Repeated exclusive enteral nutrition in the treatment of paediatric Crohn's disease: predictors of efficacy and outcome.
BACKGROUND
Exclusive enteral nutrition (EEN) induces remission and mucosal healing in children with active Crohn's disease (CD).


OBJECTIVE
To compare short- and long-term outcomes of the first vs. second courses of EEN, and to identify predictors of sustained remission.


METHODS
Retrospective single centre analysis of all patients with CD (6-18 years) treated with EEN over 7.5 years. Patients were excluded if exposed to anti-TNFα or corticosteroids 3 months prior to EEN. Data included disease phenotype, activity, NOD2 genotype, laboratory indices and anthropometrics. Remission and relapse were defined by mathematically weighted Paediatric Crohn's Disease Activity Index (wPCDAI) with 1-year follow-up.


RESULTS
Of 94 patients treated with EEN, 52 fulfilled inclusion criteria (31 male, mean age 13.2 years). Azathioprine was started within the first month in 33/52 patients; 26/52 received a second EEN course. First compared to second EEN revealed higher wPCDAI at start (59 vs. 40, P < 0.0001), tended to higher remission rates after 3 months (92% vs. 77%, n.s.), but showed comparable 1-year relapse rates (67% vs. 70%, median time 231 vs. 145 days, n.s.). Disease activity, weight gain and inflammatory markers showed better improvement with first EEN. Faecal calprotectin >200 μg/g during EEN was associated with shorter remission (median time 157 vs. 287 days, n.s.). Certain NOD2 genotypes were related to higher relapse rates (92% R702W or G908R vs. 50% 1007fs vs. 60% wild-type, P < 0.01).


CONCLUSIONS
Exclusive enteral nutrition induces remission in active Crohn's disease, but efficacy tends to decrease with the second course. Despite early azathioprine use, 1-year relapse rates are high, but may be related to NOD2 genotype.
Dr. von Hauner Children's Hospital, University of Munich Medical Center, Munich, Germany; 2nd Department of Pediatrics, Comenius University Medical School, Bratislava, Slovakia.
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K
Frivolt
T
T
Schwerd
K J
KJ
Werkstetter
A
A
Schwarzer
S B
SB
Schatz
P
P
Bufler
S
S
Koletzko
D000293:Adolescent; D001379:Azathioprine / Q000627:therapeutic use; D002648:Child; D003424:Crohn Disease / Q000235:genetics / Q000628:therapy*; D004750:Enteral Nutrition; D005260:Female; D005838:Genotype; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008297:Male; D053473:Nod2 Signaling Adaptor Protein / Q000235:genetics; D012008:Recurrence; D012074:Remission Induction; D012189:Retrospective Studies; D016896:Treatment Outcome
D007166:Immunosuppressive Agents; C429018:NOD2 protein, human; D053473:Nod2 Signaling Adaptor Protein; D001379:Azathioprine