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Clode M, Tran D, Majumdar A, Ayer J, Ferrie S, Cordina R. Nutritional considerations for people living with a Fontan circulation: a narrative review. Cardiol Young 2024; 34:238-249. [PMID: 38258459 DOI: 10.1017/s1047951123004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The population of people living with a Fontan circulation are highly heterogenous, including both children and adults, who have complex health issues and comorbidities associated with their unique physiology throughout life. Research focused on nutritional considerations and interventions in the Fontan population is extremely limited beyond childhood. This review article discusses the current literature examining nutritional considerations in the setting of Fontan physiology and provides an overview of the available evidence to support nutritional management strategies and future research directions. Protein-losing enteropathy, growth deficits, bone mineral loss, and malabsorption are well-recognised nutritional concerns within this population, but increased adiposity, altered glucose metabolism, and skeletal muscle deficiency are also more recently identified issues. Emergencing evidence suggets that abnormal body composition is associated with poor circulatory function and health outcomes. Many nutrition-related issues, including the impact of congenital heart disease on nutritional status, factors contributing to altered body composition and comorbidities, as well as the role of the microbiome and metabolomics, remain poodly understood.
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Affiliation(s)
- Melanie Clode
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Derek Tran
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Avik Majumdar
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
| | - Julian Ayer
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- The Heart Centre for Children, The Sydney Children's Hospital Network, Westmead, NSW, Australia
| | - Suzie Ferrie
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Rachael Cordina
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Thom K, Patsch JM, Haufler F, Pees C, Albinni S, Weber M, Male C, Raimann A. Evaluation of bone mineral density and bone turnover in children on anticoagulation. Front Endocrinol (Lausanne) 2023; 14:1192670. [PMID: 37600706 PMCID: PMC10433196 DOI: 10.3389/fendo.2023.1192670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background Childhood and adolescence are critical periods of bone mineral acquisition. Children on anticoagulation (AC) might have an increased risk for reduced bone mineral density (BMD). Risk factors for impaired bone accumulation include chronic diseases, immobility, and medication. Vitamin K (VK) deficiency reflected by undercarboxylated osteocalcin levels (ucOC) has been identified as a predictor of osteoporosis and fractures. Data on bone health in children under AC are sparse. Aims To evaluate BMD in children on AC and characterize the risk factors of low BMD, including VK and Vitamin D (VD) status. Methods Single-center cross-sectional study of clinical, biochemical, and densitometric parameters. Assessment of VK surrogate parameters included ucOC and matrix gla protein (MGP). Results A total of 39 children (4-18 years; 12 females) receiving AC were included, 31 (79%) on VK antagonists and 8 (21%) on direct oral anticoagulants. Overall, BMD was decreased for both the lumbar spine (LS; -0.7SDS) and total body less head (TBLH; -1.32SDS) compared with pediatric reference data. Significant associations were found between early pubertal development and TBLH-BMD, and between BMI and LS-BMD. VK surrogate parameters were highly related to patients' age and pubertal development. Neither serum parameters nor AC-related factors predicted BMD. VD was detected in 10/39 patients with lower values during puberty. Conclusion Our data indicate BMD reduction in pediatric patients on AC. Although AC-related factors did not predict reduced BMD, low BMI and pubertal stages represented important risk factors. Awareness of risk factors for low BMD and high prevalence of VD deficiency during puberty could contribute to the improvement of bone health in this vulnerable patient group.
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Affiliation(s)
- Katharina Thom
- Division of Pediatric Cardiology and Haemostaseology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Janina Maria Patsch
- Division of General and Pediatric Radiology, Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Florentina Haufler
- Vienna Bone and Growth Center, Vienna, Austria
- Division of Pulmonology, Allergology and Endocrinology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Christiane Pees
- Division of Pediatric Cardiology and Haemostaseology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Sulaima Albinni
- Division of Pediatric Cardiology and Haemostaseology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Division of General and Pediatric Radiology, Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christoph Male
- Division of Pediatric Cardiology and Haemostaseology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Division of Pulmonology, Allergology and Endocrinology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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Abstract
BACKGROUND Cyanotic CHD is one of many disorders in paediatrics that influence the health of children in different clinical aspects. One of the fundamental aspects that may be affected is bone mineral density. OBJECTIVES The aim of our study is to assess bone mineral density in children with congenital cyanotic heart disease of different anatomical diagnoses. DESIGN/METHODS Cross-sectional, observational study included 39 patients (20 males) with congenital cyanotic heart disease of different anatomical diagnoses following with the cardiology clinic in Mansoura University children's hospital. All patients were subjected to anthropometric measures, oxygen saturation assessment, and lumber bone mineral density using dual-energy X-ray absorptiometry. RESULTS Six patients (15.4%) out of the 39 included patients showed bone mineral density reduction, 13 patients (33.3%) showed bone mineral density with Z-score between -1 and -2, while 20 patients (51.3%) showed bone mineral density with Z-score more than -1. CONCLUSION Low bone mineral density can be found in children with cyanotic CHD, making it important to consider bone mineral density assessment and early treatment if needed to avoid further complications.
