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Miida S, Maruyama M, Sato T, Nagoya T, Goto R, Isokawa O, Koizumi N, Terai S. Acute pancreatitis as a rare complication of leptospirosis: A case report and literature review. J Infect Chemother 2024; 30:552-556. [PMID: 38052307 DOI: 10.1016/j.jiac.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
Leptospirosis is a zoonotic disease. We present a case of acute pancreatitis associated with leptospirosis. An 88-year-old woman was admitted to the hospital with high fever and severe myalgia of the lower extremities. Based on the clinical presentation, hepatic dysfunction with a mild increase in bilirubin, renal dysfunction, and life history, the possibility of leptospirosis was considered. Plain computed tomography of the trunk on admission revealed no special findings. Appropriate antimicrobial therapy was administered at an early stage. After treatment initiation, the clinical symptoms and blood test abnormalities began to improve, and the patient appeared to be doing well. Although no abdominal or back pain was consistently noted during hospitalization, the serum amylase level increased over time; therefore, the patient underwent another computed tomography scan on the ninth day. Acute pancreatitis, which was absent upon admission, was noted. Appropriate treatment for pancreatitis was administered, and the patient was discharged. A subsequent serum antibody test confirmed the diagnosis of leptospirosis. Herein, we also summarized previous cases of acute pancreatitis associated with leptospirosis. The time of onset for pancreatitis was inconsistent, and there were a few cases of pancreatitis without abdominal or back pain. In contrast, serum amylase or lipase levels were elevated in all patients, which could be an important trigger for suspected complications of pancreatitis. When leptospirosis is suspected, complications of pancreatitis should always be considered, even in the absence of apparent abdominal pain. Regular monitoring of pancreatic enzymes such as amylase and lipase is recommended.
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Affiliation(s)
- Suguru Miida
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
| | - Masaki Maruyama
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, Kashiwazaki, Japan
| | - Takeki Sato
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, Kashiwazaki, Japan
| | - Takuro Nagoya
- Department of Gastroenterology and Hepatology, Tsubame Rosai Hospital, Tsubame, Niigata, Japan
| | - Ryo Goto
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, Kashiwazaki, Japan
| | - Osamu Isokawa
- Department of Gastroenterology, Kashiwazaki General Hospital and Medical Center, Kashiwazaki, Japan
| | - Nobuo Koizumi
- Department of Bacteriology I, National Institute of Infectious Diseases, Shinjuku, Tokyo, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Chuaypen N, Siripongsakun S, Hiranrat P, Tanpowpong N, Avihingsanon A, Tangkijvanich P. Improvement of liver fibrosis, but not steatosis, after HCV eradication as assessment by MR-based imaging: Role of metabolic derangement and host genetic variants. PLoS One 2022; 17:e0269641. [PMID: 35696400 PMCID: PMC9191717 DOI: 10.1371/journal.pone.0269641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/22/2022] [Indexed: 12/05/2022] Open
Abstract
Significant liver fibrosis regression occurs after hepatitis C virus (HCV) therapy. However, the impact of direct-acting antivirals (DAAs) on steatosis is less clear. This study was aimed at evaluating serial fibrosis and steatosis alterations in patients with HCV genotype 1, who achieved sustained virological response (SVR). We enrolled 55 HCV mono-infected and 28 HCV/HIV co-infected patients receiving elbasvir/grazoprevir from a clinical trial. Fibrosis and steatosis were assessed at baseline, follow-up week-24 (FUw24) and week-72 (FUw72) by magnetic resonance elastography (MRE) and proton density fat fraction (PDFF), respectively. Patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs738409, transmembrane six superfamily member 2 (TM6SF2) rs58542926 and membrane bound O-acyltransferase domain-containing 7 (MBOAT7) rs641738 polymorphisms were determined by allelic discrimination. Overall, mean MRE decreased significantly from baseline to FUw24 and FUw72. At FUw72, patients with baseline F2-F4 had higher rate of ≥30% MRE decline compared with individuals with baseline F0-F1 (30.2%vs.3.3%, P = 0.004). In multivariate analysis, significant fibrosis was associated with MRE reduction. The prevalence of steatosis (PDFF≥5.2%) at baseline was 21.7%. Compared to baseline, there were 17 (20.5%) patients with decreased PDFF values at FUw72 (<30%), while 23 (27.7%) patients had increased PDFF values (≥30%). Regarding the overall cohort, mean PDFF significantly increased from baseline to FUw72, and displayed positive correlation with body mass index (BMI) alteration. In multivariate analysis, the presence of diabetes, PNPLA3 CG+GG genotypes and increased BMI at FUw72 were significantly associated with progressive steatosis after SVR. Other genetic variants were not related to fibrosis and steatosis alteration. This study concluded that HCV eradication was associated with fibrosis improvement. However, progressive steatosis was observed in a proportion of patients, particularly among individuals with metabolic derangement and PNPLA3 variants. The combined clinical parameters and host genetic factors might allow a better individualized strategy in this sub-group of patients to alleviate progressive steatosis after HCV cure.
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Affiliation(s)
- Natthaya Chuaypen
- Center of Excellence in Hepatitis and Liver Cancer, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Surachate Siripongsakun
- Sonographer School, Faculty of Health Science Technology, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Pantajaree Hiranrat
- Sonographer School, Faculty of Health Science Technology, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Natthaporn Tanpowpong
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Anchalee Avihingsanon
- The HIV Netherlands Australia Thailand Research Collaboration (HIV NAT), Bangkok, Thailand
| | - Pisit Tangkijvanich
- Center of Excellence in Hepatitis and Liver Cancer, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- * E-mail:
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Hu Y, Yang W. Paeoniflorin Can Improve Acute Lung Injury Caused by Severe Acute Pancreatitis through Nrf2/ARE Pathway. Comput Math Methods Med 2022; 2022:5712219. [PMID: 35586665 PMCID: PMC9110196 DOI: 10.1155/2022/5712219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/22/2022] [Accepted: 04/06/2022] [Indexed: 12/04/2022]
Abstract
Objective To evaluate the potential therapeutic effect of paeoniflorin on acute lung injury induced by severe acute pancreatitis (SAP) and to initially explore the possible protective mechanisms of paeoniflorin. Method The SAP lung injury rat model was established by retrograde injection of 5% sodium taurocholate to the cholangiopancreatic duct. H&E staining was used to detect pathological changes in rat lung tissue. W/D ratio method, serum amylase (AMY), and lipase activity were used to assess the degree of lung injury in rats. Oxidation indicators such as LDH, MDA, and SOD in lung tissue were measured. Levels of inflammatory factors TNF-α, IL-6, and IL-10 were measured in bronchoalveolar lavage fluid (BALF). At the same time, Western blot was used to detect the expression of related proteins in the Nrf2/ARE signaling pathway. Results In SAP rats, paeoniflorin treatment could significantly alleviate lung injury conditions such as pulmonary edema and inflammatory cell infiltration in lung tissue and reduce serum amylase and lipase activities. Paeoniflorin can reduce the content of LDH and MDA in lung tissue and increase the content of SOD. In addition, ELISA results showed that paeoniflorin could inhibit the levels of TNF-α and IL-6 in BALF and upregulate the levels of IL-10. Paeoniflorin could upregulate the expression of Nrf2/ARE signaling pathway proteins Cyt-Nrf2, HO-1, and NQO1 in lung tissue of SAP rats. Conclusion Paeoniflorin may improve acute lung injury in rats with severe pancreatitis by inhibiting inflammation and oxidative stress response. These effects may be related to activating the Nrf2/ARE signaling pathway.
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Affiliation(s)
- Yanyan Hu
- Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang 441021, China
| | - Wei Yang
- Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang 441021, China
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Bottermann K, Kalfhues L, Nederlof R, Hemmers A, Leitner LM, Oenarto V, Nemmer J, Pfeffer M, Raje V, Deenen R, Petzsch P, Zabri H, Köhrer K, Reichert AS, Grandoch M, Fischer JW, Herebian D, Stegbauer J, Harris TE, Gödecke A. Cardiomyocyte p38 MAPKα suppresses a heart-adipose tissue-neutrophil crosstalk in heart failure development. Basic Res Cardiol 2022; 117:48. [PMID: 36205817 PMCID: PMC9542472 DOI: 10.1007/s00395-022-00955-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/05/2022] [Accepted: 09/18/2022] [Indexed: 01/31/2023]
Abstract
Although p38 MAP Kinase α (p38 MAPKα) is generally accepted to play a central role in the cardiac stress response, to date its function in maladaptive cardiac hypertrophy is still not unambiguously defined. To induce a pathological type of cardiac hypertrophy we infused angiotensin II (AngII) for 2 days via osmotic mini pumps in control and tamoxifen-inducible, cardiomyocyte (CM)-specific p38 MAPKα KO mice (iCMp38αKO) and assessed cardiac function by echocardiography, complemented by transcriptomic, histological, and immune cell analysis. AngII treatment after inactivation of p38 MAPKα in CM results in left ventricular (LV) dilatation within 48 h (EDV: BL: 83.8 ± 22.5 µl, 48 h AngII: 109.7 ± 14.6 µl) and an ectopic lipid deposition in cardiomyocytes, reflecting a metabolic dysfunction in pressure overload (PO). This was accompanied by a concerted downregulation of transcripts for oxidative phosphorylation, TCA cycle, and fatty acid metabolism. Cardiac inflammation involving neutrophils, macrophages, B- and T-cells was significantly enhanced. Inhibition of adipose tissue lipolysis by the small molecule inhibitor of adipocytetriglyceride lipase (ATGL) Atglistatin reduced cardiac lipid accumulation by 70% and neutrophil infiltration by 30% and went along with an improved cardiac function. Direct targeting of neutrophils by means of anti Ly6G-antibody administration in vivo led to a reduced LV dilation in iCMp38αKO mice and an improved systolic function (EF: 39.27 ± 14%). Thus, adipose tissue lipolysis and CM lipid accumulation augmented cardiac inflammation in iCMp38αKO mice. Neutrophils, in particular, triggered the rapid left ventricular dilatation. We provide the first evidence that p38 MAPKα acts as an essential switch in cardiac adaptation to PO by mitigating metabolic dysfunction and inflammation. Moreover, we identified a heart-adipose tissue-immune cell crosstalk, which might serve as new therapeutic target in cardiac pathologies.
