Concerted changes in the pediatric single-cell intestinal ecosystem before and after anti-TNF blockade

Reviewer #1 (Public Review):

Summary: Crohn's disease is a prevalent inflammatory bowel disease that often results in patient relapse post anti-TNF blockades. This study employs a multifaceted approach utilizing single-cell RNA sequencing, flow cytometry, and histological analyses to elucidate the cellular alterations in pediatric Crohn's disease patients pre and post-anti-TNF treatment and comparing them with non-inflamed pediatric controls. Utilizing an innovative clustering approach, the research distinguishes distinct cellular states that signify the disease's progression and response to treatment. Notably, the study suggests that the anti-TNF treatment pushes pediatric patients towards a cellular state resembling adult patients with persistent relapses. This study's depth offers a nuanced understanding of cell states in CD progression that might forecast the disease trajectory and therapy response.

Robust Data Integration: The authors adeptly integrate diverse data types: scRNA-seq, histological images, flow cytometry, and clinical metadata, providing a holistic view of the disease mechanism and response to treatment.

Novel Clustering Approach: The introduction and utilization of ARBOL, a tiered clustering approach, enhances the granularity and reliability of cell type identification from scRNA-seq data.

Clinical Relevance: By associating scRNA-seq findings with clinical metadata, the study offers potentially significant insights into the trajectory of disease severity and anti-TNF response; which might help with the personalized treatment regimens.

Treatment Dynamics: The transition of the pediatric cellular ecosystem towards an adult, more treatment-refractory state upon anti-TNF treatment is a significant finding. It would be beneficial to probe deeper into the temporal dynamics and the mechanisms underlying this transition.

Comparative Analysis with Adult CD: The positioning of on-treatment biopsies between treatment-naïve pediCD and on-treatment adult CD is intriguing. A more in-depth exploration comparing pediatric and adult cellular ecosystems could provide valuable insights into disease evolution.

Areas of improvement:
1. The legends accompanying the figures are quite concise. It would be beneficial to provide a more detailed description within the legends, incorporating specifics about the experiments conducted and a clearer representation of the data points.

2. Statistical significance is missing from Fig. 1c WBC count plot, Fig. 2 b-e panels. Please provide it even if it's not significant. Also, the legend should have the details of stat test used.

3. In the study, the NOA group is characterized by patients who, after thorough clinical evaluations, were deemed to exhibit milder symptoms, negating the need for anti-TNF prescriptions. This mild nature could potentially align the NOA group closer to FIGD-a condition intrinsically defined by its low to non-inflammatory characteristics. Such an alignment sparks curiosity: is there a marked correlation between these two groups? A preliminary observation suggesting such a relationship can be spotted in Figure 6, particularly panels A and B. Given the prevalence of FIGD among the pediatric population, it might be prudent for the authors to delve deeper into this potential overlap, as insights gained from mild-CD cases could provide valuable information for managing FIGD.

4. Furthermore, Figure 7 employs multi-dimensional immunofluorescence to compare CD, encompassing all its subtypes, with FIGD. If the data permits, subdividing CD into PR, FR, and NOA for this comparison could offer a more nuanced understanding of the disease spectrum. Such a granular perspective is invaluable for clinical assessments. The key question then remains: do the sample categorizations for the immunofluorescence study accommodate this proposed stratification?

5. The study's most captivating revelation is the proximity of anti-TNF-treated pediatric CD (pediCD) biopsies to adult treatment-refractory CD. Such an observation naturally raises the question: How does this alignment compare to a standard adult colon, and what proportion of this similarity is genuinely disease-specific versus reflective of an adult state? To what degree does the similarity highlight disease-specific traits?
Delving deeper, it will be of interest to see whether anti-TNF treatment is nudging the transcriptional state of the cells towards a more mature adult stage or veering them into a treatment-resistant trajectory. If anti-TNF therapy is indeed steering cells toward a more adult-like state, it might signify a natural maturation process; however, if it's directing them toward a treatment-refractory state, the long-term therapeutic strategies for pediatric patients might need reconsideration.

Reviewer #2 (Public Review):

Summary:
Through this study, the authors combine a number of innovative technologies including scRNAseq to provide insight into Crohn's disease. Importantly samples from pediatric patients are included. The authors develop a principled and unbiased tiered clustering approach, termed ARBOL. Through high-resolution scRNAseq analysis the authors identify differences in cell subsets and states during pediCD relative to FGID. The authors provide histology data demonstrating T cell localisation within the epithelium. Importantly, the authors find anti-TNF treatment pushes the pediatric cellular ecosystem toward an adult state.

Strengths:
This study is well presented. The introduction clearly explains the important knowledge gaps in the field, the importance of this research, the samples that are used, and study design.
The results clearly explain the data, without overstating any findings. The data is well presented. The discussion expands on key findings and any limitations to the study are clearly explained.

I think the biological findings from, and bioinformatic approach used in this study, will be of interest to many and significantly add to the field.

Weaknesses:
1. The ARBOL approach for iterative tiered clustering on a specific disease condition was demonstrated to work very well on the datasets generated in this study where there were no obvious batch effects across patients. What if strong batch effects are present across donors where PCA fails to mitigate such effects? Are there any batch correction tools implemented in ARBOL for such cases?

2. The authors mentioned that the clustering tree from the recursive sub-clustering contained too much noise, and they therefore used another approach to build a hierarchical clustering tree for the bottom-level clusters based on unified gene space. But in general, how consistent are these two trees?