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Ferdek PE, Krzysztofik D, Stopa KB, Kusiak AA, Paw M, Wnuk D, Jakubowska MA. When healing turns into killing ‐ the pathophysiology of pancreatic and hepatic fibrosis. J Physiol 2022; 600:2579-2612. [DOI: 10.1113/jp281135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/12/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Pawel E. Ferdek
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Daria Krzysztofik
- Malopolska Centre of Biotechnology Jagiellonian University Krakow Poland
| | - Kinga B. Stopa
- Malopolska Centre of Biotechnology Jagiellonian University Krakow Poland
| | - Agnieszka A. Kusiak
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Milena Paw
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
| | - Dawid Wnuk
- Department of Cell Biology Faculty of Biochemistry Biophysics and Biotechnology Jagiellonian University Krakow Poland
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2
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McKay IR, Ooi CY. The Exocrine Pancreas in Cystic Fibrosis in the Era of CFTR Modulation: A Mini Review. Front Pediatr 2022; 10:914790. [PMID: 35832587 PMCID: PMC9271761 DOI: 10.3389/fped.2022.914790] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Cystic fibrosis (CF) is a common disorder of autosomal recessive inheritance, that once conferred a life expectancy of only a few months. Over recent years, significant advances have been made to CF therapeutic approaches, changing the face of the disease, and facilitating the partial restoration of pancreatic function. This mini review summarizes the current landscape of exocrine pancreatic management in CF and explores areas for future direction and development.
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Affiliation(s)
| | - Chee Y Ooi
- School of Clinical Medicine, Discipline of Paediatrics and Child Health, Randwick Clinical Campus, University of New South Wales (UNSW) Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Gastroenterology, Sydney Children's Hospital Randwick, Randwick, NSW, Australia
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3
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Scheers I, Berardis S. Congenital etiologies of exocrine pancreatic insufficiency. Front Pediatr 2022; 10:909925. [PMID: 35935370 PMCID: PMC9354839 DOI: 10.3389/fped.2022.909925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/28/2022] [Indexed: 11/22/2022] Open
Abstract
Congenital exocrine pancreatic insufficiency is a rare condition. In a vast majority of patients, exocrine dysfunction occurs as part of a multisystemic disease, the most prevalent being cystic fibrosis and Shwachman-Bodian-Diamond syndrome. Recent fundamental studies have increased our understanding of the pathophysiology of these diseases. Exocrine pancreatic dysfunction should be considered in children with failure to thrive and fatty stools. Treatment is mainly supportive and consists of pancreatic enzyme replacement and liposoluble vitamins supplementation.
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Affiliation(s)
- Isabelle Scheers
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Silvia Berardis
- Department of Pediatrics, Specialized Pediatrics, Pediatric Pneumology and Cystic Fibrosis Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
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4
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Al-Selwi Y, Shaw JA, Kattner N. Understanding the Pancreatic Islet Microenvironment in Cystic Fibrosis and the Extrinsic Pathways Leading to Cystic Fibrosis Related Diabetes. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2021; 14:11795514211048813. [PMID: 34675737 PMCID: PMC8524685 DOI: 10.1177/11795514211048813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive chronic condition
effecting approximately 70 000 to 100 000 people globally and is
caused by a loss-of-function mutation in the CF transmembrane
conductance regulator. Through improvements in clinical care, life
expectancy in CF has increased considerably associated with rising
incidence of secondary complications including CF-related diabetes
(CFRD). CFRD is believed to result from β-cell loss as well as
insufficient insulin secretion due to β-cell dysfunction, but the
underlying pathophysiology is not yet fully understood. Here we review
the morphological and cellular changes in addition to the
architectural remodelling of the pancreatic exocrine and endocrine
compartments in CF and CFRD pancreas. We consider also potential
underlying proinflammatory signalling pathways impacting on endocrine
and specifically β-cell function, concluding that further research
focused on these mechanisms may uncover novel therapeutic targets
enabling restoration of normal insulin secretion.
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Affiliation(s)
- Yara Al-Selwi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - James Am Shaw
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nicole Kattner
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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5
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Fridell JA, Bozic MA, Ulrich BJ, Lutz AJ, Powelson JA. Pancreas transplantation for cystic fibrosis: A frequently missed opportunity. Clin Transplant 2021; 35:e14371. [PMID: 34032335 DOI: 10.1111/ctr.14371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
Cystic fibrosis (CF) is an inherited autosomal recessive disorder. Despite optimized therapy, the majority of affected individuals ultimately die of respiratory failure. As patients with CF are living longer, extra-pulmonary manifestations may develop including pancreatic failure, which manifests as exocrine insufficiency, and CF-related diabetes (CFRD). Both of these can be managed through pancreas transplantation. Pancreas transplantation is usually performed in combination with another organ, most often with a kidney transplant for end-stage diabetic nephropathy. In the CF patient population, the two settings where inclusion of a pancreas transplant should be considered would be in combination with a lung transplant for CF pulmonary disease, or in combination with a liver for CF-related liver disease with cirrhosis. This report will discuss this topic in detail, including a review of the literature regarding combinations of lung/pancreas and liver/pancreas transplant.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Molly A Bozic
- Department of Pediatric Gastroenterology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Benjamin J Ulrich
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew J Lutz
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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6
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Vandebrouck C, Ferreira T. Glued in lipids: Lipointoxication in cystic fibrosis. EBioMedicine 2020; 61:103038. [PMID: 33038767 PMCID: PMC7648119 DOI: 10.1016/j.ebiom.2020.103038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/27/2020] [Accepted: 09/14/2020] [Indexed: 01/14/2023] Open
Abstract
Cystic Fibrosis (CF) is an autosomal recessive disease caused by mutations in the CF transmembrane regulator (CFTR) gene, which encodes a chloride channel located at the apical surface of epithelial cells. Unsaturated Fatty Acid (UFA) deficiency has been a persistent observation in tissues from patients with CF. However, the impacts of such deficiencies on the etiology of the disease have been the object of intense debates. The aim of the present review is first to highlight the general consensus on fatty acid dysregulations that emerges from, sometimes apparently contradictory, studies. In a second step, a unifying mechanism for the potential impacts of these fatty acid dysregulations in CF cells, based on alterations of membrane biophysical properties (known as lipointoxication), is proposed. Finally, the contribution of lipointoxication to the progression of the CF disease and how it could affect the efficacy of current treatments is also discussed.
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Affiliation(s)
- Clarisse Vandebrouck
- Laboratoire "Lipointoxication and Channelopathies (LiTch) - ConicMeds", Université de Poitiers, 1, rue Georges Bonnet, Poitiers, France; Laboratoire "Signalisation et Transports Ioniques Membranaires (STIM; EA 7349)", Université de Poitiers, 1, rue Georges Bonnet, Poitiers, France
| | - Thierry Ferreira
- Laboratoire "Lipointoxication and Channelopathies (LiTch) - ConicMeds", Université de Poitiers, 1, rue Georges Bonnet, Poitiers, France.
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7
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Berg P, Svendsen SL, Sorensen MV, Larsen CK, Andersen JF, Jensen-Fangel S, Jeppesen M, Schreiber R, Cabrita I, Kunzelmann K, Leipziger J. Impaired Renal HCO 3 - Excretion in Cystic Fibrosis. J Am Soc Nephrol 2020; 31:1711-1727. [PMID: 32703846 DOI: 10.1681/asn.2020010053] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/13/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with cystic fibrosis (CF) do not respond with increased urinary HCO3 - excretion after stimulation with secretin and often present with metabolic alkalosis. METHODS By combining RT-PCR, immunohistochemistry, isolated tubule perfusion, in vitro cell studies, and in vivo studies in different mouse models, we elucidated the mechanism of secretin-induced urinary HCO3 - excretion. For CF patients and CF mice, we developed a HCO3 - drinking test to assess the role of the cystic fibrosis transmembrane conductance regulator (CFTR) in urinary HCO3 -excretion and applied it in the patients before and after treatment with the novel CFTR modulator drug, lumacaftor-ivacaftor. RESULTS β-Intercalated cells express basolateral secretin receptors and apical CFTR and pendrin. In vivo application of secretin induced a marked urinary alkalization, an effect absent in mice lacking pendrin or CFTR. In perfused cortical collecting ducts, secretin stimulated pendrin-dependent Cl-/HCO3 - exchange. In collecting ducts in CFTR knockout mice, baseline pendrin activity was significantly lower and not responsive to secretin. Notably, patients with CF (F508del/F508del) and CF mice showed a greatly attenuated or absent urinary HCO3 --excreting ability. In patients, treatment with the CFTR modulator drug lumacaftor-ivacaftor increased the renal ability to excrete HCO3 -. CONCLUSIONS These results define the mechanism of secretin-induced urinary HCO3 - excretion, explain metabolic alkalosis in patients with CF, and suggest feasibility of an in vivo human CF urine test to validate drug efficacy.
