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Leenaars CHC, Stafleu FR, Häger C, Nieraad H, Bleich A. A systematic review of animal and human data comparing the nasal potential difference test between cystic fibrosis and control. Sci Rep 2024; 14:9664. [PMID: 38671057 PMCID: PMC11053161 DOI: 10.1038/s41598-024-60389-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Abstract
The nasal potential difference test (nPD) is an electrophysiological measurement which is altered in patients and animal models with cystic fibrosis (CF). Because protocols and outcomes vary substantially between laboratories, there are concerns over its validity and precision. We performed a systematic literature review (SR) of the nPD to answer the following review questions: A. Is the nasal potential difference similarly affected in CF patients and animal models?", and B. "Is the nPD in human patients and animal models of CF similarly affected by various changes in the experimental set-up?". The review protocol was preregistered on PROSPERO (CRD42021236047). We searched PubMed and Embase with comprehensive search strings. Two independent reviewers screened all references for inclusion and extracted all data. Included were studies about CF which described in vivo nPD measurements in separate CF and control groups. Risk of bias was assessed, and three meta-analyses were performed. We included 130 references describing nPD values for CF and control subjects, which confirmed substantial variation in the experimental design and nPD outcome between groups. The meta-analyses showed a clear difference in baseline nPD values between CF and control subjects, both in animals and in humans. However, baseline nPD values were, on average, lower in animal than in human studies. Reporting of experimental details was poor for both animal and human studies, and urgently needs to improve to ensure reproducibility of experiments within and between species.
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Affiliation(s)
| | - Frans R Stafleu
- Department of Animals in Science and Society-Human-Animal Relationship, Utrecht University, Utrecht, The Netherlands
| | - Christine Häger
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Hendrik Nieraad
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - André Bleich
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
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2
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Simmonds NJ, Southern KW, De Wachter E, De Boeck K, Bodewes F, Mainz JG, Middleton PG, Schwarz C, Vloeberghs V, Wilschanski M, Bourrat E, Chalmers JD, Ooi CY, Debray D, Downey DG, Eschenhagen P, Girodon E, Hickman G, Koitschev A, Nazareth D, Nick JA, Peckham D, VanDevanter D, Raynal C, Scheers I, Waller MD, Sermet-Gaudelus I, Castellani C. ECFS standards of care on CFTR-related disorders: Identification and care of the disorders. J Cyst Fibros 2024:S1569-1993(24)00037-7. [PMID: 38508949 DOI: 10.1016/j.jcf.2024.03.008] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.
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Affiliation(s)
- N J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - K W Southern
- Department of Women's and Children's Health, University of Liverpool, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK
| | - E De Wachter
- Cystic Fibrosis Center, Pediatric Pulmonology department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K De Boeck
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - F Bodewes
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Groningen Medical Center, Groningen, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB), University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - P G Middleton
- Cystic Fibrosis and Bronchiectasis Service, Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, News South Wales, Australia
| | - C Schwarz
- HMU-Health and Medical University Potsdam, CF Center Westbrandenburg, Campus Potsdam, Germany
| | - V Vloeberghs
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M Wilschanski
- CF Center, Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - E Bourrat
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - J D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - C Y Ooi
- a) School of Clinical Medicine, Discipline of Paediatrics and Child Health, Medicine & Health, University of New South Wales, Level 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High Streets, Randwick, Sydney, NSW, Australia, 2031; b) Sydney Children's Hospital, Gastroenterology Department, High Street, Randwick, Sydney, NSW, Australia, 2031
| | - D Debray
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - D G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - E Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, APHP.Centre - Université de Paris Cité, Hôpital Cochin, Paris, France
| | - G Hickman
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - A Koitschev
- Klinikum Stuttgart, Pediatric Otorhinolaryngology, Stuttgart, Germany
