Proteomic Analysis of Ascending Colon Biopsies from a Paediatric
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Gut Online First, published on May 23, 2016 as 10.1136/gutjnl-2015-310705 Inflammatory bowel disease ORIGINAL ARTICLE Proteomic analysis of ascending colon biopsies from Gut: first published as 10.1136/gutjnl-2015-310705 on 23 May 2016. Downloaded from a paediatric inflammatory bowel disease inception cohort identifies protein biomarkers that differentiate Crohn’s disease from UC Amanda E Starr,1 Shelley A Deeke,1 Zhibin Ning,1 Cheng-Kang Chiang,1 Xu Zhang,1 Walid Mottawea,1,2 Ruth Singleton,3 Eric I Benchimol,3,4,5 Ming Wen,1 David R Mack,3,4 Alain Stintzi,1 Daniel Figeys1,6 ▸ Additional material is ABSTRACT published online only. To view Objective Accurate differentiation between Crohn’s Significance of this study please visit the journal online (http://dx.doi.org/10.1136/ disease (CD) and UC is important to ensure early and gutjnl-2015-310705). appropriate therapeutic intervention. We sought to identify proteins that enable differentiation between CD 1Department of Biochemistry, What is already known on this subject? Microbiology and Immunology, and UC in children with new onset IBD. ▸ Accurate diagnosis of Crohn’s disease (CD) and Ottawa Institute of Systems Design Mucosal biopsies were obtained from children UC is important, so appropriate therapy can be Biology, University of Ottawa, undergoing baseline diagnostic endoscopy prior to initiated to reduce disease progression, Ottawa, Ontario, Canada therapeutic interventions. Using a super-stable isotope complications of disease related to permanent 2Department of Microbiology and Immunology, Mansoura labeling with amino acids in cell culture (SILAC)-based bowel damage and avoid unnecessary adverse University, Mansoura, Egypt approach, the proteomes of 99 paediatric control and drug events. 3Children’s Hospital of Eastern biopsies of patients with CD and UC were compared. ▸ Differentiation through clinical symptoms, site fl Ontario (CHEO) In ammatory Multivariate analysis of a subset of these (n=50) was of disease, presence of granulomas, genetics Bowel Disease Centre and applied to identify novel biomarkers, which were CHEO Research Institute, and current serological tests each have University of Ottawa, Ottawa, validated in a second subset (n=49). limitations. Ontario, Canada Results In the discovery cohort, a panel of five proteins ▸ Proteomic analyses are powerful tools to assess 4 Department of Pediatrics, was sufficient to distinguish control from IBD-affected quantitative and qualitative data about University of Ottawa, Ottawa, tissue biopsies with an AUC of 1.0 (95% CI 0.99 to biological systems. http://gut.bmj.com/ Ontario, Canada fl 5School of Epidemiology, 1.0); a second panel of 12 proteins segregated in amed CD from UC within an AUC of 0.95 (95% CI 0.86 to What are the new findings? Public Health and Preventive ▸ Medicine, University of Ottawa, 1.0). Application of the two panels to the validation An unbiased proteomics screen of biopsies Ottawa, Ontario, Canada fi from an inception cohort of patients with IBD 6 cohort resulted in accurate classi cation of 95.9% (IBD Department of Chemistry and from control) and 80% (CD from UC) of patients. 116 led to the identification of a panel of proteins Biomolecular Sciences, fi that can be used to differentiate patients with University of Ottawa, Ottawa, proteins were identi ed to have correlation with the Ontario, Canada severity of disease, four of which were components of CD from those with UC. on September 27, 2021 by guest. Protected copyright. the two panels, including visfatin and metallothionein-2. ▸ Candidate biomarkers suggest elevated fatty Correspondence to Conclusions This study has identified two panels of acid metabolism in paediatric CD and elevated Dr Daniel Figeys, Department protein metabolism in paediatric UC. of Biochemistry, Microbiology candidate biomarkers for the diagnosis of IBD and the and Immunology, Ottawa differentiation of IBD subtypes to guide appropriate How might it impact on clinical practice in Institute of Systems Biology, therapeutic interventions in paediatric patients. the foreseeable future? University of Ottawa, Roger ▸ Guidon Hall, 451 Smyth Road, The utilisation of these protein biomarkers into University of Ottawa, Ottawa, the clinical setting could improve accuracy of the Ontario, Canada K1H 8M5; current methods used to differentiate subtypes dfi[email protected] INTRODUCTION of IBD and do so in a rapid time frame. Further Received 10 September 2015 The IBDs are chronic, relapsing and remitting, GI understanding of the pathogenesis of paediatric Revised 10 March 2016 inflammatory conditions that affect over 4 million IBD may also be realised. Accepted 25 April 2016 people worldwide.1 In Canada, over 