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Affiliation(s)
- Peder Berg
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
| | - Samuel L Svendsen
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
| | - Mads V Sorensen
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
| | - Casper K Larsen
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
| | - Jesper Frank Andersen
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Majbritt Jeppesen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Rainer Schreiber
- Department of Physiology, University of Regensburg, Regensburg, Germany
| | - Ines Cabrita
- Department of Physiology, University of Regensburg, Regensburg, Germany
| | - Karl Kunzelmann
- Department of Physiology, University of Regensburg, Regensburg, Germany
| | - Jens Leipziger
- Department of Biomedicine, Physiology and Biophysics, Aarhus University, Aarhus, Denmark
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8
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Secretin-Stimulated Magnetic Resonance Imaging Reveals Variable Diagnostic Accuracy According to Etiology in Pancreatic Disease. Pancreas 2020; 49:361-367. [PMID: 32132505 DOI: 10.1097/mpa.0000000000001491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Secretin-stimulated magnetic resonance imaging (s-MRI) is the best validated radiological modality assessing pancreatic exocrine secretion. In this prospective observational study, we compare the diagnostic accuracy of s-MRI for exocrine pancreatic failure due to different pancreatic diseases and healthy controls. METHODS We performed s-MRI in 21 cystic fibrosis (CF) patients, 78 patients with chronic pancreatitis (CP) and 20 healthy controls. Exocrine failure was defined by fecal elastase-1 of less than 200 μg/g or bicarbonate concentration from endoscopic secretin test of less than 80 mmol/L. RESULTS Eleven CF and 61 CP patients were exocrine insufficient. Insufficient CF patients had lower s-MRI volume output compared with all other groups (P < 0.05). Insufficient CP patients had reduced volume output compared with controls and sufficient CF (P < 0.05). Secretin-stimulated MRI yielded overall accuracy of 0.78 (95% confidence interval [CI], 0.70-0.86) for exocrine failure. When divided according to etiology, the test yielded accuracy of 0.95 (95% CI, 0.90-1) in CF and 0.73 (95% CI, 0.64-0.82) in CP. CONCLUSIONS The accuracy of s-MRI volume output measures to diagnose exocrine failure was higher in CF than in CP. Differences in s-MRI volume output in patients with exocrine failure may be due to different etiological and pathogenic mechanisms in CF and CP.
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9
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Exocrine Pancreatic Insufficiency and Nutritional Complications. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Genetic association and transcriptome integration identify contributing genes and tissues at cystic fibrosis modifier loci. PLoS Genet 2019; 15:e1008007. [PMID: 30807572 PMCID: PMC6407791 DOI: 10.1371/journal.pgen.1008007] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/08/2019] [Accepted: 02/06/2019] [Indexed: 01/09/2023] Open
Abstract
Cystic Fibrosis (CF) exhibits morbidity in several organs, including progressive lung disease in all patients and intestinal obstruction at birth (meconium ileus) in ~15%. Individuals with the same causal CFTR mutations show variable disease presentation which is partly attributed to modifier genes. With >6,500 participants from the International CF Gene Modifier Consortium, genome-wide association investigation identified a new modifier locus for meconium ileus encompassing ATP12A on chromosome 13 (min p = 3.83x10(-10)); replicated loci encompassing SLC6A14 on chromosome X and SLC26A9 on chromosome 1, (min p<2.2x10(-16), 2.81x10(-11), respectively); and replicated a suggestive locus on chromosome 7 near PRSS1 (min p = 2.55x10(-7)). PRSS1 is exclusively expressed in the exocrine pancreas and was previously associated with non-CF pancreatitis with functional characterization demonstrating impact on PRSS1 gene expression. We thus asked whether the other meconium ileus modifier loci impact gene expression and in which organ. We developed and applied a colocalization framework called the Simple Sum (SS) that integrates regulatory and genetic association information, and also contrasts colocalization evidence across tissues or genes. The associated modifier loci colocalized with expression quantitative trait loci (eQTLs) for ATP12A (p = 3.35x10(-8)), SLC6A14 (p = 1.12x10(-10)) and SLC26A9 (p = 4.48x10(-5)) in the pancreas, even though meconium ileus manifests in the intestine. The meconium ileus susceptibility locus on chromosome X appeared shifted in location from a previously identified locus for CF lung disease severity. Using the SS we integrated the lung disease association locus with eQTLs from nasal epithelia of 63 CF participants and demonstrated evidence of colocalization with airway-specific regulation of SLC6A14 (p = 2.3x10(-4)). Cystic Fibrosis is realizing the promise of personalized medicine, and identification of the contributing organ and understanding of tissue specificity for a gene modifier is essential for the next phase of personalizing therapeutic strategies.
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11
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Yu R, Li Z, Liu S, Huwatibieke B, Li Y, Yin Y, Zhang W. Activation of mTORC1 signaling in gastric X/A-like cells induces spontaneous pancreatic fibrosis and derangement of glucose metabolism by reducing ghrelin production. EBioMedicine 2018; 36:304-315. [PMID: 30266297 PMCID: PMC6197745 DOI: 10.1016/j.ebiom.2018.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/15/2018] [Accepted: 09/15/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Pancreatic fibrosis is a pathophysiological process associated with excessive deposition of extracellular matrix in pancreas, leading to reduced insulin secretion and derangement of glucose metabolism. X/A-like cells, a group of unique endocrine cells in gastric oxyntic mucosa, produce and secret ghrelin to influence energy balance. Whether gastric X/A-like cells affect pancreatic fibrosis and subsequent glucose homeostasis remains unclear. METHODS We established a Ghrl-cre transgene in which the cre enzyme is expressed in X/A-like cells under the control of ghrelin-promoter. TSC1flox/flox mice were bred with Ghrl-cre mice to generate Ghrl-TSC1-/- (TG) mice, within which mTORC1 signaling was activated in X/A-like cells. Pancreatic fibrosis and insulin secretion were analyzed in the TG mice. FINDINGS Activation of mTORC1 signaling by deletion of TSC1 gene in gastric X/A-like cells induced spontaneous pancreatic fibrosis. This alteration was associated with reduced insulin expression and secretion, as well as impaired glucose metabolism. Activation of mTORC1 signaling in gastric X/A-like cells reduced gastric and circulating ghrelin levels. Exogenous ghrelin reversed pancreatic fibrosis and glucose intolerance induced by activation of mTORC1 signaling in these cells. Rapamycin, an inhibitor of mTOR, reversed the decrease of ghrelin levels and pancreatic fibrosis. INTERPRETATION Activation of mTORC1 signaling in gastric X/A-like cells induces spontaneous pancreatic fibrosis and subsequently impairs glucose homeostasis via suppression of ghrelin.
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Affiliation(s)
- Ruili Yu
- School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Ziru Li
- School of Basic Medical Sciences, Peking University, Beijing 100191, China; Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109-0346, USA
| | - Shiying Liu
- School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | | | - Yin Li
- School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Yue Yin
- School of Basic Medical Sciences, Peking University, Beijing 100191, China.
| | - Weizhen Zhang
- School of Basic Medical Sciences, Peking University, Beijing 100191, China.
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12
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Balázs A, Balla Z, Kui B, Maléth J, Rakonczay Z, Duerr J, Zhou-Suckow Z, Schatterny J, Sendler M, Mayerle J, Kühn JP, Tiszlavicz L, Mall MA, Hegyi P. Ductal Mucus Obstruction and Reduced Fluid Secretion Are Early Defects in Chronic Pancreatitis. Front Physiol 2018; 9:632. [PMID: 29896115 PMCID: PMC5987707 DOI: 10.3389/fphys.2018.00632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/11/2018] [Indexed: 12/22/2022] Open
Abstract
Objective: Defective mucus production in the pancreas may be an important factor in the initiation and progression of chronic pancreatitis (CP), therefore we aimed to (i) investigate the qualitative and quantitative changes of mucus both in human CP and in an experimental pancreatitis model and (ii) to correlate the mucus phenotype with epithelial ion transport function. Design: Utilizing human tissue samples and a murine model of cerulein induced CP we measured pancreatic ductal mucus content by morphometric analysis and the relative expression of different mucins in health and disease. Pancreatic fluid secretion in CP model was measured in vivo by magnetic resonance cholangiopancreatography (MRCP) and in vitro on cultured pancreatic ducts. Time-changes of ductal secretory function were correlated to those of the mucin production. Results: We demonstrate increased mucus content in the small pancreatic ducts in CP. Secretory mucins MUC6 and MUC5B were upregulated in human, Muc6 in mouse CP. In vivo and in vitro fluid secretion was decreased in cerulein-induced CP. Analysis of time-course changes showed that impaired ductal ion transport is paralleled by increased Muc6 expression. Conclusion: Mucus accumulation in the small ducts is a combined effect of mucus hypersecretion and epithelial fluid secretion defect, which may lead to ductal obstruction. These results suggest that imbalance of mucus homeostasis may have an important role in the early-phase development of CP, which may have novel diagnostic and therapeutic implications.
