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Microsoft word - 130420_research programme hit cf

Individual tailored therapy with new drugs must for the most part be realized for children and
adults suffering from CF within a period of 5 years. That is the aim of the research program HIT
CF. HIT CF was developed with scientists and Medical doctors from Utrecht and Rotterdam in
collaboration with the Dutch Cystic Fibrosis Foundation (NCFS). A total amount of 4,000,000
euro is required for this research program.

Research program HIT CF
HIT CF consists of 4 sub projects that will be completed within 5 years:
A. Preventing respiratory infections
B. Predicting effects of the treatment on individual patients
C. New drugs that address the cause of CF
D. Combination of new tailored therapies for the individual patient
Sub project A Preventing respiratory infections
When and why are people with CF so vulnerable to bacteria and viruses. The answer to this question
allows for the development of a more targeted treatment. It can help prevent damage to the lungs and
may greatly increase life expectancy.
Sub projects

A1 The difference between bacteria in children suffering from CF and healthy peers
A2 The effect of treatment with azithromycin starting at birth
A3 Hate-love relationship between microorganisms and patients
A4 New antibodies against bacteria
Sub project B: Predicting effects of the treatment in individual patients
It is important to be able to predict which medicine or combination of drugs is most effective for which
patient. Since there are so many differences between people with CF, there are equally different
reactions to new drugs. In one patient they work much better than in others. In sub project B, methods
are developed to be able to determine this in the laboratory, prior to administering the drugs.
Sub projects
B1 CFTR-function in intestinal cells of people suffering from CF
B2 CFTR-function in respiratory cells of people suffering from CF
Sub project C : New drugs that address the cause of CF
Development of drugs that address the cause of CF has begun. There are all kinds of possibilities to
restore or affect the production and function of the CFTR protein*. Sub project C is focused on
developing new cures and making existing drugs (for other illnesses) suitable for the treatment of CF.
Sub projects
C1 Study into CFTR folding and development in patients C2 Do development and transport of CFTR go hand in hand? C3 How do corrector compounds and proteins affect deviating CFTR protein? C4 CFTR, stress in the cell and inflammation: what is their relationship? C5 Guanylin, a new hormone therapy for CF C6 Treatment of CF pulmonary disease with experimental drugs; a new generation of anti-inflammatory agents C7 Validating new drugs for the treatment of CF in a model
*All patients suffering from CF have a deviation in the CF gene. That CF gene is the blueprint for the
CFTR protein. If this CFTR protein is not being produced properly in the cells, the chloride channels in
the cell wall are unable to function properly. This makes the mucus in the lungs and other organs thick
and sticky. That is how the characteristic symptoms of the CF illness arise.

Sub project D: Combination of new tailored therapies
For each patient suffering from CF the optimal combination of drugs is determined in the laboratory.
Subsequently, the effectiveness of this ‘optimal mix’ is tested in practice in 30 patients.
A. Preventing respiratory infections
B. Predicting effects of the treatment in individual patients
C. New drug combinations that address the cause of CF
The new drugs found in sub projects A and C are tested in cells and tissue of patients (such as
intestinal culture models) in the laboratory (sub project B).
Sub project A1
The difference between bacteria in children suffering from CF and healthy peers
Aim
Investigating the differences between children suffering from CF and peers in ‘picking up’ the bacteria
as of birth

Description
The airways and lungs of children are ‘sterile’ at birth. In the first week after birth, an increasing
amount of bacteria finds its way into the airway. In older children suffering from CF, the population of
bacteria in the airways differs greatly from that in healthy children. Is this because they get a lot of
antibiotic treatments or do certain bacteria specifically target children suffering from CF. Should one
fight certain (pathogenic) bacteria or should you stimulate other (protective) bacteria?
To be able to answer these questions, it is important to know the exact differences in development
between the bacteria world of children suffering from CF and of healthy children. In a group of 40
newborns suffering from CF and 120 healthy control children, the development of the bacteria
population will be monitored from birth up to the age of 5. All children being treated in the CF centers
of Utrecht and Rotterdam are eligible to participate.
Burden
The research is not very burdensome for the children. As of the first weeks of their lives, additional
nose and throat cultures are taken. Quite frequently in the beginning, but at a later stages once every
three months.
Participants
All children that appear to have CF during the heel prick screening, are eligible.
Participation
Children have been participating in this research since 2012. New children can still be enrolled.