| | - D Nazareth
- a) Adult CF Unit, Liverpool Heart and Chest Hospital NHS Foundation Trust, U.K; b) Clinical Infection, Microbiology and Immunology, University of Liverpool, UK
| | - J A Nick
- Department of Medicine, National Jewish Health, Denver, CO, 80206, USA, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - D Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - D VanDevanter
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Raynal
- Laboratory of molecular genetics, University Hospital of Montpellier and INSERM U1046 PHYMEDEXP, Montpellier, France
| | - I Scheers
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M D Waller
- Adult Cystic Fibrosis and Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Honorary Senior Lecturer, King's College London, London, United Kingdom
| | - I Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France; Université de Paris, Paris, France; Centre de référence Maladies Rares, Mucoviscidose et maladies apparentées, Hôpital Necker Enfants malades, Paris, France
| | - C Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
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Cho DY, Zhang S, Skinner D, Koch CG, Smith MJ, Lim DJ, Grayson JW, Tearney GJ, Rowe SM, Woodworth BA. Red ginseng aqueous extract improves mucociliary transport dysfunction and histopathology in CF rat airways. J Cyst Fibros 2023; 22:1113-1119. [PMID: 37704464 PMCID: PMC10843063 DOI: 10.1016/j.jcf.2023.09.002] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND We previously discovered that Korean red ginseng aqueous extract (RGAE) potentiates the TMEM16A channel, improved mucociliary transport (MCT) parameters in CF nasal epithelia in vitro, and thus could serve as a therapeutic strategy to rescue the MCT defect in cystic fibrosis (CF) airways. The hypothesis of this study is that RGAE can improve epithelial Cl- secretion, MCT, and histopathology in an in-vivo CF rat model. METHODS Seventeen 4-month old CFTR-/- rats were randomly assigned to receive daily oral control (saline, n = 9) or RGAE (Ginsenosides 0.4mg/kg/daily, n = 8) for 4 weeks. Outcomes included nasal Cl- secretion measured with the nasal potential difference (NPD), functional microanatomy of the trachea using micro-optical coherence tomography, histopathology, and immunohistochemical staining for TMEM16a. RESULTS RGAE-treated CF rats had greater mean NPD polarization with UTP (control = -5.48 +/- 2.87 mV, RGAE = -9.49 +/- 2.99 mV, p < 0.05), indicating, at least in part, potentiation of UTP-mediated Cl- secretion through TMEM16A. All measured tracheal MCT parameters (airway surface liquid, periciliary liquid, ciliary beat frequency, MCT) were significantly increased in RGAE-treated CF rats with MCT exhibiting a 3-fold increase (control, 0.45+/-0.31 vs. RGAE, 1.45+/-0.66 mm/min, p < 0.01). Maxillary mucosa histopathology was markedly improved in RGAE-treated cohort (reduced intracellular mucus, goblet cells with no distention, and shorter epithelial height). TMEM16A expression was similar between groups. CONCLUSION RGAE improves TMEM16A-mediated transepithelial Cl- secretion, functional microanatomy, and histopathology in CF rats. Therapeutic strategies utilizing TMEM16A potentiators to treat CF airway disease are appropriate and provide a new avenue for mutation-independent therapies.
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Affiliation(s)
- Do-Yeon Cho
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Otolaryngology, Department of Surgery, Veteran Affairs Medical Center, Birmingham, AL, USA
| | - Shaoyan Zhang
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel Skinner
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Connor G Koch
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Metta J Smith
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dong-Jin Lim
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica W Grayson
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA; Departments of Medicine, Pediatrics, Cell Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bradford A Woodworth
- Department of Otolaryngology - Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Manzoor J, Hughes DA. Cystic Fibrosis screen positive, inconclusive diagnosis (CFSPID) to Cystic Fibrosis: Detecting disease with serial assessments. Paediatr Respir Rev 2023; 47:19-22. [PMID: 37365112 DOI: 10.1016/j.prrv.2023.06.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
We present the case of a child given a CFSPID designation in early life who was later reclassified as having CF based on a combination of recurrent respiratory symptoms and CFTR functional testing, despite normal sweat chloride levels. Here we demonstrate the importance of monitoring these children, each time reviewing the diagnosis based on updated understanding of individual CFTR mutation phenotypes or clinical findings inconsistent with the designation. This case identifies situations in which the CFSPID designation should be challenged, and gives an approach for this when CF is suspected.