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Affiliation(s)
- Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Department of Translational Pulmonology, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Zsolt Balla
- MTA-SZTE Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,MTA-SZTE Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Julia Duerr
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany.,Department of Pediatric Pulmonology and Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Zhe Zhou-Suckow
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Jolanthe Schatterny
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Matthias Sendler
- Department of Internal Medicine A, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Department of Internal Medicine A, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Jens-P Kühn
- Institute of Radiology, Universitätsmedizin Greifswald, Greifswald, Germany
| | | | - Marcus A Mall
- Department of Translational Pulmonology, Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany.,Department of Pediatric Pulmonology and Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Peter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Institute for Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
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13
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Engjom T, Tjora E, Wathle G, Erchinger F, Lærum BN, Gilja OH, Haldorsen IS, Dimcevski G. Secretin-stimulated ultrasound estimation of pancreatic secretion in cystic fibrosis validated by magnetic resonance imaging. Eur Radiol 2018; 28:1495-1503. [PMID: 29134356 PMCID: PMC5834563 DOI: 10.1007/s00330-017-5115-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 08/07/2017] [Accepted: 10/02/2017] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Secretin-stimulated magnetic resonance imaging (s-MRI) is the best validated radiological modality assessing pancreatic secretion. The purpose of this study was to compare volume output measures from secretin-stimulated transabdominal ultrasonography (s-US) to s-MRI for the diagnosis of exocrine pancreatic failure in cystic fibrosis (CF). METHODS We performed transabdominal ultrasonography and MRI before and at timed intervals during 15 minutes after secretin stimulation in 21 CF patients and 13 healthy controls. To clearly identify the subjects with reduced exocrine pancreatic function, we classified CF patients as pancreas-sufficient or -insufficient by secretin-stimulated endoscopic short test and faecal elastase. RESULTS Pancreas-insufficient CF patients had reduced pancreatic secretions compared to pancreas-sufficient subjects based on both imaging modalities (p < 0.001). Volume output estimates assessed by s-US correlated to that of s-MRI (r = 0.56-0.62; p < 0.001). Both s-US (AUC: 0.88) and s-MRI (AUC: 0.99) demonstrated good diagnostic accuracy for exocrine pancreatic failure. CONCLUSIONS Pancreatic volume-output estimated by s-US corresponds well to exocrine pancreatic function in CF patients and yields comparable results to that of s-MRI. s-US provides a simple and feasible tool in the assessment of pancreatic secretion. KEY POINTS • Cystic fibrosis patients with affected pancreas have reduced pancreatic secretions. • Secretin-stimulated sonography is a simple and feasible method to assess pancreatic output. • Secretin-simulated MRI is a more precise method to assess pancreatic secretions. • The sonographic and MRI methods yielded comparable pancreatic secretory output estimates.
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Affiliation(s)
- Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway.
| | - Erling Tjora
- Pediatric Department, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, 5021, Bergen, Norway
| | - Gaute Wathle
- Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Friedemann Erchinger
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Voss Hospital, Sjukehusvegen 16, 5740, Voss, Norway
| | - Birger N Lærum
- Department of Clinical Science, University of Bergen, 5021, Bergen, Norway
| | - Odd H Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Ingfrid Salvesen Haldorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway
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14
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Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disorder in Caucasian populations. Individuals with CF have seen significant increases in life expectancy in the last 60 years. As a result, previously rare complications are now coming to light. The most common of these is cystic fibrosis-related diabetes (CFRD), which affects 40-50% of CF adults. CFRD significantly impacts the pulmonary function and longevity of CF patients, yet a lack of consensus on the best methods to diagnose and treat CFRD remains. We begin by reviewing our understanding of the pathogenesis of CFRD, as emerging evidence shows the cystic fibrosis transmembrane conductance regulator (CFTR) also has important roles in the release of insulin and glucagon and in the protection of β cells from oxidative stress. We then discuss how current recommended methods of CFRD diagnosis are not appropriate, as continuous glucose monitoring becomes more effective, practical, and cost-effective. Finally, we evaluate emerging treatments which have narrowed the mortality gap within the CF patient group. In the future, pharmacological potentiators and correctors directly targeting CFTR show huge promise for both CFRD and the wider CF patient groups.
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Affiliation(s)
- Kayani Kayani
- Faculty of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Raihan Mohammed
- Faculty of Medicine, University of Cambridge, Cambridge, United Kingdom
- *Correspondence: Raihan Mohammed,
| | - Hasan Mohiaddin
- Faculty of Medicine, Imperial College London, London, United Kingdom
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15
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Hohwieler M, Perkhofer L, Liebau S, Seufferlein T, Müller M, Illing A, Kleger A. Stem cell-derived organoids to model gastrointestinal facets of cystic fibrosis. United European Gastroenterol J 2017; 5:609-624. [PMID: 28815024 PMCID: PMC5548342 DOI: 10.1177/2050640616670565] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 08/25/2016] [Indexed: 12/16/2022] Open
Abstract
Cystic fibrosis (CF) is one of the most frequently occurring inherited human diseases caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) which lead to ample defects in anion transport and epithelial fluid secretion. Existing models lack both access to early stages of CF development and a coeval focus on the gastrointestinal CF phenotypes, which become increasingly important due increased life span of the affected individuals. Here, we provide a comprehensive overview of gastrointestinal facets of CF and the opportunity to model these in various systems in an attempt to understand and treat CF. A particular focus is given on forward-leading organoid cultures, which may circumvent current limitations of existing models and thereby provide a platform for drug testing and understanding of disease pathophysiology in gastrointestinal organs.
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Affiliation(s)
- Meike Hohwieler
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
| | - Stefan Liebau
- Institute of Neuroanatomy, Eberhard Karls University Tuebingen, Oesterbergstr. 3, 72074 Tuebingen, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
| | - Martin Müller
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
| | - Anett Illing
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine 1, University Medical Centre Ulm, Ulm, Germany
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16
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Bicarbonate in cystic fibrosis. J Cyst Fibros 2017; 16:653-662. [PMID: 28732801 DOI: 10.1016/j.jcf.2017.06.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cystic fibrosis (CF, mucoviscidosis) is caused by mutations in the gene encoding CF transmembrane conductance regulator (CFTR), which is a chloride and bicarbonate channel necessary for fluid secretion and extracellular alkalization. For a long time, research concentrated on abnormal Cl- and Na+ transport, but neglected bicarbonate as a crucial factor in CF. METHODS The present short review reports early findings as well as recent insights into the role of CFTR for bicarbonate transport and its defects in CF. RESULTS The available data indicate impaired bicarbonate transport not only in pancreas, intestine, airways, and reproductive organs, but also in salivary glands, sweat duct and renal tubular epithelial cells. Defective bicarbonate transport is closely related to the impaired mucus properties and mucus blocking in secretory organs of CF patients, causing the life threatening lung disease. CONCLUSIONS Apart from the devastating lung disease, abrogated bicarbonate transport also leads to many other organ dysfunctions, which are outlined in the present review.