Duration
Start 2012. New children can enroll until 2014

Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)
Sub project A2
The effect of treatment with azithromycin as of birth
Aim
Investigating whether protective treatments with antibiotics as of birth positively affect the treatment of
newborns with CF.
Description
Bacteria enter the lungs of children suffering from CF shortly after birth. There, they can cause
infection and damage to the lung tissue after several days to weeks. Azithromycin is a medicine that
slows down the growth of certain bacteria (antibiotic) but that is also able to suppress the inflammatory
reaction of the body. So, maybe children suffering from CF could benefit from the use of this medicine
as of birth.
In Australia a major study is conducted in which newborn children suffering from CF receive a long-
term treatment with azithromycin or with an agent that has no active ingredients (placebo). The course
of these two groups of children is compared with regard to their illness periods, symptoms of infection
and the development of their lungs.
Since not enough children can be treated in Australia and since the treatment in effects may be
different than in the Netherlands, 40 newborns suffering from CF can participate in this study as well.
Burden
The research is not very burdensome for the children. As of the first weeks of their lives, the children
are administered an additional medical drink. The other visits to the outpatient clinic in the CF centre
remain unchanged.
Participants
All children who appear to have CF after the heel prick screening can participate.
Participate
New children can still be enrolled .

Duration
Start late 2013 until late 2015. New children can enroll until 2014

Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)
Sub project A3
Love-hate relationship between microorganisms and patients.
Aim
Examining mechanisms that play a part in the increased sensitivity for bacteria in patients suffering
from CF.
Description
Infections in CF patients can be caused by bacteria that are hardly found in healthy people. A famous
example is the Pseudomonas Bacteria. This bacterium can be found in large numbers anywhere in our
environment, however, it hardly ever causes illness in people. However, in people suffering from CF, it
is one of the main pathogens of respiratory infections.
Other microorganisms are common in CF patients as well, such as Staphylococci and Aspergillus
fungi. It is not clear where this love hate relationship between CF patients and these bacteria comes
from.
Cells from the airways of CF patients and of healthy people can be cultivated in the laboratory. In the
laboratory, it will be studied how bacteria attach to airway cells and how they cause infection. In
addition, the reaction of airway cells on bacteria will be investigated. This way, the laboratory is able to
discover why cells of CF patients react differently than cells of healthy people. Substances will be
developed that significantly disrupt the love relationship between bacteria and CF airway cells and that
suppress the harmful reaction of airway cells where possible.
Burden
The research is not very burdensome to patients and healthy children that participate as control group.
After the airway cells have been extracted, the study is mainly conducted in the laboratory.
Participants
Anyone suffering from CF can participate in this study. Airway material of both young and older
patients with many and few infections will be examined.
Participate
Participants are more than welcome.

Duration
Start late 2013 until late 2016.
Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)
Sub project A4
New antibodies against bacteria
Aim
Researching natural substances that restore and promote resistance against viruses, bacteria and
fungi in patients suffering from CF, and making suitable for application.
Description
The lungs contain ingenious defense systems against invading viruses, bacteria and fungi. Cilia and
immune cells play an important role in this. But the mucus of healthy lungs also contains dozes of
substances that play a role in the defense against the invaders. These natural antibodies (such as
surfactant proteins, collectins) may be greatly reduced in CF patients.
In this sub project, it is investigated which of these antibodies are important for the bacteria that exist
in CF. Subsequently, it is studied whether the amount or the function of these substances can be
improved and whether this strengthens resistance against microorganisms. Subsequently, the
substances are tested in the laboratory. The eventual goal is to restore the natural immune system in
children suffering from CF, by administering these substances at a very young age. This can help
reduce the need for antibiotics.
Burden
The research is not very burdensome for patients and healthy children who participate as control
group. After extraction of the airway cells, the research is conducted mainly in the laboratory.
Participants
Everyone suffering from CF can participate in this study. Airway material of both young and older
patients, with many and few infections will be examined.
Participate
Participants are more than welcome.

Duration
Start late 2013 until late 2017.

Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)
Sub project B1
CFTR-function in the intestinal cells of people suffering from CF
Aim
The development of a reliable system that allows for the reliable measurement of the function of CFTR
and the reaction to new drugs in intestinal cells in CF patients.

