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Katz TE, Wakefield CE, Signorelli C, Day AS, Vernon-Roberts A, Ooi CY. Gastroenterology services for patients with Cystic Fibrosis across Australia and New Zealand: a multi-stakeholder assessment of patients' and professionals' perspectives. Front Pediatr 2023; 11:1322941. [PMID: 38161436 PMCID: PMC10755025 DOI: 10.3389/fped.2023.1322941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Gastrointestinal (GI) symptoms are common in individuals with Cystic Fibrosis (CF). International research has highlighted that GI care for this group of patients is lacking. Gastroenterology services to CF clinics across Australasia are yet to be examined. This study aimed to describe the current service delivery model and identify areas for improvement that may lead to positive patient outcomes. Materials and methods CF clinicians (dietitians, clinical nurse consultants, respiratory consultants), gastroenterologists (GE), and patients or their carers from Australia and New Zealand (NZ) were surveyed online to gather their opinions on CF gastroenterology services provided in their region. Data were analysed using descriptive statistics (frequencies and percentages). Likert scale questions were analysed by grouping responses 1-5 and 6-10, presented alongside the median and interquartile range (IQR). Mann-Whitney U and chi-square tests were used to look at differences between stakeholder groups. Results One hundred and fifty-six health professionals and 172 patients or their carers completed the survey. Results showed that the current GI model of care is predominantly a publicly funded service delivered outside of CF clinic time. GE are largely not integrated into the CF team and report a lack of training opportunities. There is a higher level of dissatisfaction with the current service model in NZ than Australia. Discussion No stakeholder group deemed the current CF gastroenterology service model as adequate, leaving opportunity for transformations in this field. Ideally this study will invigorate the need for promotion and integration of GI services that would ultimately benefit the whole CF community.
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Affiliation(s)
- Tamarah E. Katz
- Department of Nutrition and Dietetics, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Claire E. Wakefield
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Christina Signorelli
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Andrew S. Day
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Department of Gastroenterology, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Department of Gastroenterology, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
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Wrigley-Carr HE, van Dorst JM, Ooi CY. Intestinal dysbiosis and inflammation in cystic fibrosis impacts gut and multi-organ axes. MEDICINE IN MICROECOLOGY 2022. [DOI: 10.1016/j.medmic.2022.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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3
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Mainz JG, Zagoya C, Polte L, Naehrlich L, Sasse L, Eickmeier O, Smaczny C, Barucha A, Bechinger L, Duckstein F, Kurzidim L, Eschenhagen P, Caley L, Peckham D, Schwarz C. Elexacaftor-Tezacaftor-Ivacaftor Treatment Reduces Abdominal Symptoms in Cystic Fibrosis-Early results Obtained With the CF-Specific CFAbd-Score. Front Pharmacol 2022; 13:877118. [PMID: 35721187 PMCID: PMC9203829 DOI: 10.3389/fphar.2022.877118] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background: The novel and highly effective CFTR modulator combination of elexacaftor-tezacaftor-ivacaftor (ETI) has been shown to improve lung function and body weight in people with Cystic Fibrosis (pwCF) carrying a F508del mutation. However, the impact of these modulators on gastrointestinal (GI) symptoms is relatively unknown. Therefore, the CFAbd-Score was developed and validated following FDA recommendations for development of a PROM including focus groups, multidisciplinary CF specialists, people with CF and their families. The aim of this study was to assess effects of ETI on GI symptoms using the CFAbd-Score. Methods: Gastrointestinal symptoms were prospectively assessed in pwCF using the CFAbd-Score before and up to 26 weeks during therapy. The CFAbd-Score was also administered to a healthy control (HC) group. The one-sided questionnaire includes 28 items grouped in five domains. Data analysis included calculation of scores with a weighting tool, developed according to FDA recommendations. Results: A total of 107 pwCF attended in four CF centres in Germany and four centres in the UK completed the CFAbd-Score on at least two occasions. Results were compared to those obtained from the questionnaire of 45 HCs. Despite differences in demographics, age and proportion of pancreatic insufficiency between German and UK patients, analyses based on linear mixed-effects models at week 24 of ETI therapy revealed that estimated marginal means (EMMs) of total CFAbd-Scores significantly reduced (mean ± SE: 14.9 ± 1.2→10.6 ± 1.4; p < 0.01). Also EMMs of all five domains significantly declined ("pain" 16.3 ± 1.6→10.2 ± 2.3, "GERD" 15.8 ± 1.8→8.2 ± 1.9, "disorders of bowel movement" 20.9 ± 1.5→16.0 ± 1.7, "disorders of appetite" 7.9 ± 1.1→2.6 ± 1.1 and "quality of life impairment" 10.1 ± 1.92→3.9 ± 1.9). However, during 24 weeks, CF participants' symptoms mostly still did not reach the reference levels of HCs. Discussion: Using the CFAbd-Score, the first PROM specifically developed for assessment of CF-related abdominal symptoms, we demonstrate comprehensive improvements in GI symptoms after initiation of the highly effective modulator therapy ETI.
