High Selectivity

Liver diseases (e.g., cirrhosis, cancer) cause more than two million deaths per year worldwide. This is partly attributed to late diagnosis and insufficient screening techniques. A promising biomarker for noninvasive and inexpensive liver disease screening is breath limonene that can indicate a deficiency of the cytochrome P450 liver enzymes. Here, we introduce a compact and low-cost detector for dynamic and selective breath limonene sensing. It comprises a chemoresistive sensor based on Si/WO₃ nanoparticles pre-screened by a packed bed Tenax separation column at room temperature. We demonstrate selective limonene detection down to 20 parts per billion over up to three orders of magnitude higher concentrated acetone, ethanol, hydrogen, methanol, and 2-propanol in gas mixtures, as well as robustness to 10-90% relative humidity. Most importantly, this detector recognizes the individual breath limonene dynamics of four healthy volunteers following the ingestion (swallowing or chewing) of a limonene capsule. Limonene release and subsequent metabolization are monitored from breath measurements in real time and in excellent agreement (R² = 0.98) with high-resolution proton transfer reaction mass spectrometry. This study demonstrates the potential of the detector as a simple-to-use and noninvasive device for the routine monitoring of limonene levels in exhaled breath to facilitate early diagnosis of liver dysfunction.

Breath Biopsy® to Identify Exhaled Volatile Organic Compounds Biomarkers for Liver Cirrhosis Detection

Background and Aims

The prevalence of chronic liver disease in adults exceeds 30% in some countries and there is significant interest in developing tests and treatments to help control disease progression and reduce healthcare burden. Breath is a rich sampling matrix that offers non-invasive solutions suitable for early-stage detection and disease monitoring. Having previously investigated targeted analysis of a single biomarker, here we investigated a multiparametric approach to breath testing that would provide more robust and reliable results for clinical use.

Methods

To identify candidate biomarkers we compared 46 breath samples from cirrhosis patients and 42 from controls. Collection and analysis used Breath Biopsy OMNI™, maximizing signal and contrast to background to provide high confidence biomarker detection based upon gas chromatography mass spectrometry (GC-MS). Blank samples were also analyzed to provide detailed information on background volatile organic compounds (VOCs) levels.

Results

A set of 29 breath VOCs differed significantly between cirrhosis and controls. A classification model based on these VOCs had an area under the curve (AUC) of 0.95±0.04 in cross-validated test sets. The seven best performing VOCs were sufficient to maximize classification performance. A subset of 11 VOCs was correlated with blood metrics of liver function (bilirubin, albumin, prothrombin time) and separated patients by cirrhosis severity using principal component analysis.

Conclusions

A set of seven VOCs consisting of previously reported and novel candidates show promise as a panel for liver disease detection and monitoring, showing correlation to disease severity and serum biomarkers at late stage.

A Comparison of 13C-Methacetin and 13C-Octanoate Breath Test for the Evaluation of Nonalcoholic Steatohepatitis

Background: While non-alcoholic fatty liver disease (NAFLD) is a wide-spread liver disease, only some patients progress towards steatohepatitis and cirrhosis. Aim: We comparatively analyzed the methacetin breath test (MBT) for the microsomal function of the liver and the octanoate breath test (OBT) for mitochondrial activity, in detecting patients with steatohepatitis and estimating fibrosis. Methods: 81 patients with histologically proven NAFLD (SAF score) were evaluated. The parameters used for both breath tests were the dose/h and the cumulative dose recovery at multiple timepoints. The statistical association between histological diagnosis and breath test results used Independent Samples t Test. The accuracy for diagnosis was evaluated using area under the receiver operator characteristic (AUROC) and the sensitivity and specificity were assessed using the Youden J method. Results: Both MBT and OBT were able to differentiate patients with simple steatosis from NASH and to stratify patients with significant fibrosis and cirrhosis (p-values < 0.001 for most analyzed timepoints). The best parameter for NASH diagnosis was OBT dose at 30 min. In the case of significant fibrosis, the most accurate test was MBT cumulative dose at 30 min. Conclusions: Both MBR and OBT tests are potentially useful tools in assessing patients with NAFLD.

