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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Pryor JB, Bradford MC, Jennerich AL, Hee Wai TY, Pilewski JM, Kapnadak SG, Aitken ML, Goss CH, Ramos KJ. Body Mass Index Recovery Following Lung Transplant for Cystic Fibrosis. Ann Am Thorac Soc 2022. [PMID: 35044894 DOI: 10.1513/AnnalsATS.202108-969OC] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Many lung transplant recipients with cystic fibrosis (CF) have low pre-operative body mass index (BMI); however, post-transplant BMI recovery is not well understood. OBJECTIVE To evaluate BMI recovery (≥18.5 kg/m2) among CF lung transplant recipients with low pre-operative BMI and investigate the association of survival with BMI recovery. METHODS United Network for Organ Sharing and CF Foundation Patient registries (June 2005-December 2016) were used to identify CF lung transplant recipients. Among recipients surviving ≥1 year, Cox modeling compared post-transplant 1-year conditional survival between recipients with low (<17 and 17-18.49 kg/m2) versus normal pre-operative BMI, stratified by BMI recovery. RESULTS Of 1,977 CF lung transplant recipients, 272 (14%) and 449 (23%) had pre-operative BMI of <17 and 17-18.49 kg/m2, respectively. For BMI subgroups <17 and 17-18.49 kg/m2, 29% vs 49% of those alive at 1 year recovered their BMI, respectively. Among recipients with low pre-operative BMI, adjusted post-transplant 1-year conditional survival was worse compared to those with pre-operative BMI ≥18.5 kg/m2; however, BMI recovery mitigated this. Pre-operative BMI <17 kg/m2 had an adjusted HR of 1.29 (95% CI 0.92, 1.81) with BMI recovery vs 1.57 (95% CI 1.09, 2.25) without recovery, and pre-operative BMI 17-18.49 kg/m2 had an adjusted HR of 1.28 (95% CI 1.02, 1.61) with BMI recovery vs 1.72 (95% CI 1.14, 2.59) without recovery. CONCLUSIONS Patients with lower pre-operative BMI were less likely to achieve BMI recovery within 1 year. However, for those who did, BMI recovery within 1-year post-transplant was associated with longer survival.
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Breuer O, Shoseyov D, Koretz S, Alyan N, Reiter J, Cohen-Cymberknoh M, Wexler I, Kerem E. Ethical Dilemma: Elexacaftor-Tezacaftor-Ivacaftor or Lung Transplantation in Cystic Fibrosis and End-Stage Lung Disease? Chest 2021; 161:773-780. [PMID: 34506793 DOI: 10.1016/j.chest.2021.08.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/03/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022] Open
Abstract
Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR). Novel, highly effective, modulator therapies correcting and potentiating CFTR function are changing the course of this disease. We present an ethical dilemma involving an 11-year-old child with CF and end-stage lung disease. Shortly after starting treatment with elexacaftor-tezacaftor-ivacaftor, the family received notification that a matched donor lung had been allocated. Clinical decision-making in this case is challenging as definitive data to medically support one treatment option over the other are limited. A survey of CF center team members was conducted for the purpose of this article. Ethical principles that may guide us in these situations are discussed. Overall, results of the survey present a lack of agreement as to the best approach in this situation. Physicians, when compared with other team members, are more likely to provide a specific recommendation vs presenting the information to the family and letting them decide (OR, 4.0; 95% CI, 1.2-12.8; P = .021). A shared decision-making model, stressing our moral obligation as physicians to respect autonomy by appreciating family values, while offering to participate in the decision-making process and ensuring nonmaleficence, is presented. In summary, CFTR modulators affect the outcomes of CF disease and influence clinical decision-making. The current lack of data on long-term outcomes, in young patients with CF receiving effective modulator therapy, should not preclude CF team participation in decision-making. Shared decision-making, which is focused on respecting autonomy, is our preferred approach in these situations.
