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Mariotti Zani E, Grandinetti R, Cunico D, Torelli L, Fainardi V, Pisi G, Esposito S. Nutritional Care in Children with Cystic Fibrosis. Nutrients 2023; 15:nu15030479. [PMID: 36771186 PMCID: PMC9921127 DOI: 10.3390/nu15030479] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Patients with cystic fibrosis (CF) are prone to malnutrition and growth failure, mostly due to malabsorption caused by the derangement in the chloride transport across epithelial surfaces. Thus, optimal nutritional care and support should be an integral part of the management of the disease, with the aim of ameliorating clinical outcomes and life expectancy. In this report, we analyzed the nutrition support across the different ages, in patients with CF, with a focus on the relationships with growth, nutritional status, disease outcomes and the use of the CF transmembrane conductance regulator (CFTR) modulators. The nutrition support goal in CF care should begin as early as possible after diagnosis and include the achievement of an optimal nutritional status to support the growth stages and puberty development in children, that will further support the maintenance of an optimal nutritional status in adult life. The cornerstone of nutrition in patients with CF is a high calorie, high-fat diet, in conjunction with a better control of malabsorption due to pancreatic enzyme replacement therapy, and attention to the adequate supplementation of fat-soluble vitamins. When the oral caloric intake is not enough for reaching the anthropometric nutritional goals, supplemental enteral feeding should be initiated to improve growth and the nutritional status. In the last decade, the therapeutic possibilities towards CF have grown in a consistent way. The positive effects of CFTR modulators on nutritional status mainly consist in the improvement in weight gain and BMI, both in children and adults, and in an amelioration in terms of the pulmonary function and reduction of exacerbations. Several challenges need to be overcome with the development of new drugs, to transform CF from a fatal disease to a treatable chronic disease with specialized multidisciplinary care.
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Affiliation(s)
- Elena Mariotti Zani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Lisa Torelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-903524
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The fatty acid imbalance of cystic fibrosis exists at birth independent of feeding in pig and ferret models. Clin Sci (Lond) 2022; 136:1773-1791. [PMID: 36416119 PMCID: PMC9747517 DOI: 10.1042/cs20220450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022]
Abstract
Persons with cystic fibrosis (CF) exhibit a unique alteration of fatty acid composition, marked especially among polyunsaturates by relative deficiency of linoleic acid and excess of Mead acid. Relative deficiency of docosahexaenoic acid is variably found. However, the initial development of these abnormalities is not understood. We examined fatty acid composition in young CF ferrets and pigs, finding abnormalities from the day of birth onward including relative deficiency of linoleic acid in both species. Fatty acid composition abnormalities were present in both liver and serum phospholipids of newborn CF piglets even prior to feeding, including reduced linoleic acid and increased Mead acid. Serum fatty acid composition evolved over the first weeks of life in both non-CF and CF ferrets, though differences between CF and non-CF persisted. Although red blood cell phospholipid fatty acid composition was normal in newborn animals, it became perturbed in juvenile CF ferrets including relative deficiencies of linoleic and docosahexaenoic acids and excess of Mead acid. In summary, fatty acid composition abnormalities in CF pigs and ferrets exist from a young age including at birth independent of feeding and overlap extensively with the abnormalities found in humans with CF. That the abnormalities exist prior to feeding implies that dietary measures alone will not address the mechanisms of imbalance.
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Tuluce ME, Barutcu A, Yavuz S, Agin M, Cetiner S, Tumgor G. Evaluation of pancreatic functions in cases of primary and secondary malnutrition. Minerva Pediatr (Torino) 2022; 74:308-312. [DOI: 10.23736/s2724-5276.20.06028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lai HJ, Chin LH, Murali S, Bach T, Sander D, Farrell PM. Vitamins A, D, E status as related to supplementation and lung disease markers in young children with cystic fibrosis. Pediatr Pulmonol 2022; 57:935-944. [PMID: 35018747 PMCID: PMC8930603 DOI: 10.1002/ppul.25825] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/22/2021] [Accepted: 01/08/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The variable response to fat-soluble vitamin supplementation in young children with cystic fibrosis (CF), and factors contributing to this variability, remain under-investigated. OBJECTIVE To determine if recommended supplement doses normalize serum vitamins A (retinol), D (25-hydroxy-vitamin D, 25OHD), and E (α-tocopherol), and identify factors predictive of achieving sufficiency, in children with CF in the first 3 years of life. DESIGN We studied 144 infants born during 2012-2017 and diagnosed with CF through newborn screening. Serum retinol, 25OHD, α-tocopherol and plasma cytokines interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α were measured in early infancy and yearly thereafter. Vitamin supplement intakes and respiratory microbiology were assessed every 1-2 months in infancy and quarterly thereafter. RESULTS The prevalence of vitamin D insufficiency (<30 ng/ml) at all ages combined was significantly higher (22%) compared to vitamin A (<200 ng/ml, 3%) and vitamin E (<5 µg/ml, 5%). All children were vitamin A sufficient by age 2 years. Vitamin E insufficiency was rare. Only 42% were early responders of vitamin D and 17% remain insufficient despite high supplement intakes. IL-6 was positively correlated, while IL-8, IL-10, and TNF-α were negatively correlated, with retinol and 25OHD. Multiple regression analysis revealed that supplement dose, season, α-tocopherol, pancreatic insufficiency, respiratory infections and IL-10 were significant predictors of 25OHD. CONCLUSION Diagnosis through newborn screening coupled with supplementation normalized serum retinol and α-tocopherol in almost all infants with CF by age 3 years. However, response to vitamin D supplements in young children with CF occurred later and variably despite early and sustained supplementation.
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Affiliation(s)
- HuiChuan J Lai
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lyanne H Chin
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sangita Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Taiya Bach
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Danielle Sander
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Schlosser T, Fischer D, Büttner S, Blank V, Hoffmeister A. Cystic fibrosis transmembrane conductance regulator function in patients with chronic pancreatitis. Medicine (Baltimore) 2022; 101:e28904. [PMID: 35212296 PMCID: PMC8878632 DOI: 10.1097/md.0000000000028904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pathogenesis of chronic pancreatitis (CP) is still not entirely understood with many patients probably having more than 1 underlying etiology. Besides toxic-metabolic factors, genetics contribute to disease development. Mutations in cystic fibrosis transmembrane conductance regulator (CFTR) are shown to increase risk for CP. Activity of CFTR can easily be accessed in vivo by measurement of nasal potential difference (PD). METHODS We compared in this monocentric study 17 CP patients from the outpatient unit of our university hospital with 30 healthy controls regarding nasal PDs by using a superfusion protocol. Additionally, demographic and lifestyle data of all persons were recorded. RESULTS Seventeen patients (12% female, median age 48 years) with CP and 30 healthy volunteers (47% female, 25 years) were included in the study. Patients with CP had a significant higher proportion of CFTR dysfunction (P = .04). Furthermore, demographics differed between the 2 groups with CP patients being older (P < .001). There were differences in daily alcohol consumption (P = .001) and smoking habits (smokers vs nonsmokers: P = .01, pack years: P = .002). CONCLUSIONS PD measurement is an easily accessible way to show CFTR dysfunction as an etiological factor of CP. Cigarette smoking might impair CFTR function and therefore be 1 preventable cause of CP evolution.
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Affiliation(s)
- Tobias Schlosser
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Daniel Fischer
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
- Outpatient Psychiatry and Psychotherapy, Leipzig, Germany
| | - Sandra Büttner
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Valentin Blank
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Albrecht Hoffmeister
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
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Chen Q, Shen Y, Zheng J. A review of cystic fibrosis: Basic and clinical aspects. Animal Model Exp Med 2021; 4:220-232. [PMID: 34557648 PMCID: PMC8446696 DOI: 10.1002/ame2.12180] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022] Open
Abstract
Cystic fibrosis is an autosomal recessive disease caused by mutations of the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR). Here we summarize, at the basic descriptive level, clinical and genetic characteristics of cystic fibrosis gene mutations, while emphasizing differences between CF mutations found in Chinese pediatric CF patients compared to those found in Caucasian CF patients. In addition, we describe animal models used to study human cystic fibrosis disease and highlight unique features of each model that mimic specific human CF-associated signs and symptoms. At the clinical level, we summarize CF clinical manifestations and diagnostic, treatment, and prognostic methods to provide clinicians with information toward reducing CF misdiagnosis and missed diagnosis rates.
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Affiliation(s)
- Qionghua Chen
- Department No. 2 of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
- Department of Respiratory Medicine Quanzhou Children's Hospital Fujian Province Quanzhou China
| | - Yuelin Shen
- Department No. 2 of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Jingyang Zheng
- Department of Respiratory Medicine Quanzhou Children's Hospital Fujian Province Quanzhou China
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Lee AJ, Einarsson GG, Gilpin DF, Tunney MM. Multi-Omics Approaches: The Key to Improving Respiratory Health in People With Cystic Fibrosis? Front Pharmacol 2020; 11:569821. [PMID: 33013411 PMCID: PMC7509435 DOI: 10.3389/fphar.2020.569821] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022] Open
Abstract
The advent of high-throughput multi-omics technologies has underpinned the expansion in lung microbiome research, increasing our understanding of the nature, complexity and significance of the polymicrobial communities harbored by people with CF (PWCF). Having established that structurally complex microbial communities exist within the airways, the focus of recent research has now widened to investigating the function and dynamics of the resident microbiota during disease as well as in health. With further refinement, multi-omics approaches present the opportunity to untangle the complex interplay between microbe-microbe and microbe-host interactions in the lung and the relationship with respiratory disease progression, offering invaluable opportunities to discover new therapeutic approaches for our management of airway infection in CF.