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Vaikunth SS, Leonard MB, Whitehead KK, Goldberg DJ, Rychik J, Zemel BS, Avitabile CM. Deficits in the Functional Muscle-Bone Unit in Youths with Fontan Physiology. J Pediatr 2021; 238:202-207. [PMID: 34214589 PMCID: PMC8634795 DOI: 10.1016/j.jpeds.2021.06.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether dual energy X-ray absorptiometry (DXA), a clinically available tool, mirrors the magnitude of deficits in trabecular and cortical bone mineral density (BMD) demonstrated on peripheral quantitative computed tomography in youth with Fontan physiology. STUDY DESIGN We aimed to describe DXA-derived BMD at multiple sites and to investigate the relationship between BMD and leg lean mass, a surrogate for skeletal muscle loading. Subjects with Fontan (n = 46; aged 5-20 years) underwent DXA in a cross-sectional study of growth and bone and muscle health as described previously. Data from the Bone Mineral Density in Childhood Study were used to calculate age-, sex-, and race-specific BMD z-scores of the whole body, lumbar spine, hip, femoral neck, distal one-third radius, ultradistal radius, and leg lean mass z-score (LLMZ). RESULTS Fontan BMD z-scores were significantly lower than reference at all sites-whole body, -0.34 ± 0.85 (P = .01); spine, -0.41 ± 0.96 (P = .008); hip, -0.75 ± 1.1 (P < .001); femoral neck, -0.73 ± 1.0 (P < .001); distal one-third radius, -0.87 ± 1.1 (P < .001); and ultradistal radius. -0.92 ± 1.03 (P < .001)-as was LLMZ (-0.93 ± 1.1; P < .001). Lower LLMZ was associated with lower BMD of the whole body (R2 = 0.40; P < .001), lumbar spine (R2 = 0.16; P = .005), total hip (R2 = 0.32; P < .001), femoral neck (R2 = 0.47; P < .001), and ultradistal radius (R2 = 0.35; P < .001). CONCLUSIONS Patients with Fontan have marked deficits in both cortical (hip, distal one-third radius) and trabecular (lumbar spine, femoral neck, ultradistal radius) BMD. Lower LLMZ is associated with lower BMD and may reflect inadequate skeletal muscle loading. Interventions to increase muscle mass may improve bone accrual.
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Affiliation(s)
- Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B. Leonard
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin K. Whitehead
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S. Zemel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M. Avitabile
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Attard C, Monagle PT, d'Udekem Y, Mackay MT, Briody J, Cordina R, Hassan EB, Simm P, Rice K, Ignjatovic V. Long-term outcomes of warfarin versus aspirin after Fontan surgery. J Thorac Cardiovasc Surg 2021; 162:1218-1228.e3. [PMID: 33563422 DOI: 10.1016/j.jtcvs.2020.12.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/27/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Because of the nature of the Fontan physiology, patients are at an increased risk of thromboembolic complications. As such, warfarin or aspirin is generally prescribed lifelong for thromboprophylaxis. This study aimed to compare long-term rates of cerebrovascular injury, thrombosis, bleeding, bone mineral density, and quality of life in people living with Fontan circulation receiving warfarin compared with aspirin. METHODS This was a multicenter study of a selected cohort from the Australia and New Zealand Fontan population. Participants underwent cerebral magnetic resonance imaging to detect the presence of cerebrovascular injury (n = 84) and dual-energy X-ray absorptiometry to assess bone mineral density (n = 120). Bleeding (n = 100) and quality of life (n = 90) were assessed using validated questionnaires: Warfarin and Aspirin Bleeding assessment tool and Pediatric Quality of Life Inventory, respectively. RESULTS Stroke was detected in 33 participants (39%), with only 7 (6%) being clinically symptomatic. There was no association between stroke and Fontan type or thromboprophylaxis type. Microhemorrhage and white matter injury were detected in most participants (96% and 86%, respectively), regardless of thromboprophylaxis type. Bleeding rates were high in both groups; however, bleeding was more frequent in the warfarin group. Bone mineral density was reduced in our cohort compared with the general population; however, this was further attenuated in the warfarin group. Quality of life was similar between the warfarin and aspirin groups. Home international normalized ratio monitoring was associated with better quality of life scores in the warfarin group. CONCLUSIONS Cerebrovascular injury is a frequent occurrence in the Australia and New Zealand Fontan population regardless of thromboprophylaxis type. No benefit of long-term warfarin prophylaxis could be demonstrated over aspirin; however, consideration must be given to important clinical features such as cardiac function and lung function. Furthermore, the association of reduced bone health in children receiving warfarin warrants further mechanistic studies.
