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Formisano E, Proietti E, Perrone G, Demarco V, Galoppi P, Stefanutti C, Pisciotta L. Characteristics, Physiopathology and Management of Dyslipidemias in Pregnancy: A Narrative Review. Nutrients 2024; 16:2927. [PMID: 39275243 PMCID: PMC11397408 DOI: 10.3390/nu16172927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/28/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD). During pregnancy, physiological changes elevate cholesterol and triglyceride levels to support fetal development, which can exacerbate pre-existing conditions and lead to complications such as pre-eclampsia, gestational diabetes, and increased ASCVD risk for both mother and child. Effective management strategies are necessary, especially for pregnant women with inherited forms of dyslipidemia (i.e., familial hypertriglyceridemia, hyperchylomicronemia), where personalized dietary adjustments are crucial for successful pregnancy outcomes. Pharmacological interventions and lipoprotein apheresis may be necessary for severe cases, though their use is often limited by factors such as cost, availability, and potential fetal risks. Despite the promise of advanced therapies, their widespread application remains constrained by limited studies and high costs. Thus, a personalized, multidisciplinary approach is essential for optimizing outcomes. This review provides a comprehensive overview of current strategies and evidence-based practices for managing dyslipidemia during pregnancy, emphasizing the balance of maternal and fetal health. Additionally, it discusses the physiological changes in lipid metabolism during pregnancy and their implications, particularly for women with inherited forms of dyslipidemia.
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Affiliation(s)
- Elena Formisano
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- Dietetics and Clinical Nutrition Unit, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
| | - Elisa Proietti
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
| | - Giuseppina Perrone
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Valentina Demarco
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Paola Galoppi
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Claudia Stefanutti
- Department of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre for Rare Diseases, Immunohematology and Transfusion Medicine, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Livia Pisciotta
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- Dietetics and Clinical Nutrition Unit, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
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Bashir B, Ferdousi M, Durrington P, Soran H. Pancreatic and cardiometabolic complications of severe hypertriglyceridaemia. Curr Opin Lipidol 2024; 35:208-218. [PMID: 38841827 PMCID: PMC11224574 DOI: 10.1097/mol.0000000000000939] [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: 06/07/2024]
Abstract
PURPOSE OF REVIEW This review endeavours to explore the aetiopathogenesis and impact of severe hypertriglyceridemia (SHTG) and chylomicronaemia on cardiovascular, and pancreatic complications and summarizes the novel pharmacological options for management. RECENT FINDINGS SHTG, although rare, presents significant diagnostic and therapeutic challenges. Familial chylomicronaemia syndrome (FCS), is the rare monogenic form of SHTG, associated with increased acute pancreatitis (AP) risk, whereas relatively common multifactorial chylomicronaemia syndrome (MCS) leans more towards cardiovascular complications. Despite the introduction and validation of the FCS Score, FCS continues to be underdiagnosed and diagnosis is often delayed. Longitudinal data on disease progression remains scant. SHTG-induced AP remains a life-threatening concern, with conservative treatment as the cornerstone while blood purification techniques offer limited additional benefit. Conventional lipid-lowering medications exhibit minimal efficacy, underscoring the growing interest in novel therapeutic avenues, that is, antisense oligonucleotides (ASO) and short interfering RNA (siRNA) targeting apolipoprotein C3 (ApoC3) and angiopoietin-like protein 3 and/or 8 (ANGPTL3/8). SUMMARY Despite advancements in understanding the genetic basis and pathogenesis of SHTG, diagnostic and therapeutic challenges persist. The rarity of FCS and the heterogenous phenotype of MCS underscore the need for the development of predictive models for complications and tailored personalized treatment strategies. The establishment of national and international registries is advocated to augment disease comprehension and identify high-risk individuals.
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Affiliation(s)
- Bilal Bashir
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester University NHS Foundation Trust
- NIHR/WELLCOME Trust Clinical Research Facility, Manchester, UK
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester
- NIHR/WELLCOME Trust Clinical Research Facility, Manchester, UK
| | - Paul Durrington
- Faculty of Biology, Medicine and Health, University of Manchester
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester University NHS Foundation Trust
- NIHR/WELLCOME Trust Clinical Research Facility, Manchester, UK
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Zhan W, Peng H, Xie S, Deng Y, Zhu T, Cui Y, Cao H, Tang Z, Jin M, Zhou Q. Dietary lauric acid promoted antioxidant and immune capacity by improving intestinal structure and microbial population of swimming crab (Portunus trituberculatus). FISH & SHELLFISH IMMUNOLOGY 2024; 151:109739. [PMID: 38960108 DOI: 10.1016/j.fsi.2024.109739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/20/2024] [Accepted: 06/30/2024] [Indexed: 07/05/2024]
Abstract
Lauric acid (LA), a saturated fatty acid with 12 carbon atoms, is widely regarded as a healthy fatty acid that plays an important role in disease resistance and improving immune physiological function. The objective of this study was to determine the effects of dietary lauric acid on the growth performance, antioxidant capacity, non-specific immunity and intestinal microbiology, and evaluate the potential of lauric acids an environmentally friendly additive in swimming crab (Portunus trituberculatus) culture. A total of 192 swimming crabs with an initial body weight of 11.68 ± 0.02 g were fed six different dietary lauric acid levels, the analytical values of lauric acid were 0.09, 0.44, 0.80, 1.00, 1.53, 2.91 mg/g, respectively. There were four replicates per treatment and 8 juvenile swimming crabs per replicate. The results indicated that final weight, percent weight gain, specific growth rate, survival and feed intake were not significantly affected by dietary lauric acid levels; however, crabs fed diets with 0.80 and 1.00 mg/g lauric acid showed the lowest feed efficiency among all treatments. Proximate composition in hepatopancreas and muscle were not significantly affected by dietary lauric acid levels. The highest activities of amylase and lipase in hepatopancreas and intestine were found at crabs fed diet with 0.80 mg/g lauric acid (P < 0.05), the activity of carnitine palmityl transferase (CPT) in hepatopancreas and intestine significantly decreased with dietary lauric acid levels increasing from 0.09 to 2.91 mg/g (P < 0.05). The lowest concentration of glucose and total protein and the activity of alkaline phosphatase in hemolymph were observed at crabs fed diets with 0.80 and 1.00 mg/g lauric acid among all treatments. The activity of GSH-Px in hepatopancreas significantly increased with dietary lauric acid increasing from 0.09 to 1.53 mg/g, MDA in hepatopancreas and hemolymph was not significantly influenced by dietary lauric acid levels. The highest expression of cat and gpx in hepatopancreas were exhibited in crabs fed diet with 1.00 mg/g lauric acid, however, the expression of genes related to the inflammatory signaling pathway (relish, myd88, traf6, nf-κB) were up-regulated in the hepatopancreas with dietary lauric acid levels increasing from 0.09 to 1.00 mg/g, moreover, the expression of genes related to intestinal inflammatory, immune and antioxidant were significantly affected by dietary lauric acid levels (P < 0.05). Crabs fed diet without lauric acid supplementation exhibited higher lipid drop area in hepatopancreas than those fed the other diets (P < 0.05). The expression of genes related to lipid catabolism was up-regulated, however, and the expression of genes related to lipid synthesis was down-regulated in the hepatopancreas of crabs fed with 0.80 mg/g lauric acid. Lauric acid improved hepatic tubular integrity, and enhanced intestinal barrier function by increasing peritrophic membrane (PM) thickness and upregulating the expression of structural factors (per44, zo-1) and intestinal immunity-related genes. In addition, dietary 1.00 mg/g lauric acid significantly improved the microbiota composition of the intestinal, increased the abundance of Actinobacteria and Rhodobacteraceae, and decreased the abundance of Vibrio, thus maintaining the microbiota balance of the intestine. The correlation analysis showed that there was a relationship between intestinal microbiota and immune-antioxidant function. In conclusion, the dietary 1.00 mg/g lauric acid is beneficial to improve the antioxidant capacity and intestinal health of swimming crab.
