Dr Silvio Najt runs the Newbery Clinic in Buenos Aires, Argentina. Newbery Clinic specialises in the treatment of inflammatory illnesses, through restoration of gut health through nutrition and FMT.
What’s your background? How did you become a FMT specialist?
I specialize in Internal Medicine and am board certified in Cardiology and Emergency Medicine. Around 2005 I became interested in the link between inflammation and the human microbiome. Since then I have devoted most of my practice to a diversity of inflammatory diseases, initially with a pharmacological approach and then incorporating a number of other sources to deal with the phenomena, including nutrition, supplements, enteral and parenteral nutrition, and finally FMTs.
How did you become a FMT practitioner?
When I first heard about the method I thought it was just hot air; witchcraft. However it stayed in my mind as a treatment for Clostridium difficile and I eventually started using it in some desperate cases of IBD, used only when patients learned that their last remaining option was surgical. An infection control nurse and I did the implants in patient´s homes, and we saw they all improved, some recovered but all the patients we treated got some sort of benefit from the implants. That was the beginning of the learning curve. We have since teamed up with a high quality biochemist and microbiologist to minimize the risk of transmission of disease from our donors.
When did you open your clinic? What kind of patients do you treat?
We opened Newbery Clinic in February 2014 in the heart of Buenos Aires, and we slowly started treating patients, mostly IBD -Crohn´s and Ulcerative colitis. Our goal was to start slowly with very few cases so that we could devote sufficient time to evaluate the patients, measure before and after results, refine preparation of the slurry and learn how to choose our donors.
We focus our practice in IBD, Crohn´s and Ulcerative colitis. However, any patient with chronic diarrhea seems to benefit by replacing their microbiota. Our results are good, we are collecting data and as we are in such close contact with many of the patients we see, we expect to draw a magnificent perspective of the clinical evolution of every case, including nutritional and pharmacological interventions alongside treatment with FMT. We are getting requests to perform FMTs on many other diseases like primary sclerosing cholangitis, bad cases of psoriasis, etc.
What kind of results have you seen with FMT?
Every day when I enter the clinic, I have a certain feeling that we are performing some kind of magical procedure, that I never came across something like this in my 40 years of medical practice. We see good results in all the people we treat, some enter in a state of relapse, many don´t, but all improve their quality of life, their symptoms change, they gain energy and are able to recover control over their lives. I do not use the word “cure”, it is out of my vocabulary, as nobody is entirely healthy, nobody is entirely sick. There is always something with us that bothers our health. So my approach is, if we can reach a better situation and not jeopardize your health in any way, it is worth trying. Every time I write down a prescription for any (any I say any) drug, I know somewhere in this action, there is a risk, sometimes small, sometimes big.
What has been your most memorable success?
A young boy treated with FMTs, one of the first we saw at Newbery Clinic, he had a mild to severe ulcerative pancolitis, always with diarrhea, with bloody stools on and off, he did a very strict SCD diet (since then he developed a catering service for Celiacs) but was always in need of some sort of medication that never took him into a full recovery. He could not gain any weight, anemic, lack of energy, and something that always called my attention, his grayish skin color. His initial Fecal calprotectin was above 1100 units. He decided he did not want to get any more medication, that he wanted to try this “new” (very new those days) approach. We did 30 days in a row of daily implants, then a month of three times a week then a month of two a week, then we did them once a week and we stabilized the implants to two a month for about eight months. Now he comes to the clinic just once a month. Results, he has no symptoms whatsoever, his skin color dramatically changed, and his last Calprotectin level is 80 units, he gained some weight but is full of energy devoting all his time to this Celiac catering business with great success.
What makes a good donor?
Someone who is healthy (with the limitations of the definition of healthy in our society). Decide that the donor is apt after performing a medical examination and blood and stool tests. Also that he/she has a stable life, somehow stability (steady couple, steady job, place to live, good eating habits, some exercise, no drugs, little alcohol, etc.). And finally we “test” their stools against others, after “using his stuff” we kind of measure if his bacteria make a difference in the receptor, that means an “inclusion” parameter, we still have no way to know if a donor is a “good one” before using his stuff on someone. An those we take good care they stay healthy and willing to continue to donate!
Where do you get your donors and how do you screen them?
We need donors within a close distance from the clinic. We tend to use fresh specimens and only in special occasions we use material from our frozen bank, we are working with a microbiologist to improve the anaerobic process, and then we will test if that makes any big difference, we developing a bank of frozen stools for our facility and for some colleagues that are just starting to use FMTs in Argentina. In the meantime we stick to what we know works: fresh specimens within a certain amount of hours, then we discard them and use another batch. So we have a good number of donors, that live closeby. We discard they sample if we find out that they are sick or had a “bad night”. We keep a tight medical control over our donors.