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Affiliation(s)
- Andrew J. Lee
- Halo Research Group, Queen’s University Belfast, Belfast, United Kingdom
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Gisli G. Einarsson
- Halo Research Group, Queen’s University Belfast, Belfast, United Kingdom
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Deirdre F. Gilpin
- Halo Research Group, Queen’s University Belfast, Belfast, United Kingdom
- School of Pharmacy, Queen’s University Belfast, Belfast, United Kingdom
| | - Michael M. Tunney
- Halo Research Group, Queen’s University Belfast, Belfast, United Kingdom
- School of Pharmacy, Queen’s University Belfast, Belfast, United Kingdom
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Kristensen M, Prevaes SMPJ, Kalkman G, Tramper-Stranders GA, Hasrat R, de Winter-de Groot KM, Janssens HM, Tiddens HA, van Westreenen M, Sanders EAM, Arets B, Keijser B, van der Ent CK, Bogaert D. Development of the gut microbiota in early life: The impact of cystic fibrosis and antibiotic treatment. J Cyst Fibros 2020; 19:553-561. [PMID: 32487494 DOI: 10.1016/j.jcf.2020.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Patients with Cystic Fibrosis (CF) suffer from pancreatic insufficiency, lipid malabsorption and gastrointestinal complaints, next to progressive pulmonary disease. Altered mucosal homoeostasis due to malfunctioning chloride channels results in an adapted microbial composition of the gastrointestinal and the respiratory tract. Additionally, antibiotic treatment has the potential to distort resident microbial communities dramatically. This study aims to investigate early life development of the gut microbial community composition of children with CF compared to healthy infants and to study the independent effects of antibiotics taking into account other clinical and lifestyle factors. STUDY DESIGN Faecal samples from 20 infants with CF and 45 healthy infants were collected regularly during the first 18 months of life and microbial composition was determined using 16S rRNA based sequencing. RESULTS We observed significant differences in the overall microbiota composition between infants with CF and healthy infants (p<0.001). Akkermansia and Anaerostipes were significantly more abundant in control infants, whereas Streptococci and E. coli were significantly more abundant in infants with CF, also after correction for several clinical factors (p<0.05). Antibiotic use in infants with CF was associated with a lower alpha diversity, a reduced abundance of Bifidobacterium and Bacteroides, and a higher abundance of Enterococcus. CONCLUSION Microbial development of the gut is different in infants with CF compared to healthy infants from the first months of life on, and further deviates over time, in part as a result of antibiotic treatment. The resulting dysbiosis may have significant functional consequences for the microbial ecosystem in CF patients.
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Affiliation(s)
- Maartje Kristensen
- Department of Pediatric pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands.
| | - Sabine M P J Prevaes
- Department of Pediatric pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands
| | - Gino Kalkman
- Microbiology and Systems Biology, TNO, Zeist, the Netherlands
| | | | - Raiza Hasrat
- Department of Pediatric infectious diseases and immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands
| | - Karin M de Winter-de Groot
- Department of Pediatric pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands
| | - Hettie M Janssens
- Department of Pediatric Pulmonology and Allergology, Sophia Children's Hospital, Erasmus University Medical Center, the Netherlands
| | - Harm A Tiddens
- Department of Pediatric Pulmonology and Allergology, Sophia Children's Hospital, Erasmus University Medical Center, the Netherlands
| | - Mireille van Westreenen
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, the Netherlands
| | - Elisabeth A M Sanders
- Department of Pediatric infectious diseases and immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; Rijksinstituut voor Volksgezondheid en Milieu, Bilthoven, the Netherlands
| | - Bert Arets
- Department of Pediatric pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands
| | - Bart Keijser
- Microbiology and Systems Biology, TNO, Zeist, the Netherlands
| | - Cornelis K van der Ent
- Department of Pediatric pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands
| | - Debby Bogaert
- Department of Pediatric infectious diseases and immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; The Queen's Medical Research Institute, University of Edinburgh, United Kingdom.
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Sandy NS, Nogueira RJN. Nutritional Treatment of a Young Infant with Cystic Fibrosis Presenting with Severe Kwashiorkor Dermatosis. J Trop Pediatr 2019; 65:634-637. [PMID: 30897613 DOI: 10.1093/tropej/fmz008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Kwashiorkor in infancy is typically associated to an underlying disease. Edema, a striking feature of this type of malnutrition, can be difficult to assess in this age group. The typical dermatosis of Kwashiorkor is not fully explained the deficiency of one isolated vitamin or micronutrient. This article presents an infant with cystic fibrosis, who developed Kwashiorkor in the third month of life with extensive cutaneous manifestations. An early, individualized and aggressive nutritional intervention with optimized supplementationof sulfur amino acids, vitamins and micronutrients was established, with impressively recovery of overall nutrition and skin manifestations in a relatively short period of time.
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Affiliation(s)
- Natascha Silva Sandy
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Campinas School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Roberto José Negrão Nogueira
- São LeopldoMandic School of Medicine, Clinical Coordin of the Multi-professional Team of Nutritional Therapy at Clinics Hospital - University of Campinas São Paulo, Brazil
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Sadik I, Pérez de Algaba I, Jiménez R, Benito C, Blasco-Alonso J, Caro P, Navas-López VM, Pérez-Frías J, Pérez E, Serrano J, Yahyaoui R. Initial Evaluation of Prospective and Parallel Assessments of Cystic Fibrosis Newborn Screening Protocols in Eastern Andalusia: IRT/IRT versus IRT/PAP/IRT. Int J Neonatal Screen 2019; 5:32. [PMID: 33072991 PMCID: PMC7510193 DOI: 10.3390/ijns5030032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/01/2019] [Indexed: 11/16/2022] Open
Abstract
Identifying newborns at risk for cystic fibrosis (CF) by newborn screening (NBS) using dried blood spot (DBS) specimens provides an opportunity for presymptomatic detection. All NBS strategies for CF begin with measuring immunoreactive trypsinogen (IRT). Pancreatitis-associated protein (PAP) has been suggested as second-tier testing. The main objective of this study was to evaluate the analytical performance of an IRT/PAP/IRT strategy versus the current IRT/IRT strategy over a two-year pilot study including 68,502 newborns. The design of the study, carried out in a prospective and parallel manner, allowed us to compare four different CF-NBS protocols after performing a post hoc analysis. The best PAP cutoff point and the potential sources of PAP false positive results in our non-CF newborn population were also studied. 14 CF newborns were detected, resulting in an overall CF prevalence of 1/4, 893 newborns. The IRT/IRT algorithm detected all CF cases, but the IRT/PAP/IRT algorithm failed to detect one case of CF. The IRT/PAP/IRT with an IRT-dependent safety net protocol was a good alternative to improve sensitivity to 100%. The IRT × PAP/IRT strategy clearly performed better, with a sensitivity of 100% and a positive predictive value (PPV) of 39%. Our calculated optimal cutoffs were 2.31 µg/L for PAP and 167.4 µg2/L2 for IRT × PAP. PAP levels were higher in females and newborns with low birth weight. PAP false positive results were found mainly in newborns with conditions such as prematurity, sepsis, and hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Ilham Sadik
- Clinical Laboratory, Hospital La Línea de la Concepción, 11300 Cádiz, Spain
| | - Inmaculada Pérez de Algaba
- Laboratory of Metabolic Disorders and Newborn Screening Center of Eastern Andalusia, Málaga Regional University Hospital, Avenida Arroyo de los Angeles s/n, 29011 Málaga, Spain
| | - Rocío Jiménez
- Laboratory of Metabolic Disorders and Newborn Screening Center of Eastern Andalusia, Málaga Regional University Hospital, Avenida Arroyo de los Angeles s/n, 29011 Málaga, Spain
| | - Carmen Benito
- Department of Genetics, Málaga Regional University Hospital, 29011 Málaga, Spain
| | - Javier Blasco-Alonso
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
| | - Pilar Caro
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
- Department of Pharmacology and Pediatrics, University of Málaga, 29071 Málaga, Spain
| | - Víctor M. Navas-López
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
| | - Javier Pérez-Frías
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
- Department of Pharmacology and Pediatrics, University of Málaga, 29071 Málaga, Spain
| | - Estela Pérez
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
- Department of Pharmacology and Pediatrics, University of Málaga, 29071 Málaga, Spain
| | - Juliana Serrano
- Department of Pediatrics, Málaga Regional University Hospital, 29011 Málaga, Spain
| | - Raquel Yahyaoui
- Laboratory of Metabolic Disorders and Newborn Screening Center of Eastern Andalusia, Málaga Regional University Hospital, Avenida Arroyo de los Angeles s/n, 29011 Málaga, Spain
- Institute of Biomedical Research in Málaga-IBIMA, 29010 Málaga, Spain
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Metabolic Modeling of Cystic Fibrosis Airway Communities Predicts Mechanisms of Pathogen Dominance. mSystems 2019; 4:mSystems00026-19. [PMID: 31020043 PMCID: PMC6478966 DOI: 10.1128/msystems.00026-19] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/29/2019] [Indexed: 01/08/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease in which chronic airway infections and lung inflammation result in respiratory failure. CF airway infections are usually caused by bacterial communities that are difficult to eradicate with available antibiotics. Using species abundance data for clinically stable adult CF patients assimilated from three published studies, we developed a metabolic model of CF airway communities to better understand the interactions between bacterial species and between the bacterial community and the lung environment. Our model predicted that clinically observed CF pathogens could establish dominance over other community members across a range of lung nutrient conditions. Heterogeneity of species abundances across 75 patient samples could be predicted by assuming that sample-to-sample heterogeneity was attributable to random variations in the CF nutrient environment. Our model predictions provide new insights into the metabolic determinants of pathogen dominance in the CF lung and could facilitate the development of improved treatment strategies. Cystic fibrosis (CF) is a fatal genetic disease characterized by chronic lung infections due to aberrant mucus production and the inability to clear invading pathogens. The traditional view that CF infections are caused by a single pathogen has been replaced by the realization that the CF lung usually is colonized by a complex community of bacteria, fungi, and viruses. To help unravel the complex interplay between the CF lung environment and the infecting microbial community, we developed a community metabolic model comprised of the 17 most abundant bacterial taxa, which account for >95% of reads across samples, from three published studies in which 75 sputum samples from 46 adult CF patients were analyzed by 16S rRNA gene sequencing. The community model was able to correctly predict high abundances of the “rare” pathogens Enterobacteriaceae, Burkholderia, and Achromobacter in three patients whose polymicrobial infections were dominated by these pathogens. With these three pathogens removed, the model correctly predicted that the remaining 43 patients would be dominated by Pseudomonas and/or Streptococcus. This dominance was predicted to be driven by relatively high monoculture growth rates of Pseudomonas and Streptococcus as well as their ability to efficiently consume amino acids, organic acids, and alcohols secreted by other community members. Sample-by-sample heterogeneity of community composition could be qualitatively captured through random variation of the simulated metabolic environment, suggesting that experimental studies directly linking CF lung metabolomics and 16S sequencing could provide important insights into disease progression and treatment efficacy. IMPORTANCE Cystic fibrosis (CF) is a genetic disease in which chronic airway infections and lung inflammation result in respiratory failure. CF airway infections are usually caused by bacterial communities that are difficult to eradicate with available antibiotics. Using species abundance data for clinically stable adult CF patients assimilated from three published studies, we developed a metabolic model of CF airway communities to better understand the interactions between bacterial species and between the bacterial community and the lung environment. Our model predicted that clinically observed CF pathogens could establish dominance over other community members across a range of lung nutrient conditions. Heterogeneity of species abundances across 75 patient samples could be predicted by assuming that sample-to-sample heterogeneity was attributable to random variations in the CF nutrient environment. Our model predictions provide new insights into the metabolic determinants of pathogen dominance in the CF lung and could facilitate the development of improved treatment strategies.
