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Intestinal Fibrosis in IBD PDF
Intestinal Fibrosis in IBD PDF
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REVIEW ARTICLE
Abbreviations: ASCA, anti-Saccharomyces cerevisiae antibody; ATG16L1, autophagy-related protein 16-1; BAL, bronchoalveolar lavage; bFGF,
basic fibroblast growth factor; BNP, brain natriuretic peptide; CD, Crohn's disease; CF, cystic fibrosis; CCL, chemokine (C–C motif) ligand; CKD,
chronic kidney disease; COMP, cartilage oligomeric protein; CT, computed tomography; CTE, computed tomographic enterography; CTLA4,
cytotoxic T-lymphocyte antigen 4; CTGF, connective tissue growth factor; DLG5, disks large homolog 5; DSS, dextran sulfate sodium; ECCO,
European Crohn's and Colitis Organization; ECM, extracellular matrix; EGF, epidermal growth factor; FGF, fibroblast growth factor; HBV,
hepatitis B virus; HSP47, heat shock protein 47; IBD, inflammatory bowel disease; ICAM, intercellular adhesion molecule 1; ICTP, carboxy
terminal cross-linked telopeptide of type I collagen; IL, interleukin; INR, international normalized ratio; IP, interferon gamma-induced protein;
IPF, idiopathic pulmonary fibrosis; KL-6, Krebs von den Lungen-6; MALDI–TOF-MS, matrix-assisted laser desorption-ionization time-of-flight mass
spectrometry; MC, mesenchymal cell; miRNA, microRNA; MMP, matrix metalloproteinase; MR, magnetic resonance; MRI, magnetic resonance
imaging; mRSS, modified Rodnan skin score; MT, magnetization transfer; MUC, mucin; NOD, nucleotide-binding oligomerization domain
containing; OMUS, obliterative muscularization of the submucosa; PAI-1, plasminogen activator inhibitor-1; PDGF, platelet-derived growth factor;
PNP, amino terminal procollagen; PG-PS, peptidoglycan-polysaccharide; SMA, smooth muscle actin; SP, surfactant protein; SSc, serum of systemic
scleroderma; TERT, telomerase reverse transcriptase; TGF, transforming growth factor; TIMP, tissue inhibitor of matrix metalloproteinase; TNBS,
trinitro-benzene sulfonic acid; TNF, tumor necrosis factor; UC, ulcerative colitis; UEI, ultrasound elasticity imaging; US, ultrasonography; VCAM,
vascular cell adhesion molecule 1; VEGF, vascular endothelial growth factor.
⁎ Correspondence to: F. Rieder, The Cleveland Clinic Foundation, Lerner Research Institute, Department of Pathobiology/NC22, 9500 Euclid
Avenue, Cleveland, OH, 44195, USA. Tel.: + 1 216 445 4916; fax: + 1 216 636 0104.
⁎⁎ Correspondence to: I. Dotan, IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, 6
Weizmann Street, Tel Aviv 64239, Israel. Tel.: + 972 3 6947305; fax: + 972 3 6974184.
E-mail addresses: riederf@ccf.org (F. Rieder), j.r.debruyn@amc.uva.nl (J.R. de Bruyn), b.t.pham@rug.nl (B.T. Pham),
khkostas@hotmail.com (K. Katsanos), annesev@aou-careggi.toscana.it (V. Annese), phiggins@med.umich.edu (P.D.R. Higgins),
fm@med.up.pt (F. Magro), irisd@tasmc.health.gov.il (I. Dotan).
http://dx.doi.org/10.1016/j.crohns.2014.03.009
1873-9946/© 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
Fourth ECCO Scientific Workshop – Markers of Intestinal Fibrosis 1167
j
Department of Gastroenterology, Hospital de Sao Joao, Porto, Portugal
k
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Received 5 February 2014; received in revised form 12 March 2014; accepted 15 March 2014
KEYWORDS Abstract
Inflammatory bowel
diseases; The fourth scientific workshop of the European Crohn's and Colitis Organization (ECCO) focused
Crohn's disease; on intestinal fibrosis in inflammatory bowel disease (IBD). The objective was to better
Ulcerative colitis; understand basic mechanisms and markers of intestinal fibrosis as well as to suggest new
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167
2. Currently available markers of intestinal fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1168
3. Markers of fibrosis from other fibrotic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1168
3.1. Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1169
3.2. Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170
3.3. Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170
3.4. Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170
4. Clinical Situations Where Markers of Fibrosis Should be Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171
5. Approaches for Identifying Markers of Fibrosis in Inflammatory Bowel Disease Patients . . . . . . . . . . . . . . . . 1171
5.1. Which Body Compartments/Fluids Should be Investigated in the Quest for Novel Fibrosis Markers? . . . . 1171
5.2. Which Techniques Could be Used to Identify Novel Fibrosis Markers? . . . . . . . . . . . . . . . . . . . . . 1171
5.3. MicroRNA (miRNA) Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171
5.4. Proteome Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171
5.5. Transcriptomic Screening of Mucosal Samples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
5.6. How to Find New Markers of Fibrosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
6. Potential Trial Endpoints for Intestinal Fibrosis Marker Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . 1172
6.1. Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
6.2. Histopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
6.3. Functional Cell Assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
6.4. Radiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
6.5. Defining a Gold Standard for Use in Intestinal Fibrosis Research . . . . . . . . . . . . . . . . . . . . . . . . 1174
7. Summary and Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
cells and mesenchymal cells (MCs). MCs include fibroblasts, Table 1 Currently available markers of intestinal fibrosis.
