High-sensitivity C-reactive protein in paediatric inflammatory bowel disease

Characterization of idiopathic chronic diarrhea and associated intestinal inflammation and preliminary observations of effects of vagal nerve stimulation in a non-human primate

BACKGROUND

Diarrhea is commonly associated with irritable bowel syndrome, inflammatory bowel disease, microscopic colitis, and other gastrointestinal dysfunctions. Spontaneously occurring idiopathic chronic diarrhea is frequent in rhesus macaques, but has not been used as a model for the investigation of diarrhea or its treatment. We characterized this condition and present preliminary data demonstrating that left vagal nerve stimulation provides relief.

METHODS

Stool consistency scores were followed for up to 12 years. Inflammation was assessed by plasma C-reactive protein, [18F]fluorodeoxyglucose (FDG) uptake, measured by positron emission tomography (PET), multiplex T cell localization, endoscopy and histology. The vagus was stimulated for 9 weeks in conscious macaques, using fully implanted electrodes, under wireless control.

KEY RESULTS

Macaques exhibited recurrent periods of diarrhea for up to 12 years, and signs of inflammation: elevated plasma C-reactive protein, increased bowel FDG uptake and increased mucosal T helper1 T-cells. The colon and distal ileum were endoscopically normal, and histology revealed mild colonic inflammation. Application of vagal nerve stimulation to conscious macaques (10 Hz, 30 s every 3 h; 24 h a day for 9 weeks) significantly reduced severity of diarrhea and also reduced inflammation, as measured by FDG uptake and C-reactive protein.

CONCLUSIONS AND INFERENCES

These macaques exhibit spontaneously occurring diarrhea with intestinal inflammation that can be reduced by VNS. The data demonstrate the utility of this naturally occurring primate model to study the physiology and treatments for chronic diarrhea and the neural control circuits influencing diarrhea and inflammation that are not accessible in human subjects.

Platelet/Albumin ratio and plateletcrit levels are potential new biomarkers for assessing endoscopic inflammatory bowel disease severity

BACKGROUND

Endoscopy is currently recognized as the gold standard for assessing inflammatory bowel disease (IBD) severity. However, because the procedure is costly and invasive, endoscopy is not suitable for frequently monitoring intestinal inflammation. In this study, our aim was to identify noninvasive, low cost, and convenient biomarkers for identifying endoscopic IBD activity.

METHODS

In total, 246 patients with IBD (131 with Ulcerative colitis (UC) and 115 with Crohn's disease (CD)) and 369 healthy controls were recruited for this retrospective study. IBD activity was evaluated using endoscopic and clinical examinations. The potential of several inflammatory biomarkers, including platelets (PLT), plateletcrit (PCT), albumin (ALB), highly sensitive C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), and platelet-to-albumin ratio (PLT/ALB) to assess endoscopic IBD activity was evaluated using receiver operating characteristic (ROC) analyses.

RESULTS

PLT/ALB ratio, PLT, ALB, and hs-CRP levels were correlated with Mayo scores in UC patients, while PCT, PLT, fibrinogen (FIB), PLT/ALB ratio, hs-CRP, and ESR levels were correlated with Simple Endoscopic Scores for CD (SES-CD) in CD patients. ROC analyses showed that the area under the curve (AUC) value for the PLT/ALB ratio (0.705) was greater than hs-CRP (0.607) and ESR (0.552) values in UC patients. The AUC value for PCT (0.779) was greater than hs-CRP (0.698) and ESR (0.746) values in CD patients.

CONCLUSION

PLT/ALB ratio and PCT biomarkers were the most appropriate of all tested inflammatory biomarkers for assessing endoscopic IBD activity in UC and CD patients, respectively.

Evaluation of plasma soluble urokinase plasminogen activator receptor (SuPAR) levels in ulcerative colitis

BACKGROUND AND STUDY AIM

Soluble urokinase plasminogen activator receptor (SuPAR), a soluble form of the urokinase-type plasminogen activator receptor, is a biomarker produced by macrophages, monocytes, neutrophils, active T cells, endothelial cells, and circulating tumor cells. SuPAR is a novel biomarker showing altered inflammation in many inflammatory diseases. This study aims to investigate the SuPAR level in ulcerative colitis (UC) patients, and to evaluate the SuPAR level in active, and remission patients.