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Affiliation(s)
- Wenhao Zhan
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Hongyu Peng
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Shichao Xie
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Yao Deng
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Tingting Zhu
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Yuhui Cui
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Haiqing Cao
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Zheng Tang
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Min Jin
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China
| | - Qicun Zhou
- Laboratory of Fish and Shellfish Nutrition, School of Marine Sciences, Ningbo University, Ningbo, 315211, China.
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Bardey F, Rieck L, Spira D, März W, Binner P, Schwab S, Kleber ME, Danyel M, Barkowski R, Bobbert T, Spranger J, Steinhagen-Thiessen E, Demuth I, Kassner U. Clinical characterization and mutation spectrum of patients with hypertriglyceridemia in a German outpatient clinic. J Lipid Res 2024:100589. [PMID: 38969064 DOI: 10.1016/j.jlr.2024.100589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/13/2024] [Accepted: 06/21/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) has predominantly multifactorial causes (MCS). Yet a small subset of patients have the monogenetic form (FCS). It remains a challenge to distinguish patients clinically, since decompensated MCS might mimic FCS´s severity. Aim of the current study was to determine clinical criteria that could sufficiently distinguish both forms as well as to apply the FCS score proposed by Moulin and colleagues. METHODS We retrospectively studied 72 patients who presented with severe HTG in our clinic during a time span of seven years and received genetic testing. We classified genetic variants (ACMG-criteria), followed by genetic categorization into MCS or FCS. Clinical data were gathered from the medical records and the FCS score was calculated for each patient. RESULTS Molecular genetic screening revealed eight FCS patients and 64 MCS patients. Altogether, we found 13 pathogenic variants of which four have not been described before. The FCS patients showed a significantly higher median triglyceride level compared to the MCS. The FCS score yielded a sensitivity of 75% and a specificity of 93.7% in our cohort, and significantly differentiated between the FCS and MCS group (p<0.001). CONCLUSIONS In our cohort we identified several variables that significantly differentiated FCS from MCS. The FCS score performed similar to the original study by Moulin, thereby further validating the discriminatory power of the FCS score in an independent cohort.
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Affiliation(s)
- Frieda Bardey
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Lorenz Rieck
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Dominik Spira
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Winfried März
- Synlab Academy, P5, 7, 68167 Mannheim, Germany; Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Auenbrugger Platz 15, 8036 Graz
| | - Priska Binner
- Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Stefanie Schwab
- Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Marcus E Kleber
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; Synlab Center of Human Genetics, Harrlachweg 1, 68163 Mannheim, Germany
| | - Magdalena Danyel
- Berlin Institute of Health (BIH), Berlin, Germany; Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Rasmus Barkowski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Thomas Bobbert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Joachim Spranger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Ilja Demuth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany; Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.
| | - Ursula Kassner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Augustenburger Platz 1, 13353 Berlin, Germany
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Heath O, Allender B, Smith J, Savva E, Spencer L, Bannister EG, Brown NJ, Evans MS, Kiss S, Rozen TH, Yaplito‐Lee J. Diagnosis and stabilisation of familial chylomicronemia syndrome in two infants presenting with hypertriglyceridemia-induced acute pancreatitis. JIMD Rep 2024; 65:239-248. [PMID: 38974610 PMCID: PMC11224501 DOI: 10.1002/jmd2.12434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 07/09/2024] Open
Abstract
Familial chylomicronemia syndrome (FCS) is a rare disorder of triglyceride (TG) metabolism caused by loss of function variants in one of five known canonical genes involved in chylomicron lipolysis and clearance-LPL, APOC2, APOA5, LMF1, and GPIHBP1. Pathogenic variants in LPL, which encodes the hydrolytic enzyme lipoprotein lipase, account for over 80%-90% of cases. FCS may present in infancy with hypertriglyceridemia-induced acute pancreatitis and is challenging to manage both acutely and in the long-term. Here, we report our experience managing two unrelated infants consecutively diagnosed with hypertriglyceridemia-induced acute pancreatitis caused by LPL deficiency. Both had elevated TGs at presentation (205 and 30 mmol/L, respectively) and molecular genetic testing confirmed each infant carried a different homozygous pathogenic variant in the LPL gene, specifically, c.987C>A (p.Tyr329Ter) and c.632C>A (p.Thr211Lys). The more severely affected infant had cutaneous xanthomata, lipemia retinalis and lipemic plasma at presentation, and required management in an intensive care setting. Acute stabilisation was achieved using insulin and heparin infusions together with the iterative implementation of a fat-restricted diet, low in long chain triglycerides (LCT) and supplemented with medium chain triglycerides (MCT). In both cases, provision of adequate caloric intake (~110-120 kcal/kg/day) was also found to be important for a sustained TG reduction during the acute phase of management. In summary, a high index of suspicion is required to diagnose FCS in infants with hypertriglyceridemia-induced acute pancreatitis, management of which can be challenging, highlighting the need for more evidence-based recommendations.
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Affiliation(s)
- Oliver Heath
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | - Brooke Allender
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Joel Smith
- Laboratory Services, The Royal Children's HospitalMelbourneAustralia
- Department of Pathology, The Royal Melbourne HospitalMelbourneAustralia
| | - Elena Savva
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | - Lucy Spencer
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | | | - Natasha J. Brown
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
- Department of PaediatricsUniversity of MelbourneMelbourneAustralia
| | - Maureen S. Evans
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Sharmila Kiss
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Thomas H. Rozen
- Department of PaediatricsUniversity of MelbourneMelbourneAustralia
- Paediatric Intensive Care Unit, The Royal Children's HospitalMelbourneAustralia
| | - Joy Yaplito‐Lee
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
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Makhmudova U, Schulze PC, Lorkowski S, März W, Geiling JA, Weingärtner O. Monogenic hypertriglyceridemia and recurrent pancreatitis in a homozygous carrier of a rare APOA5 mutation: a case report. J Med Case Rep 2024; 18:278. [PMID: 38872171 PMCID: PMC11177521 DOI: 10.1186/s13256-024-04532-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/25/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Homozygous mutations in the APOA5 gene constitute a rare cause of monogenic hypertriglyceridemia, or familial chylomicronemia syndrome (FCS). We searched PubMed and identified 16 cases of homozygous mutations in the APOA5 gene. Severe hypertriglyceridemia related to monogenic mutations in triglyceride-regulating genes can cause recurrent acute pancreatitis. Standard therapeutic approaches for managing this condition typically include dietary interventions, fibrates, and omega-3-fatty acids. A novel therapeutic approach, antisense oligonucleotide volanesorsen is approved for use in patients with FCS. CASE PRESENTATION We report a case of a 25-years old Afghani male presenting with acute pancreatitis due to severe hypertriglyceridemia up to 29.8 mmol/L caused by homozygosity in APOA5 (c.427delC, p.Arg143Alafs*57). A low-fat diet enriched with medium-chain TG (MCT) oil and fibrate therapy did not prevent recurrent relapses, and volanesorsen was initiated. Volanesorsen resulted in almost normalized triglyceride levels. No further relapses of acute pancreatitis occurred. Patient reported an improve life quality due to alleviated chronic abdominal pain and headaches. CONCLUSIONS Our case reports a rare yet potentially life-threatening condition-monogenic hypertriglyceridemia-induced acute pancreatitis. The implementation of the antisense drug volanesorsen resulted in improved triglyceride levels, alleviated symptoms, and enhanced the quality of life.
