Fecal microbiota transplantation (FMT)
Fecal microbiota transplantation
When diet and probiotics do not work, there is one last resort: fecal microbiota transplantation (FMT). This is a method where you administer donor feces to a patient, to directly change the recipients gut microbiota to treat dysbiosis.
History
The administration of feces to treat disease may not sound very high-tech. And that is true because the first records of FMT trace back to the 4th century in China, where they used fresh or fermented fecal suspensions (called 'yellow soup') to treat a variety of conditions like severe diarrhea, constipation and abdominal pain [3]. Then it went off the radar for a while, till Eiseman and his colleagues successfully treated pseudomembranous colitis in 1958. This was the first report of a fecal microbiota transplantation in medical literature. In 2013 Els van Nood and her colleagues performed the first RCT with FMT in patients with recurrent Clostridium Difficile infections and showed superiority of FMT over antibiotics alone [3,4].
What is it used for
Recurrent or treatment refractory C. Difficile infection is currently the only indication for FMT, since the most evidence has been found for in this condition. With cure rates up to 90%, which is way higher than antibiotic therapy, FMT has been listed in several guidelines for the treatment of C. difficile. However, a series of promising case reports and RCT's have indicated that FMT soon may be used for other diseases, like IBD, IBS and even extra-gastrointestinal diseases [1, 3].
The procedure
To perform a fecal microbiota transplantation, you need a healthy donor. Donor selection consists of questionnaires, interviews, blood tests and stool examinations [3]. The next step is the preparation of the fecal material. Since the most beneficial bacteria are anaerobic bacteria, the material has to be processed within 6 hours. After arrival of the material, it gets filtered and diluted with saline. RCTs have showed that fresh and frozen fecal material has the same efficacy, so it usually is frozen for preservation. When it is frozen, it can be stored for up to 6 years. The sample must be thawed in a warm water bath before transplantation.
The recipient should not receive antibiotics 12-48h before transplantation. The preparation of the recipient is similar to that of an endoscopic procedure, with a bowel lavage to make the gut free of contaminated fecal material prior to the donor feces infusion. There are different delivery methods. The most used is administration through the upper GI tract, with a nasojejunal or nasoduodenal tube. Another option is through a colonoscopy, but this is not preferred since it is quite invasive and has a risk of complications. There have been some trials with oral capsule of FMT, but the efficacy has yet to be determined [3].
Problems with FMT
One problem with FMT, is regulation. Since the product you have is so variable, it is hard to ensure its quality and efficacy. Another disadvantage is the risk of transmission of disease from the donor to the recipient, namely non-detectable or non-screened pathogens.
NDFB
NDFB (Nederlandse Donor Feces Bank) is an initiative of Dutch researchers and doctors, to carry out further research into FMT and its application. On top of that they provide donor feces for FMTs in the Netherlands. If you are healthy and happen to live nearby Leiden, become a donor by clicking the button below!
Written by Pepijn Gossink
Posted on 14 oct 2018
[1] Schmulson M, Bashashati M. Fecal microbiota transfer for bowel disorders: efficacy or hype? Current Opinion in Pharmacology 2018
[2] Suez J, Zmora N et al. Post-antibiotic gut mucosal microbiome reconstitution is impaired by probiotics and improved by autologous FMT. Cell 2018
[3] Wang JW, Kuo CH et al. Fecal microbiota transplantation: review and update. Journal of the Formosan Medical Association 2018
[4] Van Nood E, Vrieze A et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Eng J Med 2013