Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT05072834 |
| Other study ID # |
12-2012 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
|
| First received |
|
| Last updated |
|
| Start date |
January 2013 |
| Est. completion date |
September 2015 |
Study information
| Verified date |
October 2021 |
| Source |
Aga Khan University |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Observational
|
Clinical Trial Summary
EE is increasingly recognized as a key factor underlying malnutrition, weakened immune
response and impaired cognitive development in children in developing countries. Absence of a
distinct biomarker of EE in the blood, urine or stool makes it difficult to study the impact
of interventions against it. Biomarkers for EE have been challenging to find, partly because
of our inadequate understanding of its pathophysiology. Investigators aim to identify novel
biomarkers for EE, based on our hypothesis that EE is a result of two processes: 1) repeated
exposure to enteric pathogens and environmental toxins leading to gut inflammation and 2)
weaning on diets high in carbohydrates but low in proteins and fat, leading to atrophy of the
intestinal mucosa. This leads to gut dysfunction, including leaky gut, small bowel stasis,
bacterial overgrowth, decreased immune response to infections, and frequent diarrhea. The
candidate biomarkers investigators have selected for our study (CRP, GLP- 2, Claudin 3,
Reg-1, plasma amino acids profile, serum cytokine profile, Neopterin and Myeloperoxidase) are
markers of inflammation, hormonal dysfunction and tight junction malfunction of the small
intestines. The 'gold standard test' for EE will be direct histopathologic analysis of the
duodenal mucosa, which will be available in a subset of study children undergoing upper GI
endoscopy. For other study subjects, clinical surrogates for EE will be used to calculate the
sensitivity and specificity of biomarkers being tested. These clinical surrogates of EE
include HAZ and WAZ score < 2 SD at 12 months and 15 months of age, and the worsening in HAZ
and WAZ scores between 6, 9, 12 and 15 months of age. Investigators plan to study and compare
duodenal biopsies from children with and without EE using cutting edge technologies including
electron microscopy, immunofluorescence, and mRNA sequencing. This will allow direct
correlation of the biomarkers in the blood, urine and stools with the histopathologic
features of the gut mucosa. The mRNA sequencing of the gut tissue will allow us to identify
new evidence-based biomarkers for EE, which could be further tested in the future.
This is a strong, multidisciplinary collaboration between investigators in Pakistan and the
United States with expertise in complementary areas including chemokines, inflammation, gut
architecture, infectious diseases, field studies, and technology development.
Description:
Title of protocol:
Identification of Novel Biomarkers for Environmental Enteropathy in Children using an
Evidence Based Approach
Background
Childhood malnutrition is a major problem in third world countries. One of the primary
mechanisms behind childhood malnutrition is that consumption of low quality food and frequent
gastrointestinal (GI) infections damage the intestinal mucosa of children. The intestines are
thus not able to absorb the available nutrients and also fail to function as an effective
barrier against the translocation of GI flora into the systemic circulation. The limited
energy resources available to the child are diverted to overcome these inflammatory
challenges at the expense of normal growth. This disorder of intestines (enteropathy) is
called Environmental Enteropathy (EE). Since EE is thought to be a precursor of chronic
malnutrition, detecting EE early with the use of biomarkers in the blood, urine or stools
will allow us to predict chronic malnutrition in children early. The purpose of this research
is to identify biomarkers for EE.
Objectives
1. To test novel candidate biomarkers of EE in a cohort of children 6-15 months of age in a
rural district in Pakistan.
2. To study the histo-pathologic characteristics of small bowel mucosa of moderate to
severely malnourished children of the study cohort A, and correlate findings with the
biomarkers studied in aim 1.
3. To study the histo-pathologic characteristics of small bowel mucosa of children
(well-nourished or malnourished) who are undergoing UGI endoscopy for any clinical
indication e.g. retrieval of foreign body, evaluation of UGI bleeding etc., (cohort B)
and correlate the findings with the blood, urine and stool biomarkers studied in aim 1.
