Hyperhomocystéinémie et facteurs associés au cours des MICI : étude prospective chez 81 patients

Enteropathic spondyloarthritis: from diagnosis to treatment

Enteropathic arthritis (EA) is a spondyloarthritis (SpA) which occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases. Diagnosis is generally established on the medical history and physical examination. It was, generally, made according to the European Spondyloarthropathy Study Group (ESSG) criteria. Rheumatic manifestations are the most frequent extraintestinal findings of IBD with a prevalence between 17% and 39%, and IBD is associated, less frequently, with other rheumatic disease such as rheumatoid arthritis, Sjogren syndrome, Takayasu arteritis, and fibromyalgia. Although the pathogenesis of EA has not been plainly clarified, the most popular theory supposes that joint inflammation occurs in genetically predisposed subjects with bacterial gut infections, provided an important evidence for a possible relationship between inflammation of the gut mucosa and arthritis. The management of patients with EA requires an active cooperation between the gastroenterologist and rheumatologist.

Hyperhomocysteinemia in patients with Crohn's disease

BACKGROUND

Thromboembolic complications have been reported in patients with Crohn's disease. Among the contributing factors, hyperhomocysteinemia has been described, although controversial data exist. The aim of our study was to assess the incidence of hyperhomocysteinemia in a nonselected group of patients with Crohn's disease and to determine whether it might represent a risk marker for thrombosis in such patients.

METHODS

Fifty consecutive patients were recruited, and clinical and laboratory variables were compared between those without and those with hyperhomocysteinemia. In the latter, gene mutations in N5-N10-methyltetrahydrofolate reductase were searched for, and clinical and laboratory variables were related to hyperhomocysteinemia. The presence/absence of thrombotic episodes in both groups was determined.

RESULTS

Both groups had similar clinically active disease, with higher C-reactive protein values found in those with hyperhomocysteinemia. Hyperhomocysteinemia was found in 46 % of patients. Of these, 74 % had moderate, 13 % intermediate, and 13 % severe increase in serum homocysteine levels. No relationship was found between homocysteine levels, and age, vitamin B12 levels, folic acid levels, Crohn's Disease Activity Index score, and CRP values. Gene mutations were found in 5 (22 %) patients, 2 homozygotes and 3 heterozygotes. None of the patients with or without hyperhomocysteinemia had episodes of venous or arterial thrombosis, or stroke.

CONCLUSIONS

Hyperhomocysteinemia is frequent in patients with Crohn's disease, and it could be a cofactor for the pathogenesis of thrombotic episodes.

Meta-analysis: hyperhomocysteinaemia in inflammatory bowel diseases

BACKGROUND

The magnitude of association between homocysteine metabolism and inflammatory bowel diseases (IBD) remains unknown, whereas the association between hyperhomocysteinaemia and thrombosis remains controversial in IBD.

AIM

To conduct a systematic review and meta-analysis to examine these issues.

METHODS

The literature search was conducted using MEDLINE database and international conference abstracts from January 1966 to April 2011 and included all studies that evaluated plasma homocysteine level in IBD.

RESULTS

Twenty-eight studies evaluated the plasma homocysteine level and/or hyperhomocysteinaemia risk in IBD patients. Five studies assessed the association of hyperhomocysteinaemia with thrombosis. The mean plasma homocysteine level was significantly higher in IBD patients when compared with controls (weighted mean difference (WMD)=3.75 μmol/L; 95% CI, 2.23-5.26 μmol/L; P<0.0001; reference ranges for plasma homocysteine level: 5-12 μmol/L). The mean plasma homocysteine level did not differ between ulcerative colitis (UC) and Crohn's disease (CD) (WMD=0.41 μmol/L; 95% CI, -2.45 to 3.06 μmol/L; P=0.76). The risk of hyperhomocysteinaemia was significantly higher in IBD patients when compared with controls [odds ratio (OR)=4.65; 95% CI, 3.04-7.09; P<0.0001]. The risk of hyperhomocysteinaemia was not higher among IBD patients who experienced thromboembolic complications (OR=1.97; 95% CI, 0.83-4.67; P=0.12). Plasma folate level was inversely correlated with IBD risk associated with MTHFR C677T polymorphism (P=0.006).

CONCLUSIONS

The risk of hyperhomocysteinaemia is significantly higher in IBD patients when compared with controls. The risk assessment of hyperhomocysteinaemia-related thrombosis in IBD requires further investigation. Deficient folate status is associated with a higher impact of MTHFR C677T polymorphism on IBD risk.

Prevalence and risk factors of hyperhomocysteinemia in Tunisian patients with Crohn's disease

BACKGROUND AND AIMS

The role of hyperhomocysteinemia (HHC) and its determinants in Crohn's disease (CD) remain uncertain. This study was aimed to determine the prevalence of HHC and its main risk factors in Tunisian patients with CD.

METHODS

This study included 89 patients with CD and 103 age- and sex-matched healthy subjects. Fasting venous blood was collected in all subjects allowing the assessment of homocysteine, folate, vitamin B(12), C-reactive protein and creatinine levels. Logistic regression models were applied to identify factors associated with HHC in CD patients.

RESULTS

Plasma homocysteine was higher (13.69 ± 4.84μmol/l vs. 10.77 ± 2.80μmol/l; p<0.01) and HHC was more frequent (31.5% vs. 7.8%; p<0.001) in patients compared with controls. The association between HHC and CD persisted after adjustment for smoking, body mass index and serum folate, vitamin B(12), creatinine and C-reactive protein. In patients with CD, multivariate analysis showed that HHC was positively associated with age [multi-adjusted odds-ratio (95% confidence interval): 1.14 (1.06-1.24); p<0.001], active disease [7.54 (1.15-49.3); p=0.03], disease duration >2 years [8.69 (1.53-49.3); p=0.02] and inversely related to plasma folate [0.64 (0.48-0.84); p=0.002] and vitamin B(12) (0.993 (0.987-0.999); p=0.02].