Description
In the laboratory, a method was developed to isolate so-called stem cells from the intestinal cells of
patients. These stem cells can survive for a long time in the laboratory. In these stem cells, the
function of the CFTR protein can be accurately measured.
By cultivation of stem cells of a CF patient, the laboratory can study how well he or she responds to
new drugs. In the laboratory the perfect combination of drugs can be determined per patient. In new
drugs in the future, the effect can be tested in advance in the laboratory as well.
In this project part, the reliability of the system is examined and improved. The laboratory checks
whether the differences in severity of the illness between patients are also reflected in the intestinal
cell systems. All currently known drugs and new drugs will be tested on these systems. That way, the
most promising drugs can be selected per patient.
Burden
The examination is not very burdening to patients. A small chunk of intestinal tissue is extracted once
(thermometer method). The further examination takes place in the laboratory.
Participants
All children who appear to have CF after the heel prick screening can participate. At a later phase, all
patients suffering from CF may be eligible.
Participate
Children have been participating in this study since 2012.

Duration
Start 2012. New patients can enroll until somewhere in 2016

Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)


Sub project B2
CFTR-function in airway cells of people suffering from CF
Aim
Developing a reliable system that can be used to measure the function of CFTR and the reaction to
new drugs in the airways of patients in a reliable manner.

Description
The function of CFTR can be determined in airway cells of patients. The advantage of this is that the
airways are more easily accessible than the intestines. Moreover, most symptoms in patients suffering
from CF are in the airways. Deviations in respiratory cells may therefore be more important than
deviations in intestinal cells.
In this project part, the reliability of measurements of CFTR in respiratory cells of the nose and lungs is
examined and improved. The laboratory checks whether the differences in severity of the illness
between patients are also reflected in the cell systems of the airways. All currently known drugs and
new drugs will be tested on these systems. That way, the most promising drugs can be selected per
patient.
Burden
The examination is not very burdensome to patients. Small pieces of mucus membrane are extracted
from the nose and the airways. The further examination takes place in the laboratory.
Participants
All children who appear to have CF after the heel prick screening can participate. At a later phase, all
patients suffering from CF may be eligible.
Participate
Children have been participating in this study since 2012.

Duration
Start 2012. New patients can enroll until somewhere in 2016

Contact
Prof. dr. C.K. van der Ent (UMC Utrecht-WKZ)


