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DOI 10.1007/s00384-013-1817-3
ORIGINAL ARTICLE
Abstract
Purpose This prospective study was to evaluate the significance of fecal calprotectin and lactoferrin for the prediction of
ulcerative colitis (UC) relapse.
Methods Eighty UC patients in remission for 3 months on
mesalamine as maintenance therapy were included. At entry,
stool samples were collected for the measurement of
calprotectin and lactoferrin. All patients were followed up
for the following 12 months. To identify predictive factors
for relapse, time-dependent analyses using the Kaplan-Meier
graphs and Cox's proportional hazard model were applied.
Results During the 12 months, 21 patients relapsed. Mean
calprotectin and lactoferrin levels were significantly higher
in patients with relapse than those in remission
(calprotectin173.7 vs 135.5 g/g, P =0.02; lactoferrin
165.1 vs 130.7 g/g, P =0.03). A cutoff value of 170 g/g
for calprotectin had a sensitivity of 76 % and a specificity of
76 % to predict relapse, while a cutoff value of 140 g/g for
lactoferrin had a sensitivity of 67 % and a specificity of 68 %.
In a multivariate analysis, calprotectin (170 g/g) was a
predictor of relapse (hazard ratio, 7.23; P =0.002). None of
the following parameters were significantly associated with
relapse: age, gender, duration of UC, number of UC episode,
severity of the previous episode, extent of UC, extraintestinal
manifestation, and lactoferrin level.
Conclusions Fecal calprotectin showed a higher sensitivity
and specificity than fecal lactoferrin for predicting UC relapse.
Fecal calprotectin level appeared to be a significant predictor
of relapse in patients with quiescent UC on mesalamine as
maintenance therapy.
T. Yamamoto (*) : M. Shiraki : T. Bamba : S. Umegae :
K. Matsumoto
Inflammatory Bowel Disease Center, Yokkaichi Social Insurance
Hospital, 10-8 Hazuyamacho, Yokkaichi, Mie 510-0016, Japan
e-mail: nao-taka@sannet.ne.jp
Introduction
Ulcerative colitis (UC) is a chronic disease characterized by
mucosal inflammation in the colon and the rectum [1]. The
course of UC is characterized by spontaneous remission,
which may be followed by a relapse, and is typically unpredictable. The main goal of medical therapy in patients with
UC is effective and sustained suppression of intestinal inflammation in order to induce and maintain clinical remission.
Identifying patients at a significant risk of relapse during
quiescent UC should help to determine a strategy for maintenance therapy during remission. Previous studies have reported that younger age, multiple previous episodes of relapse,
extraintestinal manifestations, a low-fiber diet, seasonal factors, and a long-term perceived stress were risk factors for
future relapse in patients with quiescent UC [25]. These
factors are of limited value in clinical setting, and therefore
more objective parameters that may predict future relapse
would be desirable in our clinical practice.
The presence of active intestinal inflammation in patients
with UC is associated with an acute phase reaction and migration of leucocytes to the gut, and this leads to the release of
several neutrophil proteins, which may be measured in stool
samples [6]. Fecal markers fulfill all the criteria of being
noninvasive, simple, inexpensive, sensitive, and specific
markers to detect gastrointestinal inflammation. Calprotectin
is a calcium-binding protein, representing up to 60 % of the
cytosolic proteins in neutrophils [7]. Since calprotectin is
primarily derived from neutrophils, its concentration is directly proportional to the concentration of neutrophils in the
colonic/rectal mucosa [8]. It is resistant to bacterial
486
54
26
28
41
11
60
20
11
3
63
47
48
10
2
Study design
35.10.8 years
49:31
50.02.7 months
clinical remission with medical treatment. As remission induction therapy, high-dose mesalamine (Pentasa, 4 g/day) was
used in 63 patients, prednisolone (3060 mg/day) in 47 patients, therapeutic leucocytapheresis (Adacolumn, JIMRO,
Takasaki, Japan) in 48 patients, tacrolimus (Prograf) in 10
patients and infliximab (Remicade, 5 mg/kg at weeks 0, 2,
and 6, and then at 8-week intervals) in 2 patients.
Patients
Patient inclusion criteria were: (1) age between 20 and 75, (2)
having endoscopic and histologic diagnosis of UC, (3) UC
confined to the colon and the rectum, and (4) patient in clinical
remission (normal stool frequency and no rectal bleeding) on
oral mesalamine for 3 months. Exclusion criteria were: (1)
patients who had received corticosteroids, immunosuppressants, or biologic agents at entry; (2) had received mesalamine
enema; and (3) had received nonsteroidal anti-inflammatory
drugs, antidiarrheal (loperamide or codeine), or antispasmodic
medications at entry.