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Affiliation(s)
- J Manzoor
- Department of Paediatric Respiratory Medicine, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - D A Hughes
- Department of Paediatric Respiratory Medicine, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Lex C, Minso R, Alfeis N, Rosewich H, Schucht S, Tümmler B. Clinical presentation and basic defect of the CFTR genotype p.Phe508del / p.Arg117His in a mother and her monozygous twin daughters. J Cyst Fibros 2021; 21:375-377. [PMID: 34489188 DOI: 10.1016/j.jcf.2021.08.018] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/25/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
A non-consanguineous two-generation family of parent and monozygous twins who all three share the same CFTR mutation genotype p.Phe508del / p.Arg117His, was examined in clinical features, sweat test, nasal potential difference and intestinal current measurements. As expected the twins were very much alike in anthropometry and appearance and shared the clinical manifestation of CFTR dysfunction albeit at different intensity but unexpectedly like in comparison to their mother they were discordant in their CFTR-mediated basic defect and the response thereof to CFTR potentiation by ivacaftor. This case report illustrates the strong impact of non-inherited factors on the electrophysiological phenotype of the most common CFTR mutation genotype of variable clinical significance.
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Affiliation(s)
- Christiane Lex
- Department of Paediatric Cardiology and Intensive Care Medicine, Paediatric Pulmonary and Allergology Outpatient Clinic, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Rebecca Minso
- Clinical Research Group 'Molecular Pathology of Cystic Fibrosis', Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Nadine Alfeis
- Clinical Research Group 'Molecular Pathology of Cystic Fibrosis', Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Hendrik Rosewich
- Department of Paediatric and Adolescent Medicine, Paediatric Gastroenterology Outpatient Clinic, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Sylvia Schucht
- Department of Paediatric Cardiology and Intensive Care Medicine, Paediatric Pulmonary and Allergology Outpatient Clinic, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Burkhard Tümmler
- Clinical Research Group 'Molecular Pathology of Cystic Fibrosis', Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Hannover, Germany.
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6
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Naehrlich L. Have courage in using nasal potential difference for diagnostic decisions and clinical research. J Cyst Fibros 2020; 19:507-508. [PMID: 32593372 DOI: 10.1016/j.jcf.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Feulgenstrasse 12, D-35385 Giessen, Germany.
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Kyrilli S, Henry T, Wilschanski M, Fajac I, Davies JC, Jais JP, Sermet-Gaudelus I. Insights into the variability of nasal potential difference, a biomarker of CFTR activity. J Cyst Fibros 2019; 19:620-626. [PMID: 31699569 DOI: 10.1016/j.jcf.2019.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 07/05/2019] [Revised: 09/07/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Nasal potential difference (NPD) is used to evaluate CFTR function in vivo. We aimed to evaluate the intrasubject and intersubject variability of NPD measurements. METHODS We reviewed NPD tracings of 116 patients with CF enrolled in the placebo arm of a multicenter study. Patients carried at least one nonsense mutation and underwent repeated NPD tests every 16 weeks. NPD parameters included basal potential difference (basal PD), inhibition of sodium absorption by amiloride (Δ Amiloride), chloride (Cl-) transport in response to a Cl--free solution (Δ Low Cl-), isoproterenol (Δ Isoproterenol), the sum of Δ Low Cl- and Δ Isoproterenol (Δ Low Cl--Isoproterenol) and ATP (Δ ATP). RESULTS Basal PD and Δ Amiloride displayed the highest variabilities, mainly stemming from intercenter and intrasubject effect. Δ Low Cl-, Δ Isoproterenol and Δ Low Cl--Isoproterenol demonstrated a large intrasubject variability but a smaller intersubject variability. The intrasubject measurement variability for Δ Low Cl--Isoproterenol, was within ± 7.2 mV with 95% probability. It was greater in patients reporting ongoing pulmonary exacerbations. CONCLUSIONS The large intercenter variability of basal PD and Δ Amiloride highlights the operator-dependent aspect of these measurements. A difference greater than 7.2 mV in Δ Low Cl--Isoproterenol in a given patient on CFTR modulator can be attributed, with 95% probability, to a treatment effect rather than to the variability inherent in the measurement.