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Affiliation(s)
- Umidakhon Makhmudova
- Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203, Berlin, Germany.
- Friede Springer Cardiovascular Prevention Center @Charité, Hindenburgdamm 30, 12203, Berlin, Germany.
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik/Centrum, Charitéplatz 1, 10117, Berlin, Germany.
- Klinik für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Germany.
| | - P Christian Schulze
- Klinik für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Germany
| | - Stefan Lorkowski
- Institute of Nutritional Sciences, Friedrich Schiller University Jena, Jena, Germany
- Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Halle-Jena-Leipzig, Germany
| | - Winfried März
- SYNLAB Academy, SYNLAB Holding Deutschland GmbH Mannheim and Augsburg GmbH, Mannheim, Germany
| | - J-A Geiling
- Klinik für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Germany
| | - Oliver Weingärtner
- Klinik für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Germany
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7
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Agarwala A, Dixon DL, Gianos E, Kirkpatrick CF, Michos ED, Satish P, Birtcher KK, Braun LT, Pillai P, Watson K, Wild R, Mehta LS. Dyslipidemia management in women of reproductive potential: An expert clinical consensus from the national lipid association. J Clin Lipidol 2024:S1933-2874(24)00188-0. [PMID: 38824114 DOI: 10.1016/j.jacl.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.
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Affiliation(s)
- Anandita Agarwala
- Center for Cardiovascular Disease Prevention Cardiovascular Division, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Agarwala).
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA (Dr Dixon); Center for Pharmacy Practice Innovation, Virginia Commonwealth University, Richmond, Virginia, USA (Dr Dixon)
| | - Eugenia Gianos
- Department of Cardiology, Northwell Health, New Hyde Park, Cardiovascular Institute, Lenox Hill Hospital Northwell, New York, NY, USA (Dr Gianos)
| | - Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA (Dr Kirkpatrick); Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA (Dr Kirkpatrick)
| | - Erin D Michos
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore, MD, USA (Dr Michos)
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA (Dr Satish)
| | - Kim K Birtcher
- University of Houston College of Pharmacy, Houston, TX, USA (Dr Birtcher)
| | - Lynne T Braun
- Rush University College of Nursing, Rush Heart Center for Women, Chicago, IL, USA (Dr Braun)
| | - Priyamvada Pillai
- Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Pillai)
| | - Karol Watson
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (Dr Watson)
| | - Robert Wild
- Oklahoma University Health Sciences Center, Oklahoma City, OK, USA (Dr Wild)
| | - Laxmi S Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (Dr Mehta)
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8
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Stroes ESG, Alexander VJ, Karwatowska-Prokopczuk E, Hegele RA, Arca M, Ballantyne CM, Soran H, Prohaska TA, Xia S, Ginsberg HN, Witztum JL, Tsimikas S. Olezarsen, Acute Pancreatitis, and Familial Chylomicronemia Syndrome. N Engl J Med 2024; 390:1781-1792. [PMID: 38587247 DOI: 10.1056/nejmoa2400201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Familial chylomicronemia syndrome is a genetic disorder associated with severe hypertriglyceridemia and severe acute pancreatitis. Olezarsen reduces the plasma triglyceride level by reducing hepatic synthesis of apolipoprotein C-III. METHODS In a phase 3, double-blind, placebo-controlled trial, we randomly assigned patients with genetically identified familial chylomicronemia syndrome to receive olezarsen at a dose of 80 mg or 50 mg or placebo subcutaneously every 4 weeks for 49 weeks. There were two primary end points: the difference between the 80-mg olezarsen group and the placebo group in the percent change in the fasting triglyceride level from baseline to 6 months, and (to be assessed if the first was significant) the difference between the 50-mg olezarsen group and the placebo group. Secondary end points included the mean percent change from baseline in the apolipoprotein C-III level and an independently adjudicated episode of acute pancreatitis. RESULTS A total of 66 patients underwent randomization; 22 were assigned to the 80-mg olezarsen group, 21 to the 50-mg olezarsen group, and 23 to the placebo group. At baseline, the mean (±SD) triglyceride level among the patients was 2630±1315 mg per deciliter, and 71% had a history of acute pancreatitis within the previous 10 years. Triglyceride levels at 6 months were significantly reduced with the 80-mg dose of olezarsen as compared with placebo (-43.5 percentage points; 95% confidence interval [CI], -69.1 to -17.9; P<0.001) but not with the 50-mg dose (-22.4 percentage points; 95% CI, -47.2 to 2.5; P = 0.08). The difference in the mean percent change in the apolipoprotein C-III level from baseline to 6 months in the 80-mg group as compared with the placebo group was -73.7 percentage points (95% CI, -94.6 to -52.8) and between the 50-mg group as compared with the placebo group was -65.5 percentage points (95% CI, -82.6 to -48.3). By 53 weeks, 11 episodes of acute pancreatitis had occurred in the placebo group, and 1 episode had occurred in each olezarsen group (rate ratio [pooled olezarsen groups vs. placebo], 0.12; 95% CI, 0.02 to 0.66). Adverse events of moderate severity that were considered by a trial investigator at the site to be related to the trial drug or placebo occurred in 4 patients in the 80-mg olezarsen group. CONCLUSIONS In patients with familial chylomicronemia syndrome, olezarsen may represent a new therapy to reduce plasma triglyceride levels. (Funded by Ionis Pharmaceuticals; Balance ClinicalTrials.gov number, NCT04568434.).
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Affiliation(s)
- Erik S G Stroes
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Veronica J Alexander
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Ewa Karwatowska-Prokopczuk
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Robert A Hegele
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Marcello Arca
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Christie M Ballantyne
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Handrean Soran
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Thomas A Prohaska
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Shuting Xia
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Henry N Ginsberg
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Joseph L Witztum
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
| | - Sotirios Tsimikas
- From the Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, (E.S.G.S.); Ionis Pharmaceuticals, Carlsbad (V.J.A., E.K.-P., T.A.P., S.X., S.T.), and the Divisions of Endocrinology and Metabolism (J.L.W.) and Cardiovascular Medicine (S.T.), Department of Medicine, University of California, San Diego, La Jolla - both in California; the Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (R.A.H.); the Department of Translational and Precision Medicine, Center for Rare Disorders of Lipid Metabolism, Sapienza University of Rome, Rome (M.A.); Baylor College of Medicine and the Texas Heart Institute, Houston (C.M.B.); the National Institute for Health Research and Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom (H.S.); and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York (H.N.G.)
