Fecal microbiota transplantation augmented by a sulfide‐reducing diet for refractory ulcerative colitis: A case report with functional metagenomic analysis

Abstract

Fecal microbiota transplantation (FMT) is effective for induction of remission in ulcerative colitis (UC). Diet has potential to augment the efficacy and durability of FMT by encouraging engraftment of transplanted microorganisms. A trial of FMT combined with a defined diet was undertaken as salvage therapy for a 71‐year‐old woman with active steroid‐refractory extensive UC. A multidimensional sulfide‐reducing diet (4‐SURE diet) was commenced followed by single‐donor FMT administered by colonoscopy and then enemas over 7 days. Dietary adherence, clinical evaluation, and stool samples for metagenomic profiling were undertaken at weeks 0, 4, 8, and 24. Colonoscopy was performed 8 weeks post‐FMT. Shotgun metagenomic profiling of the donor fecal suspension was also performed. A rapid clinical response to FMT and 4‐SURE diet was observed with normalization of stool frequency (≤2 motions/day) and resolution of rectal bleeding within 2 weeks. Dietary adherence was excellent. Colonoscopy at week 8 revealed no evidence of active colitis (Mayo endoscopic sub‐score 0) with histology showing no evidence of acute or chronic lamina propria inflammatory cell infiltrate. Sustained clinical and endoscopic remission out to 24 weeks was observed. Metagenomic sequencing confirmed sustained engraftment of beneficial donor microbiota with increased alpha‐diversity and capacity for short‐chain fatty acid production, including Faecalibacterium prauznitzii and Eubacterium hallii. This case report supports the rationale of prescribed diet therapy to support engraftment of donor microbiota following FMT for UC. Further large trials with a diet‐arm control group are needed to evaluate FMT augmented by a defined diet in UC.

Faecal microbiota transplantation with anti-inflammatory diet (FMT-AID) followed by anti-inflammatory diet alone is effective in inducing and maintaining remission over 1 year in mild to moderate ulcerative colitis: a randomised controlled trial

“…However, these studies have been heterogeneous in terms of FMT protocol, method of preparation, dose and intensity of FMT, and there is no FMT-based induction RCT from Asia. Diet has a potential to enhance the success of FMT by creating a favourable niche for the engraftment of donor microbiota and by its own anti-inflammatory effect 12. However, except for a recent three-arm study which compared FMT and diet, FMT alone and diet alone in patients with refractory UC, there is no study which has evaluated the combination of diet and FMT in UC 13.…”

Case report: Fecal microbiota transplantation in refractory ankylosing spondylitis

“…High dietary fiber intake might be helpful to maintain the efficacy of FMT through promoting beneficial bacteria and increasing the production of SCFAs (35). Moreover, a successful combination of FMT and a multidimensional sulfide-reducing diet on one patient with UC supported a defined diet that might also be conducive to prolong the efficacy of FMT (36). Prebiotics was also reported to improve the anti-inflammatory effect of FMT (37).…”

Encapsulated Fecal Microbiota Transplantation: Development, Efficacy, and Clinical Application

“…As the use of FMT is expanded as a potential treatment in other conditions, evaluating these interactions will be increasingly important both to improve clinical efficacy and over deleterious off-target effects. Donor screening is now increasingly considered with a hypothesis that a specific microbiota consortium may prove more beneficial in correcting dysbiosis underlying a specific disease; e.g., bacterial sulfur metabolism related to IBD ( Bryant et al., 2021 ). In addition, understanding the competitive dynamics associated with engraftment and invasion will be necessary to optimize formulation, dosing strategies, and adjunctive therapies to improve outcomes following FMT.…”