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Safety, pharmacokinetics, and pharmacodynamics of lumacaftor and ivacaftor combination therapy in children aged 2–5 years with cystic fibrosis homozygous for F508del-CFTR: an open-label phase 3 study. THE LANCET RESPIRATORY MEDICINE 2019; 7:325-335. [DOI: 10.1016/s2213-2600(18)30460-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 11/24/2022]
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13
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Rosenfeld M, Wainwright CE, Higgins M, Wang LT, McKee C, Campbell D, Tian S, Schneider J, Cunningham S, Davies JC. Ivacaftor treatment of cystic fibrosis in children aged 12 to <24 months and with a CFTR gating mutation (ARRIVAL): a phase 3 single-arm study. THE LANCET RESPIRATORY MEDICINE 2018; 6:545-553. [PMID: 29886024 DOI: 10.1016/s2213-2600(18)30202-9] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/01/2018] [Accepted: 05/04/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ivacaftor is generally safe and effective in patients aged 2 years and older who have cystic fibrosis and specific CFTR mutations. We assessed its use in children aged 12 to <24 months. METHODS The ARRIVAL study is a phase 3, single-arm, two-part, multicentre study. Eligible children were aged 12 to <24 months at enrolment and had a confirmed diagnosis of cystic fibrosis and a CFTR gating mutation on at least one allele and could participate in one or both parts of the study. Children received 50 mg (bodyweight 7 to <14 kg) or 75 mg (bodyweight ≥14 to <25 kg) ivacaftor orally every 12 h. In study part A, children received ivacaftor for 3 days plus one morning. In study part B, children received 24 weeks of treatment. Children were enrolled into part A at seven sites in Australia (one site), the UK (one), and the USA (five) and into part B at 13 sites in Australia (two sites), Canada (one), the UK (three), and the USA (seven). Primary endpoints were pharmacokinetics (part A) and safety (parts A and B) in children who received at least one dose of ivacaftor. Secondary endpoints in part B were pharmacokinetics in children who received at least one dose of ivacaftor and absolute change from baseline in sweat chloride concentration. We also explored changes in growth parameters and markers of pancreatic function. This study is registered with ClinicalTrials.gov, number NCT02725567. FINDINGS Children aged 12 to <24 months were enrolled between Aug 25, 2016, and Nov 1, 2017. Seven children were enrolled in part A, of whom five received 50 mg and two received 75 mg ivacaftor. All completed treatment. Of 19 children enrolled in part B, including one from part A, all received 50 mg ivacaftor and 18 completed treatment (one withdrew because of difficulty with blood draws). All children received at least one dose of ivacaftor. Pharmacokinetics indicated exposure was similar to that in children aged 2 to <6 years and adults. No children discontinued because of adverse events or safety findings. In part A, three (43%) of seven children had treatment-emergent adverse events, all of which were mild and deemed not to be or unlikely to be related to ivacaftor. By 24 weeks in part B, treatment-emergent adverse events had been reported in 18 (95%) of 19 children, of which most were mild or moderate and the most frequent was cough (14 [74%] children). Two children in part B had four serious adverse events: one had constipation (possibly related to ivacaftor), distal intestinal obstruction syndrome, and eczema herpeticum, and one had persistent cough, all needing hospital admission. In five (28%) of 18 children aspartate or alanine aminotransferase concentrations rose to more than three times the upper limit of normal (to more than eight times in two children with concurrent infections). At week 24, the mean absolute change from baseline in sweat chloride concentration was -73·5 (SD 17·5) mmol/L. Growth parameters for age were normal at baseline and at week 24. At week 24, concentrations of faecal elastase-1 had increased and concentrations of immunoreactive trypsinogen had decreased from baseline. Mean serum lipase and amylase were raised at baseline and rapidly decreased after treatment was started. INTERPRETATION Ivacaftor was generally safe and well tolerated in children aged 12 to <24 months for up to 24 weeks and was associated with rapid and sustained reductions in sweat chloride concentrations. Improvements in biomarkers of pancreatic function suggest that ivacaftor preserves exocrine pancreatic function if started early. The study is continuing in infants younger than 12 months. FUNDING Vertex Pharmaceuticals Incorporated.
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Affiliation(s)
- Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire E Wainwright
- Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital and Child Health Research Centre, University of Queensland, South Brisbane, QLD, Australia
| | | | | | | | | | | | | | - Steve Cunningham
- University of Edinburgh MRC Centre for Inflammation Research, Royal Hospital for Sick Children and University of Edinburgh, Edinburgh, UK
| | - Jane C Davies
- Cystic Fibrosis and Chronic Lung Infection, National Heart & Lung Institute, Imperial College London & Royal Brompton Hospital, London, UK.
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Taylor CJ, Beckles-Willson N, Wolfe S. The Child with Cystic Fibrosis who Fails to Gain Weight. J R Soc Med 2018; 94 Suppl 40:25-8. [PMID: 11601161 PMCID: PMC1310583 DOI: 10.1177/014107680109440s07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- C J Taylor
- Division of Child Health, University of Sheffield, UK
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15
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Sanders DB, Zhang Z, Farrell PM, Lai HJ. Early life growth patterns persist for 12 years and impact pulmonary outcomes in cystic fibrosis. J Cyst Fibros 2018; 17:528-535. [PMID: 29396025 DOI: 10.1016/j.jcf.2018.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND In children with cystic fibrosis (CF), recovery from growth faltering within 2 years of diagnosis (Responders) is associated with better growth and less lung disease at age 6 years. This study examined whether these benefits are sustained through 12 years of age. METHODS Longitudinal growth from 76 children with CF enrolled in the Wisconsin CF Neonatal Screening Project was examined and categorized into 5 groups: R12, R6, and R2, representing Responders who maintained growth improvement to age 12, 6, and 2 years, respectively, and I6 and N6, representing Non-responders whose growth did and did not improve during ages 2-6 years, respectively. Lung disease was evaluated by % predicted forced expiratory volume in one second (FEV1) and chest radiograph (CXR) scores. RESULTS Sixty-two percent were Responders. Within this group, 47% were R12, 28% were R6, and 25% were R2. Among Non-responders, 76% were N6. CF children with meconium ileus (MI) had worse lung function and CXR scores compared to other CF children. Among 53 children with pancreatic insufficiency without MI, R12 had significantly better FEV1 (97-99% predicted) and CXR scores during ages 6-12 years than N6 (89-93% predicted). Both R6 and R2 experienced a decline in FEV1 by ages 10-12 years. CONCLUSIONS Early growth recovery in CF is critical, as malnutrition during infancy tends to persist and catch-up growth after age 2 years is difficult. The longer adequate growth was maintained after early growth recovery, the better the pulmonary outcomes at age 12 years.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, 705 Riley Hospital Dr, Suite 4270, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - Zhumin Zhang
- Department of Nutritional Sciences, 1415 Linden Dr, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53706, USA
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - HuiChuan J Lai
- Department of Nutritional Sciences, 1415 Linden Dr, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53706, USA; Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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16
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Abstract
OBJECTIVE The relation between malnutrition and exocrine pancreatic insufficiency (EPI) has been described previously, but it is unclear if malnutrition leads to EPI or vice versa. We systematically synthesized current evidence evaluating the association between malnutrition and EPI in children. METHODS Pubmed, Embase, and Cochrane databases were searched from inception until February 2017. We included cohort or case-controlled studies in children reporting on prevalence or incidence of EPI and malnutrition. Data generation was performed independently by 2 authors. Quality was assessed by using quality assessment tools from the National Heart, Lung, and Blood Institute. RESULTS Nineteen studies were divided into 2 groups: 10 studies showing EPI leading to malnutrition, and 9 studies showing malnutrition leading to EPI. Because of heterogeneity in design, definitions, and outcome measures, pooling of results was impossible. Quality was good in 4 of 19 studies. Pancreatic insufficiency was linked to decreased nutritional status in 8 of 10 articles, although this link was not specified properly in most articles. In malnourished children, improvement was seen in pancreatic function in 7 of 9 articles after nutritional rehabilitation. The link between the 2 was not further specified. Heterogeneity exists with respect to definitions, outcome measures, and study design. CONCLUSIONS There is sufficient evidence for an association between EPI and malnutrition. We could not confirm whether there is a correlation or causality between EPI or malnutrition. It was therefore not possible to draw firm conclusions from this systematic review on underlying pathophysiological mechanisms between EPI and malnutrition. More observational clinical trials are crucially needed.
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DiFranco KM, Mulligan JK, Sumal AS, Diamond G. Induction of CFTR gene expression by 1,25(OH) 2 vitamin D 3, 25OH vitamin D 3, and vitamin D 3 in cultured human airway epithelial cells and in mouse airways. J Steroid Biochem Mol Biol 2017; 173:323-332. [PMID: 28130182 PMCID: PMC5785933 DOI: 10.1016/j.jsbmb.2017.01.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 01/08/2023]
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, which often leads to protein misfolding and no CFTR surface localization. This then leads to chronic airway infections, inflammation, and tissue damage. Although vitamin D has been explored as a therapy to treat CF due to its antimicrobial-inducing and anti-inflammatory properties, the effect of 1,25-dihydroxyvitamin D3 (1α,25(OH)2D3) on CFTR directly has not been studied. We treated cultured healthy and diseased bronchial epithelial cells (BEC) with 10nM 1α,25(OH)2D3 for 6 and 24h and found that 1α,25(OH)2D3 increases both mRNA and protein CFTR levels using RT-qPCR, flow cytometry and fluorescence immunohistochemistry. Treatment of CF cells with 10nM 1α,25(OH)2D3 led to an increase in both total and surface CFTR expression, suggesting 1α,25(OH)2D3 could be used to increase properly localized CFTR in airway cells. To determine if BEC could convert the more clinically relevant cholecalciferol to 25OHD3, cultured non-CF and CF BECs were treated with a range of cholecalciferol concentrations, and 25OHD3 levels were quantified by ELISA. We found that 25OHD3 levels increased in a concentration-dependent manner. Treatment of BEC with 10μM cholecalciferol led to increases in both CYP24A1 and CFTR mRNA levels, even when added to the apical surface of cells grown in an air-liquid interface, suggesting that topical administration of vitamin D could be used therapeutically. To demonstrate this in vivo, we intranasally delivered 1μM 1α,25(OH)2D3 into mice. After 6h, we observed induction of both Cyp24A1 and CFTR expression in the tracheas of treated mice. The major findings of this study are that vitamin D can be converted to the active form when topically administered to the airway, and this could be used to increase CFTR levels in patients with CF. This could potentially be useful as an adjunctive therapy, together with newly developed CF treatments.