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9
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Ogura M, Okazaki S, Okazaki H, Tada H, Dobashi K, Nakamura K, Matsunaga K, Miida T, Minamino T, Yokoyama S, Harada-Shiba M. Transitional Medicine of Intractable Primary Dyslipidemias in Japan. J Atheroscler Thromb 2024; 31:501-519. [PMID: 38538336 PMCID: PMC11079492 DOI: 10.5551/jat.rv22016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 05/03/2024] Open
Abstract
Transitional medicine refers to the seamless continuity of medical care for patients with childhood-onset diseases as they grow into adulthood. The transition of care must be seamless in medical treatment as the patients grow and in other medical aids such as subsidies for medical expenses in the health care system. Inappropriate transitional care, either medical or social, directly causes poorer prognosis for many early-onset diseases, including primary dyslipidemia caused by genetic abnormalities. Many primary dyslipidemias are designated as intractable diseases in the Japanese health care system for specific medical aids, as having no curative treatment and requiring enormous treatment costs for lipid management and prevention of complications. However, there are problems in transitional medicine for primary dyslipidemia in Japan. As for the medical treatment system, the diagnosis rate remains low due to the shortage of specialists, their insufficient link with generalists and other field specialists, and poor linkage between pediatricians and physicians for adults. In the medical care system, there is a mismatch of diagnostic criteria of primary dyslipidemias between children and adults for medical care expense subsidization, as between The Program for the Specific Pediatric Chronic Diseases and the Program for Designated Adult Intractable Diseases. This could lead some patients subsidized in their childhood to no longer be under the coverage of the aids after transition. This review intends to describe these issues in transitional medicine of primary dyslipidemia in Japan as a part of the efforts to resolve the problems by the Committee on Primary Dyslipidemia under the Research Program on Rare and Intractable Disease of the Ministry of Health, Labour and Welfare of Japan.
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Affiliation(s)
- Masatsune Ogura
- Department of Clinical Laboratory Technology, Faculty of Medical Science, Juntendo University, Chiba, Japan
| | - Sachiko Okazaki
- Division for Health Service Promotion, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Okazaki
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Jichi Medical University, Tochigi, Japan
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kazushige Dobashi
- Department of Pediatrics, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Keiji Matsunaga
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Miida
- Department of Clinical Laboratory Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Tetsuo Minamino
- Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shinji Yokoyama
- Food and Nutritional Sciences, Chubu University, Aichi, Japan
| | - Mariko Harada-Shiba
- Cardiovascular Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
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10
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Grammatikopoulou MG, Vassilakou T. Nutrition in Pediatric Patients and Vulnerable Populations: Updates and Advances. CHILDREN (BASEL, SWITZERLAND) 2024; 11:430. [PMID: 38671646 PMCID: PMC11049479 DOI: 10.3390/children11040430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024]
Abstract
Nutrition is a modifiable factor of paramount importance for the prevention and attainment of health and the development of youngsters [...].
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Affiliation(s)
- Maria G. Grammatikopoulou
- Immunonutrition and Clinical Nutrition Unit, Department of Rheumatology and Clinical Immunology, Medical School, University of Thessaly, Biopolis Campus, GR-43100 Larissa, Greece
| | - Tonia Vassilakou
- Department of Public Health Policy, School of Public Health, University of West Attica, GR-11521 Athens, Greece
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11
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Arslan S, Abuşoğlu Y, Altınkaynak K, Kahveci H. Exchange Transfusion: A Good Option for the Acute Treatment of Familial Chylomicronemia Syndrome in the Neonatal Period. Cureus 2024; 16:e57019. [PMID: 38681269 PMCID: PMC11046373 DOI: 10.7759/cureus.57019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Familial chylomicronemia syndrome (FCS) is one of the rare causes of hypertriglyceridemia. Plasmapheresis is recommended in patients with triglyceride levels greater than 2000 mg/dL. However, plasmapheresis is difficult to perform in most centers due to technical inadequacies in the neonatal period. There are some reports in the literature on the efficacy of exchange transfusion. The index case involves a 20-day-old male patient who was admitted to the emergency department for restlessness and poor feeding. He was born at term with a birth weight of 4000 g. He was exclusively breastfed. The patient was taken to the neonatal intensive care unit due to his plasma being in the form of excessive lipemia. The first measurable triglyceride level was 5100 mg/dL (57.6 mmol/L). Breast milk was restricted, and intravenous hydration was started. However, his triglyceride level did not decrease despite this treatment. Other laboratory values could not be read due to excessive lipemic serum. On the third day of hospitalization, an exchange transfusion was decided upon in this case due to the development of respiratory distress (oxygen support, tachypnea). After exchange transfusion, the patient's triglyceride level reduced dramatically to 592 mg/dL (6.6 mmol/L), and his respiratory symptoms resolved. The aim of this case report is to demonstrate that exchange transfusion therapy is a safe and effective treatment modality in the neonatal period for the acute management of FCS. Furthermore, dietary therapy restricted to long-chain fatty acids combined with medium-chain fatty acid supplementation is highly effective in the chronic management of these patients.
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Affiliation(s)
- Sezai Arslan
- Department of Inherited Metabolic Diseases, Erzurum City Hospital, Erzurum, TUR
| | - Yasemin Abuşoğlu
- Department of Nutrition and Dietetics, Erzurum City Hospital, Erzurum, TUR
| | - Konca Altınkaynak
- Department of Medical Biochemistry, University of Health Sciences Erzurum Medical Faculty, Erzurum, TUR
| | - Hasan Kahveci
- Department of Neonatology, University of Health Sciences Erzurum Medical Faculty, Erzurum, TUR
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12
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Chen YY, Hu LY, Zhang K, Zhang XP, Cao Y, Yang L, Wu BB, Zhou WH, Wang J. [A case of neonatal-onset type I hyperlipoproteinemia with bloody ascites]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1293-1298. [PMID: 38112150 PMCID: PMC10731962 DOI: 10.7499/j.issn.1008-8830.2307113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/11/2023] [Indexed: 12/20/2023]
Abstract
This report presents a case of a male infant, aged 32 days, who was admitted to the hospital due to 2 days of bloody stools and 1 day of fever. Upon admission, venous blood samples were collected, which appeared pink. Blood biochemistry tests revealed elevated levels of triglycerides and total cholesterol. The familial whole genome sequencing revealed a compound heterozygous variation in the LPL gene, with one variation inherited from the father and the other from the mother. The patient was diagnosed with lipoprotein lipase deficiency-related hyperlipoproteinemia. Acute symptoms including bloody stools, fever, and bloody ascites led to the consideration of acute pancreatitis, and the treatment involved fasting, plasma exchange, and whole blood exchange. Following the definitive diagnosis based on the genetic results, the patient was given a low-fat diet and received treatment with fat-soluble vitamins and trace elements, as well as adjustments to the feeding plan. After a 4-week hospitalization, the patient's condition improved and he was discharged. Follow-up showed a decrease in triglycerides and total cholesterol levels. At the age of 1 year, the patient's growth and psychomotor development were normal. This article emphasizes the multidisciplinary diagnosis and treatment of familial hyperlipoproteinemia presenting with symptoms suggestive of acute pancreatitis, including bloody ascites, in the neonatal period.
