For Fecal Microbiota Transplantation Research Articles

Changes in the gut microbiota caused by ASBTi suppress intrahepatic steatosis and inflammation in a mouse model of non-alcoholic fatty liver disease (NAFLD)

Abstract Although the estimated prevalence of NAFLD is approximately 25%, an effective treatment has not been established. Recently, gut microbiota has been shown to affect the pathogenesis of NAFLD. In this study, the protective effect of Apical Sodium-dependent Bile acid Transporter inhibitor (ASBTi) against NAFLD was investigated in mice fed a high-fat diet for 12 weeks (HFD mice) via changing their gut microbiota. ASBTi mice were mice treated with ASBTi (2.5 μmol/kg/day) during HFD feeding. For fecal microbiota transplantation (FMT), stools were collected from HFD mice and ASBTi mice. Fecal materials obtained from HFD mice and ASBTi mice were transplanted to normal mice, fed HFD for 12 weeks, and designated as HFD-FMT mice and ASBTi-FMT mice, respectively. Microbiota in these groups of mice were analyzed by 16S rRNA gene sequencing. The degrees of hepatic steatosis and inflammation in these mice were determined pathologically. The shannon index of the microbiota from ASBTi mice (3.31±0.19) and ASBTi-FMT mice (3.29±0.18) was significantly high as compared to that from HFD mice (2.90±0.19) and HFD-FMT mice (2.89±0.16). Steatosis and inflammation in the liver of HFD mice and HFD-FMT mice were shown to be pathologically severe and NAFLD Activity Score (NAS) was 7.67±0.58 in HFD mice and 5.67±2.08 in HFD-FMT mice. However, those in the liver of ASBTi mice and ASBTi-FMT mice were improved and NAS was reduced in ASBTi mice (1.67±0.58) and in ASBTi-FMT mice (2.67±0.58). These results suggest that changes in the gut microbiota caused by ASBTi suppress intrahepatic steatosis and inflammation in NAFLD mice. Elobixibat can be expected to prevent fatty liver.

Therapies to modulate gut microbiota: Past, present and future.

The human gut microbiota comprises of a complex and diverse array of microorganisms, and over the years the interaction between human diseases and the gut microbiota has become a subject of growing interest. Disturbed microbial milieu in the gastrointestinal tract is central to the pathogenesis of several diseases including antibiotic-associated diarrhea and Clostridioides difficile infection (CDI). Manipulation of this microbial milieu to restore balance by microbial replacement therapies has proven to be a safe and effective treatment for recurrent CDI. There is considerable heterogeneity in various aspects of stool processing and administration for fecal microbiota transplantation (FMT) across different centers globally, and standardized microbioal replacement therapies offer an attractive alternative. The adverse effects associated with FMT are usually mild. However, there is paucity of data on long term safety of FMT and there is a need for further studies in this regard. With our increasing understanding of the host-microbiome interaction, there is immense potential for microbial replacement therapies to emerge as a treatment option for several diseases. The role of microbioal replacement therapies in diseases other than CDI is being extensively studied in ongoing clinical trials and it may be a potential treatment option for inflammatory bowel disease, irritable bowel syndrome, obesity, multidrug resistant infections, and neuropsychiatric illnesses. Fecal microbiota transplantation for non-CDI disease states should currently be limited only to research settings.

Harnessing the microbiota for therapeutic purposes.

The myriads of microorganisms colonizing the human host (microbiome) affect virtually every aspect of its physiology in health and disease. The past decade witnessed unprecedented advances in microbiome research. The field rapidly transitioned from descriptive studies to deep mechanistic insights into host-microbiome interactions. This offers the opportunity for microbiome-targeted therapeutic manipulation. Currently, several strategies of microbiome-targeted interventions are intensively explored. Best evidence from human randomized clinical trials is available for fecal microbiota transplantation (FMT). However, patient eligibility as well as long-term efficacy and safety are not sufficiently defined. Therefore, there is currently no officially approved indication for FMT. Probiotics (live microorganisms) have long been discussed as a means to aid human health but have yielded varying results. Emerging techniques utilizing microbiota-targeted diets, small microbial molecules, recombinant bacteriophages, and precise control of strain abundance recently yielded promising results but require further investigation. The rapid technological progress of "omics" tools spurs advances in personalized medicine. Understanding and integration of interindividual microbiome variability holds potential to promote personalized preventive and therapeutic approaches. Emerging evidence points towards the microbiome as an important player having an impact on transplantation outcomes. Microbiome-targeted interventions have potential to aid against the many challenges faced by transplant recipients.

Framework for rational donor selection in fecal microbiota transplant clinical trials.