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Affiliation(s)
- Spyridoula Kyrilli
- Centre Maladies Rares Mucoviscidose, Hôpital Universitaire Necker-Enfants Malades, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Theophraste Henry
- Bio-statistics Department, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | | | - Isabelle Fajac
- AP-HP, Hopital Cochin, Physiology Department, Paris, France; UPRES EA 2511, Paris, France; Université Paris Sorbonne, Paris, France
| | - Jane C Davies
- CF and Chronic Lung Infection, National Heart and Lung Institute, Imperial College London, UK; Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Jean-Philippe Jais
- Bio-statistics Department, Hôpital Universitaire Necker-Enfants Malades, Paris, France; Université Paris Sorbonne, Paris, France
| | - Isabelle Sermet-Gaudelus
- Centre Maladies Rares Mucoviscidose, Hôpital Universitaire Necker-Enfants Malades, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Sorbonne, Paris, France; Institut Necker-Enfants Malades. INSERM U1151, Paris, France.
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Abstract
The spectrum of conditions caused by abnormal CFTR function is broad - from 'classic' cystic fibrosis (CF) to single organ conditions termed CFTR-related disorders. Defining and securing the diagnosis in an important minority of patients can be a challenge as the sweat test is equivocal or normal; the impact this has on the patient (at different stages of their life) can be very significant as it has the potential to lead to misdiagnosis and over (or under) treatment with associated psychological burden. The nasal potential difference test and intestinal current measurements are physiological measurements of CFTR function and thus can provide important diagnostic information. This article provides an overview of the latest developments in CF diagnostics, outlining the approach to be taken when the diagnosis is unclear and some of the areas of uncertainty.
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Aalbers BL, Yaakov Y, Derichs N, Simmonds NJ, De Wachter E, Melotti P, De Boeck K, Leal T, Tümmler B, Wilschanski M, Bronsveld I. Nasal potential difference in suspected cystic fibrosis patients with 5T polymorphism. J Cyst Fibros 2019; 19:627-631. [PMID: 31331863 DOI: 10.1016/j.jcf.2019.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 03/30/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND 5T polymorphism is a CFTR mutation with unclear clinical consequences: the phenotype varies from healthy individuals to Cystic Fibrosis (CF). The aim of this study was to evaluate if nasal potential difference (NPD) and sweat testing correlate with symptoms and CF diagnosis in 5T patients. METHODS 86 patients with 5T who had undergone NPD measurement, were included (6 homozygous (5T/5T), 41 with a PI-CF causing mutation in trans (5T/PI-CF), 11 with a PS-CF causing mutation in trans (5T/PS-CF) and 28 without a known mutation in trans (5T/?). Data including age, phenotype, sweat chloride and follow up were collected. RESULTS 33% of the 5T/5T patients had abnormal NPD results, compared to 70% in 5T/PI-CF; 33% in 5T/PS-CF and 29% in 5T/?. The percentage of high or borderline sweat chloride was highest in 5T/PI-CF, and 5T/?, compared to 5T/5T and 5T/PS-CF (91, 96, 80, and 63%, respectively). TGm (number of TG repeats in intron 8) analysis was performed in 21 5T/PI-CF patients. TG11 was associated with lower sweat chloride, lower percentage of abnormal NPD and less progression of symptoms compared to TG12 and TG13. CONCLUSION There is much variation in clinical status among 5T patients. All patients in this study with 5T/PS CF, all patients with both normal NPD and sweat test, and most patients with TG11 were stable or improving over time. Therefore, NPD measurement and TGm status aid to assess if a patient is at high risk for developing CF or CFTR-related disease and if specific follow up in a CF center is required.