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Affiliation(s)
- Yuan-Yuan Chen
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | - Li-Yuan Hu
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | - Ke Zhang
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | - Xue-Ping Zhang
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | | | | | - Wen-Hao Zhou
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
| | - Jin Wang
- Department of Neonatology, Children's Hospital of Fudan University/National Children's Medical Center, Shanghai 201102, China (Wang J, . cn)
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13
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Larouche M, Khoury E, Brisson D, Gaudet D. Inhibition of Angiopoietin-Like Protein 3 or 3/8 Complex and ApoC-III in Severe Hypertriglyceridemia. Curr Atheroscler Rep 2023; 25:1101-1111. [PMID: 38095804 DOI: 10.1007/s11883-023-01179-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW The role of the inhibition of ANGPTL3 in severe or refractory hypercholesterolemia is well documented, less in severe hyperTG. This review focuses on the preclinical and clinical development of ApoC-III inhibitors and ANGPTL3, 4, and 3/8 complex inhibitors for the treatment of severe or refractory forms of hypertriglyceridemia to prevent cardiovascular disease or other morbidities. RECENT FINDINGS APOC3 and ANGPTL3 became targets for drug development following the identification of naturally occurring loss of function variants in families with a favorable lipid profile and low cardiovascular risk. The inhibition of ANGPTL3 covers a broad spectrum of lipid disorders from severe hypercholesterolemia to severe hypertriglyceridemia, while the inhibition of ApoC-III can treat hypertriglyceridemia regardless of the severity. Preclinical and clinical data suggest that ApoC-III inhibitors, ANGPTL3 inhibitors, and inhibitors of the ANGPTL3/8 complex that is formed postprandially are highly effective for the treatment of severe or refractory hypertriglyceridemia. Inhibition of ANGPTL3 or the ANGPTL3/8 complex upregulates LPL and facilitates the hydrolysis and clearance of triglyceride-rich lipoproteins (TRL) (LPL-dependent mechanisms), whereas ApoC-III inhibitors contribute to the management and clearance of TRL through both LPL-dependent and LPL-independent mechanisms making it possible to successfully lower TG in subjects completely lacking LPL (familial chylomicronemia syndrome). Most of these agents are biologicals including monoclonal antibodies (mAb), antisense nucleotides (ASO), small interfering RNA (siRNA), or CRISPR-cas gene editing strategies.
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Affiliation(s)
- Miriam Larouche
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Etienne Khoury
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Diane Brisson
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada
| | - Daniel Gaudet
- Lipidology Unit, Community Genomic Medicine Center, Department of Medicine, Université de Montréal and ECOGENE-21 Clinical Research Center, Chicoutimi, QC, Canada.
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Xia Y, Zheng W, Du T, Gong Z, Liang L, Wang R, Yang Y, Zhang K, Lu D, Chen X, Sun Y, Sun Y, Xiao B, Qiu W. Clinical profile, genetic spectrum and therapy evaluation of 19 Chinese pediatric patients with lipoprotein lipase deficiency. J Clin Lipidol 2023; 17:808-817. [PMID: 37858495 DOI: 10.1016/j.jacl.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Lipoprotein lipase (LPL) deficiency, the most common familial chylomicronemia syndrome (FCS), is a rare autosomal recessive disease characterized by chylomicronemia and severe hypertriglyceridemia (HTG), with limited clinical and genetic characterization. OBJECTIVE To describe the manifestations and management of 19 pediatric patients with LPL-FCS. METHODS LPL-FCS patients from 2014 to 2022 were divided into low-fat (LF), very-low-fat (VLF) and medium-chain-triglyceride (MCT) groups. Their clinical data were evaluated to investigate the effect of different diets. The genotype-phenotype relationship was assessed. Linear regression comparing long-chain triglyceride (LCT) intake and TG levels was analyzed. RESULTS Nine novel LPL variants were identified in 19 LPL-FCS pediatric patients. At baseline, eruptive xanthomas occurred in 3/19 patients, acute pancreatitis in 2/19, splenomegaly in 6/19 and hepatomegaly in 3/19. The median triglyceride (TG) level (30.3 mmol/L) was markedly increased. The MCT group and VLF group with LCT intakes <20 en% (energy percentage) had considerably lower TG levels than the LF group (both p<0.05). The LF group presented with severe HTG and significantly decreased TG levels after restricting LCT intakes to <20 en% (p<0.05). Six infants decreased TG levels to <10 mmol/L by keeping LCT intake <10 en%. TG levels and LCT intake were positively correlated in both patients under 2 years (r=0.84) and those aged 2-9 years (r=0.89). No genotype-phenotype relationship was observed. CONCLUSIONS This study broadens the clinical and genetic spectra of LPL-FCS. The primary therapy for LPL-FCS pediatric patients is restricting dietary LCTs to <10 en% or <20 en% depending on different ages. MCTs potentially provide extra energy.
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Affiliation(s)
- Yu Xia
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Wanqi Zheng
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Taozi Du
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Zizhen Gong
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Ruifang Wang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Yi Yang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Kaichuang Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Deyun Lu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Xiaohong Chen
- Department of Endocrinology and Metabolism, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Dr Chen)
| | - Yuning Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu); Departement of Clinical Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Sun, Xiao).
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu); Departement of Clinical Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Sun, Xiao).
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu).
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15
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Torii T, Taniguchi-Fukatsu A, Kawawaki M, Shimoura Y, Ozaki K. Long-Term Nutritional Counseling for a Patient with Lipoprotein Lipase Deficiency. J Atheroscler Thromb 2023; 30:1507-1515. [PMID: 36878607 PMCID: PMC10564650 DOI: 10.5551/jat.63821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 01/18/2023] [Indexed: 03/08/2023] Open
Abstract
A one-year-and-nine-month-old Japanese boy was admitted with hypertriglyceridemia (fasting triglycerides 2548 mg/dL). After close examination, he was diagnosed with lipoprotein lipase (LPL) deficiency (compound heterozygous) and was immediately started on a fat-restricted dietary therapy. He responded well to the regimen (1200 kcal/day, 20 g fat/day) and his triglycerides decreased to 628 mg/dL within 7 days of starting the dietary therapy. It was decided to manage his illness without using any drugs because he was still an infant and responded well to a fat-restricted diet. During his hospital stay, dietitians provided him with nutritional counseling using a food exchange list, which was designed to easily calculate the fat content by including foods that are commonly served. His family quickly learned the skills to prepare a fat-restricted diet. Moreover, since dietary restrictions may have impaired the child's growth and development, the dietitians continued to intervene regularly after the child was discharged from the hospital. The dietitians confirmed that the patient was receiving nutritional intake appropriate for his growth and discussed the dietary concerns in his daily life and how to participate in school events that involved eating and drinking. Nutritional counseling was provided every 3-4 months from disease onset to age 23 years, except for a 14-month break at age 20 years. The patient grew up without developing acute pancreatitis, a serious complication of LPL deficiency. The long-term intervention of dieticians is necessary to achieve a balance between living on a strict diet for disease management and ensuring appropriate nutritional intakes for growth/development.
