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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Sankararaman S, Schindler T. Exocrine Pancreatic Insufficiency in Children - Challenges in Management. Pediatric Health Med Ther 2023; 14:361-378. [PMID: 37908317 PMCID: PMC10615098 DOI: 10.2147/phmt.s402589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Abstract
Cystic fibrosis (CF) is the leading etiology for exocrine pancreatic insufficiency (EPI) in children, followed by chronic pancreatitis, Shwachman-Diamond syndrome, and other genetic disorders. Management of EPI in children poses several unique challenges such as difficulties in early recognition, lack of widespread availability of diagnostic tests and limited number of pediatric-specific pancreatic centers. Pancreatic enzyme replacement therapy is the cornerstone of EPI management and in young children difficulties in administering pancreatic enzymes are frequently encountered. Patients with EPI also should be screened for fat-soluble vitamin deficiencies and receive appropriate supplementation. Among disorders with EPI in children, CF is the relatively well-studied condition, and most management recommendations for EPI in children come from expert consensus and conventional practice guidelines. The impact of EPI can be greater in children given their high metabolic demands and rapid growth. Early diagnosis and aggressive management of EPI prevent consequences of complications such as malnutrition, fat-soluble vitamin deficiencies, and poor bone health and improve outcomes. Management by multi-disciplinary team is the key to success.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital / Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
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Cao Y, Donaldson R, Lee D. "Summer hypokalemia" as an initial presentation of cystic fibrosis in a morbidly obese African American adult: case report. BMC Nephrol 2020; 21:462. [PMID: 33160331 PMCID: PMC7648400 DOI: 10.1186/s12882-020-02130-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 10/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most patients with cystic fibrosis (CF) present with respiratory or digestive symptoms. About 3% of patients have electrolyte disturbances at the time of diagnosis, but most of the described cases presenting with this manifestation have been in children. Only 3 adult patients are identified in the literature who first presented with hypokalemia. We describe a morbidly obese African American adult who presented with severe hypokalemia and metabolic alkalosis, which eventually led to the diagnosis of CF after multiple hospitalizations over 4 consecutive summers. Besides being the first African American adult with this presentation, he had the highest BMI, lowest serum potassium, highest pH, and highest bicarbonate level. CASE PRESENTATION In the summer of 2015, a 26 year-old African American man presented to the hospital for generalized weakness. His BMI was 54 kg/M2, and he had been on a special diet for a few months with a weight loss of 50 pounds. He sweated profusely while working as a chef. Laboratory tests showed severe hypokalemia and metabolic alkalosis. Further work-up pointed toward extrarenal losses of potassium. He was treated with intravenous normal saline and potassium chloride. After discharge, his potassium level remained normal through the winter while the potassium was tapered off. However, over the following three summers, he repeatedly presented to hospitals for the same problems. Cystic fibrosis was suspected and confirmed by an abnormal pilocarpine sweat test. Gene test revealed two mutations of cystic fibrosis transmembrane conductance regulator (CFTR). Thereafter, his potassium level remained normal with potassium replacement during summertime. Unexpectedly, however, his BMI rose to 83 kg/M2 after he stopped the special diet for weight reduction. The reason for the delayed diagnosis is discussed. CONCLUSION We present an exceedingly rare case of CF in a morbidly obese African American adult male whose only manifestation of CF was hypokalemia and metabolic alkalosis. Clinicians should keep an open mind to the diagnosis of CF in ethnically diverse populations, even if it seems unlikely at first glance. For "summer hypokalemia", consider cystic fibrosis.
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Affiliation(s)
- Yangming Cao
- Divisions of Nephrology, Department of Internal Medicine, UCSF Fresno Center for Medical Education and Research, 155 N Fresno St, Fresno, CA, 93701, USA. .,The Nephrology Group, 568 E Herndon Ave, Suite 201, Fresno, CA, 93720, USA.
