Fecal microbiota tRAnspLantation uSed TO improve postpraNdial bacterIAl translocation;
the RALSTONIA study.

De prevalence of obesity and related conditions such as metabolic syndroom and
type 2 diabetes mellitus continues to rise world wide. The rol of the gut
microbiota in metabolic disorders has recently been identified. Obesity has
been associated with changes in the composition of the gut microbiota and the
obese gut microbiota seems to be more efficient in harvesting energy from the
diet. The potential causal relationship between metabolism and the gut
microbiota was recently implied in the FATLOSE-1 trial, where men with
metabolic syndrome showed a marked improvement of insulin sensitivity after
infusion of lean donor feces. Moreover, in the IMAGE-trial we showed that
visceral fat tissue of obese, insulin resistant subjects contained bacterial
DNA, notably Ralstonia pickettii. The amount of Ralsonia pickettii DNA in this
fat tissue correlated with the amount in feces and with inflammatory
parameters. Bacterial translocation, especially after a high fat meal, from the
intestines into plasma and fat tissue may be a crucial factor in the
development of inflammation and insulin resistance.

In the RALSTONIA study we would like to investigate whether and to what extend
patients with metabolic syndrome show postprandial bacterial translocation into
plasma and fat tissue and whether we can improve this by lean donor fecal
transplantation. By relating the results to differences in (small) intestinal
gut microbiota, we could contribute to the growing knowledge about the
relationship betweet the gut microbiota and type 2 diabetes mellitus.

To investigate whether changes in (small) intestinal microbiota composition
regulate postprandial bacterial translocation into plasma and visceral and
subcutaneous adipose tissue. Moreover, we will study whether single lean donor
feces transplantation influences bacterial translocation compared to autologous
fecal transplantation.

Randomized, double blind, controlled, single center, intervention study.

Patients will be randomised to receive either single allogenous donor feces
(n=12) or single autologous feces (n=12).

De screening contains filling out a questionnaire, a physical examination and
taking a blood sample (60ml). On the first study day, patients will will visit
the AMC to do a mixed-meal test, where they will receive a standardized meal
and blood will be taken from a cannula 5 times (140ml). Prior to this, a
subcutaneous fat biopsy will be taken. The visit will take 8 hours. On the
second study day, a gastroscopy will be performed, with small intestinal
biopsies and placement of a probe, followed by a fecal transplant. This visit
will also take 8 hours. 3 weeks later, the mixed-meal test and gastroscopy with
small intestinal biopsies will be repeated. However, this time no subcutaneous
biopsy and fecal transplant will be performed. During the study, patients will
twice keep track of their diet for a week, twice collect 2x24h feces and twice
collect 1x24h urine. All together, the visits will take 25 hours.
For the donors the burden contains filling out a questionnaire, followed by
providing a fecal sample to test for transmissible diseases. If the tests come
back negative, a single venous sample (25ml) will be taken to screen the blood
of the potential donor for viruses. Suitable donors will then receive a single
mixed-meal test (with drawing of 140ml blood) with subcutaneous biopsy. During
the study, the donors will keep track of their diet for a week once and once
collect 2x24h feces and 1x24h urine. All together, the visits will take 5 hours.

In theory there may be a risk for transmitting unknown diseases via feces (as
has been described with blood transfusion). However, by screening the donors
thoroughly, we aim to minimise this risk.

Gastroscopy: this is a standard procedure.1 in 1000 procedures are complicated
by bleeding or a small tear in the gut. This can often be treated immediately
(through the endoscope). Sometimes surgery is necessary. The risk of this
procedure is considered minimal. Inspecting the stomach and duodenum has the
added advantage of being able to visualise and treat abnormalities of the
stomach or duodenum (e.g. ulcer) immediately.

The subcutaneous biopsy will be taken under local anesthesia and will thus not
be painful. However, after the procedure a bruise may appear and the puncture
site may be painful.

Mixed-meal test: patients will receive a standardized meal, which is not
associated with risks. Oral vitamin A has not ben associated with risks.

The harvesting of fat tissue after the fecal transplant has a minimal risk of
bleeding. Because harvesting will be done during an already planned procedure,
direct action can be taken when this happens. Thus, the added risk is minimal.

Although there is no direct benefit for participating in the study, this
research may provide important knowledge about the concept of bacterial
translocation and its rol in the development of insulin resistance. Thus, this
study may help us in the future to develop new treatment modalities for insulin
resistance and type 2 diabetes mellitus.