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Affiliation(s)
- Takashi Torii
- Department of Nutrition Management, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | | | - Megumi Kawawaki
- Department of Nutrition Management, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | | | - Kayo Ozaki
- Department of Endocrinology and Metabolism, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
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16
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Aljouda L, Nagy L, Schulze A. Long-Term Treatment of Lipoprotein Lipase Deficiency with Medium-Chain Triglyceride-Enriched Diet: A Case Series. Nutrients 2023; 15:3535. [PMID: 37630727 PMCID: PMC10458522 DOI: 10.3390/nu15163535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Background: Lipoprotein lipase (LPL) deficiency is a genetic condition. Affected individuals typically develop symptoms related to severe and persistent hypertriglyceridemia, such as abdominal pain and recurrent pancreatitis, before 10 years of age. No pharmacological treatment sustainably lowering triglycerides (TGs) in LPL deficiency patients has been proven to be effective. This study investigated whether a long-chain triglyceride (LCT)-restricted, medium-chain triglyceride (MCT)-supplemented diet enables a meaningful reduction in TGs and reduces LPL-related symptoms in children with LPL deficiency. Methods: A single-center retrospective case series study of LPL deficiency patients treated at the Hospital of Sick Children between January 2000 and December 2022 was carried out. Data, extracted from hospital charts, included demographics, diagnosis confirmation, clinical and imaging observations, and biochemical profiles. Results: Seven patients with hypertriglyceridemia > 20 mmol/L suspected of an LPL deficiency diagnosis were included. Six patients had a confirmed molecular diagnosis of LPL deficiency, and one had glycogen storage disease type 1a (GSD1a). Clinical presentation was at a median of 30 days of age (range 1-105), and treatment start, excluding one late-treated patient, was at a median of 42 days (range 2-106). The observation and treatment period of the LPL patients was 48.0 patient years (median 7.1, range 4.3-15.5). The LCT-restricted and MCT-supplemented diet led to an immediate drop in TGs in six out of six LPL patients. TGs improved from a median of 40.9 mmol/L (range 11.4-276.5) pre-treatment to a median of 12.0 mmol/L (range 1.1-36.6) during treatment, total cholesterol from 7.6 mmol/L (4.9-27.0) to 3.9 mmol/L (1.7-8.2), and pancreatic lipase from 631 IU/L (30-1200) to 26.5 IU/L (5-289). In 48 patient years, there was only one complication of pancreatitis and no other disease-specific manifestations or complications. Catch-up growth was observed in one late-treated patient. All patients maintained normal growth and development. As expected, the diet failed to treat hypertriglyceridemia in the GSD1a patient. Conclusions: The dietary restriction of LCT in combination with MCT supplementation as long-term management of pediatric patients with LPL deficiency was feasible, well tolerated, and clinically effective in reducing TG levels and in preventing LPL-related complications.
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Affiliation(s)
- Liali Aljouda
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
| | - Laura Nagy
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
| | - Andreas Schulze
- Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada (L.N.)
- Department of Pediatrics, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON M5S 1A1, Canada
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17
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Kirkpatrick CF, Sikand G, Petersen KS, Anderson CAM, Aspry KE, Bolick JP, Kris-Etherton PM, Maki KC. Nutrition interventions for adults with dyslipidemia: A Clinical Perspective from the National Lipid Association. J Clin Lipidol 2023; 17:428-451. [PMID: 37271600 DOI: 10.1016/j.jacl.2023.05.099] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
Lifestyle habits can have a profound impact on atherosclerotic cardiovascular disease (ASCVD) risk. The National Lipid Association previously published recommendations for lifestyle therapies to manage dyslipidemia. This Clinical Perspective provides an update with a focus on nutrition interventions for the three most common dyslipidemias in adults: 1) low-density lipoprotein cholesterol (LDL-C) elevation; 2) triglyceride (TG) elevation, including severe hypertriglyceridemia with chylomicronemia; and 3) combined dyslipidemia, with elevations in both LDL-C and TG levels. Lowering LDL-C and non-high-density lipoprotein cholesterol are the primary objectives for reducing ASCVD risk. With severe TG elevation (≥500 mg/dL), the primary objective is to prevent pancreatitis and ASCVD risk reduction is secondary. Nutrition interventions that lower LDL-C levels include reducing cholesterol-raising fatty acids and dietary cholesterol, as well as increasing intakes of unsaturated fatty acids, plant proteins, viscous fibers, and reducing adiposity for patients with overweight or obesity. Selected dietary supplements may be employed as dietary adjuncts. Nutrition interventions for all patients with elevated TG levels include restricting intakes of alcohol, added sugars, and refined starches. Additional lifestyle factors that reduce TG levels are participating in daily physical activity and reducing adiposity in patients with overweight or obesity. For patients with severe hypertriglyceridemia, an individualized approach is essential. Nutrition interventions for addressing concurrent elevations in LDL-C and TG include a combination of the strategies described for lowering LDL-C and TG. A multidisciplinary approach is recommended to facilitate success in making and sustaining dietary changes and the assistance of a registered dietitian nutritionist is highly recommended.
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Affiliation(s)
- Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA; Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA
| | - Geeta Sikand
- University of California Irvine Heart Disease Prevention Program, Irvine, CA, USA
| | | | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Karen E Aspry
- Lifespan Cardiovascular Institute, and Alpert Medical School, Brown University, Providence, RI, USA
| | | | - Penny M Kris-Etherton
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Kevin C Maki
- Midwest Biomedical Research, Addison, IL, USA; Indiana University School of Public Health-Bloomington, Bloomington, IN, USA.
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18
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Bashir B, Ho JH, Downie P, Hamilton P, Ferns G, Datta D, Cegla J, Wierzbicki AS, Dawson C, Jenkinson F, Delaney H, Mansfield M, Teoh Y, Miedzybrodzka Z, Haso H, Durrington PN, Soran H. Severe Hypertriglyceridaemia and Chylomicronaemia Syndrome-Causes, Clinical Presentation, and Therapeutic Options. Metabolites 2023; 13:metabo13050621. [PMID: 37233662 DOI: 10.3390/metabo13050621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
We have reviewed the genetic basis of chylomicronaemia, the difference between monogenic and polygenic hypertriglyceridaemia, its effects on pancreatic, cardiovascular, and microvascular complications, and current and potential future pharmacotherapies. Severe hypertriglyceridaemia (TG > 10 mmol/L or 1000 mg/dL) is rare with a prevalence of <1%. It has a complex genetic basis. In some individuals, the inheritance of a single rare variant with a large effect size leads to severe hypertriglyceridaemia and fasting chylomicronaemia of monogenic origin, termed as familial chylomicronaemia syndrome (FCS). Alternatively, the accumulation of multiple low-effect variants causes polygenic hypertriglyceridaemia, which increases the tendency to develop fasting chylomicronaemia in presence of acquired factors, termed as multifactorial chylomicronaemia syndrome (MCS). FCS is an autosomal recessive disease characterized by a pathogenic variant of the lipoprotein lipase (LPL) gene or one of its regulators. The risk of pancreatic complications and associated morbidity and mortality are higher in FCS than in MCS. FCS has a more favourable cardiometabolic profile and a low prevalence of atherosclerotic cardiovascular disease (ASCVD) compared to MCS. The cornerstone of the management of severe hypertriglyceridaemia is a very-low-fat diet. FCS does not respond to traditional lipid-lowering therapies. Several novel pharmacotherapeutic agents are in various phases of development. Data on the correlation between genotype and phenotype in FCS are scarce. Further research to investigate the impact of individual gene variants on the natural history of the disease, and its link with ASCVD, microvascular disease, and acute or recurrent pancreatitis, is warranted. Volanesorsen reduces triglyceride concentration and frequency of pancreatitis effectively in patients with FCS and MCS. Several other therapeutic agents are in development. Understanding the natural history of FCS and MCS is necessary to rationalise healthcare resources and decide when to deploy these high-cost low-volume therapeutic agents.