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Affiliation(s)
- Chantal Attard
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia.
| | - Paul T Monagle
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Julie Briody
- Nuclear Medicine, The Children's Hospital at Westmead, Westmead, Australia; The University of Sydney Children's Hospital, Westmead Clinical School, Westmead, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health Sciences, University of Sydney, Sydney, Australia
| | - Ebrahim Bani Hassan
- Australian Institute for Musculoskeletal Science, The University of Melbourne and Western Health, Melbourne, Australia; Department of Medicine-Western Health, The University of Melbourne, Melbourne, Australia
| | - Peter Simm
- Murdoch Children's Research Institute, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia; Department of Paediatric Endocrinology and Diabetes, Monash Children's Hospital, Clayton, Australia
| | - Kathryn Rice
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia
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Low bone mineral density in adults with complex congenital heart disease. Int J Cardiol 2020; 319:62-66. [DOI: 10.1016/j.ijcard.2020.06.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/31/2020] [Accepted: 06/26/2020] [Indexed: 11/18/2022]
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Defining the path ahead for NOAC use in the pediatric population: A Cardiac Safety Research Consortium Think Tank. Am Heart J 2020; 224:138-147. [PMID: 32388153 DOI: 10.1016/j.ahj.2020.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 11/20/2022]
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Reddy S, Handler SS, Wu S, Rabinovitch M, Wright G. Proceedings From the 2019 Stanford Single Ventricle Scientific Summit: Advancing Science for Single Ventricle Patients: From Discovery to Clinical Applications. J Am Heart Assoc 2020; 9:e015871. [PMID: 32188306 PMCID: PMC7428620 DOI: 10.1161/jaha.119.015871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Because of remarkable advances in survival over the past 40 years, the worldwide population of individuals with single ventricle heart disease living with Fontan circulation has grown to ≈70 000, with nearly half aged >18 years. Survival to at least 30 years of age is now achievable for 75% of Fontan patients. On the other hand, single ventricle patients account for the largest group of the 6000 to 8000 children hospitalized with circulation failure, with or without heart failure annually in the United States, with the highest in‐hospital mortality. Because there is little understanding of the underlying mechanisms of heart failure, arrhythmias, pulmonary and lymphatic vascular abnormalities, and other morbidities, there are no specific treatments to maintain long‐term myocardial performance or to optimize overall patient outcomes.