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Affiliation(s)
- Kristina M DiFranco
- Department of Oral Biology, University of Florida, Gainesville, FL 32610, United States, United States
| | - Jennifer K Mulligan
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Aman S Sumal
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Gill Diamond
- Department of Oral Biology, University of Florida, Gainesville, FL 32610, United States, United States.
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Bulloch MN, Hanna C, Giovane R. Lumacaftor/ivacaftor, a novel agent for the treatment of cystic fibrosis patients who are homozygous for the F580del CFTR mutation. Expert Rev Clin Pharmacol 2017; 10:1055-1072. [PMID: 28891346 DOI: 10.1080/17512433.2017.1378094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Cystic Fibrosis (CF) is an autosomal recessive disease affecting up to 90,000 people worldwide. Approximately 73% of patients are homozygous for the F508del cystic fibrosis transmembrane conductance regulator [CFTR] mutation. Traditionally treatment has only included supportive care. Therefore, there is a need for safe and effective novel therapies targeting the underlying molecular defects seen with CF. Areas covered: In 2016, the Food and Drug Administration and the European Commission approved LUM/IVA (Orkambi), a CFTR modulator that includes both a CFTR corrector and potentiator, for CF patients homozygous for the F508del CFTR mutation. This article reviews the pharmacologic features, clinical efficacy, and safety of LUM/IVA and summarize the available pre-clinical and clinical data of LUM/IVA use. Expert commentary: LUM/IVA showed modest, but significant improvements from baseline in percent predicted FEV1 (ppFEV1) as well as a reduction in pulmonary exacerbations by 35% It was shown to be safe for short- and long-term use. Currently, LUM/IVA is the only oral agent in its class available and represents a milestone the development of therapies for the management of CF. Nonetheless, pharmacoeconomic data are necessary to justify its high cost before is use becomes standard of care.
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Affiliation(s)
- Marilyn N Bulloch
- a Harrison School of Pharmacy , Auburn University , Auburn , AL , USA.,b College of Community Health Sciences , University of Alabama , Tuscaloosa , AL , USA
| | - Cameron Hanna
- a Harrison School of Pharmacy , Auburn University , Auburn , AL , USA
| | - Richard Giovane
- c Harrison School of Pharmacy , Auburn University , Tuscaloosa , AL , USA
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19
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Question 10: Could the Burden of Care with Cystic Fibrosis Impact on Educational Outcomes? Paediatr Respir Rev 2017; 23:56-60. [PMID: 27427312 DOI: 10.1016/j.prrv.2016.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 11/21/2022]
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20
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Farrell PM, White TB, Howenstine MS, Munck A, Parad RB, Rosenfeld M, Sommerburg O, Accurso FJ, Davies JC, Rock MJ, Sanders DB, Wilschanski M, Sermet-Gaudelus I, Blau H, Gartner S, McColley SA. Diagnosis of Cystic Fibrosis in Screened Populations. J Pediatr 2017; 181S:S33-S44.e2. [PMID: 28129810 DOI: 10.1016/j.jpeds.2016.09.065] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cystic fibrosis (CF) can be difficult to diagnose, even when newborn screening (NBS) tests yield positive results. This challenge is exacerbated by the multitude of NBS protocols, misunderstandings about screening vs diagnostic tests, and the lack of guidelines for presumptive diagnoses. There is also confusion regarding the designation of age at diagnosis. STUDY DESIGN To improve diagnosis and achieve standardization in definitions worldwide, the CF Foundation convened a committee of 32 experts with a mission to develop clear and actionable consensus guidelines on diagnosis of CF with an emphasis on screened populations, especially the newborn population. A comprehensive literature review was performed with emphasis on relevant articles published during the past decade. RESULTS After reviewing the common screening protocols and outcome scenarios, 14 of 27 consensus statements were drafted that apply to screened populations. These were approved by 80% or more of the participants. CONCLUSIONS It is recommended that all diagnoses be established by demonstrating dysfunction of the CF transmembrane conductance regulator (CFTR) channel, initially with a sweat chloride test and, when needed, potentially with newer methods assessing membrane transport directly, such as intestinal current measurements. Even in babies with 2 CF-causing mutations detected via NBS, diagnosis must be confirmed by demonstrating CFTR dysfunction. The committee also recommends that the latest classifications identified in the Clinical and Functional Translation of CFTR project [http://www.cftr2.org/index.php] should be used to aid with CF diagnosis. Finally, to avoid delays in treatment, we provide guidelines for presumptive diagnoses and recommend how to determine the age of diagnosis.
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Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Michelle S Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Anne Munck
- Centres de Ressources et de Compétences pour la Mucoviscidose, Hôpital Robert Debre, Paris, France
| | - Richard B Parad
- Department of Pediatric and Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | - Frank J Accurso
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jane C Davies
- Pediatric Respirology and Experimental Medicine, Imperial College London and Pediatric Respiratory Medicine, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Michael J Rock
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Don B Sanders
- Department of Pediatrics, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Hôpital Necker Enfants Malades, Centres de Ressources et de Compétences pour la Mucoviscidose, Paris, France
| | - Hannah Blau
- Sackler Faculty of Medicine, Graub Cystic Fibrosis Center, Pulmonary Institute Schneider Children's Medical Center of Israel, Petah Tikva, Tel Aviv University, Tel Aviv, Israel
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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21
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Boutin S, Dalpke AH. Acquisition and adaptation of the airway microbiota in the early life of cystic fibrosis patients. Mol Cell Pediatr 2017; 4:1. [PMID: 28097632 PMCID: PMC5241261 DOI: 10.1186/s40348-016-0067-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/15/2016] [Indexed: 12/26/2022] Open
Abstract
Cystic fibrosis (CF) is a genetic disease in which bacterial infections of the airways play a major role in the long-term clinical outcome. In recent years, a number of next-generation sequencing (NGS)-based studies aimed at deciphering the structure and composition of the airways’ microbiota. It was shown that the nasal cavity of CF patients displays dysbiosis early in life indicating a failure in the first establishment of a healthy microbiota. In contrast, within the conducting and lower airways, the establishment occurs normally first, but is sensitive to future dysbiosis including chronic infections with classical pathogens in later life. The objective of this mini-review is to give an update on the current knowledge about the development of the microbiota in the early life of CF patients. Microbial acquisition in the human airways can be described by the island model: Microbes found in the lower airways of CF patients represent “islands” that are at first populated from the upper airways reflecting the “mainland.” Colonization can be modeled following the neutral theory in which the most abundant bacteria in the mainland are also frequently found in the lower airways initially. At later times, however, the colonization process of the lower airways segregates by active selection of specific microbes. Future research should focus on those processes of microbial and host interactions to understand how microbial communities are shaped on short- and long-term scales. We point out what therapeutic consequences arise from the microbiome data obtained within ecological framework models.
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Affiliation(s)
- Sébastien Boutin
- Department of Infectious Disease, Medical Microbiology and Hygiene, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Alexander H Dalpke
- Department of Infectious Disease, Medical Microbiology and Hygiene, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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22
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Sathe MN, Freeman AJ. Gastrointestinal, Pancreatic, and Hepatobiliary Manifestations of Cystic Fibrosis. Pediatr Clin North Am 2016; 63:679-98. [PMID: 27469182 DOI: 10.1016/j.pcl.2016.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary disease is the primary cause of morbidity and mortality in people with cystic fibrosis (CF), but significant involvement within gastrointestinal, pancreatic, and hepatobiliary systems occurs as well. As in the airways, defects in CFTR alter epithelial surface fluid, mucus viscosity, and pH, increasing risk of stasis through the various hollow epithelial-lined structures of the gastrointestinal tract. This exerts secondary influences that are responsible for most gastrointestinal, pancreatic, and hepatobiliary manifestations of CF. Understanding these gastrointestinal morbidities of CF is essential in understanding and treating CF as a multisystem disease process and improving overall patient care.
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Affiliation(s)
- Meghana Nitin Sathe
- Division of Pediatric Gastroenterology and Nutrition, Children's Health, University of Texas Southwestern, F4.06, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Alvin Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, Northeast, Atlanta, GA 30322, USA.
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23
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Abstract
The diagnosis of cystic fibrosis (CF) has evolved over the past decade as newborn screening has become universal in the United States and elsewhere. The heterogeneity of phenotypes associated with CF transmembrane conductance regulator (CFTR) dysfunction and mutations in the CFTR gene has become clearer, ranging from classic pancreatic-insufficient CF to manifestations in only 1 organ system to indeterminate diagnoses identified by newborn screening. The tools available for diagnosis have also expanded. This article reviews the newest diagnostic criteria for CF, newborn screening, prenatal screening and diagnosis, and indeterminate diagnoses in newborn-screened infants and symptomatic adults.
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24
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Yi Y, Sun X, Gibson-Corley K, Xie W, Liang B, He N, Tyler SR, Uc A, Philipson LH, Wang K, Hara M, Ode KL, Norris AW, Engelhardt JF. A Transient Metabolic Recovery from Early Life Glucose Intolerance in Cystic Fibrosis Ferrets Occurs During Pancreatic Remodeling. Endocrinology 2016; 157:1852-65. [PMID: 26862997 PMCID: PMC4870869 DOI: 10.1210/en.2015-1935] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cystic fibrosis (CF)-related diabetes in humans is intimately related to exocrine pancreatic insufficiency, yet little is known about how these 2 disease processes simultaneously evolve in CF. In this context, we examined CF ferrets during the evolution of exocrine pancreatic disease. At 1 month of age, CF ferrets experienced a glycemic crisis with spontaneous diabetic-level hyperglycemia. This occurred during a spike in pancreatic inflammation that was preceded by pancreatic fibrosis and loss of β-cell mass. Surprisingly, there was spontaneous normalization of glucose levels at 2-3 months, with intermediate hyperglycemia thereafter. Mixed meal tolerance was impaired at all ages, but glucose intolerance was not detected until 4 months. Insulin secretion in response to hyperglycemic clamp and to arginine was impaired. Insulin sensitivity, measured by euglycemic hyperinsulinemic clamp, was normal. Pancreatic inflammation rapidly diminished after 2 months of age during a period where β-cell mass rose and gene expression of islet hormones, peroxisome proliferator-activated receptor-γ, and adiponectin increased. We conclude that active CF exocrine pancreatic inflammation adversely affects β-cells but is followed by islet resurgence. We predict that very young humans with CF may experience a transient glycemic crisis and postulate that pancreatic inflammatory to adipogenic remodeling may facilitate islet adaptation in CF.