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Affiliation(s)
- Katharina Bottermann
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
- Institute of Pharmacology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Lisa Kalfhues
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Rianne Nederlof
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Anne Hemmers
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Lucia M Leitner
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Vici Oenarto
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Jana Nemmer
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Mirjam Pfeffer
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Vidisha Raje
- Department of Pharmacology, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Rene Deenen
- Biological and Medical Research Center (BMFZ), Medical Faculty, Heinrich-Heine-University, Universitätsstraße 1, 40225, Duesseldorf, Germany
| | - Patrick Petzsch
- Biological and Medical Research Center (BMFZ), Medical Faculty, Heinrich-Heine-University, Universitätsstraße 1, 40225, Duesseldorf, Germany
| | - Heba Zabri
- Institute of Pharmacology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Karl Köhrer
- Biological and Medical Research Center (BMFZ), Medical Faculty, Heinrich-Heine-University, Universitätsstraße 1, 40225, Duesseldorf, Germany
| | - Andreas S Reichert
- Institute of Biochemistry and Molecular Biology I, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Maria Grandoch
- Institute of Translational Pharmacology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Jens W Fischer
- Institute of Pharmacology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine-University, Universitätsstraße 1, 40225, Duesseldorf, Germany
| | - Diran Herebian
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany
| | - Thurl E Harris
- Department of Pharmacology, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Axel Gödecke
- Institute of Cardiovascular Physiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Postfach 101007, 40001, Düsseldorf, Germany.
- CARID-Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine-University, Universitätsstraße 1, 40225, Duesseldorf, Germany.
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Abstract
BACKGROUND Orlistat, a reversible inhibitor of pancreatic and gastric lipase, is known to have anti-obesity and antioxidant properties. Cholesterol intermediates and metabolites have diverse and important functions in cardiovascular disease. Therefore, we aimed to evaluate the effect of orlistat on sterol metabolism in overweight and obese adults after weight loss during the intervention or weight loss at 12 weeks. METHODS A total of 51 (27 in the control group and 24 in the experimental group), patients with a BMI of 27 or greater were randomly assigned in a 1:1 ratio to receive either orlistat (120 mg) three times a day plus phentermine hydrochloride (37.5 mg) once daily or a placebo three times a day plus phentermine hydrochloride (37.5 mg) once daily. The primary study outcome was sterol metabolism. RESULTS The experimental group exhibited significantly decreased metabolic signatures of serum sterols, free cholesterol, sitosterol, 7α-hydroxycholesterol (7α-OHC), and 7β-OHC at 12 weeks. The experimental group also exhibited significantly decreased metabolic ratios of sitosterol and 7α-OHC to cholesterol at 12 weeks. Regarding changes in sterol signatures from baseline to 6-month follow-up, free cholesterol, plant sterols, and cholesterol precursors tended to decrease with weight loss during the intervention and increase again as the weight was regained in both groups. CONCLUSION Orlistat treatment improves oxysterol metabolism in overweight and obese adults. Our findings support that orlistat plays a crucial role in the process of endothelial dysfunction and atherosclerosis via oxysterol modulation.
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Affiliation(s)
- Yu-Jin Kwon
- Department of Family Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Go Eun Kwon
- Molecular Recognition Research Center, Korea Institute of Science and Technology, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Man Ho Choi
- Molecular Recognition Research Center, Korea Institute of Science and Technology, Seoul, South Korea
- *Correspondence: Man Ho Choi, ; Ji-Won Lee,
| | - Ji-Won Lee
- Department of Family Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Man Ho Choi, ; Ji-Won Lee,
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Arutla M, Sarkar S, Unnisa M, Sarkar P, Raj MA, Mrudula MR, G D, Pasham S, Jakkampudi A, Prasanna A, Reddy DN, Talukdar R. Malnutrition after pancreatic enzyme replacement therapy in chronic pancreatitis: Risk factors in real world practice. Pancreatology 2021; 21:34-41. [PMID: 33303371 DOI: 10.1016/j.pan.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND RCTs that have shown improvement in coefficient of fat absorption with pancreatic enzyme replacement therapy (PERT) have seldom evaluated the impact on overall nutritional status. OBJECTIVE In this study we evaluated factors responsible for persistence of malnutrition after PERT. METHODS In this cross-sectional observational study, patients were enrolled based on predefined enrolment criteria. Patients were divided into those taking PERT regularly (Group A), irregularly (Group B) and not taking (Group C) for at least 3 months. Comprehensive evaluation of anthropometric measurements, nutritional assessment and dietary intake was performed. Malnutrition was measured using the Subjective Global Assessment (SGA) tool. Relationship between PERT status, dietary intake and nutritional status were evaluated using standard statistical methods. Logistic regression was performed to identify factors associated with persistence of malnutrition after PERT. RESULTS 377 patients with CP and 50 controls were included. 95 (25.2%) patients with CP were in Group A, 106 (28.1%) in Group B and 176 (46.7%) in Group C. 130 (34.5%) patients were malnourished, of which 76 (58.5%) were continuing PERT. There were no differences in clinical and biochemical nutritional markers between Groups A, B, and C. Calorie deficit and daily intake of calorie, protein, carbohydrates and fats were not different between those with and without PERT, but was significantly less in those with malnutrition. Logistic regression demonstrated inadequate dietary intake as independent risk factor for persistence of malnutrition. CONCLUSION Even though PERT is effective in PEI, comprehensive nutritional assessment, personalized nutritional counselling and therapy along with PERT is mandatory.
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Affiliation(s)
- Madhulika Arutla
- Dept. of Clinical Nutrition, Asian Institute of Gastroenterology, Hyderabad, India
| | - Subhaleena Sarkar
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Misbah Unnisa
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Priyanka Sarkar
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Merlin Annie Raj
- Dept. of Clinical Nutrition, Asian Institute of Gastroenterology, Hyderabad, India
| | - M R Mrudula
- Dept. of Clinical Nutrition, Asian Institute of Gastroenterology, Hyderabad, India
| | - Deepika G
- Dept. of Biochemistry, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Aparna Jakkampudi
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ambika Prasanna
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Dept. of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Wellcome DBT Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India; Dept. of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
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Calvo-Lerma J, Hulst J, Boon M, Colombo C, Masip E, Ruperto M, Fornés-Ferrer V, van der Wiel E, Claes I, Garriga M, Roca M, Crespo-Escobar P, Bulfamante A, Woodcock S, Martínez-Barona S, Andrés A, de Boeck K, Ribes-Koninckx C. Clinical validation of an evidence-based method to adjust Pancreatic Enzyme Replacement Therapy through a prospective interventional study in paediatric patients with Cystic Fibrosis. PLoS One 2019; 14:e0213216. [PMID: 30861039 PMCID: PMC6413926 DOI: 10.1371/journal.pone.0213216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/15/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A method to adjust Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis is not currently available. OBJECTIVES To assess the in vivo efficacy of a method to adjust the dose of enzymatic supplement in CF extrapolated from previous in vitro digestion studies (theoretical optimal dose, TOD). Secondly, to assess how individual patient characteristics influence the expected coefficient of fat absorption (CFA) and thus to identify an individual correction factor to improve TOD. METHODS A prospective interventional study in 43 paediatric patients with CF from 5 European centres. They followed a 24h fixed diet with the theoretical optimal dose for each meal. Faecal collection was carried out between colorimetric markers in order to include all the faeces corresponding to the fixed diet. Beta regression models were applied to assess the associations of individual patient characteristics with the CFA. RESULTS Median CFA was 90% (84, 94% 1st, 3rd Q.) with no significant differences among centres. Intestinal transit time was positively associated with CFA (p = 0.007), but no statistical associations were found with and age, gender, phenotype or BMI. Regression model showed no improvement of the in vitro predicted theoretical optimal dose when taking individual patient characteristics into account. CONCLUSION Strict adherence to the theoretical optimal dose of enzymatic supplement for a prescribed meal, led to median CFA levels at the clinical target of 90% with a low variability between patients. The proposed method can be considered as a first approach for an evidence-based method in PERT dosing based on food characteristics. Results have to be confirmed in free dietary settings.