Early clinical successes are driving enthusiasm for fecal microbiota transplantation (FMT), the transfer of healthy gut bacteria through whole stool, as emerging research is linking the microbiome to many different diseases. However, preliminary trials have yielded mixed results and suggest that heterogeneity in donor stool may play a role in patient response. Thus, clinical trials may fail because an ineffective donor was chosen rather than because FMT is not appropriate for the indication. Here, we describe a conceptual framework to guide rational donor selection to increase the likelihood that FMT clinical trials will succeed. We argue that the mechanism by which the microbiome is hypothesized to be associated with a given indication should inform how healthy donors are selected for FMT trials, categorizing these mechanisms into four disease models and presenting associated donor selection strategies. We next walk through examples based on previously published FMT trials and ongoing investigations to illustrate how donor selection might occur in practice. Finally, we show that typical FMT trials are not powered to discover individual taxa mediating patient responses, suggesting that clinicians should develop targeted hypotheses for retrospective analyses and design their clinical trials accordingly. Moving forward, developing and applying novel clinical trial design methodologies like rational donor selection will be necessary to ensure that FMT successfully translates into clinical impact.

A Guide for Ex Vivo Handling and Storage of Stool Samples Intended for Fecal Microbiota Transplantation

Owing to the growing recognition of the gut microbiota as a main partner of human health, we are expecting that the number of indications for fecal microbiota transplantation (FMT) will increase. Thus, there is an urgent need for standardization of the entire process of fecal transplant production. This study provides a complete standardized procedure to prepare and store live and ready-to-use transplants that meet the standard requirements of good practices to applied use in pharmaceutical industry. We show that, if time before transformation to transplants would exceed 24 hours, fresh samples should not be exposed to temperatures above 20 °C, and refrigeration at 4 °C can be a safe solution. Oxygen-free atmosphere was not necessary and simply removing air above collected samples was sufficient to preserve viability. Transplants prepared in maltodextrin-trehalose solutions, stored in a -80 °C standard freezer and then rapidly thawed at 37 °C, retained the best revivification potential as proven by 16S rRNA profiles, metabolomic fingerprints, and flow cytometry assays over a 3-month observation period. Maltodextrin-trehalose containing cryoprotectants were also efficient in preserving viability of lyophilized transplants, either in their crude or purified form, an option that can be attractive for fecal transplant biobanking and oral formulation.

The need to move away from fecal transplant towards targeted, refined microbiome therapy.

The recent editorial entitled “ Microbiota replacement for Clostridium difficile by capsule is as effective as via colonoscopy ” by Saha & Khanna provides an excellent review of the clinical efficacy, as well as the delivery options, for fecal microbiota transplantation (FMT) for patients suffering from a recurrent, C. difficile infection (rCDI) (1). The review also highlights the uncertainty that is relating to the optimal dose, or the delivery route for FMT (1). Admittedly, FMT is a crude and archaic method, with many drawbacks despite the high efficacy and lack of short term safety concerns. The long-term consequences remain to be determined, as the potentials for transferring infectious agents, or donor traits such as obesity, exist.

Competitively Selected Donor Fecal Microbiota Transplantation: Butyrate Concentration and Diversity as Measures of Donor Quality.

In this prospective cohort study, we examine the feasibility of a protocol to optimize microbiota for fecal microbiota transplantation (FMT). Donor stool metrics generally accepted as markers of gut health were used to select a stool donor based on superior microbial diversity, balanced constitution of Bacteroidetes versus Firmicutes and high concentration of fecal butyrate. Selected donor microbiota was then administered via FMT. A total of 10 patients with median age of 12 years with recurrent Clostridium difficile infection received the intervention. The rate of recurrence-free resolution with 1-2 FMTs was 100% at Week 10. With a single FMT, 80% of patients cleared Clostridium difficile infection without recurrence, whereas 20% of patients required a single re-treatment. No serious adverse events occurred. Microbiota sequencing revealed that recipients' gut microbiota phylogenic diversity increased by 72-hours post-transplantation, with sustainment over 10-week follow-up. This study highlights the feasibility of purposefully selecting the most ideal microbiota for transplantation.