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Affiliation(s)
- Yaling Yi
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Xingshen Sun
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Katherine Gibson-Corley
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Weiliang Xie
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Bo Liang
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Nan He
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Scott R Tyler
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Aliye Uc
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Louis H Philipson
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Kai Wang
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Manami Hara
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Katie Larson Ode
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - Andrew W Norris
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
| | - John F Engelhardt
- Anatomy and Cell Biology (Y.Y., X.S., W.X., B.L., N.H., S.R.T., J.F.E.), Departments of Pathology (K.G.-C.) and Pediatrics (A.U., K.L.O., A.W.N.), Fraternal Order of Eagles Diabetes Research Center (A.W.N., J.F.E.), and Department of Biostatistics (K.W.), College of Public Health, University of Iowa, Iowa City, Iowa 52242; and Department of Medicine (L.H.P., M.H.), University of Chicago, Chicago, Illinois 60637
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Madan JC. Neonatal Gastrointestinal and Respiratory Microbiome in Cystic Fibrosis: Potential Interactions and Implications for Systemic Health. Clin Ther 2016; 38:740-6. [PMID: 26973296 DOI: 10.1016/j.clinthera.2016.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/04/2016] [Accepted: 02/06/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE The gastrointestinal microbiome plays a critical role in nutrition and metabolic and immune functions in infants and young children and has implications for lifelong health. Cystic fibrosis (CF) transmembrane conductance regulator (CFTR) mutations in CF result in viscous mucous production, frequent exposure to antibiotics, and atypical colonization patterns, resulting in an evolving dysbiosis of the gastrointestinal and respiratory microsystems; dysbiosis in CF results in systemic inflammation, chronic infection, and dysregulation of immune function. Dysbiosis in both the respiratory system and gut contributes to undernutrition, growth failure, and long-term respiratory and systemic morbidity in infants and children with CF. Understanding the role that the gut and respiratory microbiome plays in health or disease progression in CF will afford opportunities to better identify interventions to affect clinical changes. METHODS Summary was done of the pertinent literature in CF and the study of the microbiome and probiotics. FINDINGS New studies have identified bacteria in the respiratory tract in CF that are typically members of the intestinal microbiota, and enteral exposures to breast milk and probiotics are associated with prolonged periods of respiratory stability in CF. IMPLICATIONS Understanding the complex interactions between the CFTR mutations, microbial colonization, and mucosal and systemic immunity is of major importance to inform new treatment strategies (such as restoring a healthier microbiome with probiotics or dietary interventions) to improve nutritional status and immune competence and to decrease morbidity and mortality in CF.
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Affiliation(s)
- Juliette C Madan
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Dartmouth, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
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VanDevanter DR, Kahle JS, O’Sullivan AK, Sikirica S, Hodgkins PS. Cystic fibrosis in young children: A review of disease manifestation, progression, and response to early treatment. J Cyst Fibros 2016; 15:147-57. [DOI: 10.1016/j.jcf.2015.09.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 12/31/2022]
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Corral JE, Dye CW, Mascarenhas MR, Barkin JS, Salathe M, Moshiree B. Is Gastroparesis Found More Frequently in Patients with Cystic Fibrosis? A Systematic Review. SCIENTIFICA 2016; 2016:2918139. [PMID: 27313953 PMCID: PMC4904114 DOI: 10.1155/2016/2918139] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/06/2016] [Indexed: 05/08/2023]
Abstract
Cystic fibrosis (CF) is associated with different gastrointestinal motility disturbances and syndromes. We aim to assess gastric emptying in patients with CF compared to healthy controls by a systematic review of existing literature. Medical databases and abstracts from major gastroenterology and CF meetings were reviewed. Emptying times in CF patients were compared with healthy controls using random effects models. Subgroup analysis stratified results by age and diagnostic modality. Nineteen studies from 7 countries included 574 subjects (359 CF patients and 215 controls). Using pooled analysis frequency of gastroparesis was high (38%, 95% CI 30-45%) but results were highly dependent on the diagnostic modality. Delayed gastric emptying is more common in CF compared to general population. Scintigraphy identified rapid gastric emptying in a subgroup of CF patients, but this finding disappeared with adequate pancreatic enzyme replacement and after other diagnostic modalities were included.
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Affiliation(s)
- Juan E. Corral
- Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- *Juan E. Corral:
| | - Corey W. Dye
- Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Maria R. Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jamie S. Barkin
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Matthias Salathe
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Baharak Moshiree
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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29
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Abstract
The diagnosis of cystic fibrosis (CF) is being made with increasing frequency in adults. Patients with CF diagnosed in adulthood typically present with respiratory complaints, and often have recurrent or chronic airway infection. At the time of initial presentation individuals may appear to have clinical manifestation limited to a single organ, but with subclinical involvement of the respiratory tract. Adult-diagnosed patients have a good response to CF center care, and newly available cystic fibrosis transmembrane receptor-modulating therapies are promising for the treatment of residual function mutation, thus increasing the importance of the diagnosis in adults with unexplained bronchiectasis.
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Affiliation(s)
- Jerry A Nick
- Department of Medicine, National Jewish Health, 1400 Jackson, Denver, CO 80206, USA; Department of Medicine, University of Colorado Denver School of Medicine, 13001 East 17th Pl, Aurora, CO 80045, USA.
| | - David P Nichols
- Department of Medicine, University of Colorado Denver School of Medicine, 13001 East 17th Pl, Aurora, CO 80045, USA; Department of Pediatrics, National Jewish Health, Denver, CO 80206, USA
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30
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Hoen AG, Li J, Moulton LA, O’Toole GA, Housman ML, Koestler DC, Guill MF, Moore JH, Hibberd PL, Morrison HG, Sogin ML, Karagas MR, Madan JC. Associations between Gut Microbial Colonization in Early Life and Respiratory Outcomes in Cystic Fibrosis. J Pediatr 2015; 167:138-47.e1-3. [PMID: 25818499 PMCID: PMC4674690 DOI: 10.1016/j.jpeds.2015.02.049] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 01/28/2015] [Accepted: 02/18/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine patterns of microbial colonization of the respiratory and intestinal tracts in early life in infants with cystic fibrosis (CF) and their associations with breastfeeding and clinical outcomes. STUDY DESIGN A comprehensive, prospective longitudinal analysis of the upper respiratory and intestinal microbiota in a cohort of infants and young children with CF followed from birth was performed. Genus-level microbial community composition was characterized using 16S-targeted pyrosequencing, and relationships with exposures and outcomes were assessed using linear mixed-effects models, time-to-event analysis, and principal components analysis. RESULTS Sequencing of 120 samples from 13 subjects collected from birth to 34 months revealed relationships between breastfeeding, microbial diversity in the respiratory and intestinal tracts, and the timing of onset of respiratory complications, including exacerbations and colonization with Pseudomonas aeruginosa. Fluctuations in the abundance of specific bacterial taxa preceded clinical outcomes, including a significant decrease in bacteria of the genus Parabacteroides within the intestinal tract prior to the onset of chronic P aeruginosa colonization. Specific assemblages of bacteria in intestinal samples, but not respiratory samples, were associated with CF exacerbation in early life, indicating that the intestinal microbiome may play a role in lung health. CONCLUSIONS Our findings relating breastfeeding to respiratory outcomes, gut diversity to prolonged periods of health, and specific bacterial communities in the gut prior to respiratory complications in CF highlight a connection between the intestinal microbiome and health and point to potential opportunities for antibiotic or probiotic interventions. Further studies in larger cohorts validating these findings are needed.
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Affiliation(s)
- Anne G. Hoen
- Computational Genetics Laboratory, Institute for Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755
| | - Jing Li
- Computational Genetics Laboratory, Institute for Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755
| | - Lisa A. Moulton
- Division of Allergy and Pediatric Pulmonology, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon NH 03756
| | - George A. O’Toole
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH 03755
| | - Molly L. Housman
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH 03755
| | - Devin C. Koestler
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS 66160
| | - Margaret F. Guill
- Division of Allergy and Pediatric Pulmonology, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon NH 03756
| | - Jason H. Moore
- Computational Genetics Laboratory, Institute for Quantitative Biomedical Sciences, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755
| | - Patricia L. Hibberd
- Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114
| | - Hilary G. Morrison
- Josephine Bay Paul Center for Comparative Molecular Biology and Evolution, Marine Biological Laboratory, Woods Hole, MA 02543
| | - Mitchell L. Sogin
- Josephine Bay Paul Center for Comparative Molecular Biology and Evolution, Marine Biological Laboratory, Woods Hole, MA 02543
| | - Margaret R. Karagas
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755
| | - Juliette C. Madan
- Division of Neonatology, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756
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Miller MR, Soave D, Li W, Gong J, Pace RG, Boëlle PY, Cutting GR, Drumm ML, Knowles MR, Sun L, Rommens JM, Accurso F, Durie PR, Corvol H, Levy H, Sontag MK, Strug LJ. Variants in Solute Carrier SLC26A9 Modify Prenatal Exocrine Pancreatic Damage in Cystic Fibrosis. J Pediatr 2015; 166:1152-1157.e6. [PMID: 25771386 PMCID: PMC4530786 DOI: 10.1016/j.jpeds.2015.01.044] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 12/12/2014] [Accepted: 01/23/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To test the hypothesis that multiple constituents of the apical plasma membrane residing alongside the causal cystic fibrosis (CF) transmembrane conductance regulator protein, including known CF modifiers SLC26A9, SLC6A14, and SLC9A3, would be associated with prenatal exocrine pancreatic damage as measured by newborn screened (NBS) immunoreactive trypsinogen (IRT) levels. STUDY DESIGN NBS IRT measures and genome-wide genotype data were available on 111 subjects from Colorado, 37 subjects from Wisconsin, and 80 subjects from France. Multiple linear regression was used to determine whether any of 8 single nucleotide polymorphisms (SNPs) in SLC26A9, SLC6A14, and SLC9A3 were associated with IRT and whether other constituents of the apical plasma membrane contributed to IRT. RESULTS In the Colorado sample, 3 SLC26A9 SNPs were associated with NBS IRT (min P=1.16×10(-3); rs7512462), but no SLC6A14 or SLC9A3 SNPs were associated (P>.05). The rs7512462 association replicated in the Wisconsin sample (P=.03) but not in the French sample (P=.76). Furthermore, rs7512462 was the top-ranked apical membrane constituent in the combined Colorado and Wisconsin sample. CONCLUSIONS NBS IRT is a biomarker of prenatal exocrine pancreatic disease in patients with CF, and a SNP in SLC26A9 accounts for significant IRT variability. This work suggests SLC26A9 as a potential therapeutic target to ameliorate exocrine pancreatic disease.