What percentage of donors do you reject?
I would say we discard about 30-40 % of the potential candidates, maybe less, before we send them to the lab to get their blood and stool testing, we perform a very thorough interview and physical examination -don´t forget that we are a medical group and that is what we do, medicine and in some patients we recommend FMTs, not the other way around.
Do you think donor diet matters?
Yes, we are convinced that our bacteria need a huge amount of fiber, probably two to three times the dietary recommendations, so we elaborate a diet for our donors that include a fantastic and healthy combination of nutrients, fiber and fermented foods. They are part of the team and they share this view of “magical” stuff they are giving us to improve the life of people that suffer from very sad diseases. We share the spirit of sharing their good health with others. Many of our donors learned how to follow a “healthy diet” after starting collaborating with us.
Do you use enema or colonoscopy delivery?
We do not do colonoscopy, we prefer to preserve the flora as is and replace it gradually instead of “cleansing” the field with antibiotics and bowel preparations and stressing an already sick gut further. That way we get good results and see less gut reactions.
We use a long and thin silicone cannula to make our implants.
We take advantage of a normal gut movement called “peristalsis”. Peristalsis refers to the smooth muscle gut contraction, which occurs in sequences to produce a wave. It forces a ball of food (bolus) to move from the esophagus to the anus. This automatic movement is highly efficient and coordinated until the end of the small intestine. However when the bolus enters the colon, peristalsis exists but is not as coordinated. The colon content moves back and forth like a washing machine to extract energy from the undigested fibers. We can take advantage of this physiological movement to send new microbiota to the ascending colon, simply by implanting good bacteria in final sector of the sigmoid. Peristalsis will take care of seeding the whole organ and beyond. So only bottom-up techniques, our group think that the Top-down (nasogastric approach) is highly risky and we do not sense we need to go that way.
Why don’t you support top-down FMT?
Top down vs bottom up is a controversial area that has polarizes FMT practitioners. I am very concerned about these magic FMT pills that are receiving so much publicity. The small intestine is essentially sterile when compared with the colon (1000 vs one trillion bacteria) yet there seems to be a “crosstalk” between both communities. I believe ‘bottom-up’ is is a much better approach than carpet bombing the entire gut. From a theoretical point of view there is a very strong argument against “infecting the small gut”. One of the most feared complications of Ulcerative colitis is primary sclerosing cholangitis (PSC), which is a situation that can lead to liver transplant, high incidence of colon cancer and premature death. One of the experimental ways of provoking PSC in experimental animals, is to surgically perform in their guts what is called a “blind loop”. It consists in contaminating the small gut with colonic bacteria, over and over. So if there is the slightest or remote possibility of developing a PSC or any other complication in the small gut (SIBO) this approach should be avoided.
What side-effects have you seen from FMT?
We have seen a few but very mild side effects, our approach is to minimize rejection of the new implanted bacteria so we generally use some amount of steroids a few days before we start and we then slowly tapper from it, this way we have seen almost no side-effects, other than some bloating or a mild exacerbation of the symptoms the patient already had.
What do you see as the risks of FMT generally?
My feeling is to perform the technique without medical knowledge and medical supervision. It is very brave to see this mothers and dads that are left without options when they are faced with surgery and they have to do FMTs by themselves because the medical community can´t do them yet in some certain countries. The main risk is by using the wrong donors, or hurting the already damaged gut with very aggressive techniques as are described over the internet. The gut is very delicate and can be teared down by inappropriate maneuvers, and the worst part of this is that those complications may not even be realized by the operators as they lack the medical experience of evaluating a punctured gut and its clinical manifestations. That concerns me a lot.
How long does stool stay fresh once exposed to air?
We tend not to “expose the stools to the air”. We collect the materials in a low oxygen receptacle, then we manipulate the sample with a vacuum devise to preserve it until we blend it. It usually takes no more than two, max three hours from the moment the stools are emitted until they are implanted.
How do you preserve anaerobic microbiota?
We do our best not to expose feces to oxygen and light, and our results so far are very good. We are starting to use a new technique to make the atmosphere more anaerobic, but it’s still under experimentation. There is still a lot of room for improvement. We are working side by side with a very enthusiastic group of Doctors in Microbiology to organize the first South American Stool bank.
Have you used frozen FMT? Do you think it is as good as fresh?
We have a frozen bank and we use them as a back-up. Even though we use the best techniques known in this area, we tend to use them occasionally as we see better results with the fresh specimens, as I said we are still in the phase of developing a professional bank of frozen stools. We expect to have it up and working by July/August 2015.
Have you treated anyone with a J-pouch?
No we have not yet treated anyone with J-pouch yet, although I have some local patients with that intervention. Our biggest experience is with Colitis and Crohn`s with intact guts.