CONCLUSION

HHC is common in Tunisian patients with CD and is related to B vitamins deficit, as well as disease activity and duration. Further studies should test the effect of correction of HHC by vitamin B supplementation on progression and complications of CD.

ESPEN Guidelines on Parenteral Nutrition: gastroenterology

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Increased folate intake with no changes in serum homocysteine and decreased levels of C-reactive protein in patients with inflammatory bowel diseases

In order to increase dietary folic acid intake and to improve nutritional status regarding folate by controlling homocysteine concentrations, ten patients with inflammatory bowel diseases (Crohn's disease in the colon and ulcerative colitis) received individualized nutritional guidance and were followed up as outpatients for 2 months. The following procedures were performed at the beginning of the study (T0), after 1 month (T1) and at the end of the study (T2): collection of anthropometric data (weight and height), dietary data (24 h diet recall), and blood under fasting condition for the determination of serum folic acid, homocysteine, C-reactive protein, and vitamin B12. Plasma folic acid deficiency was not detected but hyperhomocysteinemia was present in six individuals and C-reactive protein (CRP) was increased (>0.5 mg/dl) in seven patients. After the patients were instructed there was a significant increase in vitamin B6 intake (about 35%) and in folate intake (49.6%). Mean plasma levels of folic acid, homocysteine, and vitamin B12 did not change, but there was a significant decrease of CRP at T1, 0.36 mg dl(-1) on average (P = 0.01), which was maintained at T2. We conclude that the increased folate intake reported by this group of patients was not reflected in improved serum concentrations of folic acid and homocysteine. However, the guidelines for the patients probably induced them to choose a more adequate diet, providing nutrients that help control the inflammatory process.

Association of hyperhomocysteinemia and folate deficiency with colon tumors in patients with inflammatory bowel disease

BACKGROUND

Folate deficiency associated with hyperhomocysteinemia might increase the risk of developing colorectal cancer. The aim of this study was to evaluate factors associated with colonic carcinogenesis, in particular, folate and homocysteinemia levels, in a cross-sectional study of patients with inflammatory bowel disease (IBD).

METHODS

IBD patients with carcinogenic lesions discovered during colonoscopy [dysplasia-associated lesion or masses (DALM), colorectal cancer] were included and compared with the whole population of IBD patients with a normal colonoscopy performed during the same period. The following parameters were collected at the time of colonoscopy: age, sex, type, duration, activity, and extent of the disease, treatment, smoking status, and vitamin B12, folate, and homocysteinemia levels. Univariate and multivariate analyses were performed after adjusting for the main parameters.

RESULTS

One hundred and fourteen patients [41 with ulcerative colitis (UC), 73 with Crohn's disease (CD)] were included. Twenty-six carcinogenic lesions were isolated: 18 DALM (7 high-grade and 11 low-grade dysplasia) and 8 colorectal cancers. In univariate analysis, the factors associated with carcinogenesis were: active smoking (P = 0.03), folate level < 145 pmol/L (P = 0.02), hyperhomocysteinemia > 15 micromol/L (P = 0.003), duration of disease > 10 years (P = 0.006), and UC (P = 0.02). In multivariate analysis, patients with hyperhomocysteinemia associated with folate deficiency had 17 times as many carcinogenic lesions as patients with normal homocysteinemia whatever the folate status and duration of the disease (P = 0.01). Patients with hyperhomocysteinemia without folate deficiency had 2.5 times as many carcinogenic lesions as patients with normal homocysteinemia (P = 0.08).

CONCLUSIONS

Our data suggest that in IBD patients with normal homocysteinemia, the increase in carcinogenic risk is negligible. Conversely, in patients with hyperhomocysteinemia, folate deficiency may be associated with increased colorectal carcinogenesis in IBD patients.

Hyperhomocysteinaemia is associated with osteoporosis in patients with Crohn's disease

BACKGROUND

A high prevalence of osteoporosis is observed in Crohn's disease. Recent data have shown that homocysteinaemia is an important risk factor in low-bone mineralization and fracture.

AIM

To look for an association between homocysteinaemia and low-bone mineralization in Crohn's disease patients.

PATIENTS AND METHODS

Ninety-two consecutive patients (sex ratio M/F 0.87; mean age: 36.6 +/- 13.2 years) were recruited between 2003 and 2005. Bone densitometry was performed on inclusion. The following parameters were analysed: age, sex, Crohn's Disease Activity Index, duration and extent of Crohn's disease, smoking status, corticosteroid treatment, immunosuppressive drugs, plasma homocysteine, folate and vitamin B12 concentration.

RESULTS

The prevalence of a high homocysteine level (>15 micromol/L) was 60%. Osteoporosis and low-bone mineralization observed in 26 (28%), and 60 (65%) patients, respectively. On a multivariate analysis, associated factors for osteoporosis and low-bone mineralization were respectively: hyperhomocysteinaemia (OR: 61.4; CI: 95: 23-250; P < 0.001), and ileal Crohn's disease [OR: 13.8; CI: 95: 2.5-150; P = 0.036] for osteoporosis and hyperhomocysteinaemia [OR: 63.7; CI: 95: 8.5-250; P < 0.001] and disease duration of at least 5 years [OR: 11.4; CI: 95: 1.31-99; P = 0.039] for low-bone mineralization. Results were similar whichever site osteoporosis was detected.

CONCLUSION

Hyperhomocysteinaemia was observed in 60% of our Crohn's disease patients and was strongly associated with low-bone mineralization and osteoporosis (OR: 61.4).