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Darrah R, Bederman I, Vitko M, Valerio DM, Drumm ML, Hodges CA. Growth deficits in cystic fibrosis mice begin in utero prior to IGF-1 reduction. PLoS One 2017; 12:e0175467. [PMID: 28384265 PMCID: PMC5383306 DOI: 10.1371/journal.pone.0175467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/27/2017] [Indexed: 12/16/2022] Open
Abstract
Growth deficits are common in cystic fibrosis (CF), but their cause is complex, with contributions from exocrine pancreatic insufficiency, pulmonary complications, gastrointestinal obstructions, and endocrine abnormalities. The CF mouse model displays similar growth impairment despite exocrine pancreatic function and in the absence of chronic pulmonary infection. The high incidence of intestinal obstruction in the CF mouse has been suggested to significantly contribute to the observed growth deficits. Previous studies by our group have shown that restoration of the cystic fibrosis transmembrane conductance regulator (CFTR) in the intestinal epithelium prevents intestinal obstruction but does not improve growth. In this study, we further investigate growth deficits in CF and gut-corrected CF mice by assessing insulin-like growth factor 1 (IGF-1). IGF-1 levels were significantly decreased in CF and gut-corrected CF adult mice compared to wildtype littermates and were highly correlated with weight. Interestingly, perinatal IGF-1 levels were not significantly different between CF and wildtype littermates, even though growth deficits in CF mice could be detected late in gestation. Since CFTR has been suggested to play a role in water and nutrient exchange in the placenta through its interaction with aquaporins, we analyzed placental aquaporin expression in late-gestation CF and control littermates. While significant differences were observed in Aquaporin 9 expression in CF placentas in late gestation, there was no evidence of placental fluid exchange differences between CF and control littermates. The results from this study indicate that decreased IGF-1 levels are highly correlated with growth in CF mice, independent of CF intestinal obstruction. However, the perinatal growth deficits that are observed in CF mice are not due to decreased IGF-1 levels or differences in placenta-mediated fluid exchange. Further investigation is necessary to understand the etiology of early growth deficits in CF, as growth has been shown to be a significant factor in disease outcomes.
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Affiliation(s)
- Rebecca Darrah
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Ilya Bederman
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Megan Vitko
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Dana M. Valerio
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Mitchell L. Drumm
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Craig A. Hodges
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
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18
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Madzak A, Engjom T, Wathle GK, Olesen SS, Tjora E, Njølstad PR, Lærum BN, Drewes AM, Dimcevski G, Frøkjær JB, Haldorsen IS. Secretin-stimulated MRI assessment of exocrine pancreatic function in patients with cystic fibrosis and healthy controls. Abdom Radiol (NY) 2017; 42:890-899. [PMID: 27832324 DOI: 10.1007/s00261-016-0972-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Secretin-stimulated magnetic resonance imaging (s-MRI) and pancreatic diffusion weighted imaging (DWI) are novel non-invasive imaging techniques for assessment of exocrine pancreatic insufficiency (EPI). The aim was to validate s-MRI assessed pancreatic secreted volume using novel semi-automatic quantification software, and to assess the ability of s-MRI with DWI to diagnose EPI in patients with cystic fibrosis (CF). METHODS s-MRI and DWI was performed in 19 patients with CF (median age 21 years; range 16-56; eight men) and in 10 healthy controls (HC) (median age 46 years; range 20-65; four men). Sequential coronal T2-weighted images covering the duodenum and small bowel and axial DWI were acquired before and 1, 5, 9, and 13 min after secretin stimulation. A short endoscopic secretin test was used as reference method for EPI. RESULTS CF patients with EPI had lower apparent diffusion coefficient before secretin in the pancreatic head (P < 0.001) and lower secreted bowel fluid volumes (P = 0.035) compared to HC and CF patients without EPI. ROC curve analyses identified that secreted fluid volume after 13 min yielded the highest diagnostic accuracy for diagnosing EPI (AUC 0.93; 95% CI [0.80-1.00]). CONCLUSION Pancreatic s-MRI is useful for the assessment of exocrine pancreatic function with high diagnostic accuracy for the diagnosis of EPI in CF.
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Affiliation(s)
- Adnan Madzak
- Mech-Sense, Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark.
| | - Trond Engjom
- Department of Clinical Medicine, University of Bergen, Mons, Norway
- Department of Medicine, Haukeland University Hospital, Mons, Norway
| | - Gaute K Wathle
- Department of Clinical Medicine, University of Bergen, Mons, Norway
- Department of Radiology, Haukeland University Hospital, Mons, Norway
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology & HepatologyAalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Erling Tjora
- Department of Clinical Science, University of Bergen, Mons, Norway
- Pediatric Department, Haukeland University Hospital, Mons, Norway
| | - Pål R Njølstad
- Department of Clinical Science, University of Bergen, Mons, Norway
- Pediatric Department, Haukeland University Hospital, Mons, Norway
| | - Birger Norderud Lærum
- Department of Clinical Science, University of Bergen, Mons, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Mons, Norway
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology & HepatologyAalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Mons, Norway
- Department of Medicine, Haukeland University Hospital, Mons, Norway
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ingfrid S Haldorsen
- Department of Clinical Medicine, University of Bergen, Mons, Norway
- Department of Radiology, Haukeland University Hospital, Mons, Norway
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Michl RK, Tabori H, Hentschel J, Beck JF, Mainz JG. Clinical approach to the diagnosis and treatment of cystic fibrosis and CFTR-related disorders. Expert Rev Respir Med 2016; 10:1177-1186. [DOI: 10.1080/17476348.2016.1240032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Saint-Criq V, Gray MA. Role of CFTR in epithelial physiology. Cell Mol Life Sci 2016; 74:93-115. [PMID: 27714410 PMCID: PMC5209439 DOI: 10.1007/s00018-016-2391-y] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 12/20/2022]
Abstract
Salt and fluid absorption and secretion are two processes that are fundamental to epithelial function and whole body fluid homeostasis, and as such are tightly regulated in epithelial tissues. The CFTR anion channel plays a major role in regulating both secretion and absorption in a diverse range of epithelial tissues, including the airways, the GI and reproductive tracts, sweat and salivary glands. It is not surprising then that defects in CFTR function are linked to disease, including life-threatening secretory diarrhoeas, such as cholera, as well as the inherited disease, cystic fibrosis (CF), one of the most common life-limiting genetic diseases in Caucasian populations. More recently, CFTR dysfunction has also been implicated in the pathogenesis of acute pancreatitis, chronic obstructive pulmonary disease (COPD), and the hyper-responsiveness in asthma, underscoring its fundamental role in whole body health and disease. CFTR regulates many mechanisms in epithelial physiology, such as maintaining epithelial surface hydration and regulating luminal pH. Indeed, recent studies have identified luminal pH as an important arbiter of epithelial barrier function and innate defence, particularly in the airways and GI tract. In this chapter, we will illustrate the different operational roles of CFTR in epithelial function by describing its characteristics in three different tissues: the airways, the pancreas, and the sweat gland.
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Affiliation(s)
- Vinciane Saint-Criq
- Epithelial Research Group, Institute for Cell and Molecular Biosciences, University Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Michael A. Gray
- Epithelial Research Group, Institute for Cell and Molecular Biosciences, University Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
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21
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Hegyi P, Wilschanski M, Muallem S, Lukacs GL, Sahin-Tóth M, Uc A, Gray MA, Rakonczay Z, Maléth J. CFTR: A New Horizon in the Pathomechanism and Treatment of Pancreatitis. Rev Physiol Biochem Pharmacol 2016; 170:37-66. [PMID: 26856995 DOI: 10.1007/112_2015_5002] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) is an ion channel that conducts chloride and bicarbonate ions across epithelial cell membranes. Mutations in the CFTR gene diminish the ion channel function and lead to impaired epithelial fluid transport in multiple organs such as the lung and the pancreas resulting in cystic fibrosis. Heterozygous carriers of CFTR mutations do not develop cystic fibrosis but exhibit increased risk for pancreatitis and associated pancreatic damage characterized by elevated mucus levels, fibrosis, and cyst formation. Importantly, recent studies demonstrated that pancreatitis causing insults, such as alcohol, smoking, or bile acids, strongly inhibit CFTR function. Furthermore, human studies showed reduced levels of CFTR expression and function in all forms of pancreatitis. These findings indicate that impairment of CFTR is critical in the development of pancreatitis; therefore, correcting CFTR function could be the first specific therapy in pancreatitis. In this review, we summarize recent advances in the field and discuss new possibilities for the treatment of pancreatitis.
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Affiliation(s)
- Péter Hegyi
- Institute for Translational Medicine and 1st Department of Medicine, University of Pécs, Pécs, Hungary.
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary.
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Shmuel Muallem
- National Institute of Dental and Craniofacial Research, Bethesda, MD, USA
| | | | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
| | - Aliye Uc
- Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Michael A Gray
- Institute for Cell & Molecular Biosciences, University Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Zoltán Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
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22
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Abstract
OBJECTIVE Short endoscopic secretin tests for exocrine pancreatic function are not properly evaluated in cystic fibrosis (CF). METHODS Patients with CF and healthy controls (HCs) underwent endoscopic collection of duodenal juice between 30 and 45 minutes after secretin stimulation. Duodenal juice was analyzed for HCO3 concentration and pancreatic enzyme activities. Stool was analyzed for fecal elastase. RESULTS Thirty-one patients with CF and 25 HCs were tested. Patients were classified as exocrine pancreatic sufficient (n = 13) or insufficient (n = 18). Both bicarbonate concentrations and enzyme activities in duodenal juice differentiated patients with CFI from patients with CFS and HC (P < 0.001). The population displays strong correlation between severe CF genotype in both alleles and pancreatic insufficient phenotype (P < 0.001). CONCLUSIONS Pancreatic exocrine insufficient CF patients could be differentiated from exocrine sufficient patients and HCs using short endoscopic secretin test.