Highly Selective Ethyl Mercaptan Sensing Using a MoSe2/SnO2 Composite at Room Temperature

Volatile organic sulfur compounds (VOSCs) serve not only as biomarkers for dental diseases such as halitosis but also as a tracer for monitoring air quality. Room-temperature selective detection and superior sensitivity against VOSCs at a sub-ppm level has remained a challenging task. Here, we propose a heterostructure-based design using a MoSe2/SnO2 composite for achieving sensitive and selective detection of ethyl mercaptan at room temperature. The composite was synthesized via a facile two-step method. A composite-based device has shown detection down to 1 ppm of ethyl mercaptan over a wider range of relative humidity (40-90%). Notably, the composite has shown adsorption selectivity toward ethyl mercaptan compared to hydrogen sulfide and other reducing or oxidizing analytes. Moreover, a density functional theory (DFT) study has been performed to understand the adsorption selectivity, charge transfer, and modification in the electronic properties after molecule adsorption on the host surface. Simulations predicted the lowest negative adsorption energy for ethyl mercaptan, implying the chemisorption (-142.029 kJ mol-1) process of adsorption. The device thus-obtained has also shown a stable response even at an extreme relative humidity level of 90%. The obtained results and superior signal-to-noise ratio indicate that a MoSe2/SnO2-based sensor may be a promising candidate for highly selective and sensitive detection of ethyl mercaptan even below 1 ppm.

Reproducibility and reporting, the routes to progress in breath research - highlights from the Breath Biopsy Conference 2021

With the continued presence of COVID-19 worldwide, it has been a challenge for the breath research community to progress with clinical studies and travel restrictions have also limited the opportunities to meet up, share ideas and celebrate the latest advances. The Breath Biopsy Conference 2021 provided a much-needed opportunityoffered the chance to catch up with the latest breath research and to share the researchprogress that researchers in the community have been able to progress make in these difficult times. Limited opportunities for clinical research have provided opportunitiesled many in the field to look more closely at different methods for breath collection and have contributed to the growing calls for consistent standards in how results are reported, shared and even how breath studies themselves are carried out. As such, standardization was a key theme for this year's event and featured prominently in the keynotes, discussions and throughout many of the presentation sessions. With over 900 registrants, almost 400 live attendees and 16 speakers, the Breath Biopsy Conference continues to bring together breath research leaders from around the world. This article provides an overview of the highlights from this event.

Breathing new life into clinical testing and diagnostics: perspectives on volatile biomarkers from breath

Human breath offers several benefits for diagnostic applications, including simple, noninvasive collection. Breath is a rich source of clinically-relevant biological information; this includes a volatile fraction, where greater than 1,000 volatile organic compounds (VOCs) have been described so far, and breath aerosols that carry nucleic acids, proteins, signaling molecules, and pathogens. Many of these factors, especially VOCs, are delivered to the lung by the systemic circulation, and diffusion of candidate biomarkers from blood into breath allows systematic profiling of organismal health. Biomarkers on breath offer the capability to advance early detection and precision medicine in areas of global clinical need. Breath tests are noninvasive and can be performed at home or in a primary care setting, which makes them well-suited for the kind of public screening program that could dramatically improve the early detection of conditions such as lung cancer. Since measurements of VOCs on breath largely report on metabolic changes, this too aids in the early detection of a broader range of illnesses and can be used to detect metabolic shifts that could be targeted through precision medicine. Furthermore, the ability to perform frequent sampling has envisioned applications in monitoring treatment responses. Breath has been investigated in respiratory, liver, gut, and neurological diseases and in contexts as diverse as infectious diseases and cancer. Preclinical research studies using breath have been ongoing for some time, yet only a few breath-based diagnostics tests are currently available and in widespread clinical use. Most recently, tests assessing the gut microbiome using hydrogen and methane on breath, in addition to tests using urea to detect Helicobacter pylori infections have been released, yet there are many more applications of breath tests still to be realized. Here, we discuss the strengths of breath as a clinical sampling matrix and the technical challenges to be addressed in developing it for clinical use. Historically, a lack of standardized methodologies has delayed the discovery and validation of biomarker candidates, resulting in a proliferation of early-stage pilot studies. We will explore how advancements in breath collection and analysis are in the process of driving renewed progress in the field, particularly in the context of gastrointestinal and chronic liver disease. Finally, we will provide a forward-looking outlook for developing the next generation of clinically relevant breath tests and how they may emerge into clinical practice.