PATIENTS AND METHODS

Patient and healthy control SuPAR levels were analyzed by immunoassay method. SuPAR levels between UC patients and control group were compared. The difference between SuPAR levels in patients with active UC and UC in remission was analyzed. The relationship between C-reactive protein level, Total Mayo score, Mayo Endoscopic score used to predict disease activity, and amount of SuPAR were evaluated.

RESULTS

SuPAR levels were determined in the UC patient group (2170,3 ± 121,0 pg/ml), and healthy controls (2130,7 ± 164,8 pg/ml) (p = 0. 805). Median SuPAR levels were determined in moderate UC (2479 pg/ml), mild UC (1944 pg/ml), and patients in remission (1774 pg/ml) (p = 0,207). There were no significant relationships between SuPAR levels and CRP levels, Total Mayo score, disease duration in the UC group (r = 0.177, r = 0.267, and r = 0,007; respectively p > 0.05). A slightly positive correlation was found between Mayo Endoscopic Score and SuPAR level (r = 0.303; p = 0.031).

CONCLUSION

SuPAR is of limited value in the diagnosis of ulcerative colitis and in the assessment of disease activation.

Clinical and biochemical status of patients with ulcerative collitis

Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), are chronic inflammatory conditions of the gastrointestinal tract characterized by a relapsing and remitting course. Aim - to analyze clinical data and the most significant hematological and biochemical blood parameters used for diagnosis in patients with ulcerative colitis. Materials and methods. Between 2020 and 2021 examined 50 patients with the diagnosis "Ulcerative colitis" living in the Samara region. The diagnosis of ulcerative colitis was confirmed by a combination of clinical, radiological, endoscopic, and histopathological criteria generally accepted for inflammatory bowel diseases. A hematological blood test was performed on an automatic hematological analyzer Sysmex KX-21N, Japan, and a biochemical blood test was performed on an automatic biochemical analyzer Hitachi 902, Japan. Results. In the biochemical analysis of blood, an increase in the content of C-reactive protein in the blood is expected in 64% of patients. In 40% of patients, the concentration of total protein and electrolytes decreases. An increase in glucose levels was revealed in 44% of patients, in 10% of cases, a decrease in creatinine concentration, an increase in the activity of ALAT and ASAT was noted in 6 and 4% of cases, respectively. Reduced urea levels are noted in 6% of patients. Conclusion. As a result of the study, the data necessary for the diagnosis and monitoring of the effectiveness of the treatment of ulcerative colitis were obtained.

Doping of MXenes enhances the electrochemical response of peptide-imprinted conductive polymers for the recognition of C-Reactive protein

The level of C-reactive protein (CRP) in serum is frequently used to evaluate risk of coronary heart disease, and its concentration is related to cardiovascular disease, fibrosis and inflammation, cancer, and viral infections. In this work, three novel peptides, never previously used as imprinted templates, were selected, synthesized, and employed for epitope imprinting. Various imprinting concentrations of the template and various ratios of aniline (AN) to m-aminobenzenesulfonic acid (MSAN) were used in electropolymerization to form molecularly imprinted polymers (MIPs). The imprinting template and functional monomer concentrations were optimized to maximize the electrochemical response to target peptides. The surface morphologies of peptide- and non-imprinting poly(AN-co-MSAN) were observed using a scanning electron microscope (SEM) and an atomic force microscope (AFM). Moreover, the effect of doping of MIPs with a very small percentage of an MXene (e.g. Ti₂C at 0.1 wt% in the preparation solution) on the electrochemical response was also studied. Ti₂C doping dramatically increased sensing range from 0.1 to 100 fg/mL to 10000 fg/mL, and electrochemical responses were amplified by a factor of approximately 1.3 within the sensing range. Finally, commercially available serum was diluted and then measured using the MXene-doped PIP-coated electrodes to estimate the accuracy compared with ELISA results.