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Affiliation(s)
- Bente L Aalbers
- Department of Pulmonology, University Medical Center Utrecht, Postbus 85500, 3508, GA, Utrecht, the Netherlands.
| | - Yasmin Yaakov
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Nico Derichs
- CF Center, Pediatric Pulmonology and Immunology, Charité Universitätsmedizin, Charitépl. 1, 10117 Berlin, Germany
| | - Nicholas J Simmonds
- Department of Cystic Fibrosis, Royal Brompton Hospital and Imperial College, Sydney Street, SW3 6NP London, United Kingdom
| | - Elke De Wachter
- Department of Pediatric Pneumology, UZ Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium
| | - Paola Melotti
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata. Piazzale Aristide Stefani 1, 37126 Verona, Italy
| | - Kris De Boeck
- Department of Pediatric Pulmonology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Teresinha Leal
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Place de l'Université 1, B-1348 Louvain-la-Neuve, Brussels, Belgium
| | - Burkhart Tümmler
- CF Center and Clinical Research Group, Department of Pediatric Pneumology and Neonatology, OE 6710, Medical School Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Inez Bronsveld
- Department of Pulmonology, University Medical Center Utrecht, Postbus 85500, 3508, GA, Utrecht, the Netherlands
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10
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Werlin S, Scotet V, Uguen K, Audrezet MP, Cohen M, Yaakov Y, Safadi R, Ilan Y, Konikoff F, Galun E, Mizrahi M, Slae M, Sayag S, Cohen-Cymberknoh M, Wilschanski M, Ferec C. Primary sclerosing cholangitis is associated with abnormalities in CFTR. J Cyst Fibros 2018; 17:666-671. [PMID: 29807875 DOI: 10.1016/j.jcf.2018.04.005] [Citation(s) in RCA: 8] [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: 08/10/2017] [Revised: 04/13/2018] [Accepted: 04/22/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The etiology of primary sclerosing cholangitis (PSC) is unknown. PSC and Cystic Fibrosis related liver disease have common features: chronic inflammation, biliary damage and similar cholangiographic findings. It is unknown whether or not PSC is related to cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. We hypothesize that a sub-group of PSC patients may be a "single-organ" presentation of CF. METHODS Patients with PSC underwent nasal potential difference (NPD) measurement, sweat chloride measurement and complete CFTR sequencing by new generation sequencing. RESULTS 6/32 patients aged 46 ± 13 yrs. had CFTR causing mutations on one allele and 19 had CFTR polymorphisms; 6/23 tested had abnormal and 21 had intermediate sweat tests; 4/32 patients had abnormal NPD. One patient had chronic pancreatitis and was infertile. CONCLUSIONS 19% of PSC patients had features of CFTR related disorder, 19% carry CFTR mutations and 50% had CFTR polymorphisms. In some patients, PSC may be a single organ presentation of CF or a CFTR-related disorder.
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Affiliation(s)
- Steven Werlin
- Pediatric Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginie Scotet
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Kevin Uguen
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Marie-Pierre Audrezet
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Michael Cohen
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yasmin Yaakov
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Rifaat Safadi
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yaron Ilan
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Fred Konikoff
- Gastroenterology and Hepatology Department, Meir Medical Center, Kfar Saba, Israel
| | - Eitan Galun
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Meir Mizrahi
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mordechai Slae
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shirley Sayag
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Claude Ferec
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
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11
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da Cunha MF, Simonin J, Sassi A, Freund R, Hatton A, Cottart CH, Elganfoud N, Zoubairi R, Dragu C, Jais JP, Hinzpeter A, Edelman A, Sermet-Gaudelus I. Analysis of nasal potential in murine cystic fibrosis models. Int J Biochem Cell Biol 2016; 80:87-97. [PMID: 27717840 DOI: 10.1016/j.biocel.2016.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 08/01/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 12/27/2022]
Abstract
The nasal epithelium of the mouse closely mimics the bioelectrical phenotype of the human airways. Ion transport across the nasal epithelium induces a nasal transepithelial potential difference. Its measurement by a relatively non-invasive method adapted from humans allows in vivo longitudinal measurements of CFTR-dependent ionic transport in the murine nasal mucosa. This test offers a useful tool to assess CFTR function in preclinical studies for novel therapeutics modulating CFTR activity. Here we extensively review work done to assess transepithelial transport in the murine respiratory epithelium in the basal state and after administration of CFTR modulators. Factors of variability and discriminative threshold between the CF and the WT mice for different readouts are discussed.