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Affiliation(s)
- Joaquim Calvo-Lerma
- Instituto de Investigación Sanitaria La Fe de Valencia, Valencia, Spain
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
| | - Jessie Hulst
- Erasmus Medical Center, Sophia Children’s Hospital, GD Rotterdam, the Netherlands
| | - Mieke Boon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Carla Colombo
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 9, Milan, Italy
| | - Etna Masip
- Instituto de Investigación Sanitaria La Fe de Valencia, Valencia, Spain
| | - Mar Ruperto
- Hospital Universitario Ramón y Cajal, Carretera Colmenar Viejo km 9, Madrid, Spain
| | | | - Els van der Wiel
- Erasmus Medical Center, Sophia Children’s Hospital, GD Rotterdam, the Netherlands
| | - Ine Claes
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Maria Garriga
- Hospital Universitario Ramón y Cajal, Carretera Colmenar Viejo km 9, Madrid, Spain
| | - Maria Roca
- Instituto de Investigación Sanitaria La Fe de Valencia, Valencia, Spain
| | | | - Anna Bulfamante
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 9, Milan, Italy
| | - Sandra Woodcock
- Erasmus Medical Center, Sophia Children’s Hospital, GD Rotterdam, the Netherlands
| | | | - Ana Andrés
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
| | - Kris de Boeck
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
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Calvo-Lerma J, Fornés-Ferrer V, Peinado I, Heredia A, Ribes-Koninckx C, Andrés A. A first approach for an evidence-based in vitro digestion method to adjust pancreatic enzyme replacement therapy in cystic fibrosis. PLoS One 2019; 14:e0212459. [PMID: 30794618 PMCID: PMC6386532 DOI: 10.1371/journal.pone.0212459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/01/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with cystic fibrosis have to take enzymatic supplements to allow for food digestion. However, an evidence-based method to adjust Pancreatic Enzyme Replacement Therapy (PERT) is inexistent, and lipid content of meals is used as a rough criterion. OBJECTIVE In this study, an in vitro digestion model was set up to determine the theoretical optimal dose (TOD) of enzymatic supplement for a selection of foods, which is the dose that allows for maximum lipolysis extent. METHODS A static in vitro digestion model was applied to simulate digestion of eight foods covering a wide range of lipid contents. First, the dose of the enzymatic supplement was fixed at 2000 lipase units per gram of fat (LU/g fat) using intestinal pH and bile salt concentration as variables. Second, intestinal pH and bile salt concentrations were fixed and the variable was the dose of the enzymatic supplement. Lipolysis extent was determined by measuring the free fatty acids released from initial triglycerides content of foods after digestion. Results in terms of percentage of lipolysis extent were fitted into a linear-mixed segmented model and the deducted equations were used to predict the TOD to reach 90% of lipolysis in every food. In addition, the effect of intestinal pH and bile salt concentration were investigated. RESULTS The predictive equations obtained for the assessed foods showed that lipolysis was not only dependent on the dose of the enzyme supplement or the lipid content. Moreover, intestinal pH and bile salt concentration had significant effects on lipolysis. Therefore an evidence-based model can be developed taking into account these variables. CONCLUSIONS Depending on food characteristics, a specific TOD should be assigned to achieve an optimal digestion extent. This work represents a first step towards an evidence-based method for PERT dosing, which will be applied in an in vivo setting to validate its efficacy.
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Affiliation(s)
- Joaquim Calvo-Lerma
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe de Valencia, Valencia, Spain
| | | | - Irene Peinado
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
| | - Ana Heredia
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
| | | | - Ana Andrés
- Universitat Politècnica de València, Research Institute of Food Engineering for Development, Valencia, Spain
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Wang Y, Ding F, Wang T, Liu W, Lindquist S, Hernell O, Wang J, Li J, Li L, Zhao Y, Dai Y, Li N. Purification and characterization of recombinant human bile salt-stimulated lipase expressed in milk of transgenic cloned cows. PLoS One 2017; 12:e0176864. [PMID: 28475629 PMCID: PMC5419509 DOI: 10.1371/journal.pone.0176864] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 04/18/2017] [Indexed: 01/13/2023] Open
Abstract
Bile salt-stimulated lipase (BSSL) is a lipolytic digestive enzyme with broad substrate specificity secreted from exocrine pancreas into the intestinal lumen in all species and from the lactating mammary gland into the milk of some species, notably humans but not cows. BSSL in breast milk facilitates digestion and absorption of milk fat and promotes growth of small for gestational age preterm infants. Thus, purified recombinant human BSSL (rhBSSL) can be used for treatment of patients with fat malabsorption and expressing rhBSSL in the milk of transgenic cloned cows would therefore be a mean to meet a medical need. In the present study, a vector pBAC-hLF-hBSSL was constructed, which efficiently expressed active rhBSSL in milk of transgenic cloned cows to a concentration of 9.8 mg/ml. The rhBSSL purified from cow milk had the same enzymatic activity, N-terminal amino acid sequence, amino acid composition and isoelectric point and similar physicochemical characteristics as human native BSSL. Our study supports the use of transgenic cattle for the cost-competitive, large-scale production of therapeutic rhBSSL.
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Affiliation(s)
- Yuhang Wang
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Fangrong Ding
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Tao Wang
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Wenjie Liu
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Susanne Lindquist
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Olle Hernell
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Jianwu Wang
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Jing Li
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Ling Li
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Yaofeng Zhao
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
| | - Yunping Dai
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
- * E-mail: (YD); (NL)
| | - Ning Li
- State Key Laboratory for Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, P. R. China
- * E-mail: (YD); (NL)
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Chernyavskiy VV, Gvozdetska LS. [DELAYED RESULTS OF ENZYME REPLACEMENT THERAPY, PRESCRIBED BY RESULTS OF 13C-TRIGLYCERIDE BREATH TEST]. Lik Sprava 2015:94-99. [PMID: 26827447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Maldigestion persists in most patients with chronic pancreatitis (CP). The objective lipase and amylase insufficiency diagnosis is needed to achieve an adequate clinical response to oral pancreatic enzyme substitution therapy. The novel data is presented in the article about the role of 13C-mixed triglyceride breath test as a tool for exocrine pancreatic insufficiency diagnosis, for evaluating fat malabsorbtion in CP patients. 135 patients were included in the investigation. Delayed results of enzyme replacement therapy were estimated after 1 and 2 year of surveillance. It has been shown, that partial recovery of exocrine pancreatic function is possible, and replacement therapy leads to patients nutritional status improving. Thus 13C-triglyceride breath test could be useful tool in clinical practice for CP diagnosis. The test make it possible to choose the initial pancreatic enzyme dosage and are beneficial during the treatment for pancreatic enzyme dose correction.
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Cherniavskiĭ VV. [The clinical application of 13C-breath tests in pancreatic diseases]. Lik Sprava 2014:76-82. [PMID: 25528838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Maldigestion persists in most patients with chronic pancreatitis (GP). The objective lipase and amylase insufficiency diagnosis is needed to achieve an adequate clinical response to oral pancreatic enzyme substitution therapy. The novel data is presented in the article about the role of 13C-mixed triglyceride and 13C-corn starch breath tests as a tools for exocrine pancreatic insufficiency diagnosis, for evaluating fat and starch malabsorbtion in CP patients. 135 patients were included in the investigation. It has been shown, that 13C-breath tests could be useful tools in clinical practice for CP diagnosis. They are well correlate with fecal elastase-1 level, has high sensitivity and specificity for diagnosis of lipase and amylase deficiency. Tests make it possible to choose the initial pancreatic enzyme dosage and are beneficial during the treatment for pancreatic enzyme dose correction.
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12
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Gubergrits NB, Lukashevich GM. [Cholestasis and pancreatic insufficiency: how to start treatment?]. Eksp Klin Gastroenterol 2014:84-90. [PMID: 25911918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The article presents a detailed analysis of pathogenesis and clinical manifestation of secondary pancreatic excretory insufficiency due to disorders of bile production and choleresis. Pathogenesis of hepatogenic (chologenic) pancreatic insufficiency considered in view of impairment of bile acids' different functions in cholestasis. Authors review pathology of liver and bile ducts resulted in steatorrhea. It was conducted pathogenetic substantiation treatment tactics of patients, which have a combination of cholestasis and secondary pancreatic insufficiency.