230 000 indi- viduals suffer from IBD, with an additional 10 000 cases diagnosed each year.2 IBD includes Crohn’s symptoms, and instead have a range of presenting disease (CD) and UC, which differ in clinical pres- features including atypical symptoms such as short entation and complications and may have different stature or weight loss leading to delayed recogni- – responses to treatment.3 5 Paediatric patients, tion and diagnosis.9 Generally, CD is characterised To cite: Starr AE, Deeke SA, 10%–25% of the IBD population,67often present by discreet mucosal and submucosal lesions, which Ning Z, et al. Gut Published Online First: [please include with different features from adult patients with can occur anywhere throughout the GI tract, and Day Month Year] IBD, and have more aggressive and extensive are transmural in nature. In contrast, UC extends – doi:10.1136/gutjnl-2015- disease and more long-term severe outcomes.4 8 proximally from the rectum, with contiguous, but 310705 Fewer children have the so-called classical generally superficial inflammation. However, non- Starr AE, et al. Gut 2016;0:1–11. doi:10.1136/gutjnl-2015-310705 1 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& BSG) under licence. Inflammatory bowel disease specific gastric involvement, relative rectal sparing and periap- patient biopsies, for which the variance of the proteomic data pendiceal patch involvement in UC10 can add to diagnostic con- were <2.0, were randomly divided into equal groups between fusion and misclassification of disease. Differential diagnosis is the discovery and the validation phase using a balanced stratifi- Gut: first published as 10.1136/gutjnl-2015-310705 on 23 May 2016. Downloaded from important for the induction and maintenance of appropriate cation approach for gender and diagnosis (Etcetera in WinPepi, therapy, which can differ between CD and UC. In the paediatric BixtonHealth.ca). The study was approved by the Children’s population, exclusive enteral nutrition is an effective induction Hospital of Eastern Ontario (CHEO) Research Ethics Board. therapy in CD but not in UC.11 For maintenance therapy, Study data were collected and managed using Research methotrexate is established for CD,12 but not for UC,13 whereas Electronic Data Capture (REDCap), hosted at the CHEO mesalamine is not.14 Furthermore, complications related to the Research Institute. REDCap is a secure, web-based application diseases are very different. For those unfortunate patients who designed to support data capture for research studies.31 do not respond to therapy, surgical options are very different with surgery for UC offering the end of the UC disease process Study population and the opportunity for reservoir formation and reconstitution All patients under 18 years of age and scheduled to undergo of the bowel continuity. For CD, with the very real possibility of diagnostic colonoscopy between October 2011 and February recurrence elsewhere in the GI tract, surgery to remove inflamed 2015 were considered eligible for recruitment. Exclusion cri- segments of inflamed mucosa is generally not offered unless teria, related to conditions known to affect the intestinal micro- disease complications necessitate such action. Thus, for both biome and mucosal gene expression, included (1) a body mass consideration of therapeutic options and discussion of out- index >95th percentile for age; (2) diabetes mellitus (insulin comes, correct diagnosis is an important factor in effective treat- and non-insulin-dependent); (3) infectious gastroenteritis within ment in IBD. the preceding 2 months or (4) use of any antibiotics, probiotics Genome-wide association studies have identified nearly 170 or immunomodulatory agents within the preceding 4 weeks. All susceptibility loci associated with IBD, including many loci that IBD cases met the standard diagnostic criteria for either UC or – overlap in CD and UC,15 17 yet disease manifestation due to CD following thorough clinical, microbiological, endoscopic, these variants is less than 15%.17 Biomarkers have been sought histological and radiological evaluation.32 Phenotyping of to complement current IBD diagnostic tools such as endoscopy, disease was based on endoscopy and radiological findings and imaging and histology to reduce ambiguous diagnosis of IBD, based on the Paris modification of the Montreal Classification assist in subtype differentiation and provide objective measures for IBD.33 Clinical disease activity of CD or UC was determined of disease. Previous studies have identified proteins that are ele- using the Pediatric Crohn’s Disease Activity Index (PCDAI)34 or vated and measurable in serum or stool;3 however, these pro- the Pediatric UC Activity Index (PUCAI),35 respectively. Since teins have been found to perform best in the more obvious ascending