4. To identify new candidate biomarkers for EE through studying mRNA expression in the
small bowel mucosa of children with and without EE for wide range of proteins involved
in inflammation, hormonal dysfunction, immune system and tight junction structure and
function.
Methods
In a cohort of children already being followed for growth and infections since birth for the
RESPAK study in Matiari, Sindh (Cohort A), investigators will collect blood, urine and stools
at 6 and 9 months of age and test for biomarkers including GLP-2, Claudin 3, CRP, Reg 1,
serum cytokines profile, plasma amino acids profile, Neopterin and Myeloperoxidase. These
biomarkers will be correlated with clinical surrogates of EE, including Height for Age Z
score (HAZ) and Weight for Age Z score (WAZ) of children at 6, 9, 12 and 15 months of age,
and the change in HAZ and WAZ scores between 6, 9, 12 and 15 months of age Investigators will
identify 20-30 children within cohort A who are moderately or severely malnourished and have
history of frequent or prolonged diarrhea at 10 -11 months of age, whose diagnosis remains
unknown despite a comprehensive non-invasive workup and who fail to respond to first line of
nutritional interventions. These children will undergo upper GI endoscopy at the Aga Khan
University, in line with the American Society for Gastroenterologlists (ASGE) guidelines for
the evaluation of children who are FTT and have associated frequent or prolonged diarrhea(1).
The duodenal biopsies obtained through the endoscopies will be used for H&E staining
(standard of care to diagnose celiac disease, other inflammatory and autoimmune causes of
enteropathy) as well as EE research, including study of inflammation, hormone dysfunction and
tight junction malfunction at AKU, University of Chicago and University of Virginia.
In a separate cohort of children (Cohort B) 6-24 months old who present to our collaborating
pediatric gastroenterologists at the Aga Khan University or at Children's Hospital Lahore for
UGI endoscopy for any appropriate indication, additional duodenal biopsies and
blood/urine/stool samples will be collected after informed consent. The workup done on these
children will be as described above.
The RNA will be extracted from the entire biopsy specimen obtained, and the mRNA targets
which are differentially expressed in children with and without EE will be identified, so
their downstream proteins could be identified and tested as candidate biomarkers for EE in
the future.
Adverse effects
Obtaining blood, urine and stools from the child at 6 and 9 months of age will cause
discomfort to the child though any serious adverse event resulting from these procedures is
unlikely. For subjects not responding to nutritional rehabilitation, and in whom the first
line of diagnostic workup is unrevealing, advanced workup will be offered per the ASGE
guidelines, which include UGI endoscopy in selected cases. Although rare, risks of endoscopy
include general anaesthesia related complications, perforation, bleeding and infection.
Ethical issues
Besides the issue of privacy invasion and blood, urine and stool collection, the major
ethical challenge in cohort A is the conduct of UGI endoscopies in some children in whom
cause of malnutrition is unclear despite first line of investigations and interventions.
Investigators think that these endoscopies are in the interest of these children, since the
ASGE recommends them as part of the workup in children who are failing to thrive and have
gastrointestinal symptoms like chronic or recurrent diarrhoea. The endoscopies may help
identify treatable inflammatory, infectious or autoimmune causes of failure to thrive in
these children.
Investigators are collecting additional biopsies for research during the endoscopies. The
risks associated with endoscopy are primarily with anaesthesia and procedure. Taking
additional biopsies is relatively safe since GI mucosa is one of the fastest healing organs
of the body and essentially no residual sign of the biopsy is left after 24 hours of the
procedure. Endoscopies at AKU and Children's hospital will be conducted by expert paediatric
gastroenterologists. Nonetheless, investigators are well equipped to handle any complication
that may arise.
In cohort B, investigators are taking additional biopsies from children who are already
undergoing UGI endoscopies for an appropriate indication not related to this study. The only
additional risk to the subjects in cohort B is with taking additional biopsies, which should
be minimal as explained above.