| | - Rachel Donaldson
- Divisions of Pulmonology, Department of Internal Medicine, UCSF Fresno Center for Medical Education and Research, 155 N Fresno St, Fresno, CA, 93701, USA
| | - David Lee
- Divisions of Pulmonology, Department of Internal Medicine, UCSF Fresno Center for Medical Education and Research, 155 N Fresno St, Fresno, CA, 93701, USA
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Di W, Clark HA. Optical Nanosensors for in vivo Physiological Chloride Detection for Monitoring Cystic Fibrosis Treatment. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2020; 12:1441-1448. [PMID: 32226484 PMCID: PMC7100910 DOI: 10.1039/c9ay02717c] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Personalized approaches for continuous monitoring of chloride levels are potentially valuable for evaluating the efficacy of new treatments of genetic disorders such as cystic fibrosis. In this report, we validated optode-based nanosensors for real-time chloride monitoring in the interstitial fluid of living animals. These nanosensors take advantage of a ratiometric sensing scheme which demonstrates reversible and selective chloride detection in the physiological range. We further investigate how skin pigmentation affects the sensor performance during in vivo fluorescence imaging. We successfully monitored endogenous chloride changes using nanosensors during pharmacological treatment in a cystic fibrosis mouse model. We believe this platform is a valuable tool for chloride detection which could assess the efficacy of new treatments for cystic fibrosis.
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Affiliation(s)
- Wenjun Di
- Department of Pharmaceutical Sciences, Northeastern University, Boston, Massachusetts 02115, United States
| | - Heather A Clark
- Department of Bioengineering, Northeastern University, Boston, Massachusetts 02115, United States
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, Massachusetts 02115, United States
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Pedchenko V, Bauer R, Pokidysheva EN, Al-Shaer A, Forde NR, Fidler AL, Hudson BG, Boudko SP. A chloride ring is an ancient evolutionary innovation mediating the assembly of the collagen IV scaffold of basement membranes. J Biol Chem 2019; 294:7968-7981. [PMID: 30923125 PMCID: PMC6527180 DOI: 10.1074/jbc.ra119.007426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/13/2019] [Indexed: 12/22/2022] Open
Abstract
Collagen IV scaffold is a principal component of the basement membrane (BM), a specialized extracellular matrix that is essential for animal multicellularity and tissue evolution. Scaffold assembly begins with the trimerization of α-chains into protomers inside the cell, which then are secreted and undergo oligomerization outside the cell. For the ubiquitous scaffold composed of α1- and α2-chains, both intracellular and extracellular stages are mediated by the noncollagenous domain (NC1). The association of protomers is chloride-dependent, whereby chloride ions induce interactions of the protomers' trimeric NC1 domains leading to NC1 hexamer formation. Here, we investigated the mechanisms, kinetics, and functionality of the chloride ion-mediated protomer assembly by using a single-chain technology to produce a stable NC1 trimer comprising α1, α2, and α1 NC1 monomers. We observed that in the presence of chloride, the single-chain NC1-trimer self-assembles into a hexamer, for which the crystal structure was determined. We discovered that a chloride ring, comprising 12 ions, induces the assembly of and stabilizes the NC1 hexamer. Furthermore, we found that the chloride ring is evolutionarily conserved across all animals, first appearing in cnidarians. These findings reveal a fundamental role for the chloride ring in the assembly of collagen IV scaffolds of BMs, a critical event enabling tissue evolution and development. Moreover, the single-chain technology is foundational for generating trimeric NC1 domains of other α-chain compositions to investigate the α121, α345, and α565 collagen IV scaffolds and to develop therapies for managing Alport syndrome, Goodpasture's disease, and cancerous tumor growth.
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Affiliation(s)
- Vadim Pedchenko
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Ryan Bauer
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Elena N Pokidysheva
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Alaa Al-Shaer
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| | - Nancy R Forde
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada; Department of Physics, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| | - Aaron L Fidler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Department of AspirnautTM Program, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Billy G Hudson
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Department of AspirnautTM Program, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Department of Biochemistry, Vanderbilt University, Nashville, Tennessee 37232; Department of Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee 37232; Department of Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232
| | - Sergei P Boudko
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232; Vanderbilt Center for Matrix Biology, Vanderbilt University Medical Center, Nashville, Tennessee 37232.
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Turck D, Braegger CP, Colombo C, Declercq D, Morton A, Pancheva R, Robberecht E, Stern M, Strandvik B, Wolfe S, Schneider SM, Wilschanski M. ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis. Clin Nutr 2016; 35:557-77. [PMID: 27068495 DOI: 10.1016/j.clnu.2016.03.004] [Citation(s) in RCA: 309] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/04/2016] [Accepted: 03/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members. RESULTS The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended. CONCLUSION Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.