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Affiliation(s)
- Sushma Reddy
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
| | | | - Sean Wu
- Department of Medicine (Cardiology) Stanford University Palo Alto CA
| | | | - Gail Wright
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
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Abstract
BACKGROUND This is a cross-sectional study aiming to understand the early characteristics and background of bone health impairment in clinically well children with Fontan circulation. METHODS We enrolled 10 clinically well children with Fontan palliation (operated >5 years before study entrance, Tanner stage ≤3, age 12.1 ± 1.77 years, 7 males) and 11 healthy controls (age 12.0 ± 1.45 years, 9 males) at two children's hospitals. All patients underwent peripheral quantitative CT. For the Fontan group, we obtained clinical characteristics, NYHA class, cardiac index by MRI, dual x-ray absorptiometry, and biochemical studies. Linear regression was used to compare radius and tibia peripheral quantitative CT measures between Fontan patients and controls. RESULTS All Fontan patients were clinically well (NYHA class 1 or 2, cardiac index 4.85 ± 1.51 L/min/m2) and without significant comorbidities. Adjusted trabecular bone mineral density, cortical thickness, and bone strength index at the radius were significantly decreased in Fontan patients compared to controls with mean differences -30.13 mg/cm3 (p = 0.041), -0.31 mm (p = 0.043), and -6.65 mg2/mm4 (p = 0.036), respectively. No differences were found for tibial measures. In Fontan patients, the mean height-adjusted lumbar bone mineral density and total body less head z scores were -0.46 ± 1.1 and -0.63 ± 1.1, respectively, which are below the average, but within normal range for age and sex. CONCLUSIONS In a clinically well Fontan cohort, we found significant bone deficits by peripheral quantitative CT in the radius but not the tibia, suggesting non-weight-bearing bones may be more vulnerable to the unique haemodynamics of the Fontan circulation.
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D’Ambrosio P, Tran D, Verrall CE, Attard C, Singh MF, Ayer J, d’Udekem Y, Twigg S, Celermajer DS, Cordina R. Prevalence and risk factors for low bone density in adults with a Fontan circulation. CONGENIT HEART DIS 2019; 14:987-995. [DOI: 10.1111/chd.12836] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Paolo D’Ambrosio
- Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health Sciences University of Sydney Sydney New South Wales Australia
| | - Derek Tran
- Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health Sciences University of Sydney Sydney New South Wales Australia
| | - Charlotte E. Verrall
- The Heart Centre for Children The Children’s Hospital at Westmead Sydney New South Wales Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health and Medicine University of Sydney Sydney New South Wales Australia
| | - Chantal Attard
- Murdoch Children’s Research Institute Royal Children’s Hospital Melbourne Victoria Australia
| | - Maria Fiatarone Singh
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Sydney Medical School, Faculty of Health Sciences The University of Sydney Sydney New South Wales Australia
- Hebrew SeniorLife and Jean Mayer USDA Human Nutrition Research Center on Ageing Tufts University Boston Massachusetts
| | - Julian Ayer
- The Heart Centre for Children The Children’s Hospital at Westmead Sydney New South Wales Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health and Medicine University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre, University of Sydney Sydney New South Wales Australia
| | - Yves d’Udekem
- Murdoch Children’s Research Institute Royal Children’s Hospital Melbourne Victoria Australia
- Department of Cardiothoracic Surgery Royal Children’s Hospital Melbourne Victoria Australia
- Department of Pediatrics University of Melbourne Melbourne Victoria Australia
| | - Stephen Twigg
- Faculty of Medicine and Health Sciences University of Sydney Sydney New South Wales Australia
- Department of Endocrinology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - David S. Celermajer
- Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health Sciences University of Sydney Sydney New South Wales Australia
- Heart Research Institute Sydney New South Wales Australia
| | - Rachael Cordina
- Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health Sciences University of Sydney Sydney New South Wales Australia
- Murdoch Children’s Research Institute Royal Children’s Hospital Melbourne Victoria Australia
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Kampouraki E, Avery PJ, Biss T, Kamali F. Association between CYP4F2 genotype and circulating plasma vitamin K concentration in children on chronic warfarin therapy: Possible long-term implications for bone development and vascular health. Pediatr Blood Cancer 2017; 64. [PMID: 28521079 DOI: 10.1002/pbc.26653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/31/2017] [Accepted: 05/03/2017] [Indexed: 11/11/2022]
Abstract
Vitamin K is essential, for the activation of clotting proteins, as well as the biosynthesis of osteocalcin in bones and the activation of matrix-Gla protein needed in maintaining vasculature health. Cytochrome p450 4F2 (CYP4F2) enzyme is involved in vitamin K catabolism. Genetic polymorphism in CYP4F2 is thus likely to affect vitamin K systemic availability. We show that children on chronic warfarin therapy have low levels of vitamin K and vitamin K levels are linked to CYP4F2 genotype. Long-term low levels of vitamin K, influenced by CYP4F2 genotype, might affect bone development and vascular health in children on chronic warfarin therapy.