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23
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Gibson-Corley KN, Meyerholz DK, Engelhardt JF. Pancreatic pathophysiology in cystic fibrosis. J Pathol 2015; 238:311-20. [PMID: 26365583 DOI: 10.1002/path.4634] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/04/2015] [Accepted: 09/08/2015] [Indexed: 12/28/2022]
Abstract
The pancreas is one of the earliest, and most commonly affected, organs in patients with cystic fibrosis (CF). Studying the pathogenesis of pancreatic disease is limited in CF patients, due to its early clinical onset, co-morbidities and lack of tissue samples from the early phases of disease. In recent years, several new CF animal models have been developed that have advanced our understanding of both CF exocrine and endocrine pancreatic disease. Additionally, these models have helped us to better define the influence of pancreatic lesions on CF disease progression in other organs, such as the gastrointestinal tract and lung.
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Affiliation(s)
| | - David K Meyerholz
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - John F Engelhardt
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
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24
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Kelly T, Buxbaum J. Gastrointestinal Manifestations of Cystic Fibrosis. Dig Dis Sci 2015; 60:1903-13. [PMID: 25648641 DOI: 10.1007/s10620-015-3546-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/19/2015] [Indexed: 12/27/2022]
Abstract
Gastrointestinal symptoms of cystic fibrosis are the most important non-pulmonary manifestations of this genetic illness. Pancreatic manifestations include acute and chronic pancreatitis as well as pancreas insufficiency resulting in malnutrition. Complications in the gastrointestinal lumen are diverse and include distal intestinal obstruction syndrome (DIOS), meconium ileus, intussusception, and constipation; biliary tract complications include focal biliary cirrhosis and cholangiectasis. The common pathophysiology is the inspissation of secretions in the hollow structures of the gastrointestinal tract. Improved survival of CF patients mandates that the adult gastroenterologist be aware of the presentation and treatment of pancreatic, luminal, and hepatobiliary CF complications.
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Affiliation(s)
- Thomas Kelly
- Division of Gastroenterology and Liver Diseases, Los Angeles County Hospital, Keck School of Medicine, The University of Southern California, D & T Building Room B4H100, 1983 Marengo St, Los Angeles, CA, 90033-1370, USA
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25
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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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Ledder O, Haller W, Couper RT, Lewindon P, Oliver M. Cystic fibrosis: an update for clinicians. Part 2: hepatobiliary and pancreatic manifestations. J Gastroenterol Hepatol 2014; 29:1954-62. [PMID: 25238538 DOI: 10.1111/jgh.12785] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2014] [Indexed: 12/14/2022]
Abstract
This paper, the second in the series, will build on the first and explore the importance of liver and pancreatic manifestations of cystic fibrosis (CF) and the effect on morbidity and mortality of this multifaceted genetic condition. It will also further develop the critical role of the gastroenterologist as part of the multidisciplinary group of clinicians and allied health staff in the effective management of patients with CF.
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Affiliation(s)
- Oren Ledder
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital Parkville, Melbourne, Victoria
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27
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Pancreas volume measurement in patients with Type 2 diabetes using magnetic resonance imaging-based planimetry. Pancreatology 2014; 14:268-74. [PMID: 25062875 DOI: 10.1016/j.pan.2014.04.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 04/23/2014] [Accepted: 04/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES To compare pancreas volume (PV) measurement using MRI-based planimetry in patients with Type 2 diabetes mellitus (DM) to PV in normoglycemic individuals. METHODS Our institutional review board granted approval of this retrospective study with waiver of informed consent. We searched 2296 consecutive abdominal MRI studies performed at our hospital on patients with no pancreas pathology between September 1, 2010 and February 28, 2013, for those who also had a fasting plasma glucose and/or hemoglobin A1C within six months of the MRI examination. For those patients who met biochemical criteria for DM, we used medication and clinical records to confirm that 32 of these patients had Type 2 DM. The pancreas contours of 32 Type 2 diabetics and 50 normoglycemic individuals were then traced on non-gadolinium T1-weighted 3D fat suppressed gradient echo images by a radiologist trained in abdominal MRI to calculate PV. PV index (PVI) was calculated as PV/weight to adjust PV for each patient's weight. PVs and PVIs in both cohorts were compared using t-tests and regression models correcting for weight, age and gender. RESULTS Patients with Type 2 DM had significantly lower PVs than normoglycemic individuals (72.7 ± 20.7 cm(3) versus 89.6 ± 22.7 cm(3), p < 0.001), and significantly lower PVIs (1.0 ± 0.3 cm(3)/kg versus 1.3 ± 0.3 cm(3)/kg, p < 0.001). Using regression models, we found that given the same age, weight and gender, the PV in a patient with Type 2 DM was 17.9 mL (20%) lower compared to a normoglycemic individual (p < 0.001). CONCLUSION PV is reduced in Type 2 DM compared to normoglycemic individuals and can be measured using MRI without contrast injection.
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28
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Payet LA, Kadri L, Giraud S, Norez C, Berjeaud JM, Jayle C, Mirval S, Becq F, Vandebrouck C, Ferreira T. Cystic fibrosis bronchial epithelial cells are lipointoxicated by membrane palmitate accumulation. PLoS One 2014; 9:e89044. [PMID: 24586495 PMCID: PMC3929646 DOI: 10.1371/journal.pone.0089044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 01/14/2014] [Indexed: 12/11/2022] Open
Abstract
The F508del-CFTR mutation, responsible for Cystic Fibrosis (CF), leads to the retention of the protein in the endoplasmic reticulum (ER). The mistrafficking of this mutant form can be corrected by pharmacological chaperones, but these molecules showed limitations in clinical trials. We therefore hypothesized that important factors in CF patients may have not been considered in the in vitro assays. CF has also been associated with an altered lipid homeostasis, i. e. a decrease in polyunsaturated fatty acid levels in plasma and tissues. However, the precise fatty acyl content of membrane phospholipids from human CF bronchial epithelial cells had not been studied to date. Since the saturation level of phospholipids can modulate crucial membrane properties, with potential impacts on membrane protein folding/trafficking, we analyzed this parameter for freshly isolated bronchial epithelial cells from CF patients. Interestingly, we could show that Palmitate, a saturated fatty acid, accumulates within Phosphatidylcholine (PC) in CF freshly isolated cells, in a process that could result from hypoxia. The observed PC pattern can be recapitulated in the CFBE41o(-) cell line by incubation with 100 µM Palmitate. At this concentration, Palmitate induces an ER stress, impacts calcium homeostasis and leads to a decrease in the activity of the corrected F508del-CFTR. Overall, these data suggest that bronchial epithelial cells are lipointoxicated by hypoxia-related Palmitate accumulation in CF patients. We propose that this phenomenon could be an important bottleneck for F508del-CFTR trafficking correction by pharmacological agents in clinical trials.
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Affiliation(s)
- Laurie-Anne Payet
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
| | - Linette Kadri
- Ecologie et Biologie des Interactions, UMR CNRS 7267, Université de Poitiers, Poitiers, France
| | - Sébastien Giraud
- Service de Biochimie, CHU Poitiers, Poitiers, France
- Inserm U1082, Poitiers, France
- Faculté de Médecine et de Pharmacie Université de Poitiers, Poitiers, France
| | - Caroline Norez
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
| | - Jean Marc Berjeaud
- Ecologie et Biologie des Interactions, UMR CNRS 7267, Université de Poitiers, Poitiers, France
| | - Christophe Jayle
- Service de Chirurgie Cardiothoracique, CHU Poitiers, Poitiers, France
| | - Sandra Mirval
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
| | - Frédéric Becq
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
| | - Clarisse Vandebrouck
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
| | - Thierry Ferreira
- Signalisation et Transports Ioniques Membranaires, ERL CNRS 7368, Université de Poitiers, Poitiers, France
- * E-mail:
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29
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Abstract
The clinical manifestations of cystic fibrosis (CF) result from dysfunction of the cystic fibrosis transmembrane regulator protein (CFTR). The majority of people with CF have a limited life span as a consequence of CFTR dysfunction in the respiratory tract. However, CFTR dysfunction in the gastrointestinal (GI) tract occurs earlier in ontogeny and is present in all patients, regardless of genotype. The same pathophysiologic triad of obstruction, infection, and inflammation that causes disease in the airways also causes disease in the intestines. This article describes the effects of CFTR dysfunction on the intestinal tissues and the intraluminal environment. Mouse models of CF have greatly advanced our understanding of the GI manifestations of CF, which can be directly applied to understanding CF disease in humans.