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Affiliation(s)
- Dominique Turck
- Univ. Lille, Inserm U995, LIRIC - Lille Inflammation Research International Center, Division of Gastroenterology, Hepatology and Nutrition, and Cystic Fibrosis Center, Department of Pediatrics, CHU Lille, F-59000 Lille, France.
| | - Christian P Braegger
- Division of Gastroenterology and Nutrition and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032, 10 Zurich, Switzerland.
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico (IRCCS), Università degli Studi di Milano, Milan, Italy.
| | - Dimitri Declercq
- Department of Pediatrics, CF Centre, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
| | - Alison Morton
- Regional Adult CF Unit, St. James' University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Ruzha Pancheva
- Department of Hygiene, Faculty of Public Health, Prof. Dr. Paraskev Stoyanov Medical University of Varna, 55 Marin Drinov Str., 9002 Varna, Bulgaria.
| | - Eddy Robberecht
- Pediatric Gastroenterology, Hepatology & Nutrition, University Ghent, CF Centre Ghent, Princess Elisabeth Pediatric Hospital, B 9000 Ghent, Belgium.
| | - Martin Stern
- University Children's Hospital, University of Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany.
| | - Birgitta Strandvik
- Department of Bioscience and Nutrition, Karolinska Institutet, Novum, Hälsovägen 7-9, 14183 Huddinge, Stockholm, Sweden.
| | - Sue Wolfe
- Regional Pediatric CF Unit, The Leeds Children's Hospital, Belmont Grove, Leeds, LS2 9NS, UK.
| | - Stephane M Schneider
- Gastroenterology and Clinical Nutrition, Archet University Hospital and University of Nice Sophia-Antipolis, Nice, France.
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, PO Box 24035 Jerusalem, 91240, Israel.
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Li L, Somerset S. Dietary intake and nutritional status of micronutrients in adults with cystic fibrosis in relation to current recommendations. Clin Nutr 2015; 35:775-82. [PMID: 26159903 DOI: 10.1016/j.clnu.2015.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 05/25/2015] [Accepted: 06/12/2015] [Indexed: 01/29/2023]
Abstract
An increased prevalence of cystic fibrosis (CF) related complications such as impaired bone health and diabetes has accompanied increased survival of patients with CF. This review was conducted to determine the extent to which adults with CF are meeting current nutrition recommendations for micronutrients in association with CF-related complications management. Although dietary intake and nutritional status in CF has improved significantly in recent decades, micronutrient status seems to have diverged. While vitamin A and E intakes appear adequate, frequent vitamin D and K deficiency/insufficiency and compromised bone health in CF, occurs despite supplementation. Although deficiency of water-soluble vitamins and minerals is uncommon, ongoing surveillance will enhance overall health outcomes, particularly in cases of CF-related liver disease and deteriorated lung function and bone health. Salt and fluid status in CF may also need attention due to diminished thirst sensation and voluntary rehydration. Further investigation in micronutrient status optimisation in CF will inform the development of more effective and targeted nutrition therapies to enable integration of more refined recommendations for micronutrient intakes in CF based on individual needs and disease progression.
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Affiliation(s)
- Li Li
- School of Medicine, Griffith Health Institute, Griffith University, Brisbane, Queensland, Australia
| | - Shawn Somerset
- School of Medicine, Griffith Health Institute, Griffith University, Brisbane, Queensland, Australia; School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Queensland, Australia.
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Scurati-Manzoni E, Fossali EF, Agostoni C, Riva E, Simonetti GD, Zanolari-Calderari M, Bianchetti MG, Lava SAG. Electrolyte abnormalities in cystic fibrosis: systematic review of the literature. Pediatr Nephrol 2014; 29:1015-23. [PMID: 24326787 DOI: 10.1007/s00467-013-2712-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/12/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cystic fibrosis per se can sometimes lead to hyponatremia, hypokalemia, hypochloremia or hyperbicarbonatemia. This tendency was first documented 60 years ago and has subsequently been confirmed in single case reports or small case series, most of which were retrospective. However, this issue has not been addressed analytically. We have therefore systematically reviewed and analyzed the available literature on this subject. METHODS This was a systematic review of the literature. RESULTS The reports included in this review cover 172 subacute and 90 chronic cases of electrolyte imbalances in patients with cystic fibrosis. The male:female ratio was 1.57. Electrolyte abnormalities were mostly associated with clinically inapparent fluid volume depletion, mainly affected patients aged ≤2.5 years, frequently tended to recur and often were found before the diagnosis of cystic fibrosis was established. Subacute presentation often included an history of heat exposure, vomiting, excessive sweating and pulmonary infection. History of chronic presentation, in contrast, was often inconspicuous. The tendency to hypochloremia, hypokalemia and metabolic alkalosis was similar between subacute and chronic patients, with hyponatremia being more pronounced (P < 0.02) in subacute compared to chronic presentations. Subacute cases were treated parenterally; chronic ones were usually managed with oral salt supplementation. Retention of urea and creatinine was documented in 38 % of subacute cases. CONCLUSIONS The findings of our review suggest that physicians should be aware that electrolyte abnormalities can occur both as a presenting and a recurring feature of cystic fibrosis.