A Cross-Sectional Study on Malnutrition in Inflammatory Bowel Disease: Is There a Difference Based on Pediatric or Adult Age Grouping?

BACKGROUND

Malnutrition, commonly observed in inflammatory bowel disease (IBD), is associated with increased morbidity and mortality and is attributed to multiple causes. The added energy costs of growth in the child and adolescent with IBD are an additional risk factor.

METHODS

The aim of the study was to perform a cross-sectional comparison of nutritional parameters in IBD between pediatric and adult cases.

RESULTS

We found that prevalence of undernutrition (low body mass index) and hypoalbuminemia was not different in pediatric, compared with adult patients. Anemia and iron deficiency were more often observed in pediatric subjects, compared with adults (59.1% vs 36.9%, respectively, P < 0.0001; and 37.9% vs 25.3%, P < 0.002). Vitamin B12 deficiency was significantly less common in the pediatric than in the adult group (5.4% vs 19.4%, P < 0.0001). Elevated C-reactive protein was more frequent in pediatric compared with adult cases (49.8% vs 38.4%, P < 0.01).

CONCLUSIONS

Patients with active Crohn's disease were more likely to be undernourished in both pediatric and adult populations. In both groups, predicators of undernutrition included low albumin levels (odds ratio [OR], 2.53; P < 0.006) and active disease (OR, 1.99; P < 0.03). Our results call for close surveillance of nutritional status for IBD patients, regardless of age.

Update on C-reactive protein and fecal calprotectin: are they accurate measures of disease activity in Crohn's disease?

'Treat-to-target' paradigms in Crohn's disease (CD) directed at suppressing intestinal inflammation require accurate and reliable measures of disease activity. Although endoscopy has traditionally been considered a gold standard, cost, complexity, resource limitations, and invasiveness are important limitations. Hence, substantial interest exists for non-invasive serum and fecal biomarkers, namely C-reactive protein (CRP) and fecal calprotectin (FC), in the diagnosis, monitoring, and treatment of CD. Areas covered: We review the evidence for using serum CRP and FC in distinguishing patients with CD from those with irritable bowel syndrome, categorizing disease activity among patients with an established diagnosis of CD, predicting the likelihood of treatment response, identifying asymptomatic patients in medically or surgically induced remission who are at risk for disease relapse, and as treatment targets. Expert commentary: Accurate interpretation of CRP and FC is dependent on several factors including the clinical context, the performance characteristics of the assay, the specified test cut-offs, and the pre-test probability of disease. Emerging evidence indicates that CRP and FC are valuable adjuncts for the management of CD in specific circumstances described in this review.

What is the role of C-reactive protein and fecal calprotectin in evaluating Crohn's disease activity?

Historically, the evaluation of patients with Crohn's disease (CD) has centered on use of subjective symptom-based assessment. However, patients with CD experience a broad spectrum of non-specific symptoms that may not directly correlate with objective measures of inflammation. Endoscopy has been the gold standard for evaluating the burden and severity of mucosal disease. However, use of ileocolonoscopy for disease monitoring in long-term follow-up is limited by considerations of cost, resource utilization, and invasiveness. As treatment goals in CD have shifted towards 'treat-to-target' paradigms that emphasize tight control of inflammation, it has become increasingly evident that sensitive, accurate, and reliable measures of disease activity are required. The use of non-invasive serum and fecal biomarkers such as C-reactive protein (CRP) and fecal calprotectin (FC) has been evaluated in patients with CD for categorizing disease activity, predicting treatment response, identifying patients at risk for disease relapse, and as a potential therapeutic target. In this review, we summarize the interpretation of CRP and FC in patients with CD within specific clinical contexts and according to assay performance characteristics.

Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND

The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points.

METHODS

These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate.

RESULTS

These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines.

CONCLUSIONS

These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.