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Borowitz D, Stevens C, Brettman LR, Campion M, Chatfield B, Cipolli M. International phase III trial of liprotamase efficacy and safety in pancreatic-insufficient cystic fibrosis patients. J Cyst Fibros 2011; 10:443-52. [PMID: 21831726 DOI: 10.1016/j.jcf.2011.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 07/01/2011] [Accepted: 07/05/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most cystic fibrosis (CF) patients have exocrine pancreatic insufficiency (EPI) and need supplementation with pancreatic enzyme replacement therapy (PERT). Liprotamase, a novel non-porcine PERT containing highly purified biotechnology-derived lipase, protease, and amylase, has successfully undergone initial efficacy and safety testing. METHODS In this international phase III parallel-group, randomized-withdrawal, double-blind placebo-controlled trial, CF patients with EPI 7 years and older, including nutritionally and functionally compromised individuals, underwent baseline testing for coefficients of fat and nitrogen absorption (CFA and CNA) and stool weight and frequency while off PERT. After an open-label treatment period with liprotamase, subjects were randomized 1:1 to one liprotamase or placebo capsule taken with 3 meals and 2 snacks per day. The dose was fixed and increases were not allowed. The same measurements were obtained again after treatment with double-blind study drug or placebo. RESULTS 138 subjects were randomized. The adjusted least squares mean (LSM) difference between the treatment and placebo groups for change in CFA was 15.1% (p=0.001) for the subgroup with baseline CFA <40%, 8.6% (p=0.006) for subjects with baseline CFA ≥40%, and 10.6% (p<0.001) for the overall intent-to-treat population. Similar results were seen for change in CNA. Stool weight was significantly decreased although not stool frequency. Liprotamase was well tolerated with no safety concerns identified. CONCLUSIONS In a CF patient population reflective of that encountered in clinical practice, this trial demonstrated that liprotamase at a fixed dose of one capsule per meal or snack (5 capsules per day) was well tolerated and significantly increased fat absorption as measured by improvement in CFA, significantly increased protein absorption as measured by improvement in CNA, and significantly decreased stool weight.
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Affiliation(s)
- Drucy Borowitz
- Division of Pediatric Pulmonology, State University of New York at Buffalo, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA.
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14
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Kuo P, Stevens JE, Russo A, Maddox A, Wishart JM, Jones KL, Greville H, Hetzel D, Chapman I, Horowitz M, Rayner CK. Gastric emptying, incretin hormone secretion, and postprandial glycemia in cystic fibrosis--effects of pancreatic enzyme supplementation. J Clin Endocrinol Metab 2011; 96:E851-5. [PMID: 21389144 DOI: 10.1210/jc.2010-2460] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Postprandial hyperglycemia is an important clinical problem in cystic fibrosis (CF), but the contribution of fat malabsorption, rapid gastric emptying, and the incretin axis has not been widely considered. OBJECTIVE The aim of this study was to evaluate these aspects of gut function in nondiabetic CF patients. DESIGN AND SETTING We conducted a randomized, double-blind, placebo-controlled crossover study at a clinical research laboratory. PATIENTS Five nondiabetic CF patients (three males; age, 25.8 ± 1.0 yr; body mass index, 20.2 ± 1.1 kg/m(2)) with exocrine pancreatic insufficiency and six healthy subjects of similar age and body mass index participated in the study. INTERVENTIONS CF patients consumed a radiolabeled mashed potato meal on 2 separate days, together with four capsules of Creon Forte (100,000 IU lipase) or placebo. Healthy subjects consumed the meal once, without pancreatic enzymes. MAIN OUTCOME MEASURES Gastric emptying was measured using scintigraphy, and blood was sampled frequently for blood glucose and plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon concentrations. RESULTS CF patients had more rapid gastric emptying (P < 0.001), impaired secretion of GLP-1 (P < 0.01) and GIP (P < 0.001), and greater postprandial glycemic excursions (P < 0.001) than healthy subjects. Pancreatic enzyme supplementation normalized gastric emptying and GLP-1 secretion and tended to increase glucagon (P = 0.08), but did not completely restore GIP secretion or normalize postprandial blood glucose. There was an excellent correlation between gastric emptying and blood glucose concentration at 60 min (R = 0.75; P = 0.01). CONCLUSIONS Pancreatic enzyme supplementation plays an important role in incretin secretion, gastric emptying, and postprandial hyperglycemia in CF.
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Affiliation(s)
- Paul Kuo
- Discipline of Medicine, University of Adelaide, Level 6, Eleanor Harrald Building, Royal Adelaide Hospital, Adelaide 5000, Australia
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Barzdo M, Zydek L, Smedra-Kaźmirska A, Zgoda M, Machała W, Berent J. Erroneous administration of vinblastine. Pharm World Sci 2009; 31:362-364. [PMID: 19306070 DOI: 10.1007/s11096-009-9291-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 03/11/2009] [Indexed: 05/27/2023]
Abstract
This case describes a series of errors which resulted in an avoidable death of the patient. Upon being presented with the 83-year-old patient and her complaints, the physician in charge attempted to prescribe Vasolastine (a complex preparation used, for example, in treatment of angiopathy, which is administered intramuscularly once a day). Unfortunately he misspelled the name of the medicine as Vinplastyna--a non-existent preparation. When the patient's daughter went to collect the prescription from the pharmacist she was dispensed Vinblastin (vinblastine--a cytostatic medicine used, for example, in treating Hodgkin's disease, non-Hodgkin's lymphoma, chronic lymphatic leukemia and testicular cancer). The visiting community nurses administered a dose of this medicine on seven consecutive days. Upon being given the seventh dose, the patient displayed symptoms of myelophthisis, and was admitted to an Intensive Care Ward, where despite the treatment, she died.
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Affiliation(s)
- Maciej Barzdo
- Department of Forensic Court and Insurance Certification, Medical University of Lodz, ul. Sedziowska 18a, 91-304, Lodz, Poland
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16
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Vasil'ev IV. [Enzymatic drugs in the therapy of chronic pancreatitis]. Eksp Klin Gastroenterol 2008:102-107. [PMID: 19145890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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17
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Knop FK, Vilsbøll T, Larsen S, Højberg PV, Vølund A, Madsbad S, Holst JJ, Krarup T. Increased postprandial responses of GLP-1 and GIP in patients with chronic pancreatitis and steatorrhea following pancreatic enzyme substitution. Am J Physiol Endocrinol Metab 2007; 292:E324-30. [PMID: 16954337 DOI: 10.1152/ajpendo.00059.2006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We aimed to investigate how assimilation of nutrients affects the postprandial responses of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) and to evaluate the effect of pancreatic enzyme substitution (PES) on insulin secretion in patients with chronic pancreatitis (CP) and pancreatic exocrine insufficiency (PEI). Eight male patients with CP and PEI were studied. Blood was sampled frequently on two separate days after ingestion of a liquid meal with and without PES, respectively. Eight healthy male subjects served as a control group. beta-Cell responsiveness was estimated as changes in insulin secretion rates in response to changes in postprandial plasma glucose (PG). There was no difference in the PG incremental area under curve (AUC) for patients with and without PES [406 +/- 100 vs. 425 +/- 80 mM.4 h (mean +/- SE), P = 0.8]. The response of total GLP-1 was higher after PES (AUC: 7.8 +/- 1.2 vs. 5.3 +/- 0.6 nM.4 h, P = 0.01), as was the response of total GIP (AUC: 32.7 +/- 7.5 vs. 21.1 +/- 8.3 nM.4 h, P = 0.01). Concurrently, both plasma insulin, plasma C-peptide, and total insulin secretion increased after PES (AUC: 17.7 +/- 4.2 vs. 13.6 +/- 2.9 nM.4 h, P = 0.02; 237 +/- 31.4 vs. 200 +/- 27.4 nM.4 h, P = 0.005; and 595 +/- 82 vs. 497 +/- 80 pmol.kg(-1).4 h, P = 0.01, respectively). beta-Cell responsiveness to glucose was not significantly different on the two study days for patients with CP. These results suggest that the secretion of GLP-1 and GIP is under influence of the digestion and absorption of nutrients in the small intestine and that PES increases insulin secretion.
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Affiliation(s)
- Filip K Knop
- Dept. of Internal Medicine F, Gentofte Hospital, Univ. of Copenhagen, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark.
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18
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Iakovenko AV, Agafonova NA, Iakovenko EP. [Practical approaches to the treatment of chronic pancreatitis]. Eksp Klin Gastroenterol 2007:67-70. [PMID: 18416099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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19
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Borowitz D, Goss CH, Limauro S, Konstan MW, Blake K, Casey S, Quittner AL, Murray FT. Study of a novel pancreatic enzyme replacement therapy in pancreatic insufficient subjects with cystic fibrosis. J Pediatr 2006; 149:658-662. [PMID: 17095338 DOI: 10.1016/j.jpeds.2006.07.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Revised: 06/07/2006] [Accepted: 07/14/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We studied a novel pancreatic enzyme product, ALTU-135, a proprietary formulation of microbially derived lipase, protease, and amylase, to determine its efficacy and safety in treatment of pancreatic insufficiency (PI) in patients with cystic fibrosis (CF). STUDY DESIGN Ambulatory subjects with CF-PI (n = 117) had baseline coefficient of fat and nitrogen absorption (CFA and CNA, respectively) determined in an inpatient setting while not receiving pancreatic enzyme replacement therapy. Subjects were then randomized to treatment with ALTU-135 containing 5000 (low), 25,000 (mid), or 100,000 (highest) units of lipase (1:1:0.15 of lipase:protease:amylase) for 28 days. After 14 days, CFA and CNA were re-measured. The primary outcomes were change from baseline in CFA and CNA between treatments. RESULTS Treatment CFA was significantly greater in the mid and highest dose groups compared with that in the low dose group (P = .0229 and P =.0041, respectively); findings were similar for CNA. Subjects with baseline CFA < or = 40% and > 40% in the 2 higher dose groups had a mean increase of 31 and 8 percentage points in CFA, respectively (P < .0001). CONCLUSION ALTU-135 was efficacious during the 1-month study period at the dose of 25,000 units of lipase, 25,000 units of protease, and 3750 units of amylase.