Sub project C : New drugs that address the cause of CF
Development on drugs that address the cause of Cystic Fibrosis (CF) has started. There are all kinds
of options to restore or affect the production and function of the CFTR-protein *. Sub project C is
focused on developing new cures and making existing drugs (for other illnesses) suitable for the
treatment of CF.
Sub projects
C1 Study into CFTR folding and development in patients C2 Do development and transport of CFTR go hand in hand? C3 How do corrector compounds and proteins affect deviating CFTR protein? C4 CFTR, stress in the cell and inflammation: what is their relationship? C5 Guanylin, a new hormone therapy for CF C6 Treatment of CF pulmonary disease with experimental drugs; a new generation of anti-inflammatory agents C7 Validating new drugs for the treatment of CF in a model * All patients suffering from CF have a deviation in the CF gene. That CF gene is the blueprint for the CFTR protein. If this CFTR protein is not being produced properly in the body, the chloride channels in the cell wall are unable to function properly. This makes the mucus in the lungs and other organs thick and tough. That is how the characteristic symptoms of the CF illness arise. Sub project C1
Study into CFTR-folding and development in patients
Aim
Adjusting folding study to cells and tissue of patients.
Description
In the call, amino acids are threated into a long chain of protein (CFTR) in the protein factory.
Subsequently, they are folded to be transported to the wall of the cells. There, the proteins are
required to build a properly functioning chloride channel. In people that have a deltaF508-mutation,
this folding process is faulty, due to which good CFTR protein is unable to reach the cell wall.
The primary folding defect in deltaF508 CFTR has been identified and in the laboratory, a solution was
found to correct it instantly with another mutation in the protein. However, this is not yet possible in
patients.
It has however resulted in a lot of information about the folding defects of the various mutations and what is required for recovery, for correction. The study into cell lines seems easily transferrable into cells of patients, but that does not appear to be the case. For this type of study, larger amounts of cells of people suffering from CF are required. However, these are not sufficiently available. Study into cells of patients is essential, since there are great differences in the disease progression of patients with the same mutation. This may be caused by differences in genetic design of patients. Differences in genetic design, actually means differences in protein groups in the cell. The aim of this study is to use new developments in the cultivation of patient cells from a patient biopsy (the so-called intestinal culture models (organoids) and to study whether the examination techniques can be adjusted to that material. First, samples of mice intestines will be used. As soon as the first successes have been realized, the organoids of patients will be used for testing. Burden
Single small bowel biopsy
Participants
Children suffering from CF
Participate
Possible
Duration
2013-2017
Contact
Professor I Braakman, Utrecht University
together with Professor C.K. van der Ent and Dr. J. Beekman, UMC Utrecht-WKZ
Sub project C2
Do development and transport of CFTR go hand in hand?
Aim
Investigating the role of the machinery that provides transport of CFTR from its ‘cradle’ to its
‘workplace’ in the cell.
Description
The CFTR protein is created in the protein factory in the cell (Endoplasmic Reticulum), which can be
considered its cradle: this is where he is first aided by aiding substances (chaperones) and receives a
lot of care to grown into a functioning protein. After the development into properly folded protein, the
chaperones let go. Subsequently, a group of coat proteins accompany CFTR to the first of a series of
chambers (cell compartments) that it will pass through up to the cell surface, where the protein must
do its job and has to make sure that properly functioning chloride channels are created. There is some
attention for the various chaperones and how they work together, but it is unclear how the coat
proteins work and how they may even work together with the chaperones.
This aim of this study is to investigate which coat proteins are required for the transport of CFTR and how they work. This is studied for the healthy CFTR and for deltaF508 and other mutations of CFTR. The work will take place in laboratory cell lines. Insight into the operation of both chaperones and coat proteins leads to better insight into all steps the CFTR protein has to go through on road to its workplace in the cell wall. Each of these steps may be a possible defect in a CFTR mutation and each defect has its own options with regard to correction. Participants
Laboratory study into cell lines and in case of success of C1, cells of patients as well
Duration
2013-2017
Contact
Professor I. Braakman, Utrecht University
Sub project C3
How do correctors affect deviating CFTR proteins?
Aim
Determining the effect of potential corrector compounds and proteins in the cell on CFTR protein.
Description
The first candidate drugs that correct the incorrectly produced deltaF508 CFTR proteins are currently
tested in a study among patients suffering from CF (clinical trials). The correction of the defect is too
small to make other treatments of the CF patients obsolete. The deltaF508 mutation leads to a series
of defects in the CFTR protein. Therefore, more corrector drugs are required with different effects.
The aim of this study is to examine a number of proteins in the cell and candidate drugs, with regard to their effect on deltaF508 and other mutations in CF patients. Of some candidate drugs, it will be easy to quickly figure out the mechanism, for others it may take longer. The study is conducted in cell lines in the laboratory, with provisions, due to which the place where the point of engagement is in the CFTR protein can be measured to great detail. Participants
Laboratory study into cell lines and in case of success of C1, cells of patients as well
Duration
2013-2015
Contact
Professor I. Braakman, Utrecht University
Sub project C4
CFTR, stress in the cell and inflammation: what is their relationship?
Aim
Determining the connection between CFTR, protein folding stress in the cell and inflammatory
reactions of cells.
Description