In vitro enteroid-derived three-dimensional tissue model of human small intestinal epithelium with innate immune responses

There is a need for functional in vitro 3D human intestine systems that can bridge the gap between conventional cell culture studies and human trials. The successful engineering in vitro of human intestinal tissues relies on the use of the appropriate cell sources, biomimetic scaffolds, and 3D culture conditions to support vital organ functions. We previously established a compartmentalized scaffold consisting of a hollow space within a porous bulk matrix, in which a functional and physiologically relevant intestinal epithelium system was generated using intestinal cell lines. In this study, we adopt the 3D scaffold system for the cultivation of stem cell-derived human small intestinal enteriods (HIEs) to engineer an in vitro 3D model of a nonstransformed human small intestinal epithelium. Characterization of tissue properties revealed a mature HIE-derived epithelium displaying four major terminally differentiated epithelial cell types (enterocytes, Goblet cells, Paneth cells, enteroendocrine cells), with tight junction formation, microvilli polarization, digestive enzyme secretion, and low oxygen tension in the lumen. Moreover, the tissue model demonstrates significant antibacterial responses to E. coli infection, as evidenced by the significant upregulation of genes involved in the innate immune response. Importantly, many of these genes are activated in human patients with inflammatory bowel disease (IBD), implicating the potential application of the 3D stem-cell derived epithelium for the in vitro study of host-microbe-pathogen interplay and IBD pathogenesis.

Correlation of Erythrocyte Sedimentation Rate and C-Reactive Protein With Pediatric Inflammatory Bowel Disease Activity

We aimed to examine correlation of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) with diagnosis of inflammatory bowel disease and with clinical, endoscopic, histological, and radiographic disease activity during follow-up. We reviewed charts of 135 children with inflammatory bowel disease and correlated their ESR and CRP values with disease activity in various encounters during 5 years. Normal ESR and CRP values were observed in up to 28% of children with Crohn disease and 42% of children with ulcerative colitis at diagnosis, respectively. Correlation of ESR and CRP with Crohn disease clinical, endoscopic, and histologic activity during follow-up depended on their value at diagnosis and mode of analysis (continuous or dichotomous). Both markers were not useful in predicting clinical, endoscopic, or histologic ulcerative colitis disease activity and radiographic small bowel Crohn disease during follow-up.

Establishment of a rat model of ulcerative colitis with abnormal sapra syndrome of traditional Uyghur medicine and detection of changes in inflammation related factors in colon tissue of this model

AIM

To develop a rat model of ulcerative colitis (UC) with abnormal sapra syndrome and detect the changes in inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) hnRNA and mRNA expression in colon tissues of this model.

METHODS

Based on a rat model of abnormal sapra syndrome, trinitrobenzene sulfonic acid/ethanol was used to induce UC in rats with abnormal sapra syndrome. Rats were randomly divided into two groups: normal group and UC with abnormal sapra syndrome model group. Quantitative RT-PCR was used to detect the differences in iNOS and eNOS hnRNA and mRNA expression in colon tissues of rats in the two groups.

RESULTS

UC with abnormal sapra syndrome was successfully induced as evidenced by the presence of anticipated signs, symptoms and colonic mucosa damage. Compared with the normal group, the expression of iNOS hnRNA in colon tissue was significantly upregulated in the model group (P < 0.05), but the expression of eNOS hnRNA in colon tissue showed no statistical difference between the two groups (P > 0.05). The expression of iNOS and eNOS mRNA was significantly upregulated in the model group compared with the normal group (P < 0.05).

CONCLUSION

The inflammatory factors iNOS and eNOS are involved in the development of UC in rats with abnormal sapra syndrome, and changes in inflammation related factors are mediated by a post-transcriptional regulatory mechanism.

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.

Baseline Characteristics and Disease Phenotype in Inflammatory Bowel Disease

OBJECTIVES

Predicting short-term relapses and long-term prognosis is of utmost importance in paediatric inflammatory bowel disease (IBD). Our aim was to investigate the short-term disease outcome and medication during the first year in a paediatric incident cohort from Hungary. In addition, association laboratory markers and disease activity indices with short-term disease outcome and medication were analysed.

METHODS

From January 1, 2008 to December 31, 2010, demographic data and clinical characteristics of newly diagnosed paediatric patients with IBD < 18 years of age were prospectively recorded.

