The reduction of faecal calprotectin during exclusive enteral nutrition is lost rapidly after food re-introduction

Michael Logan, Clare M Clark, Umer Zeeshan Ijaz, Lisa Gervais, Hazel Duncan, Vikki Garrick, Lee Curtis, Elaine Buchanan, Tracey Cardigan, Lawrence Armstrong, Caroline Delahunty, Diana M Flynn, Andrew R Barclay, Rachel Tayler, Elizabeth McDonald, Simon Milling, Richard K Hansen, Konstantinos Gerasimidis, Richard K Russell, Michael Logan, Clare M Clark, Umer Zeeshan Ijaz, Lisa Gervais, Hazel Duncan, Vikki Garrick, Lee Curtis, Elaine Buchanan, Tracey Cardigan, Lawrence Armstrong, Caroline Delahunty, Diana M Flynn, Andrew R Barclay, Rachel Tayler, Elizabeth McDonald, Simon Milling, Richard K Hansen, Konstantinos Gerasimidis, Richard K Russell

Abstract

Background: Faecal calprotectin decreases during exclusive enteral nutrition in children with active Crohn's disease. It is unknown how faecal calprotectin changes during food re-introduction and the influence of maintenance enteral nutrition.

Aims: To study changes to faecal calprotectin during exclusive enteral nutrition and at food reintroduction, and explore associations with maintenance enteral nutrition.

Methods: Children with Crohn's disease were followed during exclusive enteral nutrition and during food-reintroduction. Faecal calprotectin was measured before, at 33 and 54 days of exclusive enteral nutrition, and at 17, 52 and 72 days after food-reintroduction. Maintenance enteral nutrition use was recorded with estimated weight food diaries. Data are presented with medians and Q1:Q3.

Results: Sixty-six patients started exclusive enteral nutrition and 41 (62%) achieved clinical remission (weighted paediatric Crohn's disease activity index <12.5). Baseline faecal calprotectin (mg/kg) decreased after 4 and 8 weeks of exclusive enteral nutrition (Start: 1433 [Q1: 946, Q3: 1820] vs 33 days: 844 [314, 1438] vs 54 days: 453 [165, 1100]; P < .001). Within 17 days of food reintroduction, faecal calprotectin increased to 953 [Q1: 519, Q3: 1611] and by 52 days to 1094 [660, 1625] (both P < .02). Fifteen of 41 (37%) children in remission used maintenance enteral nutrition (333 kcal or 18% of energy intake). At 17 days of food reintroduction, faecal calprotectin was lower in maintenance enteral nutrition users than non-users (651 [Q1: 271, Q3: 1781] vs 1238 [749, 2102], P = .049) and correlated inversely with maintenance enteral nutrition volume (rho: -0.573, P = .041), kcals (rho: -0.584, P = .036) and % energy intake (rho: -0.649, P = .016). Maintenance enteral nutrition use was not associated with longer periods of remission (P = .7). Faecal calprotectin at the end of exclusive enteral nutrition did not predict length of remission.

Conclusions: The effect of exclusive enteral nutrition on faecal calprotectin is diminished early during food reintroduction. Maintenance enteral nutrition at ~18% of energy intake is associated with a lower faecal calprotectin at the early phase of food reintroduction but is ineffective in maintaining longer term remission.

© 2019 The Authors. Alimentary Pharmacology & Therapeutics Published by John Wiley & Sons Ltd.

Figures

Figure 1
Figure 1
Schematic flowchart of patients recruited to study with treatment outcomes during EEN (response defined by weighted paediatric Crohn's disease activity index). Abbreviations: EEN, exclusive enteral nutrition
Figure 2
Figure 2
Faecal calprotectin concentrations during a course of EEN and at food reintroduction in patients entering clinical remission on EEN. Comparisons made between EEN start vs EEN End, and from EEN End till food reintroduction period; connecting lines indicating paired sample; reference line added at 250 mg/kg, indicating raised FC. P for Fisher pairwise comparisons following general linear model. Abbreviations: EEN, exclusive enteral nutrition
Figure 3
Figure 3
Faecal calprotectin concentrations during the early (17 d) food reintroduction period, grouping based on self‐reported MEN use. Dots representing individual values, line showing median and IQR. Abbreviations: MEN, Maintenance enteral nutrition
Figure 4
Figure 4
Kaplan‐Meier survival analysis using various cut‐offs in FC at the end of EEN to stratify patients with their time to subsequent relapse, censored at 1 y. FC, faecal calprotectin; EEN, Exclusive enteral nutrition.

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