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Affiliation(s)
- Robert C De Lisle
- Anatomy and Cell Biology, University of Kansas School of Medicine, Kansas City, Kansas 66160
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30
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Abstract
The cystic fibrosis transmembrane conductance regulator (CFTR) protein is highly expressed in the pancreatic duct epithelia and permits anions and water to enter the ductal lumen. This results in an increased volume of alkaline fluid allowing the highly concentrated proteins secreted by the acinar cells to remain in a soluble state. This work will expound on the pathophysiology and pathology caused by the malfunctioning CFTR protein with special reference to ion transport and acid-base abnormalities both in humans and animal models. We will also discuss the relationship between cystic fibrosis (CF) and pancreatitis, and outline present and potential therapeutic approaches in CF treatment relevant to the pancreas.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah University Hospital, Jerusalem 91240, Israel
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31
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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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32
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Abstract
Early studies showed that airway cells secrete HCO(3)(-) in response to cAMP-mediated agonists and HCO(3)(-) secretion was impaired in cystic fibrosis (CF). Studies with Calu-3 cells, an airway serous model with high expression of CFTR, also show the secretion of HCO(3)(-) when cells are stimulated with cAMP-mediated agonists. Activation of basolateral membrane hIK-1 K(+) channels inhibits HCO(3)(-) secretion and stimulates Cl(-) secretion. CFTR mediates the exit of both HCO(3)(-) and Cl(-) across the apical membrane. Entry of HCO(3)(-) on a basolateral membrane NBC or Cl(-) on the NKCC determines which anion is secreted. Switching between these two secreted anions is determined by the activity of hIK-1 K(+) channels.
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Affiliation(s)
- Robert J Bridges
- Department of Physiology and Biophysics, Rosalind Franklin University of Medicine and Sciences, North Chicago, IL 60064, USA.
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33
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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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34
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Abstract
We review important new clinical observations in pancreas divisum (PD) made since 2007. PD is common and has the same prevalence in the general population and idiopathic pancreatitis (IP). Up to 53% of patients with PD and IP have underlying idiopathic chronic pancreatitis (CP), and in rigorous prospective clinical follow-up and/or natural history studies, many with idiopathic recurrent acute pancreatitis (IRAP) have idiopathic CP. According to retrospective studies, PD does not modify the natural course of nonalcoholic or alcoholic CP. CFTR and/or SPINK1 gene mutations associate with IP (idiopathic CP and IRAP) independently of the presence of PD. More than one third of patients with pancreatitis or presumed pancreaticobiliary pain respond to placebo. Authors of uncontrolled studies report a significant symptomatic response to surgery and endotherapy in patients with IP and PD, but the response remains unproven and is largely limited to those with IRAP and not idiopathic CP or chronic pain.
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Affiliation(s)
- Matthew J DiMagno
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical School, 1150 West Medical Center Drive, Room 6520 MSRB I, Ann Arbor, MI 48109-0682, USA.
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35
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Sequeiros IM, Hester K, Callaway M, Williams A, Garland Z, Powell T, Wong FS, Jarad NA. MRI appearance of the pancreas in patients with cystic fibrosis: a comparison of pancreas volume in diabetic and non-diabetic patients. Br J Radiol 2010; 83:921-6. [PMID: 20965902 DOI: 10.1259/bjr/24009651] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We investigated differences in the volume of the pancreas in cystic fibrosis (CF) patients with and without diabetes using MRI to study the natural history of CF-related diabetes (CFRD). We investigated 29 pancreas-insufficient adult CF patients, 13 with CFRD and 16 without diabetes. Patients with CFRD were receiving insulin therapy at the time of study. None of the non-diabetic CF patients had evidence of impaired glucose tolerance. Pancreas volume was estimated by MRI scans using T₁ weighted fat-suppression sequences and assessed by an examiner who was unaware of the patients' diabetes status. Pancreas volume of CF patients was measured and subsequently compared with that of non-CF age-matched Type 1 diabetes (T1DM) patients and healthy controls previously investigated. The two CF groups were matched for age and gender. There were no differences in spirometry values, body mass index or pancreatic exocrine function. The pancreas was visible by MRI in only 3 of 13 (23.1%) patients with CFRD and in 5 of 16 (31.3%) patients without diabetes (p-value = 0.7). In total, the pancreas was not detected by MRI as an anatomical entity in 21 of 29 (72.4%) CF patients, irrespective of their diabetes status. When comparing the four study groups, the pancreas was significantly smaller in CF patients than in T1DM patients and healthy controls.
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Affiliation(s)
- I M Sequeiros
- Bristol Adult Cystic Fibrosis Centre, Bristol Royal Infirmary, UK
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36
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Abstract
PURPOSE OF REVIEW To provide an updated literature review highlighting important aspects of cystic fibrosis-related diabetes (CFRD) including epidemiology, pathogenesis, complications, screening, and management. RECENT FINDINGS Although CFRD continues to be associated with increased rates of mortality in the cystic fibrosis (CF) population, this has improved over the past several years, and the previous sex difference is no longer present. Recent studies support that CFRD is primarily caused by insulin deficiency due to loss of beta cells, which may occur via a number of mechanisms including oxidative stress. Aggressive screening programs with oral-glucose tolerance testing and early treatment with insulin for patients with CFRD with or without fasting hyperglycemia have led to improvements in nutritional states and lung function. Oral agents do not appear to be effective in CFRD. SUMMARY CFRD is the most common comorbidity in the CF population and is associated with microvascular complications and protein catabolism leading to worse health outcomes. Recognition of glycemic abnormalities through aggressive screening has led to improvements in nutritional status, pulmonary function, and mortality rates.
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Affiliation(s)
- Brandon M Nathan
- Divisions of Pediatric Endocrinology, University of Minnesota, Minneapolis, Minnesota, USA.
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37
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Abstract
BACKGROUND : Because the acinar cells of the exocrine pancreas in patients with Shwachman-Diamond syndrome (SDS) are severely depleted, we hypothesized that a similar deficiency may be present in acinar cells of the parotid gland. PATIENTS AND METHODS : We determined serum pancreatic isoamylase and parotid amylase activities in 16 patients with SDS, 13 healthy controls, and 13 disease controls (cystic fibrosis or fibrosing pancreatitis). Parotid amylase and electrolyte concentrations were measured in stimulated parotid gland secretions. Starch digestion was assessed by breath hydrogen testing in patients with SDS (with and without enzyme supplements) and healthy controls. RESULTS : Serum pancreatic and parotid isoamylase values were lower in the patients with SDS than in the healthy controls (P < 0.0001 and P = 0.0002, respectively). Serum pancreatic isoamylase, but not parotid isoamylase, was significantly lower in the disease controls than in the healthy controls (P < 0.0001 and P = 0.17, respectively). Secreted parotid gland amylase concentration (units per milligram of protein) in patients with SDS was lower than that in the healthy controls (P = 0.04), whereas the disease controls were comparable to the healthy subjects (P = 0.09). Secreted parotid chloride concentration was inversely correlated with amylase concentration in the patients with SDS (P = 0.01), but no correlation was seen in the healthy controls or disease controls. When patients with SDS ingested starch without enzyme supplementation, their breath hydrogen excretion was significantly higher than that in the healthy controls (P = 0.009). Following starch ingestion with enzymes, breath hydrogen in the patients with SDS was lower (P < 0.05) than with no enzyme treatment, and no different from controls (P = 0.37). CONCLUSIONS : Mutations in the SBDS gene cause a generalized functional abnormality of exocrine acinar cells.