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Affiliation(s)
- Mélanie Faria da Cunha
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Juliette Simonin
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Ali Sassi
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Romain Freund
- Unité de Biostatistiques, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Aurélie Hatton
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Charles-Henry Cottart
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Nadia Elganfoud
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Rachid Zoubairi
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Corina Dragu
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Jean Philippe Jais
- Unité de Biostatistiques, Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Hinzpeter
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
| | - Aleksander Edelman
- INSERM U 1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France
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12
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Mesbahi M, Shteinberg M, Wilschanski M, Hatton A, Nguyen-Khoa T, Friedman H, Cohen M, Escabasse V, Le Bourgeois M, Lucidi V, Sermet-Gaudelus I, Bassinet L, Livnat G. Changes of CFTR functional measurements and clinical improvements in cystic fibrosis patients with non p.Gly551Asp gating mutations treated with ivacaftor. J Cyst Fibros 2016; 16:45-48. [PMID: 27659740 DOI: 10.1016/j.jcf.2016.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 04/24/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 11/16/2022]
Abstract
Ivacaftor, a CFTR potentiator, has been found to improve CFTR function and clinical outcomes in patients with cystic fibrosis (CF) gating mutations. We investigated the effects of ivacaftor on CFTR functional measurement in CF patients carrying gating mutations other than p.Gly551Asp. Two siblings aged 13 and 12 carrying the p.Ser549Asn mutation, two sisters (45 and 43years old) compound heterozygotes for p.Asp1152His and p.Gly1244Glu, a 37year old man homozygous for the p.Gly1244Glu mutation, and a 7year old girl with p.Arg352Gln and p.Gly1244Glu mutations commenced treatment with ivacaftor. NPD was performed in all the patients and approached normal for four patients who had also clinical improvement (p.Ser549Asn compound heterozygotes, and p.Asp1152His/p.Gly1244Glu siblings). Beta-adrenergic sweat chloride secretion performed in thep.Asp1152His/p.Gly1244Glu patients improved significantly. The p.Gly1244Glu mutation homozygous patient, who had undergone an ileal resection with ileostomy and enterocutaneous fistula, did not respond clinically to ivacaftor and did not modify his sweat test. These results highlight the importance of different CFTR activity measurements to explore CFTR modulator efficacy.