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Affiliation(s)
- Melissa R. Miller
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Soave
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Weili Li
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jiafen Gong
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rhonda G. Pace
- Cystic Fibrosis-Pulmonary Research and Treatment Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Pierre-Yves Boëlle
- Pierre et Marie Curie University-Paris 6, Paris, France,Biostatistics Department, St Antoine Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP); Institut National de la Santé et la Researche Médicale (INSERM), UMR-S 1136, Paris, France
| | - Garry R. Cutting
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mitchell L. Drumm
- Departments of Pediatrics and Genetics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael R. Knowles
- Cystic Fibrosis-Pulmonary Research and Treatment Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lei Sun
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Johanna M. Rommens
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada,Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Frank Accurso
- Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA,Department of Pediatrics, Children’s Hospital of Colorado, Aurora, Colorado, USA
| | - Peter R. Durie
- Program in Physiology and Experimental Medicine, the Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Harriet Corvol
- Pierre et Marie Curie University-Paris 6, Paris, France,Pediatric Pulmonology Department, Trousseau Hospital, AP-HP, Inserm U938, Paris, France
| | - Hara Levy
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marci K. Sontag
- Department of Pediatrics, Children’s Hospital of Colorado, Aurora, Colorado, USA,Department of Epidemiology, Colorado School of Public Health University of Colorado Denver, Aurora, Colorado, USA
| | - Lisa J. Strug
- Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, Ontario, Canada,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Camargos P, Gomes DL, Alvim CG, Gomes FS, Cajazeiro JMD. From lip to lab: salty tasting skin is the main clue that raises clinical suspicion of cystic fibrosis in young infants. Acta Paediatr 2015; 104:e210-5. [PMID: 25640976 DOI: 10.1111/apa.12958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/05/2014] [Accepted: 01/28/2015] [Indexed: 11/28/2022]
Abstract
AIM This study developed a clinical decision rule (CDR) to rule in or rule out cystic fibrosis (CF) in the first weeks of life. METHODS We combined a two-step nonconcurrent birth cohort and a cross-sectional controlled study in which observers and mothers were blinded to confirmatory sweat test results. Neonates from uncomplicated pregnancies and deliveries, with two subsequent tests for immunoreactive trypsinogen (IRT) higher than 70 ng/mL, were eligible to take part. RESULTS We included 49 CF-affected and 177 CF-unaffected infants with an average age of 34 days. CF-affected infants demonstrated statistically significant differences in weight gain, stool frequency and salty tasting skin from birth. Multivariate analysis showed that the main predictors of CF were salty tasting skin (odds ratio 17.2) and weight gain of <10.5 g per day (odds ratio 4.6). Depending on the CDR score, we obtained the following results: sensitivity (42.9-61.2%), specificity (89.6-96.5%), positive (62.5-77.8%) and negative (85.6-89.1%) predictive value and positive (5.8-12.3) and negative (0.4-0.6) likelihood ratio. CONCLUSION The CDR could provide a reliable index of clinical suspicion and timely referral for sweat testing in settings without newborn screening programmes and may also be applied to false-negative individuals where such programmes already exist.
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Affiliation(s)
- Paulo Camargos
- Department of Pediatrics, Medical School; Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Daniela Lima Gomes
- Department of Pediatrics, Medical School; Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Cristina Gonçalves Alvim
- Department of Pediatrics, Medical School; Federal University of Minas Gerais; Belo Horizonte MG Brazil
| | - Fabrício Silva Gomes
- Department of Pediatrics, Medical School; Federal University of Minas Gerais; Belo Horizonte MG Brazil
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33
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Safety and efficacy of Creon® Micro in children with exocrine pancreatic insufficiency due to cystic fibrosis. J Cyst Fibros 2015; 14:275-81. [DOI: 10.1016/j.jcf.2014.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 07/08/2014] [Accepted: 07/09/2014] [Indexed: 01/31/2023]
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Hortencio TDR, Nogueira RJN, Marson FADL, Hessel G, Ribeiro JD, Ribeiro AF. [Factors impacting the growth and nutritional status of cystic fibrosis patients younger than 10 years of age who did not undergo neonatal screening]. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2015; 33:3-11. [PMID: 25681074 PMCID: PMC4436950 DOI: 10.1016/j.rpped.2014.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/30/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate by clinical and laboratory parameters how cystic fibrosis (CF) affects growth and nutritional status of children who were undergoing CF treatment but did not receive newborn screening. METHODS A historical cohort study of 52 CF patients younger than 10 years of age were followed in a reference center in Campinas, Southeast Brazil. Anthropometric measurements were abstracted from medical records until March/2010, when neonatal screening program was implemented. Between September/2009 and March/2010, parental height of the 52 CF patients were also measured. RESULTS Regarding nutritional status, four patients had Z-scores ≤ -2 for height/age (H/A) and body mass index/age (BMI/A). The following variables were associated with improved H/A ratio: fewer hospitalizations, longer time from first appointment to diagnosis, longer time from birth to diagnosis and later onset of respiratory disease. Forced vital capacity [FVC(%)], forced expiratory flow between 25-75% of FVC [FEF25-75(%)], forced expiratory volume in the first second [FEV1(%)], gestational age, birth weight and early respiratory symptoms were associated with IMC/A. CONCLUSIONS Greater number of hospitalizations, diagnosis delay and early onset of respiratory disease had a negative impact on growth. Lower spirometric values, lower gestational age, lower birth weight, and early onset of respiratory symptoms had negative impact on nutritional status. Malnutrition was observed in 7.7% of cases, but 23% of children had nutritional risk.
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Affiliation(s)
| | | | | | - Gabriel Hessel
- Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil.
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35
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Gagermeier J, Rusinak J, Lurain N, Alex C, Dilling D, Wigfield C, Love R. Subtherapeutic ganciclovir (GCV) levels and GCV-resistant cytomegalovirus in lung transplant recipients. Transpl Infect Dis 2014; 16:941-50. [DOI: 10.1111/tid.12317] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 08/20/2014] [Accepted: 09/14/2014] [Indexed: 11/30/2022]
Affiliation(s)
- J.P. Gagermeier
- Department of Pulmonary and Critical Care Medicine; Loyola University Medical Center; Maywood Illinois USA
| | - J.D. Rusinak
- Department of Pulmonary and Critical Care Medicine; Loyola University Medical Center; Maywood Illinois USA
| | - N.S. Lurain
- Department of Immunology/Microbiology; Rush University; Chicago Illinois USA
| | - C.G. Alex
- Department of Pulmonary and Critical Care Medicine; Loyola University Medical Center; Maywood Illinois USA
- Advocate Christ Medical Center; Oak Lawn Illinois USA
| | - D.F. Dilling
- Department of Pulmonary and Critical Care Medicine; Loyola University Medical Center; Maywood Illinois USA
| | - C.H. Wigfield
- Section of Cardiac and Thoracic Surgery; University of Chicago; Chicago Illinois USA
| | - R.B. Love
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee Wisconsin USA
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Abstract
Although the incidence of acute pancreatitis among children is less than that in adults, the physical and psychosocial impact on children and their families can be overwhelming. Pancreatitis is manifested as pain accompanied by a host of other complex issues. These issues are manifested more markedly when the patient has additional concomitant diagnoses. Pain management, liver function tests, amylase and lipase levels, endocrine and exocrine functionality, and recognition of systemic inflammation are especially important. Management after discharge from the hospital is often an ongoing stress for these patients and families, and multiple admissions to the intensive care unit may be necessary for feeding and pain complications. Presented in the context of an actual clinical case at a 500-bed tertiary care pediatric hospital, this patient’s scenario illustrates the importance of ensuring adequate nutrition, maintaining hydration, providing appropriate pain management, and preventing infection and thromboembolic events.
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Affiliation(s)
- Chris Kramer
- Chris Kramer is a registered nurse in the pediatric intensive care unit at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Alvin Jeffery
- Alvin Jeffery is an education specialist in the Center for Professional Excellence/Education at Cincinnati Children’s Hospital Medical Center
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Herscovitch K, Dauletbaev N, Lands LC. Vitamin D as an anti-microbial and anti-inflammatory therapy for Cystic Fibrosis. Paediatr Respir Rev 2014; 15:154-62. [PMID: 24332502 DOI: 10.1016/j.prrv.2013.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cystic fibrosis (CF) is characterized by chronic infection and inflammation in the airways that lead to progressive lung damage and early death. Current anti-inflammatory therapies are limited by extensive adverse effects or insufficient efficacy. There is a large body of studies indicating beneficial anti-microbial and anti-inflammatory properties of vitamin D. Since most patients with CF present with vitamin D deficiency, and serum vitamin D levels demonstrate a positive correlation with lung function and negative correlation with airway inflammation and infection, correcting vitamin D deficiency may be an attractive therapeutic strategy in CF. The function of vitamin D is intricately tied to its metabolism, which may be impaired at multiple steps in patients with CF, with a potential to limit the efficacy of vitamin D supplementation. It is likely that the aforementioned beneficial properties of vitamin D require supplementation with doses of vitamin D markedly higher than those recommended to maintain proper bone function. This review will illustrate the potential for supplementation with vitamin D or its metabolites to modulate inflammation and improve defence against chronic infection in CF lung, as well as appropriate vitamin D supplementation strategies for improving lung function in CF.
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Affiliation(s)
- K Herscovitch
- Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - N Dauletbaev
- Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Larry C Lands
- Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Division of Pediatric Respiratory Medicine, Department of Pediatrics, Montreal Children's Hospital-McGill University Health Centre.