P168 WHERE WILL FECAL MICROBIOTA TRANSPLANTATION FIT IN THE TREATMENT ALGORITHMS FOR CROHN’S DISEASE AND ULCERATIVE COLITIS: A SYNTHESIS OF COMPLETED, ONGOING AND FUTURE TRIALS

The United States Food and Drug Administration (FDA) exercises enforcement discretion for fecal microbiota transplantation (FMT) for Clostridium difficile infection not responsive to standard therapies. An investigational new drug (IND) is required for all other uses. Since enforcement discretion took effect in 2013, patients with Crohn’s disease (CD) and ulcerative colitis (UC) have enrolled in multiple trials as they are at an increased risk of Clostridium difficile infection. Trials of FMT to treat the inflammatory bowel disease (IBD) directly, independent of the impact on Clostridium difficile infection, are of particular interest to patients. We aimed to summarize the completed, ongoing and future FMT trials to explore where evidence is being generated for CD and UC treatment algorithms. We searched PubMed for randomized trials related to FMT resulting in 930 citations. ClinicalTrials.gov and the WHO Trial Registry yielded an additional 257 and 262 studies. Trial registrations, published randomized trials and systematic reviews were reviewed to identify randomized trials of FMT with an IBD indication. Four randomized trials were identified in the published literature (277 UC participants). An additional 33 randomized trials were identified from the trial registries. Most trials were for UC (70%), followed by 18% for CD and 12% allowing both conditions. The majority of studies were for induction of remission (97%) with the Mayo score and HBI as the most common inclusion criteria. There are 21 ongoing trials (5 CD, 14 UC, 2 both) scheduled to end between 2017 and 2023, and 5 trials that have not yet started to recruit participants (0 CD, 4 UC, 1 for both). As more evidence is published in peer reviewed journals, the IBD community will be able to make an evidence-based decision on the role of FMT to induce remission in UC. Evidence is lacking on UC maintenance of remission and the role of FMT for CD.

Donor Screening Experience for Fecal Microbiota Transplantation in Patients With Recurrent C. difficile Infection.

To evaluate our experience with stool donor recruitment, screening, retention, and donor perception for fecal microbiota transplantation (FMT). Multiply recurrent Clostridium difficile infection is being increasingly managed with FMT from donor stools. However, donor selection and recruitment is challenging due to lack of standard evidence-based guidelines, donor exclusion criteria, frequency of screening and donor commitment. Data on donors screened using institutional guidelines with history, blood and stool testing and their perspectives on donation were analyzed. Overall 42 potential donors (21 known and 21 standard) were prescreened. Of known donors (median age 34 y, 66.6% female), none failed prescreening, blood or stool tests. Twelve standard donors (57%) failed prescreening based on history (depression, diarrhea, autoimmune disease, recent antibiotic exposure, colon polyps, pregnancy). Nine (median age 35 y, 44.4% female) passed blood and stool testing. On repeat screening, 3 were excluded (2-positive stool shiga toxin (asymptomatic), 1-pregnancy). One donor opted out and 5 became long-term donors; 3 have donated >50 times and 2 have donated >25 times. On the basis of donor perception questionnaire, most standard donors were aware of FMT for C. difficile infection as a treatment option and would not consider 3-monthly blood and stool testing inconvenient. A significant proportion of healthy individuals who volunteered to become a standard donor failed prescreening and were not subjected to blood and stool testing. Repeat testing for asymptomatic donors may be a barrier to donor retention. Universal guidelines are needed to develop strategies to facilitate donor screening.

Colonic transendoscopic enteral tubing: A novel way of transplanting fecal microbiota.

Background and study aims: Placement of a tube through the anus into the cecum has not yet been established as a method of administering whole-colonic treatment. The aim of this study was to evaluate the safety, feasibility, and value of transendoscopic enteral tubing (TET) for fecal microbiota transplantation (FMT) through the colon. Patients and methods: A prospective observational study was performed of FMT using a new colonic TET technique. Under endoscopic guidance, a TET tube was affixed to the cecum with clips. The safety, value, and satisfaction with the FMT by TET were evaluated. Results: A total of 54 patients underwent TET. The success rate of the TET procedure was 100 % (54/54). Duration of the TET procedures was 14.8 ± 5.8 min. During the TET tube retention period, 98.1 % (53/54) of patients were satisfied with TET. The retention time for whole-colon delivery of the fecal microbiota suspension was 12.4 ± 2.3 days. In 88.4 % (49/54) of cases, no discomfort was reported during injection through the TET tube of the microbiota suspension. No adverse events were see in patients who required tube extubation after FMT. Conclusions: Colonic TET is a novel, safe, convenient, and reliable procedure for FMT that results in a high degree of patient satisfaction.

A Practical Method for Preparation of Fecal Microbiota Transplantation.

Clostridium difficile is a challenging infection that can be difficult to treat with antibiotic therapy. This chapter outlines the processing material for fecal microbiota transplantation (FMT), also known as stool transplant. Fecal transplantations are effective in treating recurrent C. difficile infection (CDI). FMT uses a stool sample collected from a healthy, screened donor to restore healthy microbiota in the colon of a patient with CDI for symptom resolution. Here, we describe a rapid method for FMT preparation that uses inexpensive and disposable materials.