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Affiliation(s)
- Myriam Mesbahi
- INSERM U 1151, Service de Pneumo-Pédiatrie, Université Paris-Sorbonne, Paris, France
| | - Michal Shteinberg
- Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Wilschanski
- Cystic Fibrosis Center, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Aurelie Hatton
- INSERM U 1151, Service de Pneumo-Pédiatrie, Université Paris-Sorbonne, Paris, France
| | - Thao Nguyen-Khoa
- INSERM U 1151, Service de Pneumo-Pédiatrie, Université Paris-Sorbonne, Paris, France
| | - Hannah Friedman
- Cystic Fibrosis Center, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Michael Cohen
- Cystic Fibrosis Center, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | | | - Muriel Le Bourgeois
- INSERM U 1151, Service de Pneumo-Pédiatrie, Université Paris-Sorbonne, Paris, France
| | | | | | - Laurence Bassinet
- Service de Pneumologie, Centre Intercommunal de Créteil, Créteil, France
| | - Galit Livnat
- Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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13
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Sad IR, Higa LYS, Leal T, Martins RDS, de Almeida AC, Ramos EG, de Cabello GMK, Peixoto MVM. Repeatability and Diagnostic Value of Nasal Potential Difference in a Genetically Admixed Population. J Clin Med Res 2015; 8:15-24. [PMID: 26668678 PMCID: PMC4676341 DOI: 10.14740/jocmr2312w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Accepted: 08/18/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The genetic diversity of the Brazilian population results from three ethnic groups admixture: Europeans, Africans and Amerindians, thus increasing the difficulty of performing cystic fibrosis (CF) diagnosis. The nasal potential difference (NPD) evaluates the cystic fibrosis transmembrane conductance regulator (CFTR) and epithelial sodium channel (ENaC) activity. Despite being a useful CF diagnostic test and a biomarker of CFTR-modulator drugs, it is also highly operator dependent. Therefore, it may be difficult to get accurate results and to interpret them. Wilschanski and Sermet scores were proposed to address these issues. This study aimed to evaluate repeatability and diagnostic value of NPD parameters and Wilschanski and Sermet scores in a CF center in Rio de Janeiro. METHODS NPD was performed in 78 subjects. Maximal PD, amiloride response, total chloride response, and Wilschanski and Sermet scores were explored as means (confidence interval, CI). One-way ANOVA was used to compare mean differences and Scheffe test was used to pair-wise comparisons. Repeatability was evaluated by scatter and Bland-Altman plots. The Ethics Committee of the CF Center has approved the study protocol. Parents and adult participants signed an informed consent form. RESULTS Forty-eight healthy-volunteers, 19 non-CF and 11 CF patients were enrolled in this study. Significant differences were found when comparing CF patients' NPD parameters to the other two groups (P = 0.000). Moreover, no significant differences were found when parameters from non-CF patients were compared with those from healthy volunteers (P > 0.05). The means of NPD parameters and diagnostic scores of each group were in concordance with disease/non-disease conditions. The repeatability data - Wilschanski and Sermet and NPD - allow NPD to be performed in this Brazilian CF Center. CONCLUSIONS The present study gathered consistent data for Bland-Altman plots. The results of Wilschanski and Sermet diagnostic scores suggest that they were concordant with CF/non-CF conditions. More NPD tests should be performed in the Rio de Janeiro CF dynamic cohort to contribute to international NPD validation studies and to provide NPD as a biomarker in Brazil.
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Affiliation(s)
- Izabela Rocha Sad
- Pediatric Pulmonology, Pediatric Department, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
| | - Laurinda Yoko Shinzato Higa
- Pediatric Pulmonology, Pediatric Department, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
| | - Teresinha Leal
- Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Experimentale et Clinique (IREC) Universite Catholique de Louvain, Brussels, Belgium
| | - Raisa da Silva Martins
- Pediatric Pulmonology, Pediatric Department, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
| | - Ana Claudia de Almeida
- Laboratory of Quantitative Methods, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
| | - Eloane Goncalves Ramos
- Clinical Research Unit, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
| | - Giselda Maria Kalil de Cabello
- Laboratory of Human Genetics, Oswaldo Cruz Institute, Oswaldo Cruz Foundation/FIOCRUZ, Pavilhao Leonidas Deane, sala 611, Rio de Janeiro, Brazil
| | - Maria Virginia Marques Peixoto
- Laboratory of Quantitative Methods, Fernandes Figueira National Institute of Woman, Child and Adolescent Health, Oswaldo Cruz Foundation/FIOCRUZ, Rio de Janeiro, Brazil
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14
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Keenan K, Avolio J, Rueckes-Nilges C, Tullis E, Gonska T, Naehrlich L. Nasal potential difference: Best or average result for CFTR function as diagnostic criteria for cystic fibrosis? J Cyst Fibros 2014; 14:310-6. [PMID: 25300456 DOI: 10.1016/j.jcf.2014.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/26/2014] [Revised: 09/11/2014] [Accepted: 09/12/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The current practice of averaging the nasal potential difference (NPD) results of right and left nostril measurements reduce inter-individual variability but may underestimate individual CFTR function. METHODS Best NPD response to Cl(-)-free and isoproterenol perfusion (=largest ΔPD(0Cl/Iso)) from the right and left nostril was compared to the average result in 13 cystic fibrosis (CF), 78 query-CF patients and 22 healthy controls from 2 cohorts. RESULTS Despite moderate to good correlation (p<0.001) between right and left measured ΔPD(0Cl/Iso), we observed large differences in some individuals. A comparison of average versus best ΔPD(0Cl/Iso) showed only moderate agreement (Giessen κ=0.538; Toronto κ=0.607). Averaging ΔPD(0Cl/Iso) showed a lower composite chloride response compared to best ΔPD(0Cl/Iso) and altered diagnostic NPD interpretation in 30 of 113 (27%) subjects. CONCLUSIONS The current practice of averaging the NPD results of right and left nostril measurements leads to an underestimation of the individual CFTR function and should be reconsidered.