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Affiliation(s)
- Drucy Borowitz
- Women and Children's Hospital of Buffalo, Division of Pediatric Pulmonology, State University of New York at Buffalo, Buffalo, NY 14222, USA.
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Kłys M, Konopka T, Scisłowski M, Kowalski P. Fatality involving vinblastine overdose as a result of a complex medical error. Cancer Chemother Pharmacol 2006; 59:89-95. [PMID: 16830154 DOI: 10.1007/s00280-006-0246-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
The purpose of the study is a presentation of a fatal case involving an 83-year-old woman, who died due to an overdose of vinblastine-a cytostatic agent of a vinca alkaloid employed in cancer chemotherapy. The postmortem investigation included an autopsy and histological examination, as well as a toxicological analysis of post-mortem specimens collected in the course of autopsy. The authors performed a toxicological assessment of vinblastine employing liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (LC-MS-MS-APCI). The determined vinblastine concentration levels amounting to 29 ng/g in blood and 52.5 ng/g in liver were in a considerable excess of values encountered in patients on chemotherapy using the drug. The fatality was investigated in the context of medical error. In the described case, the erroneous and medically unjustified administration of vinblastine was identified by a series of unfortunate events involving as many as three acting consecutively individuals: a physician, a pharmacist and a nurse. The report may thus document the clinical course of vinblastine poisoning along with postmortem changes resulting from the drug action.
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Affiliation(s)
- Małgorzata Kłys
- Department of Toxicology, Institute of Forensic Medicine, Collegium Medicum, Jagiellonian University, 16 Grzegórzecka St., Krakow, Poland.
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21
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Fat-blocking drug: should you use it? Consum Rep 2006; 71:48. [PMID: 16764082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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22
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Affiliation(s)
- Lanny Monroe
- Blair E. Batson Hospital for Children, Jackson, Mississippi, USA
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23
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Sheptulin AA. [Modern principles of the diagnostics and enzyme therapy of exocrine pancreatic insufficiency]. Klin Med (Mosk) 2006; 84:11-4. [PMID: 17087185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The author considers the main reasons for the development of exocrine pancreatic insufficiency, discusses the advantages and disadvantages of modern direct and indirect techniques of exocrine pancreatic insufficiency diagnostics, and states the main requirements pancreatic enzymes used as means of substitutive therapy should meet.
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Du H, Levine M, Ganesa C, Witte DP, Cole ES, Grabowski GA. The role of mannosylated enzyme and the mannose receptor in enzyme replacement therapy. Am J Hum Genet 2005; 77:1061-74. [PMID: 16380916 PMCID: PMC1285163 DOI: 10.1086/498652] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 10/03/2005] [Indexed: 11/03/2022] Open
Abstract
Lysosomal acid lipase (LAL) is the critical enzyme for the hydrolysis of triglycerides (TGs) and cholesteryl esters (CEs) in lysosomes. LAL defects cause Wolman disease (WD) and CE storage disease (CESD). An LAL null (lal-/-) mouse model closely mimics human WD/CESD, with hepatocellular, Kupffer cell and other macrophage, and adrenal cortical storage of CEs and TGs. The effect on the cellular targeting of high-mannose and complex oligosaccharide-type oligosaccharide chains was tested with human LAL expressed in Pichia pastoris (phLAL) and CHO cells (chLAL), respectively. Only chLAL was internalized by cultured fibroblasts, whereas both chLAL and phLAL were taken up by macrophage mannose receptor (MMR)-positive J774E cells. After intraperitoneal injection into lal-/- mice, phLAL and chLAL distributed to macrophages and macrophage-derived cells of various organs. chLAL was also detected in hepatocytes. Ten injections of either enzyme over 30 d into 2- and 2.5-mo-old lal-/- mice produced normalization of hepatic color, decreased liver weight (50%-58%), and diminished hepatic cholesterol and TG storage. Lipid accumulations in macrophages were diminished with either enzyme. Only chLAL cleared lipids in hepatocytes. Mice double homozygous for the LAL and MMR deficiences (lal-/-;MMR-/-) showed phLAL uptake into Kupffer cells and hepatocytes, reversal of macrophage histopathology and lipid storage in all tissues, and clearance of hepatocytes. These results implicate MMR-independent and mannose 6-phosphate receptor-independent pathways in phLAL uptake and delivery to lysosomes in vivo. In addition, these studies show specific cellular targeting and physiologic effects of differentially oligosaccharide-modified human LALs mediated by MMR and that lysosomal targeting of mannose-terminated glycoproteins occurs and storage can be eliminated effectively without MMR.
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Affiliation(s)
- Hong Du
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
| | - Mark Levine
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
| | - Chandrashekar Ganesa
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
| | - David P. Witte
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
| | - Edward S. Cole
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
| | - Gregory A. Grabowski
- Division and Program in Human Genetics and Division of Pathology, Cincinnati Children’s Hospital Research Foundation, Cincinnati; and Genzyme, Cambridge, MA
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Schulthess G, Kolyvanos Naumann U, Käser L, Vetter W. [Chronic pancreatitis. Main symptoms: chronic abdominal pain, weight loss in steatorrhea, secondary diabetes mellitus]. Praxis (Bern 1994) 2005; 94:1139-45. [PMID: 16117468 DOI: 10.1024/0369-8394.94.30.1139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- G Schulthess
- Medizinische Poliklinik, Universitätsspital Zürich
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Czakó L, Takács T, Hegyi P, Prónai L, Tulassay Z, Lakner L, Döbrönte Z, Boda K, Lonovics J. Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis. Can J Gastroenterol 2004; 17:597-603. [PMID: 14571298 DOI: 10.1155/2003/515848] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
GOALS To evaluate the quality of life (QoL) of patients with chronic pancreatitis before and after pancreatic enzyme replacement therapy in a prospective, multicentre, follow-up study. STUDY Two groups of patients were evaluated. Group 1 consisted of 31 patients with newly diagnosed chronic pancreatitis who had never been treated with pancreatic enzyme preparations. Group 2 consisted of 39 patients whose disease was diagnosed on average 3.4 years before the start of the study. The latter group of patients had undergone pancreatic enzyme replacement therapy, but during follow-up this treatment proved to be insufficient. The dose of pancreatic enzyme replacement therapy was tailored in accordance with the degree of pancreatic exocrine insufficiency measured by means of exocrine pancreatic function tests. A modified European Organizaton for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) was used to assess QoL. RESULTS The social functioning and financial strain were significantly better, while the levels of hope and confidence were significantly reduced in group 1 compared with group 2. A significant gain in body weight and a significantly reduced defecation rate were found in both groups one month after the beginning of the pancreatic enzyme replacement therapy when compared with the pretreatment values. The prevalence of general and disease-specific symptoms and the intensity of pain were reduced in both groups after one month of enzyme substitution therapy. The working ability, the financial strain and the overall QoL scores were improved significantly in both groups, while the cognitive functioning score was found to be significantly improved during the follow-up only in group 1. The overall increase in the QoL score correlated significantly with the increase in body weight and the decrease in defecation number in both groups. CONCLUSIONS Pancreatic enzyme replacement therapy in patients with chronic pancreatitis not only reduced the extent of steatorrhea and pain, but also significantly improved a variety of other symptoms and the patient's QoL. Individually tailored enzyme replacement therapy improved the QoL not only in the untreated chronic pancreatitis patients, but also in the inadequately treated group. This study demonstrated that the EORTC QLQ-C30 questionnaire, with the addition of two further questions about steatorrhea, is a useful tool for the evaluation of QoL in patients with chronic pancreatitis.
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Affiliation(s)
- László Czakó
- First Department of Medicine, Semmelweis University, Budapest.
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Abstract
Objective—
Proof of principle is presented for targeted enzyme supplementation by using lysosomal acid lipase to decrease aortic and coronary wall lipid accumulation in a mouse model of atherosclerosis.
Methods and Results—
Mice with LDL receptor deficiency were placed on an atherogenic diet and developed predictable aortic and coronary atheroma. α-Mannosyl-terminated human lysosomal acid lipase (phLAL) was produced in
Pichia pastoris
, purified, and administered intravenously to such mice with either early or late lesions. phLAL injections reduced plasma, hepatic, and splenic cholesteryl esters and triglycerides in affected mice. phLAL was detected in hepatic Kupffer cells and in atheromatous foam cells. Repeated enzyme injections were well tolerated, with no obvious adverse effects. In addition, the coronary and aortic atheromatous lesions were (1) eliminated in their early stages and (2) quantitatively and qualitatively reduced in their advanced stages.