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Affiliation(s)
- Oded Breuer
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - David Shoseyov
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shifra Koretz
- Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Social Work Services, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nadia Alyan
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Social Work Services, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel Reiter
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Isaiah Wexler
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eitan Kerem
- Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Pediatric Pulmonology and CF Center, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Shah P, Lowery E, Chaparro C, Visner G, Hempstead SE, Abraham J, Bhakta Z, Carroll M, Christon L, Danziger-Isakov L, Diamond JM, Lease E, Leonard J, Litvin M, Poole R, Vlahos F, Werchan C, Murray MA, Tallarico E, Faro A, Pilewski JM, Hachem RR. Cystic fibrosis foundation consensus statements for the care of cystic fibrosis lung transplant recipients. J Heart Lung Transplant 2021; 40:539-56. [PMID: 34103223 DOI: 10.1016/j.healun.2021.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022] Open
Abstract
Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population.
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Shah P, Lowery E, Chaparro C, Visner G, Hempstead SE, Abraham J, Bhakta Z, Carroll M, Christon L, Danziger-Isakov L, Diamond JM, Lease E, Leonard J, Litvin M, Poole R, Vlahos F, Werchan C, Murray MA, Tallarico E, Faro A, Pilewski JM, Hachem RR. DUPLICATE: Cystic Fibrosis Foundation Consensus Statements for the Care of Cystic Fibrosis Lung Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Koutsokera A, Varughese RA, Sykes J, Orchanian-Cheff A, Shah PS, Chaparro C, Tullis E, Singer LG, Stephenson AL. Pre-transplant factors associated with mortality after lung transplantation in cystic fibrosis: A systematic review and meta-analysis. J Cyst Fibros 2019; 18:407-415. [DOI: 10.1016/j.jcf.2018.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 01/17/2023]
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Peled Y, Loewenthal R, Kassif Y, Raichlin E, Younis A, Younis A, Nachum E, Freimark D, Lavee J. Ethnic disparity in Israel impacts long-term results after heart transplantation. Isr J Health Policy Res 2019; 8:3. [PMID: 30636628 PMCID: PMC6330742 DOI: 10.1186/s13584-018-0271-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethnicity may affect graft longevity and recipient mortality after heart transplantation (HTx). We hypothesized that differences in ethnic origin between Arabs and Jews undergoing HTx in Israel may contribute to differences in long-term outcomes. METHODS The study population comprised all 254 patients who underwent HTx between 1991 and 2017 in a tertiary medical center located in the center of Israel. Patients were categorized as either Jews (226 patients, 89%) or Arabs (28 patients, 11%). The primary end point was cardiac allograft vasculopathy (CAV), secondary end points were cardiovascular (CV) mortality and the combined end point of CAV/CV mortality. RESULTS In comparison with Jews, Arab patients were significantly younger (ave. age 42 vs. 50) and had shorter in-hospital stay (45 vs. 80 days). However, Kaplan-Meier survival analysis showed that at 10 years of follow-up CAV rates were significantly higher among Arabs (58%) compared with Jews (23%; log-rank P = 0.01) for the overall difference during follow-up. Similar results were shown for the separate end point of CV mortality and the combined end point of CAV/CV mortality. Multivariate analysis, which controlled for age, gender, statin treatment, and other potential confounders, showed that Arab recipient ethnic origin was associated with a significant > 2.5-fold (p = 0.01) increase in the risk for CAV; a > 4-fold increase in the risk for CV mortality (p = 0.001); and approximately 4-fold increase in the risk for the combined end point (p = 0.001). These findings were validated by propensity score analysis. CONCLUSIONS Our data suggest that Arab ethnic origin is associated with a significantly increased risk for CAV and mortality following HTx. Suggested explanations contributing to ethnic disparities in Israel include socioeconomic, environmental and genetic factors. Further studies are required to evaluate whether more aggressive risk factor management in the Israeli Arab population following HTx would reduce CAV and CV mortality in this high-risk population. Increased awareness and early intervention of the Israeli healthcare system and cooperation with the Arab community is of paramount importance.
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Affiliation(s)
- Yael Peled
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel. .,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ron Loewenthal
- Tissue Typing Laboratory Sheba Medical Center, Ramat Gan, Israel
| | - Yigal Kassif
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eugenia Raichlin
- Cardiology Department, Loyola University Medical Center, Maywood, IL, USA
| | - Arwa Younis
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anan Younis
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Nachum
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dov Freimark
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Lavee
- The Olga and Lev Leviev Heart Center, Sheba Medical Center Tel Hashomer, Heart Transplantation Unit, Heart Failure Institute, 52621, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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