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Haack A, Aragão GG, Novaes MRCG. Pathophysiology of cystic fibrosis and drugs used in associated digestive tract diseases. World J Gastroenterol 2013; 19:8552-61. [PMID: 24379572 PMCID: PMC3870500 DOI: 10.3748/wjg.v19.i46.8552] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/28/2013] [Accepted: 10/13/2013] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF) causes chronic infections in the respiratory tract and alters the digestive tract. This paper reviews the most important aspects of drug treatment and changes in the digestive tract of patients with CF. This is a review of the literature, emphasizing the discoveries made within the last 15 years by analyzing scientific papers published in journals indexed in the Scientific Electronic Library Online, Sciences Information, United States National Library of Medicine and Medical Literature Analysis and Retrieval System Online databases, both in English and Portuguese, using the key words: cystic fibrosis, medication, therapeutic, absorption, digestion. Randomized, observational, experimental, and epidemiological clinical studies were selected, among others, with statistical significance of 5%. This review evaluates the changes found in the digestive tract of CF patients including pancreatic insufficiency, constipation and liver diseases. Changes in nutritional status are also described. Clinical treatment, nutritional supplementation and drug management were classified in this review as essential to the quality of life of CF patients, and became available through public policies for monitoring and treating CF. The information gathered on CF and a multi professional approach to the disease is essential in the treatment of these patients.
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Maximal daily dose of pancreatic enzyme replacement therapy in infants with cystic fibrosis: a reconsideration. J Cyst Fibros 2013; 12:784-5. [PMID: 23809508 DOI: 10.1016/j.jcf.2013.05.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/24/2013] [Indexed: 01/29/2023]
Abstract
The current recommendations for dosing of pancreatic enzyme replacement therapy (PERT) in infants with cystic fibrosis (CF) were made using a limited evidence base. The per meal recommended dose was extrapolated from dosing guidelines for older patients into a maximal daily dose for infants. We discuss why this maximal daily dose recommendation may be insufficient for young infants with CF, although the optimal dose of PERT for infants with CF remains unknown.
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Evolution of pancreatic function during the first year in infants with cystic fibrosis. J Pediatr 2013; 162:808-812.e1. [PMID: 23245194 DOI: 10.1016/j.jpeds.2012.10.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/21/2012] [Accepted: 10/03/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe pancreatic function during the first year of life in infants diagnosed with cystic fibrosis (CF) using serial fecal elastase measurements. STUDY DESIGN This was a longitudinal study of 82 infants diagnosed with CF through newborn screening. Monthly stool samples were sent to a central laboratory for fecal elastase measurements. RESULTS A total of 61 infants had an initial stool sample obtained at age <3.5 months and a final stool sample obtained at age >9 months. Twenty-six of 29 infants with a fecal elastase value <50 μg/g at study entry had a fecal elastase value <200 μg/g (the accepted cutoff value for pancreatic insufficiency) on all measurements during the year; all 29 had a value <200 μg/g at the end of the study. Of the 48 infants with initial fecal elastase value <200 μg/g, 13 had at least 1 fecal elastase value >200 μg/g but had a final stool fecal elastase value <200 μg/g; however, 4 infants with an initial fecal elastase value <200 μg/g ended the year with a value >200 μg/g. Eleven of 13 infants with an initial fecal elastase value of >200 μg/g still had a value >200 μg/g at the end of the first year. CONCLUSION Infants with CF exhibit variability in fecal elastase values during the first year. Infants with a fecal elastase level of 50-200 μg/g at diagnosis should be treated with pancreatic enzyme replacement therapy, but fecal elastase should be remeasured at age 1 year to ensure that those with a falsely low value do not continue to receive pancreatic enzyme replacement therapy unnecessarily. Those with a fecal elastase value >200 μg/g initially can become pancreatic insufficient with time.
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Friedrich-Rust M, Schlueter N, Smaczny C, Eickmeier O, Rosewich M, Feifel K, Herrmann E, Poynard T, Gleiber W, Lais C, Zielen S, Wagner TOF, Zeuzem S, Bojunga J. Non-invasive measurement of liver and pancreas fibrosis in patients with cystic fibrosis. J Cyst Fibros 2013; 12:431-9. [PMID: 23361108 DOI: 10.1016/j.jcf.2012.12.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 12/26/2012] [Accepted: 12/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) have a relevant morbidity and mortality caused by CF-related liver-disease. While transient elastography (TE) is an established elastography method in hepatology centers, Acoustic-Radiation-Force-Impulse (ARFI)-Imaging is a novel ultrasound-based elastography method which is integrated in a conventional ultrasound-system. The aim of the present study was to evaluate the prevalence of liver-fibrosis in patients with CF using TE, ARFI-imaging and fibrosis blood tests. METHODS 106 patients with CF were prospectively included in the present study and received ARFI-imaging of the left and right liver-lobe, ARFI of the pancreas TE of the liver and laboratory evaluation. RESULTS The prevalence of liver-fibrosis according to recently published best practice guidelines for CFLD was 22.6%. Prevalence of significant liver-fibrosis assessed by TE, ARFI-right-liver-lobe, ARFI-left-liver-lobe, Fibrotest, Fibrotest-corrected-by-haptoglobin was 17%, 24%, 40%, 7%, and 16%, respectively. The best agreement was found for TE, ARFI-right-liver-lobe and Fibrotest-corrected-by-haptoglobin. Patients with pancreatic-insufficiency had significantly lower pancreas-ARFI-values as compared to patients without. CONCLUSIONS ARFI-imaging and TE seem to be promising non-invasive methods for detection of liver-fibrosis in patients with CF.
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Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine 1, J.W. Goethe-University Hospital, Frankfurt, Germany.
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Dijk FN, Fitzgerald DA. The impact of newborn screening and earlier intervention on the clinical course of cystic fibrosis. Paediatr Respir Rev 2012; 13:220-5. [PMID: 23069119 DOI: 10.1016/j.prrv.2012.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cystic fibrosis is a life-limiting condition which is readily diagnosed in the vast majority of cases on newborn screening [NBS]. A diagnosis made on newborn screening translates into earlier initiation of therapies, improved growth, better lung function into the adult years and culminates in better survival.
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Affiliation(s)
- F Nicole Dijk
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
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Uc A, Giriyappa R, Meyerholz DK, Griffin M, Ostedgaard LS, Tang XX, Abu-El-Haija M, Stoltz DA, Ludwig P, Pezzulo A, Abu-El-Haija M, Taft P, Welsh MJ. Pancreatic and biliary secretion are both altered in cystic fibrosis pigs. Am J Physiol Gastrointest Liver Physiol 2012; 303:G961-8. [PMID: 22936270 PMCID: PMC3469695 DOI: 10.1152/ajpgi.00030.2012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The pancreas, liver, and gallbladder are commonly involved in cystic fibrosis (CF), and acidic, dehydrated, and protein-rich secretions are characteristic findings. Pancreatic function studies in humans have been done by sampling the jejunal fluid. However, it has been difficult to separately study the function of pancreatic and biliary systems in humans with CF, because jejunal fluid contains a mixture of bile and pancreatic fluids. In contrast, pancreatic and biliary ducts open separately into the porcine intestine; therefore, biliary and pancreatic fluid can be individually analyzed in CF pigs. We studied newborn wild-type (WT) and CF pigs and found that CFTR was localized to the pancreatic ducts. We collected bile and pancreatic fluid and analyzed pancreatic enzymes with activity assays and immunoblot. Pancreatic enzyme expression was significantly decreased in CF compared with WT pigs. The volume and pH of pancreatic fluid were significantly lower and protein concentration was >5-fold higher in CF pigs. Secretin stimulation increased pancreatic fluid volume and pH in WT, but not CF, pigs. Baseline bile volume did not differ between WT and CF pigs, but volume did not increase in response to secretin in CF pigs. Bile pH was lower and protein concentration was twofold higher in CF pigs. These results indicate that pancreatic and biliary secretions are altered in CF pigs. Abnormal pancreatic and biliary secretion in CF may have important implications in disease pathogenesis.
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Affiliation(s)
- Aliye Uc
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA.
| | - Radhamma Giriyappa
- 1Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa;
| | - David K. Meyerholz
- 2Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa;
| | - Michelle Griffin
- 1Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa;
| | - Lynda S. Ostedgaard
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Xiao Xiao Tang
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Marwa Abu-El-Haija
- 1Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa;
| | - David A. Stoltz
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Paula Ludwig
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Alejandro Pezzulo
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Maisam Abu-El-Haija
- 1Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa;
| | - Peter Taft
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and
| | - Michael J. Welsh
- 3Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; and ,4Howard Hughes Medical Institute, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Serial analysis of the gut and respiratory microbiome in cystic fibrosis in infancy: interaction between intestinal and respiratory tracts and impact of nutritional exposures. mBio 2012; 3:mBio.00251-12. [PMID: 22911969 PMCID: PMC3428694 DOI: 10.1128/mbio.00251-12] [Citation(s) in RCA: 249] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary damage caused by chronic colonization of the cystic fibrosis (CF) lung by microbial communities is the proximal cause of respiratory failure. While there has been an effort to document the microbiome of the CF lung in pediatric and adult patients, little is known regarding the developing microflora in infants. We examined the respiratory and intestinal microbiota development in infants with CF from birth to 21 months. Distinct genera dominated in the gut compared to those in the respiratory tract, yet some bacteria overlapped, demonstrating a core microbiota dominated by Veillonella and Streptococcus. Bacterial diversity increased significantly over time, with evidence of more rapidly acquired diversity in the respiratory tract. There was a high degree of concordance between the bacteria that were increasing or decreasing over time in both compartments; in particular, a significant proportion (14/16 genera) increasing in the gut were also increasing in the respiratory tract. For 7 genera, gut colonization presages their appearance in the respiratory tract. Clustering analysis of respiratory samples indicated profiles of bacteria associated with breast-feeding, and for gut samples, introduction of solid foods even after adjustment for the time at which the sample was collected. Furthermore, changes in diet also result in altered respiratory microflora, suggesting a link between nutrition and development of microbial communities in the respiratory tract. Our findings suggest that nutritional factors and gut colonization patterns are determinants of the microbial development of respiratory tract microbiota in infants with CF and present opportunities for early intervention in CF with altered dietary or probiotic strategies. While efforts have been focused on assessing the microbiome of pediatric and adult cystic fibrosis (CF) patients to understand how chronic colonization by these microbes contributes to pulmonary damage, little is known regarding the earliest development of respiratory and gut microflora in infants with CF. Our findings suggest that colonization of the respiratory tract by microbes is presaged by colonization of the gut and demonstrated a role of nutrition in development of the respiratory microflora. Thus, targeted dietary or probiotic strategies may be an effective means to change the course of the colonization of the CF lung and thereby improve patient outcomes.