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Affiliation(s)
- Bilal Bashir
- Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Jan H Ho
- Department of Endocrinology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Paul Downie
- Department of Laboratory Medicine, Salisbury NHS Foundation Trust, Salisbury SP2 8BJ, UK
| | - Paul Hamilton
- Centre for Medical Education, Queen's University Belfast, Belfast BT7 1NN, UK
- Department of Clinical Biochemistry, Belfast Health and Social Care Trust, Belfast BT13 1FD, UK
| | - Gordon Ferns
- Brighton and Sussex Medical School, Brighton BN1 9PH, UK
| | - Dev Datta
- Lipid Unit, University Hospital Llandough, Cardiff CF64 2XX, UK
| | - Jaimini Cegla
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2BX, UK
| | - Anthony S Wierzbicki
- Department of Metabolic Medicine and Chemical Pathology, Guy's and St. Thomas' Hospitals, London SE1 7EH, UK
| | - Charlotte Dawson
- Department of Metabolic Medicine, Queen Elizabeth Hospital NHS Foundation Trust, Birmingham PE30 4ET, UK
| | - Fiona Jenkinson
- Clinical Biochemistry and Metabolic Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - Hannah Delaney
- Department of Clinical Chemistry, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Michael Mansfield
- Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Yee Teoh
- Department of Chemical Pathology & Metabolic Medicine, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - Zosia Miedzybrodzka
- Department of Medical Genetics, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - Haya Haso
- School of Medicine, University of Kurdistan Hewler, Erbil 44001, Iraq
| | - Paul N Durrington
- Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Handrean Soran
- Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
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19
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Izar MCDO, Santos Filho RDD, Assad MHV, Chagas ACP, Toledo Júnior ADO, Nogueira ACC, Souto ACCF, Lottenberg AMP, Chacra APM, Ferreira CEDS, Lourenço CM, Valerio CM, Cintra DE, Fonseca FAH, Campana GA, Bianco HT, Lima JGD, Castelo MHCG, Scartezini M, Moretti MA, Barreto NSF, Maia RE, Montenegro Junior RM, Alves RJ, Figueiredo RMM, Fock RA, Martinez TLDR. Brazilian Position Statement for Familial Chylomicronemia Syndrome - 2023. Arq Bras Cardiol 2023; 120:e20230203. [PMID: 37075362 PMCID: PMC10348387 DOI: 10.36660/abc.20230203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Ana Maria Pitta Lottenberg
- Laboratório de Lípides (LIM 10) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
| | - Ana Paula Marte Chacra
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE-RJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Josivan Gomes de Lima
- Hospital Universitário Onofre Lopes da Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Miguel Antonio Moretti
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Renan Magalhães Montenegro Junior
- Complexo Hospitalar da Universidade Federal do Ceará (UFCE), Empresa Brasileira de Serviços Hospitalares (EBSERH), Fortaleza, CE - Brasil
| | - Renato Jorge Alves
- Hospital Santa Casa de Misericórdia de São Paulo, São Paulo, SP - Brasil
| | - Roberta Marcondes Machado Figueiredo
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
- Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
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20
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Capra ME, Biasucci G, Banderali G, Pederiva C. Nutritional Treatment of Hypertriglyceridemia in Childhood: From Healthy-Heart Counselling to Life-Saving Diet. Nutrients 2023; 15:nu15051088. [PMID: 36904088 PMCID: PMC10005617 DOI: 10.3390/nu15051088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
Hypertriglyceridemia is a lipid disorder with a varying prevalence; it is very common if we consider triglyceride plasma values slightly above the threshold, whereas it is extremely rare if only severely elevated triglyceride levels are considered. In most cases, severe forms of hypertriglyceridemia are caused by genetic mutations in the genes that regulate triglyceride metabolism, thus leading to extreme triglyceride plasma values and acute pancreatitis risk. Secondary forms of hypertriglyceridemia are usually less severe and are mainly associated with weight excess, but they can also be linked to liver, kidney, endocrinologic, or autoimmune diseases or to some class of drugs. Nutritional intervention is the milestone treatment for patients with hypertriglyceridemia and it has to be modulated on the underlying cause and on triglyceride plasma levels. In pediatric patients, nutritional intervention must be tailored according to specific age-related energy, growth and neurodevelopment requests. Nutritional intervention is extremely strict in case of severe hypertriglyceridemia, whereas it is similar to good healthy nutritional habits counselling for mild forms, mainly related to wrong habits and lifestyles, and to secondary causes. The aim of this narrative review is to define different nutritional intervention for various forms of hypertriglyceridemia in children and adolescents.
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Affiliation(s)
- Maria Elena Capra
- Centre for Pediatric Dyslipidemias, Pediatrics and Neonatology Unit, University of Parma, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
- Department of Translational Medical and Surgical Sciences, University of Parma, 43126 Parma, Italy
- Società Italiana di Nutrizione Pediatrica, 20126 Milan, Italy
| | - Giacomo Biasucci
- Centre for Pediatric Dyslipidemias, Pediatrics and Neonatology Unit, University of Parma, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
- Società Italiana di Nutrizione Pediatrica, 20126 Milan, Italy
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence:
| | - Giuseppe Banderali
- Clinical Service for Dyslipidemias, Study and Prevention of Atherosclerosis in Childhood, Pediatrics Unit, ASST-Santi Paolo e Carlo, 20142 Milan, Italy
| | - Cristina Pederiva
- Società Italiana di Nutrizione Pediatrica, 20126 Milan, Italy
- Clinical Service for Dyslipidemias, Study and Prevention of Atherosclerosis in Childhood, Pediatrics Unit, ASST-Santi Paolo e Carlo, 20142 Milan, Italy
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21
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Abstract
PURPOSE OF REVIEW This review will briefly revise the evidence concerning the pharmacological inhibition of Apolipoprotein CIII (ApoCIII) in patients with hypertriglyceridemia. RECENT FINDINGS ApoCIII is a plasma apolipoprotein playing a major role in the metabolism of triglyceride-rich lipoproteins, namely chylomicrons and very-low-density lipoproteins as well as in the pathological processes involved in atherosclerosis. Therefore, ApoCIII is a potential new target for reducing plasma levels of TRLs and, thereby, cardiovascular risk. In recent years, there have been extensive preclinical and clinical pharmacological studies aimed at testing drugs directed against ApoCIII. SUMMARY In this review, firstly we will summarize the molecular function of ApoCIII in lipoprotein metabolism. Then, we will examine the lipid-lowering potential of the pharmacological inhibition of ApoCIII based on the results of clinical trial employing Volansesorsen, the first approved antisense therapeutic oligonucleotide against ApoCIII mRNA. The future perspectives for ApoCIII inhibition will be also revised.
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Affiliation(s)
- Daniele Tramontano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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22
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Schefelker JM, Peterson AL. Screening and Management of Dyslipidemia in Children and Adolescents. J Clin Med 2022; 11:6479. [PMID: 36362707 PMCID: PMC9656613 DOI: 10.3390/jcm11216479] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 07/30/2023] Open
Abstract
This review provides an overview of pediatric dyslipidemia emphasizing screening and treatment recommendations. The presence of risk factors for cardiovascular disease in childhood poses significant risk for the development of atherosclerotic cardiovascular disease and cardiovascular events in adulthood. While atherogenic dyslipidemia is the most common dyslipidemia seen in children and can be suspected based on the presence of risk factors (such as obesity), familial hypercholesterolemia can be found in children with no risk factors. As such, universal cholesterol screening is recommended to identify children with these disorders in order to initiate treatment and reduce the risk of future cardiovascular disease. Treatment of pediatric dyslipidemia begins with lifestyle modifications, but primary genetic dyslipidemias may require medications such as statins. As pediatric lipid disorders often have genetic or familial components, it is important that all physicians are aware that cardiovascular risk begins in childhood, and can both identify these disorders in pediatric patients and counsel their adult patients with dyslipidemia to have their children screened.