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Affiliation(s)
- Katherine Keenan
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto and Physiology and Experimental Medicine, Research Institute, the Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Julie Avolio
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto and Physiology and Experimental Medicine, Research Institute, the Hospital for Sick Children, Toronto, Ontario, Canada.
| | | | - Elizabeth Tullis
- Department of Medicine, University of Toronto and Division of Respirology and Keenan Research Centre of Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Tanja Gonska
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto and Physiology and Experimental Medicine, Research Institute, the Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany.
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15
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Naehrlich L, Ballmann M, Davies J, Derichs N, Gonska T, Hjelte L, van Konigsbruggen-Rietschel S, Leal T, Melotti P, Middleton P, Tümmler B, Vermeulen F, Wilschanski M. Nasal potential difference measurements in diagnosis of cystic fibrosis: an international survey. J Cyst Fibros 2013; 13:24-8. [PMID: 24022019 DOI: 10.1016/j.jcf.2013.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [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: 05/11/2013] [Revised: 08/02/2013] [Accepted: 08/13/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND The role of nasal potential difference (NPD) measurement as a diagnostic test for cystic fibrosis (CF) is a subject of global controversy because of the lack of validation studies, clear reference values, and standardized protocols for diagnostic NPD. METHODS To determine diagnostic NPD frequency, protocols, interpretation, and rater agreement, we surveyed the 18 NPD centres of the European Cystic Fibrosis Society Diagnostic Network Working Group. RESULTS Fifteen centres reported performing 373 diagnostic NPDs in 2012. Most use the CFF-TDN-SOP (67%) and the chloride-free + isoproterenol response of the side with the largest response (47%) as diagnostic criteria and use centre-specific reference ranges. Rater agreement for five NPD tracings - in general - was good, but poor in tracings with different responses between the two nostrils. CONCLUSIONS NPD is frequently used as a diagnostic and research tool for CF. Performance is highly standardized, centre-specific reference ranges are established, and rater agreement - in general - is good. Centre-independent diagnostic criteria and reference ranges must be defined by multicentre validation studies to improve standardized interpretation for diagnostic use.
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Affiliation(s)
- Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany.
| | - Manfred Ballmann
- Ruhr University Paediatric Clinic at St Josef Hospital, Bochum, Germany
| | - Jane Davies
- Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, United Kingdom; Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, United Kingdom; Department of Gene Therapy, Imperial College London, United Kingdom
| | - Nico Derichs
- CFTR Biomarker Centre and Translational CF Research Group Christiane Herzog Cystic Fibrosis Centre, Paediatric Pulmonology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Lena Hjelte
- Stockholm Cystic Fibrosis Center, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | - Teresinha Leal
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Université catholique de Louvain, Brussels, Belgium
| | - Paola Melotti
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Peter Middleton
- Cystic Fibrosis Unit, Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, University of Sydney at Westmead, Westmead, NSW, Australia
| | - Burkhard Tümmler
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, OE 6710, Medizinische Hochschule Hannover, Hannover, Germany
| | - Francois Vermeulen
- Cystic Fibrosis Reference Centre, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium
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