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38
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Huffmyer JL, Littlewood KE, Nemergut EC. Perioperative Management of the Adult with Cystic Fibrosis. Anesth Analg 2009; 109:1949-61. [PMID: 19923526 DOI: 10.1213/ane.0b013e3181b845d0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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39
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Allan Tucker J, Spock A, Spicer SS, Shelburne JD, Bradford W. Inspissation of Pancreatic Zymogen Material in Cystic Fibrosis. Ultrastruct Pathol 2009. [DOI: 10.1080/01913120390231717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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40
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Keller J, Aghdassi AA, Lerch MM, Mayerle JV, Layer P. Tests of pancreatic exocrine function - clinical significance in pancreatic and non-pancreatic disorders. Best Pract Res Clin Gastroenterol 2009; 23:425-39. [PMID: 19505669 DOI: 10.1016/j.bpg.2009.02.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pancreas functions as the main factory for digestive enzymes and therefore enables food utilisation. Pancreatic exocrine insufficiency, partial or complete loss of digestive enzyme synthesis, occurs primarily in disorders directly affecting pancreatic tissue integrity. However, other disorders of the gastrointestinal tract, such as coeliac disease, inflammatory bowel disease, Zollinger-Ellison syndrome or gastric resection can either mimic or cause pancreatic exocrine insufficiency. The overt clinical symptoms of pancreatic exocrine insufficiency are steatorrhoea and maldigestion, which frequently become apparent in advanced stages. Several direct and indirect function tests are available for assessment of pancreatic function but until today diagnosis of excretory insufficiency is difficult as in mild impairment clinically available function tests show limitations of diagnostic accuracy. This review focuses on diagnosis of pancreatic exocrine insufficiency in pancreatic and non-pancreatic disorders.
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Affiliation(s)
- Jutta Keller
- Department of Medicine, Israelitisches Krankenhaus, Hamburg, Germany
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41
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Abstract
OBJECTIVES A small group of cystic fibrosis (CF) patients develop symptomatic pancreatitis. The clinical characteristics of these cases are not well documented in the literature. Most cases are in pancreatic sufficient (PS) patients, but it is not clear whether pancreatitis does occur in pancreatic insufficient (PI) patients. There is no information on how the group with PS and pancreatitis differs from the group with PS that does not develop pancreatitis. METHODS The Royal Brompton Hospital database of adult CF patients was searched to identify all patients with symptomatic pancreatitis. Clinical details were taken from the case notes. PS pancreatitis patients were then compared with an age- and sex-matched PS control group drawn from the database. RESULTS Sixteen patients (9 males) had suffered symptomatic pancreatitis, representing 1.6% of the total database. The mean age at CF diagnosis was 18.7 years, and at presentation with pancreatitis it was 28.8 years. Twelve were PS at diagnosis of CF. At presentation with pancreatitis, seven patients were PS and at the most recent follow-up or death, two remained PS. There was a median of three hospital admissions with pancreatitis. Eight cases developed pancreatic or hepatobiliary complications. In the comparison of pancreatitis patients with controls, there was no difference in survival but pancreatitis patients were significantly more likely to develop PI status. Mild CF transmembrane conductance regulator mutations in general, and R117H in particular, were found more often in pancreatitis patients. CONCLUSIONS Symptomatic pancreatitis is a significant problem in 1-2% of patients with CF. These patients are PS at birth but are more likely to develop late PI status than PS patients without pancreatitis. R117H may be associated with this phenotype.
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42
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Abstract
This review focuses on the pathobiology of the gastrointestinal and hepatic manifestations of cystic fibrosis (CF) disease in relation to their genetic basis in mutations of the CF transmembrane conductance regulator (CFTR) gene. It reviews the nature of the CFTR protein, a categorization of the types of gene mutations underlying CF's various manifestations, and the ways in which absent or reduced CFTR produces various functional abnormalities in the different organs affected by CF. Subsequently, the particular organ-related clinical manifestations of CF directly associated with loss of CFTR function are addressed. Thereafter, the review discusses some of the complexities of the genotype-phenotype relationships related to milder mutations or complex genetic disorders in which CFTR abnormalities interact with other genetic and environmental factors, and the potential diagnostic roles of sweat testing or other electrophysiologic testing. This discussion examines secondary gastrointestinal manifestations of CF and the particular cases of diseases that may be related to abnormalities of CFTR.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology Unit, Division of Pediatrics, Hadassah University Hospitals, Hebrew University, POB 24035, Jerusalem, Israel.
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43
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Walkowiak J, Lisowska A, Blaszczyński M. The changing face of the exocrine pancreas in cystic fibrosis: pancreatic sufficiency, pancreatitis and genotype. Eur J Gastroenterol Hepatol 2008; 20:157-60. [PMID: 18301292 DOI: 10.1097/meg.0b013e3282f36d16] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
(Table is included in full-text article.)Cystic fibrosis (CF) is the most frequent cause of exocrine pancreatic insufficiency in childhood. The cystic fibrosis transmembrane conductance regulator (CFTR) gene encodes CFTR protein that functions as cyclic AMP-dependent chloride channel allowing the passage of anions and secondarily water into the lumen of pancreatic ducts. Luminal chlorides are exchanged for bicarbonates. The lack of CFTR channel or its disrupted function (being the consequence of CFTR gene mutations) results in reduced volume of more acidic secretion. It has been suggested that such a situation leads to the precipitation of highly concentrated protein-containing secretion with obstruction and organ damage. The intensity of this process determines the progression of the disease. Steatorrhea is the significant symptom of classical form of CF. Residual pancreatic secretion in a subset of patients, however, allows for normal lipid digestion and absorption. Previous cross-sectional clinical studies estimated that about 85-90% of CF patients in preschool, school and older age are pancreatic insufficient. More frequent detection of mild and nonclassic forms of CF leads to higher frequency of pancreatic sufficiency (PS). The potential decline of exocrine pancreatic function, however, should be always considered. All PS patients with at least one severe or unknown CFTR mutation should be longitudinally assessed for the progression of pancreatic dysfunction. Recurrent acute and chronic pancreatitis is not a rare clinical condition in PS patients with PS: it might be the presenting symptom, even preceding CF diagnosis by several years. Potential appearance of this complication in individuals with pancreatic insufficiency demands elucidation.
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Affiliation(s)
- Jarosław Walkowiak
- Department of Gastroenterology and Metabolism, Poznan University of Medical Sciences, Poznañ, Poland.
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44
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Choi JY, Joo NS, Krouse ME, Wu JV, Robbins RC, Ianowski JP, Hanrahan JW, Wine JJ. Synergistic airway gland mucus secretion in response to vasoactive intestinal peptide and carbachol is lost in cystic fibrosis. J Clin Invest 2007; 117:3118-27. [PMID: 17853942 PMCID: PMC1974867 DOI: 10.1172/jci31992] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 06/20/2007] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is caused by dysfunction of the CF transmembrane conductance regulator (CFTR), an anion channel whose dysfunction leads to chronic bacterial and fungal airway infections via a pathophysiological cascade that is incompletely understood. Airway glands, which produce most airway mucus, do so in response to both acetylcholine (ACh) and vasoactive intestinal peptide (VIP). CF glands fail to secrete mucus in response to VIP, but do so in response to ACh. Because vagal cholinergic pathways still elicit strong gland mucus secretion in CF subjects, it is unclear whether VIP-stimulated, CFTR-dependent gland secretion participates in innate defense. It was recently hypothesized that airway intrinsic neurons, which express abundant VIP and ACh, are normally active and stimulate low-level gland mucus secretion that is a component of innate mucosal defenses. Here we show that low levels of VIP and ACh produced significant mucus secretion in human glands via strong synergistic interactions; synergy was lost in glands of CF patients. VIP/ACh synergy also existed in pig glands, where it was CFTR dependent, mediated by both Cl(-) and HCO(3) (-), and clotrimazole sensitive. Loss of "housekeeping" gland mucus secretion in CF, in combination with demonstrated defects in surface epithelia, may play a role in the vulnerability of CF airways to bacterial infections.
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Affiliation(s)
- Jae Young Choi
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Nam Soo Joo
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Mauri E. Krouse
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Jin V. Wu
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Robert C. Robbins
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Juan P. Ianowski
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - John W. Hanrahan
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Jeffrey J. Wine
- Cystic Fibrosis Research Laboratory, Stanford University, Stanford, California, USA.
Department of Otorhinolaryngology, Yonsei University, Seoul, Republic of Korea.
Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
Department of Physiology, McGill University, Montreal, Quebec, Canada
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45
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Boom A, Lybaert P, Pollet JF, Jacobs P, Jijakli H, Golstein PE, Sener A, Malaisse WJ, Beauwens R. Expression and localization of cystic fibrosis transmembrane conductance regulator in the rat endocrine pancreas. Endocrine 2007; 32:197-205. [PMID: 18040894 DOI: 10.1007/s12020-007-9026-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 10/08/2007] [Accepted: 10/17/2007] [Indexed: 12/12/2022]
Abstract
Impaired glucose tolerance and overt diabetes mellitus are becoming increasingly common complications of cystic fibrosis (CF), most probably merely as a result of increased life expectancy. In order to understand the pathophysiology of cystic fibrosis-related diabetes (CFRD), knowledge on the possible expression and cell distribution of the cystic fibrosis transmembrane conductance regulator (CFTR) protein within the endocrine pancreas is required. In this report, we establish the first evidence for expression of CFTR protein in rat pancreatic islets by using independent techniques. First reverse transcriptase-polymerase chain reaction (RT-PCR) amplification showed that CFTR mRNA is present in isolated islets of Langerhans. Furthermore, the analysis of flow cytometry-separated islet cells indicated that the level of CFTR transcripts is significantly higher in the non-beta than in beta-cell populations. The expression of CFTR protein in rat islet cells was also demonstrated by Western blotting and the level of expression was also found significantly higher in the non-beta than in beta-cell populations. Last, in situ immunocytochemistry studies with two monoclonal antibodies recognizing different CFTR epitopes indicated that CFTR expression occurs mainly in glucagon-secreting alpha-cells.