Donor Recruitment for Fecal Microbiota Transplantation

Increasing demand for fecal microbiota transplantation (FMT) has created a need for stool banks sourced from long-term healthy donors. Here, we describe our experience in recruiting and screening fecal donors. Mailbox, newspaper, and online advertisements were used. Potential donors were required to satisfy a prescreen telephone conversation, pass blood and stool investigations, then undertake a screening interview including medical history, physical examination, and evaluation of donor selection criteria. One hundred sixteen potential donors were prescreened of whom 74 failed-47 declined based on study donation requirements (primarily related to frequency and duration of donations), 13 had medical comorbidities, 6 variant Creutzfeldt-Jakob disease risk factors, 8 for other reasons. Thirty-eight completed stool and blood testing-1 failed blood testing (indeterminate hepatitis C serology), whereas 15 failed stool investigations (5 Dientamoeba fragilis, 5 Blastocystis hominis, 1 B. hominis and D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus Clostridium difficile toxin positive, and 2 leucocytes or erythrocytes on stool microscopy). Of the 18 potential donors proceeding to screening interview, 6 were excluded (3 body mass index >30, 1 illicit drug use, 1 uncontrolled anxiety and concerns regarding compliance, 1 irregular bowel movements after new medication commencement). In total, only 12 of 116 (10%) potential donors were enrolled as study donors. Recruitment of fecal donors for FMT is challenging with only a small percentage ultimately serving as donors. Many were unable or unwilling to meet the donor commitment requirements. A surprisingly large proportion of healthy asymptomatic donors failed stool testing, primarily due to gastrointestinal parasites.

Obstacles to Donor Recruitment for Faecal Microbiota Transplantation: Experiences From the FOCUS Study

Introduction: The increasing interest and demand for faecal microbiota transplantation (FMT) has created a need for a bank of long-term healthy donors. Here, we describe our experience in recruiting and screening faecal donors for our clinical trial, the FOCUS Study. Methods: Recruitment of potential healthy faecal donors included letterbox, newspaper, and online advertisements. Financial reimbursement for out-of-pocket expenses, as agreed by Ethics Committee, was offered. Potential donors were required to satisfy a pre-screen telephone conversation, perform and pass comprehensive blood and stool screening investigations, then undertake a final detailed screening interview including medical history, physical examination, and evaluation of donor selection criteria. Results: A total of 116 potential donors were pre-screened over a 7-month period after responding to donor advertisements. Seventy-four failed pre-screening, 47 declined based on study donation requirements, 13 had medical comorbidities, 6 had vCJD risk factors, 1 had recent antibiotic use, and 7 failed for other reasons. Thirty-eight healthy potential donors completed stool and blood testing, of whom 1 failed blood testing due to indeterminate hepatitis C serology, 15 failed stool testing (5 Dientamoeba fragilis, 5 Blastocystis hominis, 1 B. hominis and D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus and Clostridium difficile-toxin positive, and 2 had leucocytes or erythrocytes on stool microscopy). Of 22 remaining potential donors, 2 were excluded due to interim antibiotic use and 1 was living with a household member who was positive for D. fragilis. Of the remaining 19 potential donors, 18 completed the final screening visit, but 6 were excluded (3 due to BMI >30, 1 due to illicit drug use, 1 due to uncontrolled anxiety / depression and 1 due to irregular bowel movements after new medication commencement). In total, only 12 (10%) of 116 potential donors were enrolled as study donors. Conclusion: Recruitment of healthy faecal donors for FMT is challenging and was associated with only a 10% success rate. Nearly half of the potential donors were unable or unwilling to meet the donor commitment requirements. A surprisingly large proportion of healthy and asymptomatic donors failed stool testing, primarily due to gastrointestinal parasites. Disclosure - Thomas J. Borody has a pecuniary interest in the Centre for Digestive Diseases, where faecal microbiota transplantation is a treatment option for patients and has filed patents in this area.

Editorial: Curbing our Enthusiasm for Fecal Transplantation in Ulcerative Colitis

Given the known dysbiosis of gut microflora in inflammatory bowel disease, there has been great enthusiasm about the potential for fecal microbiota transplantation (FMT) as a treatment. This editorial accompanies a prospective series of five patients with ulcerative colitis who underwent FMT, but did not achieve remission. I discuss the important observations from this study and point out that the lack of clinical efficacy and observed side effects warrant caution in the ongoing pursuit of this treatment option.