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Affiliation(s)
- Elisabetta Scurati-Manzoni
- Pediatric Emergency Unit, De Marchi Hospital, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Sezer RG, Aydemir G, Akcan AB, Paketci C, Karaoglu A, Aydinoz S, Bozaykut A. Nanoduct sweat conductivity measurements in 2664 patients: relationship to age, arterial blood gas, serum electrolyte profiles and clinical diagnosis. J Clin Med Res 2013; 5:34-41. [PMID: 23390474 PMCID: PMC3564566 DOI: 10.4021/jocmr1191w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2012] [Indexed: 12/16/2022] Open
Abstract
Background The Nanoduct® device has acceptable diagnostic accuracy, but there is not enough systematic data supporting its usage in the diagnosis of cystic fibrosis (CF). Methods A retrospective review of patients with an indication for the sweat test was conducted. The conductivity test was repeated in patients who had values higher than 60 mmol/L, and they were referred for sweat chloride measurements. Associations between sweat conductivity measurements and age, gender, (pH, HCO3, pCO2, Na, K, Cl), family history, consanguinity, indications for the test and number of hospitalization were studied. Results Among 2,664 patients, 16 children had sweat conductivity values higher than 80. The median age of patients diagnosed with CF was 4 months old. Age, pH, HCO3, Na, Cl, K and the sweat conductivity test were statistically related (P < 0.001). The ROC curve showed very high agreement between the 2nd conductivity test and the sweat test. Conclusions Patients suspected to have CF can be screened using the Nanoduct® conductivity device in non-qualified centers.
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Affiliation(s)
- Rabia Gonul Sezer
- Department of Pediatrics, Zeynep Kamil Maternity and Childrens Diseases Training and Research State Hospital, Istanbul, Turkey
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Deschênes G, Fila M. Primary molecular disorders and secondary biological adaptations in bartter syndrome. Int J Nephrol 2011; 2011:396209. [PMID: 21941653 PMCID: PMC3177086 DOI: 10.4061/2011/396209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/01/2011] [Indexed: 12/17/2022] Open
Abstract
Bartter syndrome is a hereditary disorder that has been characterized by the association of hypokalemia, alkalosis, and the hypertrophy of the juxtaglomerular complex with secondary hyperaldosteronism and normal blood pressure. By contrast, the genetic causes of Bartter syndrome primarily affect molecular structures directly involved in the sodium reabsorption at the level of the Henle loop. The ensuing urinary sodium wasting and chronic sodium depletion are responsible for the contraction of the extracellular volume, the activation of the renin-aldosterone axis, the secretion of prostaglandins, and the biological adaptations of downstream tubular segments, meaning the distal convoluted tubule and the collecting duct. These secondary biological adaptations lead to hypokalemia and alkalosis, illustrating a close integration of the solutes regulation in the tubular structures.
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Affiliation(s)
- Georges Deschênes
- Pediatric Nephrology Unit, Hôpital Robert-Debré, 48 Bd Sérurier, 75019 Paris, France
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12
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Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa KA, Spear SL, Michel SH, Parad RB, White TB, Farrell PM, Marshall BC, Accurso FJ. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr 2009; 155:S73-93. [PMID: 19914445 PMCID: PMC6324931 DOI: 10.1016/j.jpeds.2009.09.001] [Citation(s) in RCA: 270] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Newborn screening for cystic fibrosis (CF) offers the opportunity for early medical and nutritional intervention that can lead to improved outcomes. Management of the asymptomatic infant diagnosed with CF through newborn screening, prenatal diagnosis, or sibling screening is different from treatment of the symptomatically diagnosed individual. The focus of management is on maintaining health by preventing nutritional and respiratory complications. The CF Foundation convened a committee to develop recommendations based on a systematic review of the evidence and expert opinion. These guidelines encompass monitoring and treatment recommendations for infants diagnosed with CF and are intended to help guide families, primary care providers, and specialty care centers in the care of infants with CF.