myofibroblasts and smooth muscle cells and are the major
Reference
source of extracellular matrix (ECM) components.6
It is difficult to predict which patients will develop a Genetic
fibrostenosing phenotype (though a majority will do so NOD2 7
eventually) and how rapidly they will progress. No specific MMP-3 8
therapy to prevent or treat intestinal fibrosis is known. To rs1363670 9
enable progress in this area, it is essential to identify Increasing amount of risk alleles for NOD2, IBD5, 10
markers of intestinal fibrosis, in order to (1) stratify patients DLG5, ATG16L1, and IL23R
into different levels of risk before the development of
fibrosis, and (2) detect early stages of fibrosis before clinical Clinical
symptoms have occurred. An optimal fibrosis marker should Need for corticosteroids during first flare 11
Skin
miRNAs Serum and tissue 108
ICTP Serum 53
PINP and PIIINP Serum 54,55
Cytokines/chemokines Serum 57–59
CTGF Serum 48
Cartilage oligomeric protein Serum 49
Thrombospondin Serum 52
Osteopontin Plasma 51
MMP9 Serum 50
Number of myofibroblasts Skin biopsy 61
COMP, TSP-1, IFI44, and SIG1 gene expression Skin biopsy 62
Ultrasound Skin 65
Magnetic resonance imaging Skin 64
Kidney
TGFβ1 Urine 71
CTGF Urine 69
PAI-1 Urine 72
Collagen IV Urine 70
PIIINP: N-terminal propeptide of type III collagen, TIMP: tissue inhibitor of matrix metalloproteinase, CCL18: CC chemokine ligand 18, YKL-40:
tyrosine lysine leucine-40, HSP: heat shock protein, MMP: matrix metalloproteinase, ICAM: intercellular adhesion molecule, IL: interleukin,
VCAM: vascular cell adhesion molecule, S100A12: S100 calcium binding protein A12, miR: microRNA, ICTP: carboxy terminal telopeptide of
type I collagen, PINP: N-terminal propeptide of type I procollagen, CTGF: connective tissue growth factor, COMP: cartilage oligomeric matrix
protein, TSP: thrombospondin, IFI44: interferon-induced protein 44, SIG: small inducible gene, TGF: transforming growth factor, and
PAI: plasminogen activator inhibitor.
which is an essential component of ECM in virtually every collagen was significantly higher in the serum of patients
tissue in the body and substantially increased in hepatic with acute exacerbations of pulmonary fibrosis compared to
fibrosis; and tissue inhibitor of metalloproteinase 1 (TIMP-1) those with stable disease.42 Multiple genetic variants are
which inhibits interstitial collagenases and metalloprotein- linked to susceptibility for IPF, such as polymorphisms within
ases that are capable of degrading ECM.23,24 Liver and serum telomerase reverse transcriptase (TERT), IL-1, IL12p40,
TIMP-1 increase in parallel with the progression of the liver MMP1, NOD2 and others.43
disease. Therefore TIMP-1 has been considered useful in An additional novel conceptual approach has been
hepatic fibrosis.25 Another endogenous inhibitor of prote- pursued in pulmonary fibrosis, by identifying circulating
ases, serum cystatin C, also correlates with the stage of liver fibroblast precursors, the so-called fibrocytes, as markers of
fibrosis in chronic liver disorders.26 disease.44 Fibrocytes are believed to be a minor but
In addition to these molecular approaches, liver fibrosis has significant component of the pathogenesis of pulmonary
been studied with markers of tissue structure using ultrasound fibrosis. Circulating fibrocytes are elevated compared to
Unique to the kidney is the accessibility of urine as a markers of fibrosis research, and screening tools that may be
direct, kidney-specific read-out for renal fibrosis, allowing helpful in identifying new markers. Potential body products
the identification of local markers of fibrosis. Urine levels of that may be useful are stool, saliva, breath, or urine
TGF-β1, CTGF and collagen IV increase with progression of samples. Those may reflect the mediators and cells that
chronic kidney disease (CKD).68–71 Urine plasminogen acti- are active in fibrosis, without the need for invasive
vator inhibitor-1 (PAI-1) has also been shown to correlate procedures such as endoscopy and biopsies, or surgery.
with renal fibrosis in patients with diabetic nephropathy.72
Ultrasound imaging has also entered the field of kidney
fibrosis. Using the doppler ultrasound technique to calculate 5.2. Which Techniques Could be Used to Identify
the ‘resistive index’ and ‘atrophic index’ has shown promise Novel Fibrosis Markers?
in predicting time to dialysis and survival in chronic kidney
disease.73 Using single marker candidates remains a viable option.