Have you treated constipation with FMT?
We find FMTs extremely useful for constipated patients, however our experience is that it should be used along with other interventions such as diet and habit changes. We find there are many patients that are constipated and feel OK with that as they will not use their office or school bathrooms, so there is a lot to do to treat constipation, it is the other side of the coin, colitis patients would use any toilet, constipated would only use just a few.
What are your post-FMT support recommendations?
It depends on the case, we always recommend and customize a diet for each and every patient. We are all different. Then we use some, not many supplements, we have to be very cautious, every day we learn about more “vitamins and supplements” that can harm our microbiota. So good food, fresh, non processed, lots of good fats, low starch, low sugar, lots of exercise, and no stress is what we try to inculcate in our patients. We may sometimes use medication, we know how to use them and we have seen some cases improve when we combine the best of all these different worlds.
Why is the mainstream medical profession so reluctant to investigate and offer FMT? Given the success with C.diff, what’s wrong with trying it for more difficult chronic gut conditions?
I do not know, there mixed interests, one of the most profitable group of drugs in the world right now are the anti-TNF – biologics, billions of dollars are spent on this drugs. In IBD cases the best results ever reported do not exceed 40% remission of the treated cases. Usually associated with azathioprine. So as long as the medical leaders are so strongly influenced by the pharmaceutical companies, they will not change horses. We will see the clinical trials that are about to be reported quite soon, some of them will start showing what we see in our daily practice. We improve the life of the people and we cause no harm. The worst that could happen is that the patient see no changes, which is unusual, with drugs you may see no change but you know they are quite dangerous.
What’s your view on DIY FMT?
As I said, when you are left aside by the medical community you are compelled to do something for you or someone loved beside you. Not the best way to go, I think medicine has advanced in many ways, and has a lot to offer to the people. And I am not talking about technology, I am talking about been better people, listen better, be closer to the one that suffers, not become the savior -that we are not, but after 40 years of listening to lungs and hearts and palpating abdomens you acquire a certain skill that can be useful for the patient, you may advise them how to have a healthier approach to their daily life, how to eat better, how to relate with others is a less stressful way. I think DIY is a failure of the medical system and of the community as a whole, I would expect governments to take care of our health in a proper way. This is a clear and ever increasing demand the PUBLIC is demanding. So they should be listening as FDA did with Catherine Duff.
What research is on your wish list?
We want to develop some kind of devise that could help the people get access to good bacteria in their houses, not pills or capsules but something safer than that. Also improve our technique and laboratory processes, something we do every day. This is all so new that every day we find new ways and new equipment to improve the technique. As I am originally a cardiologist, I have had a huge exposure to catheters, cannulas and monitoring equipment that I am reconfiguring to use them a little lower than the heart, the gut. We still need to learn a lot about the microbiome, we ignore which is the “normal” bacterial map, although by now millions of people´s microbiota has been studied. Lot of room to improve. And of course devote most of our attention to build a very consistent bank of frozen stools.
Do you think it will soon be possible to transplant specific strains of microbiota depending on what is missing in the gut?
We are still too far away to understand what goes on in the gut microbiome. This “diagnosis” of lack of one particular family of bacteria is still futuristic medicine, as we are just at the beginning of this science. It is therefore risky and uninformed to emphatically state that something is “missing”. The accuracy of such microbiome tests are yet to be proven and what appears to be “missing’’ might just be that people are different. What we do know is that the fecal microbiota is an “organ” and should be transplanted as that, as a whole. All attempts to depurate or extract the good ones, have failed or showed poor results. It is like attempting to implant a certain part of a kidney or a liver, Can´t be done today, maybe sometime in the future.
What do you enjoy about your work? What are the frustrations?
I am totally fascinated with the results we see. We are treating very young kids, babies already suffering from IBD, cases we did not see a few years ago, so on one hand we get more severe cases but on the other hand we see them improve without exposing them to dangerous drugs, but there is something very wrong this society as a whole is doing to put so many people sick. When I started practicing medicine celiacs were estimated to be 1 in 10,000. Today, 40 years later the estimation is 1 in 80. What is that we are not doing well?
How can someone make an appointment to see you? Do you do Skype consultations for international patients?
Yes, half of our patients are international, Buenos Aires is an easy city, most of the people speak English and we are located in a very friendly neighborhood. We do a lot of Skype consults and we supervise many people from around the world that can´t move to Argentina to do the technique in their own place. Not the best scenario, we prefer to treat them and follow them here in Buenos Aires, but somehow we may offer our medical skills to help people go through this challenging therapy in a remote fashion with a system that has already helped people in places like Poland and Hong Kong. You can , Skype us via newbery.clinic or call +1-315-519-9636.
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