RESULTS

A total of 420 patients were identified (Crohn disease [CD] 266 and ulcerative colitis [UC] 124). Initially, 48% (124/256) of the patients with CD had moderate-to-severe disease (Pediatric Crohn's Disease Activity Index [PCDAI] > 31), and this rate decreased to 2.1% at 1-year follow-up. Proportion of patients with UC with moderate-to-severe disease (Pediatric Ulcerative Colitis Activity Index > 35) at diagnosis declined from 57.5% (69/120) to 6.8% at 1-year follow-up. Terminal ileal involvement correlated with higher initial C-reactive protein (CRP) (P = 0.021) and initial PCDAI (P = 0.026). In UC, elevated CRP (P = 0.002) was associated with disease extension. CRP and PCDAI at diagnosis were associated with the need for immunomodulators at 1 year in children with CD. Initial CRP was also associated with the need for immunomodulators in patients with UC at 1-year follow-up.

CONCLUSIONS

At diagnosis, half of the patients with IBD had moderate-to-severe disease, and this rate decreased to <10% after 1 year. Initial CRP and PCDAI were related to the need for aggressive therapy in CD.

Fecal Lactoferrin: Reliable Biomarker for Intestinal Inflammation in Pediatric IBD

Background. Optimal management of pediatric patients with inflammatory bowel disease (IBD) requires early diagnosis. Aim of the study is to compare fecal lactoferrin (FL) as biomarker of intestinal inflammation to CRP in pediatric patients with new-onset IBD. Methods. FL was measured by ELISA in stool specimens collected prior to endoscopy for IBD (IBD-SCAN; TechLab, Blacksburg; normal < 7.3 µg/g feces). CRP was detected in serum (normal < 5 mg/L). Three patient groups were determined: n = 21 (mean age 13.2) with Crohn's disease (CD), n = 15 (mean age 10.9) with ulcerative colitis (UC), and n = 20 (mean age 11.9) in whom IBD was ruled out. In CD patients the endoscopic severity score SES-CD was correlated with the FL levels. Results. (Mean ± SEM). CRP levels were 27.18 ± 4.2 for CD-cases, 20.8 ± 9.5 for UC, and 0.24 ± 0.06 for non-IBD patients. FL levels were 313.6 ± 46.4 in CD, 370.7 ± 46.9 in UC, and 1.3 ± 0.5 in non-IBD patients. Sensitivity of CRP to detect IBD was 75% with specificity of 100%, positive predictive value of 100%, and negative predictive value of 69%. Sensitivity of FL was 100% with specificity of 95%, positive predictive value of 97.3%, and negative predictive value of 100%. In CD, FL levels correlated positively (R² = 0.42) with disease severity as judged by the SES-CD. Conclusions. Elevated FL corresponds to intestinal inflammation, even in patients with normal CRP. With high probability, normal FL excludes intestinal inflammation.

[Evaluation of the concordance between biological markers and clinical activity in inflammatory bowel disease]

BACKGROUND AND OBJECTIVES

Endoscopy is the gold standard to assess disease severity in inflammatory bowel disease, although it is an invasive procedure. Clinical activity and biological markers have been routinely used to determine disease activity in a non-invasive manner. The aim of this study was to determine concordance between common biological markers (C reactive protein, orosomucoid, erythrocyte sedimentation rate, fibrinogen, platelets, leukocytes, neutrophils and haemoglobin) and clinical activity in inflammatory bowel disease.

PATIENTS AND METHOD

Consecutive patients with inflammatory bowel disease were included. Clinical activity was evaluated according to the Harvey-Bradshaw index in Crohn's disease and to the partial Mayo score in ulcerative colitis. Serum concentrations of the different biomarkers were analysed. Concordance between clinical activity and elevation of the serological biomarkers was determined using the kappa statistic.

RESULTS

In total, 350 patients were included (median age 46 years, Crohn's disease 59%). Eleven percent of patients had clinical activity. Crohn's disease patients had mild clinical activity in 44% of cases, moderate disease in 44% and only 12% of patients had severe clinical activity. In ulcerative colitis, patients had mild, moderate and severe clinical activity in 50, 42 and 8% of cases, respectively. None of the biomarkers included had an acceptable concordance with clinical activity (kappa statistic ≤ 0.30).