5.5. Transcriptomic Screening of Mucosal Samples with high accuracy. However the lack of a clear definition of
fibrosis useable for trial endpoints has limited progress in the
The transcriptome is the set of all RNA molecules, including field. Currently all available endpoints rely on clinically
mRNA, rRNA, tRNA, and other non-coding RNA produced in apparent strictures that are confirmed by cross-sectional
one or a population of cells. This technique was performed in imaging.
a study of chronic kidney disease progression. Among the
targets identified, periostin, an extracellular matrix pro- 6.1. Endoscopy
tein, presented a significantly higher mRNA expression in
more advanced renal fibrosis.79
Full thickness histopathological sections to assess fibrosis
generally require surgical specimens. While this is an
5.6. How to Find New Markers of Fibrosis? endpoint of the fibrotic process, it is not a helpful fibrosis
marker. Endoscopy, typically performed in order to assess
Regardless of etiology, various biological factors are mucosal healing, could in the future enable follow-up of
involved and interact in the process of chronic remodeling fibrosis. This could be achieved by determination of luminal
and fibrosis in the intestine. Thus these may be used as diameter — visually or with devices allowing quantification.
markers in Crohn's disease in a single candidate approach. In Novel optical techniques including confocal endomicroscopy
line with a systems biology approach, however, we suggest might also be adapted to measure components of intestinal
that it could be necessary to quantitatively analyze the fibrosis. Thus, subepithelial myofibroblasts, ECM compo-
interactions of all components of a biological system in order nents, and other cell types may be visualized with or without
to define fibrotic processes in Crohn's disease. The future the use of specific stains. As more insights are gained,
could well lie in the creation of a biological “profile” of the endoscopy could become a useful tool in the assessment and
pathology in intestinal fibrosis, integrating all the above the follow-up of fibrosis.
techniques in distinct body compartments.
6.2. Histopathology
6. Potential Trial Endpoints for Intestinal
Fibrosis Marker Evaluations Endoscopic biopsies are accessible during endoscopies and
could serve as potential endpoints for marker trials. The
The leap in technologies now available allows the quantifi- predominant connective tissue protein in the intestine is
cation of a wide variety of mediators in body compartments collagen. Type I is the most abundant in the body and its
Fourth ECCO Scientific Workshop – Markers of Intestinal Fibrosis 1173
function is to give tensile strength. Type III is associated with imaging techniques are being developed and tested in animal
tissues that require motile structure, type IV is the major models to detect intestinal fibrosis and assess their potential
component of epithelial basement membranes and type V is translation for human use. The high MRI T2 signal of the
pericellular and can be produced by smooth muscle cells.80 pathologic bowel wall is directly associated with the presence
The presence and composition of collagens have been of edema in the submucosal layer (active disease). In general,
investigated in intestinal fibrosis. Intestinal strictures in CD T2-weighted imaging directly expresses the amount of fluids
are characterized by an increase in type V collagen.81 within the pathological wall, more sensitively and specifically
Collagen types IV and V are elevated in the muscularis than other imaging modalities, including ultrasonography and
propria and around ganglia, while collagen type III is CT.90 On the other hand, low T2 signal was correlated with
extensively present in ulcerations.80 Moreover, in CD, a the presence of fibrosis in the intestinal wall.91 The amount of
significant increase in submucosal type III collagen fiber collagen and fibroblasts is associated with a reduced T2 signal
content has been shown in stenosed intestine, with a in the bowel wall, predominantly in the submucosal and
detect intestinal stiffness changes as a result of fibrosis we reviewed IBD markers of fibrosis, and markers of fibrosis
development, with reasonably high sensitivity and repro- in extraintestinal fibrotic diseases. Additionally, fibrosis
ducibility.100 When applied to resected bowel segments endpoints, as may be seen by histology, endoscopy and
from TNBS animals to look for evidence of inflammation and imaging studies were discussed. Finally, we investigated the
fibrosis,101 it was able to differentiate acutely inflamed vs. potential for discovery of markers of fibrosis using rapidly
chronic fibrotic changes, and between unaffected and developing omics technologies. We believe that further
fibrotic intestine in a pilot study of Crohn's disease research in this field should pursue the development and
patients.102 In this small sample of 7 patients with Crohn's validation of markers, imaging studies, and histology in
disease, UEI had 100% sensitivity and specificity in differen- order to have a common denominator to assess fibrosis in
tiating between fibrotic and normal intestine.102 It was future studies and predict clinical outcomes. We also
feasible in humans, and the transcutaneous UEI accurately illustrate key research questions through several clinical
measures the tissue properties of stenotic segments of the scenarios.
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