A total of 80 patients who met the inclusion criteria were
included in this study. The baseline characteristics of the 80
eligible patients are presented in Table 1. The severity of
previous UC episodes was mild in 28 patients, moderate in
41 patients, and severe in 11 patients. All patients achieved
487
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
Results
Fecal calprotectin and lactoferrin levels in UC and controls
Both fecal calprotectin and lactoferrin levels were markedly
higher in the UC vs the control groups. The mean fecal
calprotectin level was 145.57.0 g/g in the UC group vs
4.51.0 g/g in the control group (P <0.001), representing
more than 30-fold increase in patients with UC while in
remission relative to healthy controls. Similarly, the mean
fecal lactoferrin level was 139.76.9 g/g in the UC group
vs 9.20.7 g/g in the control group (P <0.001).
Fecal markers vs clinical and laboratory measurements
In the patient group, there was a significant correlation between fecal calprotectin and lactoferrin levels (r =0.779,
P <0.001). Fecal calprotectin and lactoferrin levels showed
no significant correlation with the following parameters: age
at entry, gender, duration of UC before entry, number of UC
episodes, severity of previous episodes, extent of UC, and
extraintestinal manifestations (Table 3). Similarly, laboratory
measurements including WBC, Hb, platelet count, albumin,
and CRP at entry did not correlate with fecal markers
(calprotectin vs WBC, r =0.060, P =0.60; Hb, r =0.174,
P =0.12; platelet count, r =0.120, P =0.29; albumin, r =0.125,
P =0.27; CRP, r =0.128, P =0.26; lactoferrin vs WBC,
r = 0.034, P = 0.77; Hb, r = 0.120, P = 0.29; platelet
count, r =0.127, P =0.26; albumin, r =0.125, P =0.27;
CRP, r =0.165, P =0.14).
488
Female (n =31)
Duration of UC before entry
<50 months (n =41)
50 months (n =39)
Number of UC episodes
14 (n =54)
5 (n =26)
Severity of the previous episodes
Mild (n =28)
Moderate (n =41)
Severe (n =11)
Extent of UC
Left-sided colitis (n =60)
Extensive colitis (n =20)
Extraintestinal manifestations
Yes (n =14)
No (n =66)
Calprotectin (g/g)
Lactoferrin (g/g)
139.69.7
151.410.1
0.40
136.89.2
142.710.5
0.68
149.311.0
0.67
148.69.6
0.31
144.311.1
146.88.4
0.86
144.110.6
135.28.9
0.52
148.59.0
139.410.9
0.55
140.68.6
137.911.9
0.86
133.111.0
152.210.5
152.316.3
0.43
134.814.0
141.68.6
145.417.1
0.86
142.27.8
155.615.4
0.41
136.88.0
148.714.0
0.46
147.320.9
145.27.3
0.91
141.515.6
139.47.8
0.91
143.19.1
134.19.5
Discussion
Given that both fecal calprotectin and lactoferrin are known to
be elevated during intestinal inflammation in patients with
489
Calprotectin
g/g
200
Lactoferrin
g/g
200
180
180
160
160
140
140
120
120
100
100
80
80
60
60
40
40
20
20
P=0.03
P=0.02
0
Yes
No
Yes
Relapse
Relapse
IBD [1518], our major interest in this study was to see if the
elevated fecal levels of these biomarkers relate to clinical
relapse in patients with UC. A major strength of this study is
that we included a well-defined and homogeneous group of
patients with quiescent UC who were on mesalamine as
maintenance therapy, and without any other medication for
UC. This allowed us to evaluate the significance of these
biomarkers in the absence of likely interference from multiple
medications patients with UC may receive. In line with this
assertion, corticosteroids are known to prolong neutrophil
survival [26]. Being the source of calprotectin and lactoferrin,
any drug effect on neutrophils potentially could impact the
fecal levels of these biomarkers. Other strengths of our study
might include a relatively large number of patients we could
include for this study, diligent monitoring of disease activity,
and measurement of two biomarkers in the same test samples.
The relapse rate was estimated by time-dependent analyses
No
Calprotectin
< 170 g/g
1.0
Lactoferrin
1.0
0.8
0.8
0.6
0.6
140 g/g
0.4
170 g/g
0.2
0.4
0.2
P<0.001
P=0.004
0
0
10
12
Months
10
12
Months
Patients at risk
170 g/g 50
50
50
49
49
47
45
Patients at risk
140 g/g 47
47
47
46
44
42
40
170 g/g 30
30
29
24
20
16
14
140 g/g 33
33
32
27
25
21
19
490
Table 4 Predictors for disease
relapse determined by multivariate analysis
CI confidence interval
Hazard ratio
95 % CI
0.84
0.72
0.72
2.28
1.37
0.292.40
0.252.12
0.242.16
0.677.71
0.424.42
0.75
0.56
0.56
0.19
0.60
2.27
2.86
0.80
7.23
1.03
0.4312.05
0.899.21
0.222.89
2.1124.79
0.323.35
0.34
0.08
0.73
0.002
0.96
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