CONCLUSIONS

Concordance between serological biomarkers and clinical activity in inflammatory bowel disease is remarkably low.

Biomarkers of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic disease mostly involved with intestine with unknown etiology. Diagnosis, evaluation of severity, and prognosis are still present as challenges for physicians. An ideal biomarker with the characters such as simple, easy to perform, noninvasive or microinvasive, cheap, rapid, and reproducible is helpful for patients and clinicians. Currently biomarkers applied in clinic include CRP, ESR, pANCA, ASCA, and fecal calprotectin. However, they are far from ideal. Lots of studies are focused on seeking for ideal biomarker for IBD. Herein, the paper reviewed recent researches on biomarkers of IBD to get advances of biomarkers in inflammatory bowel disease.

C-reactive protein in Crohn's disease: how informative is it?

C-reactive protein (CRP) is an important acute-phase marker, produced mainly in the liver. Its production by mesenteric adipocytes has been recently stressed in Crohn's disease (CD). There are many factors affecting CRP levels, both environmental and genetics. The short-life of this biomarker makes it of pertinent use in the assessment of inflammation. There are inconsistent results concerning the association of clinical activity indices, mucosal healing, histological activity and CRP. This review summarizes the role of CRP in CD, namely its importance in the differential diagnosis of CD; its relationship with clinical activity indices, other markers of inflammation and endoscopic and radiological cross sectional imaging; prediction of response to anti-TNF treatment and prediction of outcome.

The long-term outcome of anti-tumor necrosis factor-α therapy related to fecal calprotectin values during induction therapy in pediatric inflammatory bowel disease

OBJECTIVE

Monitoring fecal calprotectin (FC) could assist in the assessment of the therapeutic response of inflammatory bowel disease (IBD). There are few studies on long-term prognosis related to the FC value response to infliximab induction therapy, thus providing the aim of this study on pediatric patients.

METHODS

FC levels were measured during the induction and maintenance phase of infliximab therapy (5 mg/kg) in 76 pediatric IBD patients introduced to maintenance therapy. The long-term outcomes and clinical disease activity were retrospectively related to the FC response to induction.

RESULTS

The median pretreatment FC level of 817 μg/g stool (range <5-24,000) declined to 372 μg/g (range 5-2430) by week 6, with a low level (<100 μg/g) in 35% (pooled comparable data for ulcerative colitis and Crohn's). Clinical activity indices showed remission in 59% (pediatric Crohn's disease activity index: <10, n = 33; pediatric ulcerative colitis activity index: <10 n = 12). In 49 patients (64%), infliximab therapy was discontinued (inadequate effect/surgery = 27; remission/bridging to azathioprine = 12; adverse effect = 6; antibodies to infliximab n = 4) during the study period with a median follow up of 1.1 years (interquartile range [IQR]: 0.71-4.4). Those who discontinued the therapy within the first year due to an inadequate effect had higher median FC level during induction than the other patients (median 633 µg/g, IQR: 197-819 and median 219 µg/g, IQR: 71-508, respectively; p < 0.025) and were less frequently in clinical remission at week 6 (p < 0.01).

CONCLUSIONS

The long-term prognosis of infliximab therapy is related to the response to induction therapy in pediatric IBD and reflected in low FC values between weeks 2 and 6 and clinical remission.

Optimising monitoring in the management of Crohn's disease: a physician's perspective

Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.

Low mannose-binding lectin (MBL) is associated with paediatric inflammatory bowel diseases and ileal involvement in patients with Crohn disease

BACKGROUND

Mannose-binding lectin (MBL) is a pattern-recognition molecule of the innate immune system and may be involved in the pathogenesis of inflammatory bowel disease (IBD). Our aim was to assess the prevalence of MBL deficiency in a cohort of patients with paediatric-onset IBD and study whether it is associated with the clinical manifestations, serum antibody formation, or genetic factors.