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Affiliation(s)
- Jochen G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,Faculty of Health Sciences Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, The Brandenburg Medical School Theodor Fontane and the University of Potsdam, Potsdam, Germany
| | - Carlos Zagoya
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Louise Polte
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Lenny Sasse
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - Olaf Eickmeier
- Christiane Herzog CF-Zentrum Frankfurt am Main, Universitätsklinikum Frankfurt am Main CF-Zentrum, Frankfurt am Main, Germany
| | - Christina Smaczny
- Christiane Herzog CF-Zentrum Frankfurt am Main, Universitätsklinikum Frankfurt am Main CF-Zentrum, Frankfurt am Main, Germany
| | - Anton Barucha
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Lilith Bechinger
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Ludwik Kurzidim
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
| | - Patience Eschenhagen
- CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
| | - Laura Caley
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Daniel Peckham
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom.,Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Carsten Schwarz
- CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
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Understanding Cystic Fibrosis Comorbidities and Their Impact on Nutritional Management. Nutrients 2022; 14:nu14051028. [PMID: 35268004 PMCID: PMC8912424 DOI: 10.3390/nu14051028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is a chronic, multisystem disease with multiple comorbidities that can significantly affect nutrition and quality of life. Maintaining nutritional adequacy can be challenging in people with cystic fibrosis and has been directly associated with suboptimal clinical outcomes. Comorbidities of CF can result in significantly decreased nutritional intake and intestinal absorption, as well as increased metabolic demands. It is crucial to utilize a multidisciplinary team with expertise in CF to optimize growth and nutrition, where patients with CF and their loved ones are placed in the center of the care model. Additionally, with the advent of highly effective modulators (HEMs), CF providers have begun to identify previously unrecognized nutritional issues, such as obesity. Here, we will review and summarize commonly encountered comorbidities and their nutritional impact on this unique population.
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Tam RY, van Dorst JM, McKay I, Coffey M, Ooi CY. Intestinal Inflammation and Alterations in the Gut Microbiota in Cystic Fibrosis: A Review of the Current Evidence, Pathophysiology and Future Directions. J Clin Med 2022; 11:jcm11030649. [PMID: 35160099 PMCID: PMC8836727 DOI: 10.3390/jcm11030649] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting autosomal recessive multisystem disease. While its burden of morbidity and mortality is classically associated with pulmonary disease, CF also profoundly affects the gastrointestinal (GI) tract. Chronic low-grade inflammation and alterations to the gut microbiota are hallmarks of the CF intestine. The etiology of these manifestations is likely multifactorial, resulting from cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, a high-fat CF diet, and the use of antibiotics. There may also be a bidirectional pathophysiological link between intestinal inflammation and changes to the gut microbiome. Additionally, a growing body of evidence suggests that these GI manifestations may have significant clinical associations with growth and nutrition, quality of life, and respiratory function in CF. As such, the potential utility of GI therapies and long-term GI outcomes are areas of interest in CF. Further research involving microbial modulation and multi-omics techniques may reveal novel insights. This article provides an overview of the current evidence, pathophysiology, and future research and therapeutic considerations pertaining to intestinal inflammation and alterations in the gut microbiota in CF.
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Affiliation(s)
- Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Isabelle McKay
- Wagga Wagga Base Hospital, Wagga Wagga, NSW 2650, Australia;
| | - Michael Coffey
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
- Correspondence:
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van Dorst JM, Tam RY, Ooi CY. What Do We Know about the Microbiome in Cystic Fibrosis? Is There a Role for Probiotics and Prebiotics? Nutrients 2022; 14:nu14030480. [PMID: 35276841 PMCID: PMC8840103 DOI: 10.3390/nu14030480] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-shortening genetic disorder that affects the cystic fibrosis transmembrane conductance regulator (CFTR) protein. In the gastrointestinal (GI) tract, CFTR dysfunction results in low intestinal pH, thick and inspissated mucus, a lack of endogenous pancreatic enzymes, and reduced motility. These mechanisms, combined with antibiotic therapies, drive GI inflammation and significant alteration of the GI microbiota (dysbiosis). Dysbiosis and inflammation are key factors in systemic inflammation and GI complications including malignancy. The following review examines the potential for probiotic and prebiotic therapies to provide clinical benefits through modulation of the microbiome. Evidence from randomised control trials suggest probiotics are likely to improve GI inflammation and reduce the incidence of CF pulmonary exacerbations. However, the highly variable, low-quality data is a barrier to the implementation of probiotics into routine CF care. Epidemiological studies and clinical trials support the potential of dietary fibre and prebiotic supplements to beneficially modulate the microbiome in gastrointestinal conditions. To date, limited evidence is available on their safety and efficacy in CF. Variable responses to probiotics and prebiotics highlight the need for personalised approaches that consider an individual’s underlying microbiota, diet, and existing medications against the backdrop of the complex nutritional needs in CF.