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Coates AJ, Crofton PM, Marshall T. Evaluation of salt supplementation in CF infants. J Cyst Fibros 2009; 8:382-5. [PMID: 19800301 DOI: 10.1016/j.jcf.2009.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 08/13/2009] [Accepted: 08/21/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND CF infants may be at increased risk of sodium depletion which may lead to impaired growth. The objective of this study was to evaluate their sodium supplementation requirements. METHODS Ten CF infants had serial measurements of weight and plasma/urine sodium and creatinine. Sodium supplementation was adjusted with the aim of maintaining fractional excretion (FENa) between 0.5% and 1.5% and urinary sodium > 10 mmol/L. RESULTS Urine sodium:creatinine (UNa:Cr) ratio strongly correlated with FENa [UNa:Cr (mmol/mmol)=35.0 x FENa (r=0.99)]. The FENa target range corresponded to UNa:Cr 17-52 mmol/mmol. All infants required sodium supplementation to achieve UNa:Cr > 17 mmol/mmol. Sodium supplement requirements (mean+/-SD) at ages 0-3, 3-6, 6-9 and 9-12 months were 1.9+/-0.5, 1.8+/-0.8, 1.9+/-0.9 and 0.8+/-0.4 mmol/kg/d. No infant required calorie supplementation to achieve expected weight gain. CONCLUSIONS Using current UK guidelines, many cases of sodium depletion may be overlooked. Some infants require more than the recommended 1-2 mmol/kg/d. UNa:Cr ratio is a useful non-invasive measure to monitor sodium supplementation.
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Abstract
Newborn screening (NBS) for cystic fibrosis (CF) has evolved considerably from its beginnings. We review the early history of NBS in the USA and the evolution of CF NBS from its conception in observational studies, to the development of mass-screening methodology in the 1970s, and to its early applications in the USA and other countries. We review the development of current CF NBS algorithms, particularly the development of those used in the Wisconsin randomized controlled trial, and discuss the comparative utility of different algorithms. We also discuss the identified nutritional and respiratory benefits of CF NBS, discuss treatment strategies for newborns identified with CF, and also discuss opportunities for slowing the progression of this disease.
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Affiliation(s)
- Jack K Sharp
- Pediatric Pulmonology, Department of Pediatrics, The Women and Children's Hospital of Buffalo, The State University of New York at Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA.
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Kose M, Pekcan S, Ozcelik U, Cobanoglu N, Yalcin E, Dogru D, Kiper N. An epidemic of pseudo-Bartter syndrome in cystic fibrosis patients. Eur J Pediatr 2008; 167:115-6. [PMID: 17323076 DOI: 10.1007/s00431-007-0413-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 01/15/2007] [Indexed: 11/25/2022]
Affiliation(s)
- Mehmet Kose
- Department of Pediatrics, Division of Chest Diseases Unit, School of Medicine, Hacettepe University, 06100 Ankara, Turkey.
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Ballestero Y, Hernandez MI, Rojo P, Manzanares J, Nebreda V, Carbajosa H, Infante E, Baro M. Hyponatremic dehydration as a presentation of cystic fibrosis. Pediatr Emerg Care 2006; 22:725-7. [PMID: 17110865 DOI: 10.1097/01.pec.0000245170.31343.bb] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The purpose of this study is to present a case report of a child with hyponatremic dehydration diagnosed after CF and to review the cases of 13 patients with CF who had the same initial presentation in our hospital. METHODS This report reviewed the clinical records of children diagnosed with CF to ascertain the prevalence of metabolic alkalosis with electrolyte depletion as the presentation of CF. It also used sweat tests to diagnose a child with CF. RESULTS The laboratory tests of a 12-month-old girl presented 3 times to the ;pediatric emergency department with vomiting and weight loss showed hyponatremia, hypochloremia, and metabolic alkalosis. The patient was subsequently diagnosed with CF by means of 2 positive sweat tests. Meanwhile, the review of the clinical records of all children diagnosed with CF from 1985 to 2004 (N = 77) showed that the prevalence of metabolic alkalosis with electrolyte depletion as the presentation of CF was 16.8%. The age of the infants ranged from 3 to 14 months. All episodes took place during summer. CONCLUSIONS There are not many causes of metabolic alkalosis with hyponatremic dehydration, and one of them is CF. This report emphasizes sodium depletion as a common sign of CF presentation. This is most important in countries where the neonatal screening test for CF is not available because the disease may be asymptomatic or oligosymptomatic for several months or even years. Cystic fibrosis should be considered in differential diagnosis of any child presenting with unexplained hyponatremic dehydration.