METHODS

This prospective study included 159 paediatric patients (mean age: 14.0 years) with IBD [107 patients with Crohn disease (CD) and 52 patients with ulcerative colitis (UC)]. Furthermore, 95 controls were investigated. Serum samples were determined for MBL by enzyme-linked immunosorbent assay (ELISA) and for serologic markers [autoantibodies against Saccharomyces cerevisiae (ASCA) and perinuclear components of neutrophils (pANCA)] by indirect immunofluorescent assay. NOD2/CARD15 variants were tested by polymerase chain reaction/restriction fragment length polymorphism.

RESULTS

The MBL serum concentration was significantly lower in IBD patients(both with CD and UC) compared to controls (IBD, p=0.007, CD, p=0.04, UC p=0.004). Prevalence of low MBL level (<500 ng/mL) was significantly higher in both CD and UC groups compared to controls (p=0.002 and p=0.006). Furthermore, low MBL level was associated with isolated ileal involvement (p=0.01) and MBL deficiency (<100 ng/mL) with male gender (p=0.004) in patients with CD. We failed to confirm any correlation between MBL deficiency and serum autoantibodies or NOD2/CARD15 variants.

CONCLUSIONS

Our results suggest that low MBL associated with paediatric-onset IBD and ileal CD may be considered an additional marker of the IBD pathogenesis.

Soluble urokinase plasminogen activator receptor suPAR as a marker for inflammation in pediatric inflammatory bowel disease

OBJECTIVE

In inflammatory bowel disease (IBD), more means to monitor early therapeutic response are needed. In pediatric IBD, blood inflammatory markers erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) may be low in 10 to 20% of patients with severe disease. Recently, soluble urokinase plasminogen activator receptor (suPAR) was described as a potential blood inflammatory marker in adult IBD.

METHODS

We tested the performance of suPAR by the start of therapy with glucocorticoids (n = 19) or TNF-α-antagonist (n = 16) in pediatric IBD (Crohn's disease n = 19, ulcerative colitis (UC) n = 16).

RESULTS

The levels of suPAR were low in both patient groups studied. There was no difference in the values regarding the presence of Crohn's disease or ulcerative colitis. Thus, all analyses were performed on the entire sample set. Glucocorticoid therapy, however, resulted in a significant decline in suPAR levels from a median of 3.06 to 2.54 ng/ml (p < 0.01). In contrast, TNF-α-antagonist had no effect. The suPAR levels did not associate with ESR or CRP or fecal calprotectin (FC).

CONCLUSIONS

In pediatric IBD, the suPAR levels in blood are low and do not reflect the level of intestinal inflammation assessed with FC. The introduction of corticoids, however, results in a decline of suPAR levels in blood but not reflect therapeutic response to TNF-α-antagonist. Thus, suPAR is of limited value in assessing systemic inflammatory responses in pediatric IBD.

Diagnostic yield of upper endoscopy in paediatric patients with Crohn's disease and ulcerative colitis. Subanalysis of the HUPIR registry

BACKGROUND, AIMS

According to Porto Criteria upper gastrointestinal (UGI) endoscopy is recommended in patients with suspected inflammatory bowel disease (IBD). Nevertheless, previous studies revealed frequent involvement of UGI tract even in patients with ulcerative colitis (UC). The aim of the present study was to determine the diagnostic role of esophagogastroduodenoscopy (EGD) and assess the prevalence and different aspects of UGI involvement in children registered in the Hungarian Pediatric IBD Registry (HUPIR) from 1st of January 2007 to 31th of December 2009.

METHODS

Twenty seven institutes provided prospective follow-up data about newly diagnosed IBD patients to HUPIR. The registry was based on detailed questionnaire (76 parameters) involving anamnestic data, laboratory findings, activity indexes, diagnostic procedures, endoscopic examinations (EGD and ileocolonoscopy), and histological data. Localization and phenotype of disease were based on the Montreal classification criteria.