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Affiliation(s)
- Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
- Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney 2031, Australia
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney 2031, Australia
- Correspondence:
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Park H, Kim J, Choi S, Suh HR, Moon JE, Kim D, Choi BS, Hwang SK, Kang B, Choe BH. Case report of compound CFTR variants in Korean siblings with cystic fibrosis: importance of differentiating cystic fibrosis from inflammatory bowel disease. Transl Pediatr 2021; 10:3104-3109. [PMID: 34976777 PMCID: PMC8649608 DOI: 10.21037/tp-21-274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
The prevalence of cystic fibrosis (CF) is considerably lower in Asian populations compared with that of Caucasians. Cases of CF are typically due to mutations in the CF transmembrane conductance regulator gene with autosomal recessive inheritance. Here, we report two cases of newly diagnosed CF in Korea-a 13-year-old boy and his 5-year-old brother. The older brother was admitted to our hospital for evaluation and treatment of recurrent abdominal pain, frequent diarrhea, and failure to thrive. Fecal calprotectin (FC) was elevated, and when combining this with his clinical presentation, inflammatory bowel disease (IBD) or eosinophilic gastroenteritis (EoGE) was the first impression of his disease. Several ulcerative lesions were observed on ileocolonoscopy. However, incidental findings of suspicious bronchiectatic lesions were observed on plain radiography, which were confirmed by chest computed tomography. Moreover, diffuse bowel wall thickening with pancreatic atrophy was also incidentally detected by computed tomography of the abdomen. Comprehensively, these findings were highly suggestive of CF. Therefore, diagnostic exome sequencing was conducted, which revealed compound heterozygous variants of c.263T>G (p.Leu88*) and c.2977G>T (p.Asp993Tyr) in the CF transmembrane conductance regulator gene. Although symptoms in the younger brother were not as prominent as the older brother, genetic test was also conducted, which revealed the same mutation. We report the identification of a novel variant, p.Asp993Tyr, in siblings with Korean heritage. Although CF is rare in Koreans, it should be included in the differential diagnosis of IBD.
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Affiliation(s)
- Hyejin Park
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jinwoo Kim
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sujin Choi
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyo-Rim Suh
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Eun Moon
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dongsub Kim
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bong Seok Choi
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Su-Kyeong Hwang
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ben Kang
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung-Ho Choe
- Department of Paediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
Cystic fibrosis liver disease (CFLD) remains the third leading cause of death in patients with cystic fibrosis. Although most patients with CFLD present in childhood, recent studies suggest a second wave of liver disease in adulthood. There are no clear guidelines for diagnosing CFLD. Treatment options for CFLD remain limited, and while UDCA is widely used, its long-term benefit is unclear. Those who develop hepatic decompensation or uncontrolled variceal bleeding may benefit from liver transplant, either alone, or in combination with lung transplant.
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Affiliation(s)
- Sasan Sakiani
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, University of Maryland Medical Center, 22 South Greene Street, N3W50, Baltimore, MD 21201, USA.
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, 10 Center Drive, Building 10, Room 2S235, MSC 1500, Bethesda, MD 20892, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Building 10, Room 9B-16, MSC 1800, Bethesda, MD 20892, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Building 10, Room 9B-16, MSC 1800, Bethesda, MD 20892, USA.
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Madácsy T, Pallagi P, Maleth J. Cystic Fibrosis of the Pancreas: The Role of CFTR Channel in the Regulation of Intracellular Ca 2+ Signaling and Mitochondrial Function in the Exocrine Pancreas. Front Physiol 2018; 9:1585. [PMID: 30618777 PMCID: PMC6306458 DOI: 10.3389/fphys.2018.01585] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/23/2018] [Indexed: 12/26/2022] Open
Abstract
Cystic fibrosis (CF) is the most common genetic disorder that causes a significant damage in secretory epithelial cells due to the defective ion flux across the cystic fibrosis transmembrane conductance regulator (CFTR) Cl- channel. Pancreas is one of the organs most frequently damaged by the disease leading to pancreatic insufficiency, abdominal pain and an increased risk of acute pancreatitis in CF patients causing a significant decrease in the quality of life. CFTR plays a central role in the pancreatic ductal secretory functions by carrying Cl- and HCO3 - ions across the apical membrane. Therefore pathophysiological studies in CF mostly focused on the effects of impaired ion secretion by pancreatic ductal epithelial cells leading to exocrine pancreatic damage. However, several studies indicated that CFTR has a central role in the regulation of intracellular signaling processes and is now more widely considered as a signaling hub in epithelial cells. In contrast, elevated intracellular Ca2+ level was observed in the lack of functional CFTR in different cell types including airway epithelial cells. In addition, impaired CFTR expression has been correlated with damaged mitochondrial function in epithelial cells. These alterations of intracellular signaling in CF are not well characterized in the exocrine pancreas yet. Therefore in this review we would like to summarize the complex role of CFTR in the exocrine pancreas with a special focus on the intracellular signaling and mitochondrial function.
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Affiliation(s)
- Tamara Madácsy
- First Department of Medicine, University of Szeged, Szeged, Hungary.,HAS-USZ Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary
| | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Jozsef Maleth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,HAS-USZ Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary.,Department of Public Health, University of Szeged, Szeged, Hungary
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