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Yalçin E, Kiper N, Doğru D, Ozçelik U, Aslan AT. Clinical features and treatment approaches in cystic fibrosis with pseudo-Bartter syndrome. ACTA ACUST UNITED AC 2005; 25:119-24. [PMID: 15949200 DOI: 10.1179/146532805x45719] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Infants with cystic fibrosis (CF) are prone to develop episodes of hyponatraemic, hypochloraemic dehydration with metabolic alkalosis, which are biochemical hallmarks of the pseudo-Bartter syndrome (PB). METHOD We reviewed the clinical and laboratory features and treatment approaches of 29 children with CF and PB who were under follow-up in our institution from May 1992 to November 2003. RESULTS Of 241 patients with CF, PB was detected in 29 (12%) with a median age of 4 months at the time of the first attack. Most patients experienced vomiting, loss of appetite and dehydration during episodes of PB. All patients were managed with intravenous fluids and sodium chloride solutions. During follow-up, 12/29 cases required hospital admission for recurrent PB attacks. The oldest age at the time of the last attack was 48 months. CONCLUSIONS CF should be considered in the differential diagnosis of metabolic alkalosis in young children. Vomiting and loss of appetite are important warning signs of possible PB in CF patients, particularly before 4 years of age. To prevent serious complications, it is crucial that parents and physicians recognise PB as early as possible.
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Affiliation(s)
- Ebru Yalçin
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Abstract
The diagnosis of cystic fibrosis (CF) generally is made within the first few years of life, although some cases will not be diagnosed until adulthood. For most patients the diagnosis is suggested by typical CF-related symptoms such as chronic respiratory infection or maldigestion. The authors describe an adult patient with newly diagnosed CF whose presenting abnormalities consisted of hypokalemia and metabolic alkalosis. These are known complications of CF but are not common presenting features that lead to the diagnosis of CF. The authors discuss their patient's presentation and review his metabolic manifestations of CF.
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Affiliation(s)
- Shoban Davé
- Department of Medicine, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC 29425, USA.
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Whitehead FJ, Couper RT, Moore L, Bourne AJ, Byard RW. Dehydration deaths in infants and young children. Am J Forensic Med Pathol 1996; 17:73-8. [PMID: 8838476 DOI: 10.1097/00000433-199603000-00014] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dehydration in developed countries is an uncommon but important mechanism resulting in the death of infants and children. The clinicopathological features of a series of 37 fatal dehydration cases autopsied at the Adelaide Children's Hospital over a 33-year period (1961-1993) are presented. Causative factors for dehydration included gastroenteritis (21 cases), gastroenteritis with high environmental temperature (one case), high environmental temperatures (six cases), neglect/failure to thrive (four cases), mental retardation/chromosomal abnormality (three cases), congenital adrenal hyperplasia (one case), and unsuspected cystic fibrosis (one case). The mean age at death was 11.4 months (range 2 weeks to 6.25 years; median 6 months; 95% confidence interval 6 months to 1 year and 4 months; male-to-female ratio, 19:18). Sixteen of the 22 cases of fatal gastroenteritis (73%) occurred during the fall/winter months (March to August). There were a total of seven aboriginal or part aboriginal children in the group (19%). Children with mental retardation were at higher risk of dehydration, and previously unsuspected cases of child abuse/neglect also presented with lethal dehydration. Vitreous humor electrolyte levels and immunoassay for rotavirus were useful diagnostic adjuncts.
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Affiliation(s)
- F J Whitehead
- Department of Histopathology, Women's and Children's Hospital, Adelaide, Australia
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21
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Escobar Castro H, Medina E, Kirchschläger E, Camarero C, Suarez L. Metabolic alkalosis with hypo-electrolytaemia or pseudo-Bartter syndrome as a presentation of cystic fibrosis in infancy. Discription of three cases. Eur J Pediatr 1995; 154:868-9. [PMID: 8529696 DOI: 10.1007/bf01959806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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