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Abu-El-Haija M, Ramachandran S, Meyerholz DK, Abu-El-Haija M, Griffin M, Giriyappa RL, Stoltz DA, Welsh MJ, McCray PB, Uc A. Pancreatic damage in fetal and newborn cystic fibrosis pigs involves the activation of inflammatory and remodeling pathways. THE AMERICAN JOURNAL OF PATHOLOGY 2012; 181:499-507. [PMID: 22683312 DOI: 10.1016/j.ajpath.2012.04.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/04/2012] [Accepted: 04/12/2012] [Indexed: 01/28/2023]
Abstract
Pancreatic disease has onset in utero in humans with cystic fibrosis (CF), and progresses over time to complete destruction of the organ. The exact mechanisms leading to pancreatic damage in CF are incompletely understood. Inflammatory cells are present in the pancreas of newborn pigs with CF (CF pigs) and humans, which suggests that inflammation may have a role in the destructive process. We wondered whether tissue inflammation and genes associated with inflammatory pathways were increased in the pancreas of fetal CF pigs [83 to 90 days gestation (normal pig gestation is ~114 days)] and newborn pigs. Compared with fetal pigs without CF (non-CF pigs), in fetal CF pigs, the pancreas exhibited patchy inflammation and acinar atrophy, with progression in distribution and severity in neonatal CF pigs. Large-scale transcript profiling revealed that the pancreas in fetal and newborn CF pigs exhibited significantly increased expression of proinflammatory, complement cascade, and profibrotic genes when compared with fetal and newborn non-CF pigs. Acinar cells exhibited increased apoptosis in the pancreas of fetal and newborn CF pigs. α-Smooth muscle actin and transforming growth factor β1 were increased in both fetal and newborn CF pig pancreas, suggesting activation of profibrotic pathways. Cell proliferation and mucous cell metaplasia were detected in newborn, but not fetal, CF pigs, indicating that they were not an initiator of pathogenesis but a response. Proinflammatory, complement cascade, proapoptotic, and profibrotic pathways are activated in CF pig pancreas, and likely contribute to the destructive process.
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Affiliation(s)
- Maisam Abu-El-Haija
- Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, Iowa 52242, USA
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Fisher JT, Zhang Y, Engelhardt JF. Comparative biology of cystic fibrosis animal models. Methods Mol Biol 2011; 742:311-34. [PMID: 21547741 DOI: 10.1007/978-1-61779-120-8_19] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Animal models of human diseases are critical for dissecting mechanisms of pathophysiology and developing therapies. In the context of cystic fibrosis (CF), mouse models have been the dominant species by which to study CF disease processes in vivo for the past two decades. Although much has been learned through these CF mouse models, limitations in the ability of this species to recapitulate spontaneous lung disease and several other organ abnormalities seen in CF humans have created a need for additional species on which to study CF. To this end, pig and ferret CF models have been generated by somatic cell nuclear transfer and are currently being characterized. These new larger animal models have phenotypes that appear to closely resemble human CF disease seen in newborns, and efforts to characterize their adult phenotypes are ongoing. This chapter will review current knowledge about comparative lung cell biology and cystic fibrosis transmembrane conductance regulator (CFTR) biology among mice, pigs, and ferrets that has implications for CF disease modeling in these species. We will focus on methods used to compare the biology and function of CFTR between these species and their relevance to phenotypes seen in the animal models. These cross-species comparisons and the development of both the pig and the ferret CF models may help elucidate pathophysiologic mechanisms of CF lung disease and lead to new therapeutic approaches.
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Affiliation(s)
- John T Fisher
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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Jadin SA, Wu GS, Zhang Z, Shoff SM, Tippets BM, Farrell PM, Miller T, Rock MJ, Levy H, Lai HJ. Growth and pulmonary outcomes during the first 2 y of life of breastfed and formula-fed infants diagnosed with cystic fibrosis through the Wisconsin Routine Newborn Screening Program. Am J Clin Nutr 2011; 93:1038-47. [PMID: 21430114 PMCID: PMC3076655 DOI: 10.3945/ajcn.110.004119] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The optimal feeding (breast milk, formula, or a combination) for infants with cystic fibrosis (CF) is unknown. Recommendations from the CF Foundation are based on limited data. OBJECTIVE We compared growth and pulmonary outcomes between breastfed and formula-fed infants through the age of 2 y. DESIGN A total of 103 CF infants born in 1994-2006 and diagnosed through newborn screening in Wisconsin were studied. Breastfed infants were classified by the duration of exclusive breastfeeding (ExBF). Exclusive formula-feeding (ExFM) was classified by the formula's caloric density (ie, standard [0.67 kcal/mL (20 kcal/oz) (ExFM20)] throughout infancy or high density [≥0.74 kcal/mL (22 kcal/oz) (ExFM22+)] for some duration of infancy). RESULTS Fifty-three infants (51% of infants) were breastfed and 50 infants (49% of infants) were ExFM. In breastfed infants, the duration of ExBF was <1 mo (53% of infants), 1-1.9 mo (21% of infants), 2-3 mo (17% of infants), and 4-9 mo (9% of infants). In ExFM infants, 23 infants (46%) received a formula with a high caloric density; approximately half (n = 13) of the ExFM infants received the formula by 6 mo of age. Proportionately more infants with pancreatic sufficiency (n = 9) were ExBF ≥1 mo (44% of infants), and none of the infants were ExFM22+, compared with infants with meconium ileus (n = 24; 13% of infants were ExBF ≥1 mo, and 38% of infants were ExFM22+) or pancreatic insufficiency (n = 70; 25% of infants were ExBF ≥1 mo, and 20% of infants were ExFM22+) (P = 0.02). In infants with pancreatic insufficiency, weight z scores declined from birth to 6 mo (P < 0.0001) in infants who were ExBF ≥2 mo, and the number of Pseudomonas aeruginosa infections through the age of 2 y was fewer in breastfed than in ExFM infants (P = 0.003) but did not differ by the duration of ExBF. CONCLUSION For infants with CF, ExBF <2 mo does not compromise growth and is associated with a respiratory benefit.
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Affiliation(s)
- Sarah A Jadin
- Department of Nutritional Sciences, College of Agriculture and Life Sciences, University of Wisconsin, Madison, WI 53706, USA
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CREON (Pancrelipase Delayed-Release Capsules) for the treatment of exocrine pancreatic insufficiency. Adv Ther 2010; 27:895-916. [PMID: 21086085 DOI: 10.1007/s12325-010-0085-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Indexed: 12/12/2022]
Abstract
Exocrine pancreatic insufficiency (EPI) is associated with conditions including cystic fibrosis (CF), chronic pancreatitis (CP), and pancreatic surgery (PS). The symptoms include maldigestion, malnutrition, weight loss, flatulence, and steatorrhea. Pancreatic enzyme replacement therapy (PERT) is the standard treatment for EPI; it is regulated in many countries and most recently in the USA following a US FDA mandate for all PERT manufacturers to submit new drug applications. Pancrelipase delayed-release capsules (CREON®, Abbott, Marietta, GA, USA) have been available in Europe since 1984 and in the USA since 1987; a new formulation was the first PERT to gain approval in the USA in 2009. The efficacy and safety of CREON have been demonstrated in double-blind, randomized, placebo-controlled trials in patients with CF aged ≥7 years and in patients with CP or post-PS. The data consistently demonstrate significantly better fat and nitrogen absorption with CREON versus placebo, and improvements in clinical symptoms, stool frequency, and body weight. Additionally, efficacy and safety of CREON have been shown in open-label studies in young children with CF (aged 1 month to 6 years), with control of fat malabsorption and control of clinical symptoms. The most commonly reported adverse events (AEs) with PERT are gastrointestinal disorders and allergic skin reactions. In clinical studies, CREON was well tolerated with very few withdrawals due to AEs and a low frequency of AEs judged treatment related, regardless of patient age. To further support the known safety profile of PERT, all manufacturers are required to investigate risk factors for fibrosing colonopathy, a rare gastrointestinal complication of CF, and the theoretical risk of viral transmission from porcine-derived PERT products. Together, the clinical study data and wealth of clinical experience suggest that CREON is effective and safe in patients with EPI regardless of etiology, with a very favorable risk-benefit profile.
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Pigs and humans with cystic fibrosis have reduced insulin-like growth factor 1 (IGF1) levels at birth. Proc Natl Acad Sci U S A 2010; 107:20571-5. [PMID: 21059918 DOI: 10.1073/pnas.1015281107] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
People with cystic fibrosis (CF) exhibit growth defects. That observation has been attributed, in part, to decreased insulin-like growth factor 1 (IGF1) levels, and the reduction has been blamed on malnutrition and pulmonary inflammation. However, patients with CF already have a reduced weight at birth, a manifestation not likely secondary to poor nutrition or inflammation. We found that, like humans, CF pigs were smaller than non-CF littermates and had lower IGF1 levels. To better understand the basis of IGF1 reduction, we studied newborn pigs and found low IGF1 levels within 12 h of birth. Moreover, humerus length and bone mineral content were decreased, consistent with less IGF1 activity in utero. These findings led us to test newborn humans with CF, and we found that they also had reduced IGF1 levels. Discovering lower IGF1 levels in newborn pigs and humans indicates that the decrease is not solely a consequence of malnutrition or pulmonary inflammation and that loss of cystic fibrosis transmembrane conductance regulator function has a more direct effect. Consistent with this hypothesis, we discovered reduced growth hormone release in organotypic pituitary slice cultures of newborn CF pigs. These findings may explain the long-standing observation that CF newborns are smaller than non-CF babies and why some patients with good clinical status fail to reach their growth potential. The results also suggest that measuring IGF1 levels might be of value as a biomarker to predict disease severity or the response to therapeutics. Finally, they raise the possibility that IGF1 supplementation beginning in infancy might be beneficial in CF.
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Sermet-Gaudelus I, Mayell SJ, Southern KW. Guidelines on the early management of infants diagnosed with cystic fibrosis following newborn screening. J Cyst Fibros 2010; 9:323-9. [DOI: 10.1016/j.jcf.2010.04.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 03/30/2010] [Accepted: 04/30/2010] [Indexed: 11/25/2022]
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