Faculty of Medicine and Health, Northern Clinical School
Abstract
INTRODUCTION: Parkinson’s disease (PD) is a disabling and progressive neurodegenerative disorder that is increasing in prevalence with the aging and urbanisation of the global population. The mechanisms underlying PD pathogenesis and progression are incompletely understood. Improved clinical recognition of early and prodromal non-motor symptoms (NMS), namely gastrointestinal (GI) dysfunction, has focused research over the last two decades on the roles of the gut. More recently, the influences of the microbiota-gut-brain-axis (MGBA) in the development and progression of PD have become an intensive area of research. Studies have demonstrated an association between the GM and a variety of PD-related characteristics, identifying important impacts on levodopa metabolism by certain microbiota. Importantly, the effect of device-assisted therapies (DATs) on the GM and the robustness of microbiota compositional differences between PD patients and household controls (HCs) has not been well defined.
The aims of this thesis were to 1) investigate GI dysfunction and nutritional patterns in PD, 2) determine if the GM is a biomarker of PD, and 3) investigate the temporal stability of the GM in PD patients receiving standard therapies and those initiating DATs.
METHODS: 103 PD patients and 81 HCs were recruited and participants with PD were considered in two sub-cohorts; 1) PD patients initiating DAT; either Deep Brain Stimulation (DBS) (n=10), or levodopa-carbidopa intestinal gel (LCIG) (n=11), who had GM sampling from stool at -2, 0, 2 and 4 weeks around initiation of DAT and baseline, 6 and 12 months following DAT initiation, 2) 82 PD patients receiving standard PD therapies, who had GM sampling from stool at baseline, 6 and 12 months. Validated PD questionnaire metadata ascertaining motor characteristics and NMS, as well as nutritional data in the form of a Food Frequency Questionnaire, were collected for all participants at baseline, 6 and 12 months. Total DNA was isolated from stool before sequencing the V3-V4 region of 16S rRNA. Relative bacterial abundances, diversity measures, compositional differences and clinical-microbiome associations were determined, as well as developing predictive modelling to identify PD patients and assess disease progression.
RESULTS: PD patients reported more prevalent and severe GI dysfunction, especially constipation, which was almost three-times more common compared to HC subjects, (78.6% vs 28.4%, p<0.001). PD patients had a higher intake of total carbohydrates (279 g/day vs 232 g/day; p=0.034), which was largely attributable to an increased daily sugar intake (153 g/day vs 119 g/day; p=0.003), particularly of free sugars (61 g/day vs 41 g/day; p=0.001). Significant GM compositional differences across several taxonomic levels were apparent between PD patients and HCs and associated with a number of PD motor and NMS features, as well as certain therapies. Predictive models to distinguish PD from HCs were developed considering global GM profiles, achieving an area under the curve (AUC) of 0.71, which was improved by addition of data on carbohydrate intake (AUC 0.74).
Longitudinal analysis demonstrated persistent underrepresentation of known short-chain fatty acid producing bacteria in PD patients, particularly those concerned with butyrate production; Butyricicoccus, Fusicatenibacter, Lachnospiraceae ND3007 group and Erysipelotrichaceae UCG−003. Taxa differences observed over the short-term (four week) sampling period around DAT (DBS and LCIG) initiation, were not sustained at 6 and 12 months. Despite this, persistent longer-term overrepresentation of Prevotella was observed after DBS initiation, and a trend was found that was suggestive of overrepresentation of Roseburia after LCIG initiation. These results suggest that there may be variable shorter and longer-term DBS and LCIG influences on the GM, which are complex and multifactorial. PD progression analysis did not identify distinct persisting GM compositional differences between faster and slower progressing patients, although predictive modelling was strengthened by the consideration of nutritional data, specifically protein intake, and improved the predictive capacity for PD progression.
CONCLUSION: This thesis demonstrates that there are numerous clinically significant associations between the gut, GM and PD. GI dysfunction is common, and carbohydrate nutritional intake appears to be different from the general population in PD. Persistent alterations of GM composition in PD compared to HCs were found. These findings provide support for the existence of disturbances of gut homeostatic pathways, which may disrupt intestinal barrier permeability and lead to gut leakiness, in the pathogenesis of PD. This thesis also highlights the potential to use the GM in the identification of PD and the characterisation of disease progression