RESULTS

During the 3-year period 420 children were diagnosed with IBD, 265 (63%) of them had Crohn's disease (CD), 130 (31%) UC, and 25 (6%) IBD-unclassified (IBD-U). The mean age at diagnosis was 13.2 years (range: 1.2-18 years). EGD was performed in 237 patients (56%), in most cases in patients suffering from CD. Macroscopic lesions on EGD were noted in 64% of patients with CD and 40% of children with UC. Characteristic lesions for CD (ulcer, erosion, aphthous lesion, and granuloma) were noted in 31% of CD patients, however, EGD helped to establish the final diagnosis in 9% of CD patients (diagnostic yield, 9%).

CONCLUSIONS

There was a high frequency of UGI involvement in children with CD and UC. One third of CD patients showed significant lesions at upper endoscopy and one patient out of ten had real diagnostic help from EGD.

Infliximab in pediatric inflammatory bowel disease rapidly decreases fecal calprotectin levels

AIM: To study the response to infliximab in pediatric inflammatory bowel disease (IBD), as reflected in fecal calprotectin levels.

METHODS: Thirty-six pediatric patients with IBD [23 Crohn’s disease (CD), 13 ulcerative colitis (UC); median age 14 years] were treated with infliximab. Fecal calprotectin was measured at baseline, and 2 and 6 wk after therapy, and compared to blood inflammatory markers. Maintenance medication was unaltered until the third infusion but glucocorticoids were tapered off if the patient was doing well.

RESULTS: At introduction of infliximab, median fecal calprotectin level was 1150 μg/g (range 54-6032 μg/g). By week 2, the fecal calprotectin level had declined to a median 261 μg/g (P < 0.001). In 37% of the patients, fecal calprotectin was normal (< 100 μg/g) at 2 wk. By week 6, there was no additional improvement in the fecal calprotectin level (median 345 μg/g). In 22% of the patients, fecal calprotectin levels increased by week 6 to pretreatment levels or above, suggesting no response (or a loss of early response). Thus, in CD, the proportion of non-responsive patients by week 6 seemed lower, because only 9% showed no improvement in their fecal calprotectin level when compared to the respective figure of 46% of the UC patients (P < 0.05).

CONCLUSION: When treated with infliximab, fecal calprotectin levels reflecting intestinal inflammation normalized rapidly in one third of pediatric patients suggesting complete mucosal healing.

Plasma citrulline as surrogate marker of intestinal inflammation in pediatric and adolescent with Crohn's disease: preliminary report

PURPOSE

Several researchers have found that plasma citrulline could be a marker of reduced enterocyte mass. The aim of this study was to assess the relationship between plasma citrulline and bowel inflammation and/or disease location in pediatric and adolescent Crohn's disease (CD) patients.

METHODS

Between January 2008 and January 2010, 31 CD patients and 44 controls were included in our study, and 15 out of the 31 CD patients continued a prospective survey. We evaluated the differences between groups, at baseline, in plasma citrulline and glutamine and between their baseline and final values during the prospective survey, and correlation between baseline values of citrulline and duration of disease, C-reactive protein, and fecal calprotectin.

RESULTS

Mean citrulline value was 33.0 ± 7.5 μmol/L in controls and 23.5 ± 8.4 μmol/L in CD patients (P < 0.0001). Plasma citrulline was significantly lower in patients with small bowel (SB) location than in patient with only ileo-colon disease (14.2 ± 5.5 and 24.7 ± 8.0, respectively; P = 0.0037). Citrulline ≤22 μmol/L reached sensitivity of 100% (95% confidence interval (CI) 54-100) and specificity of 98% (CI 89-99) in differentiating control subjects from CD with SB location.

CONCLUSIONS

CD patients have reduced concentration of plasma citrulline than controls. Intestinal damage rather than inflammation seems to be responsible for the reduced biosynthesis of citrulline, which decreases particularly in CD patients with SB location. This finding suggests the potential role of citrulline as marker of disease location, but future works will be needed to confirm this suggestion.

Use of C-reactive protein in children with newly diagnosed inflammatory bowel disease

C-reactive protein (CRP), a marker for inflammation, was evaluated with other routine blood tests in children with newly diagnosed inflammatory bowel disease. Evaluation of CRP level helped identify additional patients found to have inflammatory bowel disease at endoscopy, although a sizeable number of patients with mild ulcerative colitis had a normal CRP level.