Conclusion—
These results support the potential utility of lysosomal acid lipase supplementation for the treatment of atherosclerosis, a leading cause of mortality and morbidity in Westernized nations.
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Affiliation(s)
- Hong Du
- Division and Program in Human Genetics, Children's Hospital Research Foundation, Cincinnati, OH 45229, USA
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29
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Abstract
BACKGROUND Due to maldigestion of dietary lipids, fat soluble vitamins are prone to malabsorption in cystic fibrosis (CF) patients with pancreatic insufficiency (PICF). Routine supplementation of vitamin K(1) in PICF is presently subject of discussion. METHODS Serum vitamin K, prothrombin time, PIVKA-II ('liver marker', by two different ELISAs), hydroxyapatite binding capacity (HBC, 'bone marker') and ApoE genotypes were measured in 32 PICF patients (age: 7 months to 25 years) with (PICFK) or without (PICFN) oral vitamin K(1) supplementation, all receiving lipase supplementation, and in 18 healthy controls (C). RESULTS PIVKA-II was positive only in 4/7 PICFN. HBC medians of all groups were 57-60%. HBC values of PIVKA-II positive patients were below HBC median of their group. There was no correlation between HBC and PIVKA-II. There was no correlation between prothrombin time and other measurements. HBC medians with regard to ApoE were ApoE2/3 (62.9%)>ApoE3/3 (57.6%)>ApoE3/4+ApoE4/4=(56.65%). CONCLUSIONS Vitamin K deficiency of liver or bone may occur independently. Prothrombin time is an insensitive marker. Individuals with ApoE4 allels might be more susceptible to osteopenia. As high expenditures are necessary to detect patients at risk, routine vitamin K supplementation for all PICF patients appears appropriate.
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Affiliation(s)
- Katharina Mosler
- Department of Paediatrics, Heinrich Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany.
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30
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Abstract
Treatment of steatorrhea by lipase supplementation therapy has become more successful in the last decade due to better understanding of the physiology and pathophysiology of the digestive process. Porcine lipase has been the therapeutic standard for several decades and will continue to be the treatment of choice in pancreatic exocrine insufficiency. Modern therapeutic concepts recommend administration of 25,000-40,000 units of porcine lipase per meal using pH-sensitive pancreatin microspheres. In case of treatment failure, the dose should be increased, compliance should be checked, and other reasons for malabsorption should be excluded. Still, in most patients, lipid digestion cannot be completely normalized by current standard therapy, and future developments are needed for optimizing treatment. In this article, pathophysiologic characteristics of pancreatic exocrine insufficiency, prerequisites for use of alternative lipase sources as well as currently available lipases of nonporcine origin, and new developments are discussed. Current literature suggests that bovine lipase products present a theoretical alternative but play no major role in the western world. Fungal lipase has inferior properties compared with conventional products. Bacterial lipase products show promising potential and offer future therapeutic alternatives. Moreover, human pancreatic lipase gene transfer and application of bioengineered human gastric lipase appear on the horizon.
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Affiliation(s)
- Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
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31
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Abstract
Lysosomal acid lipase (LAL) is the critical enzyme for the hydrolysis of the triglycerides (TG) and cholesteryl esters (CE) delivered to lysosomes. Its deficiency produces two human phenotypes, Wolman disease (WD) and cholesteryl ester storage disease (CESD). A targeted disruption of the LAL locus produced a null (lal( -/-)) mouse model that mimics human WD/CESD. The potential for enzyme therapy was tested using mannose terminated human LAL expressed in Pichia pastoris (phLAL), purified, and administered by tail vein injections to lal( -/-) mice. Mannose receptor (MR)-dependent uptake and lysosomal targeting of phLAL were evidenced ex vivo using competitive assays with MR-positive J774E cells, a murine monocyte/macrophage line, immunofluorescence and western blots. Following (bolus) IV injection, phLAL was detected in Kupffer cells, lung macrophages and intestinal macrophages in lal( -/-) mice. Two-month-old lal( -/-) mice received phLAL (1.5 U/dose) or saline injections once every 3 days for 30 days (10 doses). The treated lal( -/-) mice showed nearly complete resolution of hepatic yellow coloration; hepatic weight decreased by approximately 36% compared to PBS-treated lal( -/-) mice. Histologic analyses of numerous tissues from phLAL-treated mice showed reductions in macrophage lipid storage. TG and cholesterol levels decreased by approximately 50% in liver, 69% in spleen and 50% in small intestine. These studies provide feasibility for LAL enzyme therapy in human WD and CESD.
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Affiliation(s)
- H Du
- The Children's Hospital Research Foundation, Division of Human Genetics, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
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32
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Abstract
INTRODUCTION The number of patients with glucose tolerance alterations associated with cystic fibrosis (CF) has increased, probably due to the greater survival rate among sufferers of this disease. We studied impaired glucose tolerance (IGT) in patients with CF and investigated whether its appearance has any relationship with age, sex, genetic mutation and/or the degree of clinical involvement. We assessed the parameters that might allow early detection. PATIENTS AND METHODS In 28 patients with CF (14 M, 14 F; aged 22 months to 18 years), sex, genetic mutation, nutritional status and the degree of pancreatic and pulmonary involvement were recorded. The metabolic study included glycosylated hemoglobin (HbA1c) determination, oral glucose tolerance test (OGTT) and intravenous glucose tolerance tests (IVGTT). RESULTS In the patients with CF, 35.71% showed impaired glucose tolerance (IGT) and 3.57% had diabetes mellitus. The patients with IGT and CF were 3.2 years older than those with normal glucose tolerance (NGT; p<0.05), but no significant differences were found regarding sex, anthropometric measurements, percentage of pulmonary gammagraphic involvement, Shwachman-Kulczycki test or HbA1c. In the OGTT, the patients homozygous for the deltaF508 mutation had higher blood glucose values than the heterozygous group (p=0.03), but these values were not higher than those in patients with other mutations. During the OGTT, blood insulin values at 30' were reduced in patients with IGT compared to patients with NGT (p<0.02) and the insulin peak occurred at 100.9+/-24.3 min compared to 65.3+/-21.8, respectively (p<0.05). In the IVGTT, 82.14% of the patients had reduced insulin levels at 1 and 3 min (I1'+3'). No differences in the blood glucose levels during the OGTT were found between patients with normal I1'+3' values and patients with reduced values. CONCLUSIONS A high percentage of patients with CF also present with IGT. This increases with age and is more common among patients homozygous for the deltaF508 mutation and is not related to clinical status. Alterations in the kinetics of insulin secretion play an important role in the appearance of IGT and CF. We suggest that the OGTT is a more sensitive method than IVGTT for identifying early alterations in CF-related diabetes mellitus.
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Affiliation(s)
- J M Garagorri
- Unit of Pediatric Endocrinology, Lozano Blesa University Clinic Hospital, Zaragoza, Spain.
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33
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Abstract
Major pancreatic resection can cause pancreatic enzyme insufficiency with fat malabsorption, resulting in symptoms of abdominal pain, steatorrhoea and weight loss which can be extremely debilitating. The most important factors influencing subsequent development of steatorrhoea are the extent and type of surgical resection and the underlying disease process. The resultant steatorrhoea can be marked and difficult to control. There have been relatively few randomised controlled studies which have addressed this particular problem in patients who have had pancreatectomy. The use of effective doses of pancreatic enzyme supplements is essential in those patients who are symptomatic. When stabilised on therapeutically effective doses of pancreatic enzyme supplements, however, over 30% of patients still have evidence of significant levels of steatorrhoea. These results emphasise that the complete eradication of steatorrhoea is still not feasible at the present time, even using the best currently available agents, highlighting the need for further effective therapies.
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Affiliation(s)
- P Ghaneh
- Department of Surgery, University of Liverpool, 5th Floor UCD Building, Liverpool, UK
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34
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Abstract
In the majority of patients, pancreatin microsphere preparations containing 25,000-40,000 FIP units of lipase will lead to a clinical improvement and reduction of steatorrhea in patients with exocrine pancreatic insufficiency. In patients failing to respond, the following stepwise procedure is recommended: increasing enzyme dosage; checking the patient's compliance; reevaluating the diagnosis; and as a last resort to decrease fat intake or adding H2-blockers or proton pump inhibitors. Although this stepwise procedure is time-consuming, it is necessary to prevent in patients not responding to pancreatic enzyme substitution the development of late complications of exocrine pancreatic insufficiency.
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Affiliation(s)
- P G Lankisch
- Department of Internal Medicine, Municipal Clinic of Lüneburg, Germany
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35
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Abstract
A woman, then in her late 20s, underwent a cholecystectomy in 1962 for gallstone disease and subsequent common bile duct stones were managed endoscopically. However, because of unrelenting pain, a pylorus preserving pancreaticoduodenectomy was done in 1990 and in the following years the patient took large amounts of pancreatic enzyme supplements. She developed large bowel obstruction in 1997 and a right hemicolectomy was undertaken. Histology confirmed fibrosing colonopathy of the ascending colon and caecum. Her pancreatic enzyme dose was reduced and her subsequent course has been uncomplicated.