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Affiliation(s)
- Emmanouela Kampouraki
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter J Avery
- School of Mathematics & Statistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tina Biss
- Department of Haematology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Farhad Kamali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Sugiyama T, Kono Y, Sekiguchi K, Kim YT, Oda H. An evidence-based perspective on warfarin and the growing skeleton. Osteoporos Int 2016; 27:2883-2884. [PMID: 27091741 DOI: 10.1007/s00198-016-3588-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 03/30/2016] [Indexed: 12/11/2022]
Affiliation(s)
- T Sugiyama
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan.
| | - Y Kono
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - K Sekiguchi
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - Y T Kim
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - H Oda
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
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Abstract
BACKGROUND Limited data exist on the vitamin D status in Fontan patients. We determined the prevalence and potential risk factors of vitamin D deficiency in this patient subset. Methods and results Data were collected from 27 Fontan patients (55.6% male, mean age 8.1±5.3 years). Protein-losing enteropathy was diagnosed in six patients (22.2%). Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D level of <20 ng/ml. The neutrophil-to-lymphocyte ratio, a marker of systemic inflammation, was calculated. Associations between laboratory measurements and patient characteristics were explored. Mean serum 25-hydroxyvitamin D level was 14.1±10.4 ng/ml. Vitamin D deficiency was found in 19/27 patients (70.3%). Only skin type was associated with vitamin D deficiency (p=0.04). Hyperparathyroidism was present in 5/21 (23.8%) patients, and was more prevalent in patients with protein-losing enteropathy (p<0.001). Parathyroid hormone levels correlated with parameters of systemic inflammation (neutrophil-to-lymphocyte ratio: r=0.484, p=0.026; relative lymphocyte count: r=-0.635, p=0.002). Vitamin D supplementation significantly increased serum 25-hydroxyvitamin D levels (p<0.0001), and was accompanied by a reduction in parathyroid hormone concentrations (p=0.032). CONCLUSIONS A high prevalence of vitamin D deficiency was found among Fontan patients, independent of age, time after Fontan procedure, ventricular morphology, and presence of protein-losing enteropathy. A potentially important link between parathyroid hormone levels and systemic inflammation is suggested.
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Avila ML, Pullenayegum E, Williams S, Shammas A, Stimec J, Sochett E, Marr K, Brandão LR. Timing of low bone mineral density and predictors of bone mineral density trajectory in children on long-term warfarin: a longitudinal study. Osteoporos Int 2016; 27:1547-1557. [PMID: 26572757 DOI: 10.1007/s00198-015-3411-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/05/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED We studied bone mineral density (BMD) of children exposed to long-term warfarin. BMD Z-scores ≤ -2.0 were estimated to occur in less than one fifth of the patients after 10 years of warfarin exposure, and BMI and growth hormone deficiency predicted BMD changes over time. These predictors can help identify high-risk patients. INTRODUCTION Children with chronic diseases are at increased risk of developing thrombosis, which may require long-term warfarin therapy. Warfarin could further jeopardize the bone health of a population already at risk for bone fragility. Our objective was to investigate the occurrence and timing of low bone mineral density (BMD) and the predictors that influence BMD trajectory in children receiving warfarin for >1 year. METHODS We analyzed the results of an institutional protocol that includes dual-energy X-ray absorptiometry, with or without spinal X-rays and laboratory biomarkers, as required. RESULTS Low BMD (age, sex, race, and height-for-age-Z-score adjusted BMD Z-score ≤ -2.0) was detected in 13 % (9/70) of the patients at some point during their follow-up; these patients were more likely to have complex underlying medical conditions and low body mass index (BMI) percentile. BMD Z-scores remained within normal range in 87 % of children. Survival analysis showed that the estimated 10-year abnormal BMD-free rate for the entire group was 81 % (95 % confidence interval [CI] 69 to 93 %). Trajectory analysis revealed that BMI percentiles at baseline and growth hormone deficiency (GHD) were associated with lower BMD Z-scores at the first assessment, whereas baseline BMI percentile was the only predictor of BMD Z-score over time. CONCLUSIONS Our findings identified BMI and GHD as risk factors influencing BMD in children exposed to long-term warfarin, creating an opportunity for early detection and intervention in these patients.
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Affiliation(s)
- M L Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - E Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - S Williams
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - A Shammas
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - J Stimec
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - E Sochett
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - K Marr
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - L R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada.
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