CF is accompanied by inflammation of the lungs. This is caused by infections. Perhaps, inflammation
without infection is possible as well. This is caused by the lack of healthy CFTR or by the presence of
deviating (mutant) CFTR. In addition, an improperly folded protein in a cell, may active a stress
reaction of the cell. This cellular stress leads to inflammation of cells.
So, what affects what? In the laboratory, this is studied systematically by manipulating each of these processes and by investigating the consequences for the other processes. The study will identify better and new points of engagement to save deviating CFTR and to prevent stress in cells with deviating CFTR. Participants
Laboratory study into cell lines, and in case of success, cells of patients as well.
Duration
2013-2015
Contact
Professor I. Braakman, Utrecht University
Sub project C5
Guanylin, a new hormone therapy for Cystic Fibrosis
Aim
Developing a new therapy with an existing hormone to improve water and salt management in CF.
Description
In the cells of the airways and the intestines, water and salt pumps are available, in addition to the
chloride channels. In people suffering from CF, these pumps are not functioning properly. As a result
of this, the mucosa of the airways and intestines become too dry and acidic. As a result, bacteria are
given the opportunity to cause lung infections and lung damage.
In mice with CF, the operation of these pumps is affected by hormones created by the body itself ( (guanylin and uroguanylin). The production of these hormones is greatly reduced in CF. In the study project, it is tested whether these hormones are able to allow the water and salt pumps to function better, due to which the mucosa of the intestines and the airways remain moister and become less acidic. Subsequently, it is studied whether this can be achieved using hormone therapy or with currently available drugs that imitate the hormonal function. In case of positive study results, a new therapy will be within reach. Participants
Laboratory study into intestinal tissue and lung cells. In this, a CF mouse model is made in which
guanylin can be produced at any given time prior to and after birth, by administering an antibiotic. In
addition, in collaboration with an American laboratory in Iowa, the effect of guanylin on the cystic
formation in the lungs of CF pigs and ferrets is studied (CF pulmonary disease in these animals is
comparable to that in humans).
Duration
2012-2014
Contact
Dr. Hugo de Jonge , Erasmus MC, Rotterdam
Sub project C6
Treatment of CF with experimental drugs; a new generation of anti-inflammatory agents
Aim
Inflammatory reactions in the lungs of young children with CF cause increasing lung damage. This can
be examined with the help of an advanced measurement technique (mass spectrometry), with the aim
of testing a new experimental medicine.
Description
In the medical examination of newborn children suffering from CF, a lung lavage is conducted several
times. In this, a small amount of liquid is injected into a part of the lungs and extracted afterwards. This
liquid contains substances that provide important indications regarding the emergence and course of
the symptoms in the lungs in CF, which determines the lifespan and quality of life of the patient.
In this study, an advanced measurement technique (mass spectrometry) is used to measure hundreds of fatty substances (lipids) that play a role in pneumonia. A first study with material of young Australian children suffering from CF was successfully completed and indicates that several lipids exist in abnormal amounts, when compared to children who are not suffering from CF, but who do have lung conditions. In the next phase, the study is expanded with more Australian patients and with the patients of the Dutch AREST-CF study. This is expected to lead to important details about the course of the illness in individual patients and about new possibilities to intervene with experimental drugs. In the pending study with a limited number of patients, it appears that in patients whose lung function is deteriorating rapidly, certain lipids are more common than in other patients. There are experimental drugs that slow down the activity of these lipids. In existing models of CF (cultivated human cells and CF mice) and later in patients, tests will be conducted to see whether these substances are able to reduce the symptoms in the lungs in CF. Burden
For this research, materials and medical information from the AREST-CF study are used and in the
regular medical examination of older patient (no additional burden).
Participants
All CF patients in the AREST-CF study (about 20 per year for a period of five years, several lung
lavages per patient) and older patients suffering from CF insofar lung lavages are conducted. For the
laboratory study, a mice model is partly used.
Participate
Participation is still possible
Duration
2012-2016
Sub project C7
Validating new drugs for the treatment of CF in a model.
Description
Experimental drugs have been developed that positively affect the activity of the deviating CFTR protein in CF patients. These substances are currently being tested on patients. The results do show a measurable effect, but still not enough to truly cure the patient. That is why new substances and combinations of active ingredients are sought out. Before these can be tested on humans, they must be tested in the laboratory. To this end, cultivated cells of people suffering from CF are used, as well as mice that have the same mutation (deltaF508) as most CF patients. In this project the combination of substances that provide the best results in the cell examination, is used in CF mice. The effect of the short-term and long-term administration on the function of various organs affected in CF (lung, intestine, liver and salivary gland) Is measured. These results help develop an optimal treatment for CF. Participants
Experimental animal studies
Duration
Four years
Contact
Dr. B. J. Scholte, Erasmus MC Rotterdam

Source: http://www.cfonderzoek.nl/bestanden/researchprogrammehitcf.pdf

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Research Article Ulaanbaatar, Mongolia Rie Nakajima1, Takehito Takano2, Vaanchig Urnaa2, Nyambayar Khaliun1 Keiko Nakamura1 1International Health and Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku Tokyo, Japan2Health Promotion, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku Tokyo, Japan Address for Correspondenc

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