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Affiliation(s)
- D S Bansi
- Department of Gastroenterology, The Middlesex Hospital, Mortimer Street, London W1N 8AA, UK
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36
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Affiliation(s)
- J A Dodge
- Department of Child Health, University of Wales Swansea, Singleton Hospital, Swansea SA2 8QA, UK
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37
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Hardt PD, Helfrich C, Klauke T, Klör HU. Liquid pancreatic enzyme therapy for a patient with short bowel syndrome and chronic pancreatitis in a complicated case of Crohn's disease. Eur J Med Res 1999; 4:345-6. [PMID: 10471547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
The case of a 45 year old female with multiple complications of Crohn's disease is reported. After multiple resections in the gastrointestinal tract she had been suffering from short bowel syndrome and severe malnutrition. With a special continuous gastric tube feeding system, she was able to maintain her weight for years. In the beginning of 1997 the enteral nutrition was not longer tolerated for an exacerbation of chronic pancreatitis. There was a weight loss, permanent pain and total parenteral nutrition had to be performed. In this situation a new liquid preparation of pancreatic enzymes which had been tested in the laboratory before, was used for continuous enzyme replacement via gastric tube. In combination with this enzyme preparation, enteral nutrition could successfully be started again.
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Affiliation(s)
- P D Hardt
- Third Medical Department, University of Giessen, Rodthohl 6, D-35385 Giessen, Germany.
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38
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Dzieniszewski J, Jarosz M. [Pancreatic preparations in clinical practice]. Pol Arch Med Wewn 1999; 102:703-8. [PMID: 10948704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- J Dzieniszewski
- Klinika Chorób Metabolicznych i Gastroenterologii, Instytutu Zywnościi Zywienia w Warszawie
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39
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Brägelmann R, Armbrecht U, Rosemeyer D, Schneider B, Zilly W, Stockbrügger RW. The effect of pancreatic enzyme supplementation in patients with steatorrhoea after total gastrectomy. Eur J Gastroenterol Hepatol 1999; 11:231-7. [PMID: 10333193 DOI: 10.1097/00042737-199903000-00004] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the influence of pancreatic enzyme supplementation on symptoms, energy intake, bowel habits, and fat malassimilation in patients after total gastrectomy. DESIGN A prospective, double-blind, randomized, parallel, placebo-controlled, multi-centre trial. SETTING Institutionalized patients in three gastroenterological rehabilitation clinics. PARTICIPANTS 52 institutionalized patients with a faecal fat output > or = 14 g/day, operated on for malignant gastric disease a median of 198 days (interquartile range (IQR) 47-608) previously, and free from recurrence and/or metastasis. INTERVENTIONS Nine sachets of pancreatic enzymes per day (each containing lipase 36,000, amylase 27,000, protease 2400 FIP (Federation International Pharmaceutique)) or identical-looking placebo were given for 14 days. MAIN OUTCOME MEASURES Abdominal symptoms, energy intake, bowel habits and fat malassimilation. RESULTS After treatment, patients on enzyme therapy felt better overall (P = 0.006), but no improvement of a specific symptom could be identified. During the intervention, the median kilojoule intake per kilogram body weight was 9% higher in the placebo group (170.8 (IQR 146.9-202.6)) than in the enzyme-treated group (157.0 (IQR 134.8-170.4)) (P = 0.03). Enzyme treatment did not result in a significant difference between the placebo and the enzyme-treated group regarding bowel habits or fat malassimilation. CONCLUSIONS The effect of high-dose pancreatic enzymes supplementation on symptoms and steatorrhoea after total gastrectomy is marginal and does not justify its routine use.
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Affiliation(s)
- R Brägelmann
- Department of Gastroenterology, Academisch Ziekenhuis, Maastricht, The Netherlands
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40
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Connett GJ, Lucas JS, Atchley JT, Fairhurst JJ, Rolles CJ. Colonic wall thickening is related to age and not dose of high strength pancreatin microspheres in children with cystic fibrosis. Eur J Gastroenterol Hepatol 1999; 11:181-3. [PMID: 10102230 DOI: 10.1097/00042737-199902000-00020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Colonic fibrosis causing stricture is a recently described complication in cystic fibrosis (CF). Studies have suggested that ultrasound evidence of bowel thickening predicts this complication and that it is prevalent among children receiving large doses of high-strength pancreatin preparations. We performed ultrasound studies on our patients to look for evidence of bowel wall thickening or early stricture. METHOD Detailed colonic ultrasounds were carried out in 33 children with CF including 25 who had been receiving high-strength pancreatin (Creon 25,000) continuously for 3 years at the time of study. RESULTS Median lipase intake was 19 330 U/kg/day (range 0-59 880 U/kg/day) and median protease intake was 387 U/kg/day (range 0-1170 U/kg/day). The combined thickness of mucosa, sub-mucosa and muscle layers was measured in ascending, transverse and descending colon using a 7.5 MHz transducer. Measurements were also made in nine healthy controls. There was no relationship between enzyme dosage and colon thickness but simple regression identified a significant relationship (P < 0.001) between age and maximum colon thickness in all three areas. The colon of CF children was up to 50% thicker than in controls. CONCLUSIONS Thickening of the order described elsewhere did not occur among any of the children studied. The results suggest that the most important factor determining the thickness of the CF colon is age.
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Affiliation(s)
- G J Connett
- Regional Cystic Fibrosis Centre, Department of Paediatrics, Southampton University Hospitals Trust, UK
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41
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Okhlobystin AV, Bayarmaa N. [Enzyme preparations in conservative treatment of chronic pancreatitis]. TERAPEVT ARKH 1998; 70:86-8. [PMID: 9864814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
AIM To study effectiveness of enzyme medicine pancitrate 25,000 in the treatment of chronic pancreatitis (CP). MATERIALS AND METHODS Pain, stool, creato- and steatorea, other signs of CP were examined before and after pancitrate treatment of 17 patients with chronic pancreatitis aged from 28 to 62 years. RESULTS Pancitrate 25,000 reduced stomach pains in 16 of 17 patients. Stool returned to normal in 8 of 13 patients. Creato- and steatorea decreased. CONCLUSION New dosage forms of the enzyme preparations (pancitrate 25,000, in particular) are highly effective both in deficiency of pancreatic external secretion and pain relief in exacerbation of CP.
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42
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Abstract
Increased colonic wall thickness has been reported in patients exposed to large doses of high strength pancreatic enzyme preparations who did not develop fibrosing colonopathy. This has been interpreted as evidence for a spectrum of subclinical disease. The relation between sonographically measured colonic wall thickness and pancreatic enzyme preparation and dose was studied in 86 children with cystic fibrosis (CF). Colonic wall thickness of a control group was also measured. The average thickness in all colonic regions was higher in the CF group (overall average range 0.7-2.5 mm v 0.6-1.4 mm in the control group). There was no significant relation between colonic wall thickness and age, sex, total dose of lipase, or copolymer. Apart from one patient with an early colonic stricture, none of those exposed to high doses of lipase, or the methacrylic acid copolymer Eudragit L30 D55, showed evidence of subclinical damage to the colon. The reproducibility of the sonographic measurements was poor.
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Affiliation(s)
- W H Ramsden
- Regional Paediatric Cystic Fibrosis Unit, St James's University Hospital, Leeds, UK
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43
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Abstract
BACKGROUND Earlier studies report the excessive faecal excretions of bile acids and dietary residues in cystic fibrosis (CF). However, few of these investigated large groups of patients using modern pancreatin preparations and little data exists reporting carbohydrate excretion. We therefore aimed to characterise the general levels of malabsorption within age groups of 132 patients attending a regional CF centre. METHODS The faecal excretions of bile acids, fat, nitrogen and carbohydrate were measured. Most of these patients were treated with either (Creon) (n = 58) or Pancrease (n = 51) and prophylactic antibiotics. The patients were grouped in age ranges 0.5 to 5 years, 6 to 10 years, 11 to 15 years and >16 years. Carbohydrate excretion was determined in the 11 to 15 year group. RESULTS Increased excretions with increment in age group were found which, for bile acids, was twice that of age matched controls. Modest relationships were found between the overall excretion of bile acids and fat, and between the excretion of bile acids and nitrogen. Primary bile acids were a feature of cystic fibrosis stools but the patterns of individual bile acid excretion revealed a trend towards a normal bile acid types with increment in age group. Faecal carbohydrate was significantly increased to levels which may significantly alter large bowel microflora. CONCLUSIONS The data adds to the evidence that maldigestion initiates bile acid sequestration and consequently, the predominance of primary bile acids.