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Affiliation(s)
- Alain Boom
- Laboratory of Histology, Neuroanatomy and Neuropathology, School of Medicine, Université Libre de Bruxelles, CP 620, 808, route de Lennik, 1070, Brussels, Belgium.
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Yahav J, Samra Z, Blau H, Dinari G, Chodick G, Shmuely H. Helicobacter pylori and Clostridium difficile in cystic fibrosis patients. Dig Dis Sci 2006; 51:2274-9. [PMID: 17078007 DOI: 10.1007/s10620-006-9271-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 02/15/2006] [Indexed: 12/09/2022]
Abstract
We describe the prevalence of H. pylori and toxigenic Clostridium difficile (CD) infection and its relationship with gastrointestinal symptoms and pancreatic sufficiency (PS) or insufficiency (PI) in cystic fibrosis (CF) patients. Stool specimens from 30 consecutive patients with CF, aged 1-44, and from 30 healthy similarly aged subjects were tested for the H. pylori antigen by specific monoclonal antibodies and for CD toxins by Tox A/B assay and Tox A assay. CF patients were assessed clinically and tested for specific H. pylori serum antibodies and for mutations. In CF patients, the prevalence of H. pylori antigen was 16.6% (5/30), compared to 30% (9/30) in controls. Of the 26 CF patients with PI, only 2 (7.6%) were infected by H. pylori, compared with 3 of the 4 (75%) patients with PS (P=0.001). H. pylori infection was diagnosed in 3 of 5 (60%) CF patients carrying mild mutations, compared to 1 of 25 (4%) CF patients carrying severe mutations (P=0.01). Fourteen of 30 (46.6%) stool specimens from CF patients tested positive in the ToxA/B assay, and 3 of 14 tested positive for ToxA. No significant differences in antibiotic use, severity of lung disease, PI, chronic abdominal pain, or genotype were found between the two groups. None of the controls was positive for CD toxins. Prevalence of H. pylori infection in CF patients was lower than in similarly aged non-CF controls. CF patients with PI or a history of distal intestinal obstruction syndrome and those carrying mutations associated with a severe phenotype were protected against H. pylori infection. Almost half of the CF patients were asymptomatic carriers of CD producing mostly toxin B. More studies are needed to confirm our results in a larger group of CF patients.
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Affiliation(s)
- Jacob Yahav
- Helicobacter Research Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, 49100, Israel.
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Blanco PG, Salem RO, Ollero M, Zaman MM, Cluette-Brown JE, Freedman SD, Laposata M. Ethanol administration to cystic fibrosis knockout mice results in increased fatty acid ethyl ester production. Alcohol Clin Exp Res 2006; 29:2039-45. [PMID: 16340462 DOI: 10.1097/01.alc.0000187593.86202.e8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Fatty acid ethyl esters (FAEE) are nonoxidative ethanol metabolites shown to produce toxic effects in the liver and pancreas in vivo and in vitro. Because alcohol-induced chronic pancreatitis is associated with mutations in the gene responsible for cystic fibrosis (CFTR), we hypothesized that CFTR dysfunction leads to increased levels of these toxic nonoxidative ethanol metabolites following alcohol administration. METHODS Cystic fibrosis (CF) and wild-type (WT) mice were injected intraperitoneally with 1, 2, or 3 g/kg of 50% ethanol. Mice were sacrificed and the liver and pancreas removed for FAEE analysis. RESULTS The mean FAEE concentration (pmol/g) detected in the liver of cftr mice following injection with 2 g/kg of ethanol was significantly greater than the amount detected in WT (p < 0.005). A similar trend in FAEE concentration was seen in the pancreas, but the difference was not statistically different. In both the liver and pancreas, analysis of individual FAEE species demonstrated a selective increase in ethyl oleate. CONCLUSION These data show an association between CFTR dysfunction and qualitative and quantitative changes in FAEE in liver and pancreas upon ethanol exposure.
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Affiliation(s)
- Paola G Blanco
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Peretti N, Roy CC, Drouin E, Seidman E, Brochu P, Casimir G, Levy E. Abnormal intracellular lipid processing contributes to fat malabsorption in cystic fibrosis patients. Am J Physiol Gastrointest Liver Physiol 2006; 290:G609-15. [PMID: 16223944 DOI: 10.1152/ajpgi.00332.2005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A common feature of cystic fibrosis (CF) is the functional derangement of the exocrine pancreas, which affects output of pancreatic lipase. This condition results in severe dietary malabsorption due to the poor hydrolysis of triacylglycerol (TG) in the lumen of the small intestine. Despite the benefits of pancreatic enzyme supplements, patients with CF present with persistent intestinal fat malabsorption. The aim of the present investigation was to determine whether defects in the intracellular phase of lipid transport occur in this pathophysiology in addition to the known disturbed digestive processes. Our hypothesis was tested by incubating intestinal biopsies from six CF and six healthy subjects with radiolabeled lipid and protein precursors. Lipid esterification and secretion were markedly decreased by 22-31% and 38-42%, respectively, in CF samples, as noted by the low incorporation of [(14)C]palmitic acid into TGs, phospholipids, and cholesteryl esters in patients' duodenal explants and culture media compared with controls (100%). Accordingly, the output of TG-rich lipoproteins was substantially reduced (P < 0.05), and a similar trend was observed for high-density lipoproteins. Because intestinal lipoprotein assembly/secretion shows an absolute requirement for apolipoprotein (apo) B-48, radioactive labeling experiments were performed; these experiments demonstrated a significantly (P < 0.05) diminished synthesis of apoB-48 (40%) and apoA-I (30%). Given the critical role of microsomal triglyceride transfer protein in the formation of apoB-containing lipoproteins, its activity was determined and not found to be altered in CF intestinal tissue. Together, these results suggest that CF malabsorption may also be caused by defects in mucosal mechanisms leading to abnormal lipoprotein delivery into the blood circulation.
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Affiliation(s)
- Noël Peretti
- Departments of Nutrition, CHU Ste-Justine, Université de Montréal, Québec, Canada
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Schibli S, Corey M, Gaskin KJ, Ellis L, Durie PR. Towards the ideal quantitative pancreatic function test: analysis of test variables that influence validity. Clin Gastroenterol Hepatol 2006; 4:90-7. [PMID: 16431310 DOI: 10.1016/s1542-3565(05)00852-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although pancreatic stimulation tests quantify acinar and ductal exocrine pancreatic function, no standard methodology exists. We evaluated the impact of several variables on test accuracy. METHODS We performed a retrospective analysis of pancreatic stimulation tests, which involved continuous stimulation with cholecystokinin and secretin, 3 sampling periods (20-min each), and perfusion markers to correct for intestinal losses. Results were recalculated using the following variables: no correction for losses; shortened sampling time (20-min); no correction and shortened sampling time; and enzyme concentration. We examined how these variables influenced measurements of pancreatic secretion and classification of pancreatic function status (sufficient or insufficient). RESULTS We analyzed 363 tests in control patients (20), and patients with cystic fibrosis (137), Shwachman-Diamond syndrome (40), or other pancreatic or intestinal disorders (166). Recovery of pancreatic juice varied markedly between tests (median, 59%; range, 4%-106%) and was significantly poorer during the first 20-minute period compared with the 2 subsequent periods (P < .01). Failure to correct for intestinal losses underestimated secretory capacity (median trypsin output reduced by >50%, P < .0001) and shortened sampling time increased test variability. Both variables together resulted in greater discrepancies. More than 25% of the pancreatic-sufficient patients with impaired pancreatic function were misclassified as pancreatic insufficient when uncorrected output plus a shortened sampling time or enzyme concentration were used to define categories. CONCLUSIONS Pancreatic function tests using brief aspiration periods without marker perfusion or measures of concentration greatly underestimate pancreatic secretory capacity and misclassify the clinical status of an unacceptably large number of patients.
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Affiliation(s)
- Susanne Schibli
- Department of Gastroenterology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
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