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Affiliation(s)
- M P Walters
- Department of Chemical Pathology, St James's University Hospital, Leeds, United Kingdom
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44
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Abstract
AIM To examine the gastrointestinal handling and metabolic disposal of emulsified [1-13C]palmitic acid esterified into a triglyceride in nine healthy children and seven patients with cystic fibrosis on enzyme replacement treatment. METHODS After an overnight fast, each child was given 10 mg/kg body weight [1,1,1-13C]tripalmitin with a standardised test meal of low natural 13C abundance. The total enrichment of 13C was measured using isotope ratio mass spectrometry in stool collected for a period of up to five days and in breath samples collected over a 24 hour period. RESULTS The mean proportion of administered 13C label excreted in stool was 6% (range, 1-12.7%) in healthy children and 24.6% (range, 0-64%) in patients with cystic fibrosis. Healthy children excreted 31.3% of the administered label on their breath (range, 14.2-42.9%). Correcting the excretion of administered 13C label on the breath for differences in digestion and absorption in patients with cystic fibrosis increased the difference between individuals from 0-31.3% of administered dose (mean, 17.9%) to 0-49.1% of absorbed dose (mean, 23.2%) and was poorly related to the amount of 13C label in stool. CONCLUSION Measurements of breath 13CO2 do not consistently reflect the gastrointestinal handling of emulsified 13C labelled tripalmitin because of differences in digestion and absorption in cystic fibrosis. Further studies need to examine whether "breath tests" alone can predict with confidence the gastrointestinal handling of other 13C labelled triglycerides and fatty acids.
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Affiliation(s)
- J L Murphy
- Institute of Human Nutrition, University of Southampton, UK
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45
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De Boeck K, Delbeke I, Eggermont E, Veereman-Wauters G, Ghoos Y. Lipid digestion in cystic fibrosis: comparison of conventional and high-lipase enzyme therapy using the mixed-triglyceride breath test. J Pediatr Gastroenterol Nutr 1998; 26:408-11. [PMID: 9552136 DOI: 10.1097/00005176-199804000-00009] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fat maldigestion occurs in most patients with cystic fibrosis. Conventional pancreatic enzyme replacement therapy partially corrects this defect. In this study, the mixed-triglyceride breath test was used to evaluate whether high-lipase enzymes are equivalent to conventional enzymes in improving fat maldigestion in children with cystic fibrosis. METHODS Fat digestion was studied in 11 patients with a mean age of 10.5 years. The mean intake of conventional enzyme capsules a day was 19. Four 13C mixed-triglyceride tests were performed on separate days and in random order. One test was taken without enzyme substitution, one with three capsules of 8,000 FIP units Creon (pancreatinum, Kali-chemie Pharma, Hannover, Germany) and one with one capsule of 25,000 FIP units. The fourth test was made with 13C octanoic acid to study gastric emptying time. RESULTS Without enzyme intake, the mean cumulative percentage of 13C dose exhaled after 6 hours was 7.2+/-3.7%. This increased to 14.4+/-4% with intake of conventional pancreatinum and to 14.3+/-5.1% with intake of high-lipase pancreatinum (p = 0.0008 for both; paired t-test). There was no difference between both treatments. Also, the time course of 13C exhalation measured by percentage of 13CO2 exhaled per hour did not differ between enzyme treatments. CONCLUSIONS The 13C mixed-triglyceride test is noninvasive and documents improved lipid digestion with pancreatic enzyme replacement therapy. If the lipase dose is kept constant, results obtained with high-lipase preparations are equivalent to those obtained with conventional preparations.
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Affiliation(s)
- K De Boeck
- Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
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46
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Abstract
Most patients with cystic fibrosis require oral administration of pancreatic enzymes to treat pancreatic insufficiency. Recent use of higher-strength enzyme preparations in large doses has been found to be associated with fibrotic strictures of the colon. We report a case of pancolonic fibrosis due to pancreatic enzyme use.
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Affiliation(s)
- R L Moss
- Packard Children's Hospital, Stanford University School of Medicine, Division of Pediatric Surgery, Palo Alto, California 94304, USA
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47
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Abstract
BACKGROUND Length of survival of females with cystic fibrosis is worse than it is in males. Results of current research have shown an important correlation among dietary intake, nutritional status, lung function, and survival. The purpose of this study was to explore gender differences in dietary intake and pancreatic enzyme replacement therapy in males and females with cystic fibrosis. METHODS The study was a cross-sectional measurement of clinical characteristics, energy, and fat intakes in males and females attending the cystic fibrosis outpatients clinics of the John Hunter Hospital, Newcastle, Australia. Twenty-nine subjects, (17 females and 12 males), completed 4-day weighed food records to measure total energy intake and the contribution of macronutrients and to document use of pancreatic enzyme replacement therapy. Energy intake was assessed as the percentage of the recommended energy intake for age and sex. RESULTS Females with cystic fibrosis had significantly lower energy and fat intakes than males, whereas the females used significantly more pancreatic enzyme replacement therapy. There were no significant differences in clinical characteristics between groups. CONCLUSION The results support the possibility that gender differences in the energy and fat intakes of older patients may contribute to differential median survival time of males and females with cystic fibrosis.
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Affiliation(s)
- C E Collins
- Department of Nutrition and Dietetics, John Hunter Children's Hospital, New South Wales, Australia
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48
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Affiliation(s)
- T Browning
- Earlwood Animal Hospital, Earlwood, New South Wales
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49
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Stevens JC, Maguiness KM, Hollingsworth J, Heilman DK, Chong SK. Pancreatic enzyme supplementation in cystic fibrosis patients before and after fibrosing colonopathy. J Pediatr Gastroenterol Nutr 1998; 26:80-4. [PMID: 9443125 DOI: 10.1097/00005176-199801000-00014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 1994 we cared for nine cystic fibrosis patients with fibrosing colonopathy. To evaluate the relationship between fibrosing colonopathy and supplemental pancreatic enzymes we reviewed our dosing of enzymes prior to fibrosing colonopathy development and then evaluated the subsequent effect of drastically reducing pancreatic enzyme dose. METHODS We retrospectively reviewed pancreatic enzyme dosing for 267 cystic fibrosis patients with pancreatic insufficiency. The supplemental enzyme history of nine patients with fibrosing colonopathy was contrasted with the history of 258 nonaffected patients. The pancreatic enzyme doses of 75 patients taking at least 6,000 U lipase/kg/meal were systematically reduced to approximately 2,000 lipase units/kg/meal. We evaluated the effect of this dose reduction on change in height and weight z scores one year after achievement of stable enzyme dose. RESULTS In the year prior to diagnosis patients with fibrosing colonopathy took a significantly larger pancreatic enzyme dose, whether assessed by highest dose or cumulative dose, than did nonaffected patients. Similar results were observed after controlling for sex and age. All 75 patients on at least 6,000 U lipase/kg/meal were able to tolerate a significant reduction in dose while achieving clinically acceptable nutrient absorption, with no change over one year in height and weight z scores. CONCLUSIONS Our data demonstrate a strong relationship between very high doses of pancreatic enzyme supplementation and formation of fibrosing colonopathy. These very high doses do not appear to be needed for adequate nutrient absorption and growth.
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Affiliation(s)
- J C Stevens
- Section of Pediatric Pulmonology, Indiana University School of Medicine, Indianapolis, USA
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50
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Abstract
BACKGROUND In 1994, first published reports described cystic fibrosis patients who experienced a then unknown complication-ileocecal and colonic stenoses with submucosal proliferation requiring surgical intervention. To investigate a suspected correlation between increased intestinal wall diameter and high doses of pancreatic enzymes, we carried out a prospective study in our CF-outpatient clinic. METHODS By ultrasound analysis we measured the intestinal wall diameter in 201 patients. One hundred ninety-three patients treated with pancreatic enzymes had pancreatic insufficiency. Eight patients showed normal pancreatic function, seven of them had never been treated with pancreatic enzymes. The control group included 12 healthy children. Measuring points were the distal ileum, cecum, ascending, and descending colon. Measurements were made by the longitudinal and cross sectional cut. The following aspects of the patients' history were recorded (a) current type of pancreatic enzyme medication; (b) total dosage per day (with reference to lipase units); (c) duration of therapy with standard-strength pancreatic enzyme (SSPE) preparations (< or = 10,000 lipase units per capsule) and HSPE preparations (> or = 20,000 lipase units per capsule); (d) gastrointestinal complication (distal intestinal obstruction syndrome, meconium ileus, abdominal surgery, intussusception), diabetes mellitus, and hepatobiliary complications. RESULTS The intestinal wall diameter in patients receiving HSPE therapy was greater (with prominent submucosal layer) than that in patients receiving SSPE therapy or in patients with pancreatic sufficiency. Healthy subjects had the smallest intestinal wall diameter. There was no correlation between patient history and increased intestinal wall thickness. CONCLUSIONS Ultrasound detects characteristic ileocecal wall lesions in the majority of cystic fibrosis patients on pancreatic enzymes. These lesions may lead to significantly increased ileocecal wall thickness, which is correlated but not restricted to HSPE.
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Affiliation(s)
- M Pohl
- Center for Pediatrics, University Hospital, Frankfurt/Main, Germany
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