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Affiliation(s)
| | - Amy L. Peterson
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
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Cefalù AB, D'Erasmo L, Iannuzzo G, Noto D, Giammanco A, Montali A, Zambon A, Forte F, Suppressa P, Giannini S, Barbagallo CM, Ganci A, Nardi E, Vernuccio F, Caldarella R, Ciaccio M, Arca M, Averna M. Efficacy and safety of lomitapide in familial chylomicronaemia syndrome. Atherosclerosis 2022; 359:13-19. [PMID: 36152419 DOI: 10.1016/j.atherosclerosis.2022.08.017] [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: 06/18/2022] [Revised: 08/19/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Familial chylomicronaemia syndrome (FCS) is a rare autosomal recessive disorder, resulting in elevated triglycerides (TGs), abdominal pain and pancreatitis. Treatment options are limited. Lomitapide, a microsomal triglyceride transfer protein inhibitor, is approved for the treatment of homozygous familial hypercholesterolaemia. Whether its therapeutic use may be extended to FCS remains unknown. The aim of this study was to evaluate the efficacy and safety of lomitapide in adult patients with FCS. METHODS The open-label, single-arm 'LOCHNES' study of lomitapide in FCS enrolled patients >18 years with genetically confirmed FCS, elevated fasting TG ≥ 750 mg/dL and history of pancreatitis. Patients were administered lomitapide to the maximum tolerated dose for 26 weeks. The primary endpoint was the percent change in TGs from baseline to Week 26. RESULTS Eighteen patients were enrolled with median baseline TG levels 1803.5 mg/dL (97.5% CI, 1452-2391 mg/dL). At Week 26, median fasting TGs were reduced to 305 mg/dL (97.5% CI 219-801 mg/dL; 70.5% reduction); median lomitapide dose was 35 mg/day; 13 patients achieved TGs ≤750 mg/dL. Adverse events were mild to moderate and mainly related to gastrointestinal tolerability. Liver imaging at baseline and Week 26 revealed hepatic fat increases from median 12.0%-32.5%, while median hepatic stiffness remained normal. No patient experienced acute pancreatitis or severe abdominal pain during lomitapide treatment. CONCLUSIONS Lomitapide is effective and well tolerated in reducing TGs in FCS patients with a history of pancreatitis. Larger studies are warranted to determine lomitapide effectiveness in FCS.
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Affiliation(s)
- Angelo B Cefalù
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Davide Noto
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Antonina Giammanco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Anna Montali
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Alberto Zambon
- Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Francesco Forte
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Patrizia Suppressa
- Department of Internal Medicine and Rare Diseases Centre "C. Frugoni", University Hospital of Bari, Bari, Italy
| | | | - Carlo M Barbagallo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Antonina Ganci
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Emilio Nardi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Federica Vernuccio
- Section of Radiology- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Rosalia Caldarella
- Department of Laboratory Medicine, Unit of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy
| | - Marcello Ciaccio
- Department of Laboratory Medicine, Unit of Laboratory Medicine, University Hospital "P. Giaccone", Palermo, Italy; Institute of Clinical Biochemistry, Clinical Molecular Medicine and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Maurizio Averna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy; Institut of Biophysics (IBF), National Research Council CNR), Palermo, Italy.
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Guidance for the diagnosis and treatment of hypolipidemia disorders. J Clin Lipidol 2022; 16:797-812. [DOI: 10.1016/j.jacl.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022]
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Chen G, Harwood JL, Lemieux MJ, Stone SJ, Weselake RJ. Acyl-CoA:diacylglycerol acyltransferase: Properties, physiological roles, metabolic engineering and intentional control. Prog Lipid Res 2022; 88:101181. [PMID: 35820474 DOI: 10.1016/j.plipres.2022.101181] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/31/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Abstract
Acyl-CoA:diacylglycerol acyltransferase (DGAT, EC 2.3.1.20) catalyzes the last reaction in the acyl-CoA-dependent biosynthesis of triacylglycerol (TAG). DGAT activity resides mainly in membrane-bound DGAT1 and DGAT2 in eukaryotes and bifunctional wax ester synthase-diacylglycerol acyltransferase (WSD) in bacteria, which are all membrane-bound proteins but exhibit no sequence homology to each other. Recent studies also identified other DGAT enzymes such as the soluble DGAT3 and diacylglycerol acetyltransferase (EaDAcT), as well as enzymes with DGAT activities including defective in cuticular ridges (DCR) and steryl and phytyl ester synthases (PESs). This review comprehensively discusses research advances on DGATs in prokaryotes and eukaryotes with a focus on their biochemical properties, physiological roles, and biotechnological and therapeutic applications. The review begins with a discussion of DGAT assay methods, followed by a systematic discussion of TAG biosynthesis and the properties and physiological role of DGATs. Thereafter, the review discusses the three-dimensional structure and insights into mechanism of action of human DGAT1, and the modeled DGAT1 from Brassica napus. The review then examines metabolic engineering strategies involving manipulation of DGAT, followed by a discussion of its therapeutic applications. DGAT in relation to improvement of livestock traits is also discussed along with DGATs in various other eukaryotic organisms.
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Affiliation(s)
- Guanqun Chen
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Alberta T6H 2P5, Canada.
| | - John L Harwood
- School of Biosciences, Cardiff University, Cardiff CF10 3AX, UK
| | - M Joanne Lemieux
- Department of Biochemistry, University of Alberta, Membrane Protein Disease Research Group, Edmonton T6G 2H7, Canada
| | - Scot J Stone
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada.
| | - Randall J Weselake
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Alberta T6H 2P5, Canada
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Abstract
INTRODUCTION Primary chylomicronemia is characterized by pathological accumulation of chylomicrons in the plasma causing severe hypertriglyceridemia, typically >10 mmol/L (>875 mg/dL). Patients with the ultra-rare familial chylomicronemia syndrome (FCS) subtype completely lack lipolytic capacity and respond minimally to traditional triglyceride-lowering therapies. The mainstay of treatment is a low-fat diet, which is difficult to follow and compromises quality of life. New therapies are being developed primarily to prevent episodes of life-threatening acute pancreatitis. AREAS COVERED Antagonists of apolipoprotein (apo) C-III, such as the antisense oligonucleotide (ASO) volanesorsen, significantly reduce triglyceride levels in chylomicronemia. However, approval of and access to volanesorsen are restricted since a substantial proportion of treated FCS patients developed thrombocytopenia. Newer apo C-III antagonists, namely, the ASO olezarsen (formerly AKCEA-APOCIII-LRx) and short interfering RNA (siRNA) ARO-APOC3, appear to show efficacy with less risk of thrombocytopenia. Potential utility of antagonists of angiopoietin-like protein 3 (ANGPTL3) such as evinacumab and the siRNA ARO-ANG3 in subtypes of chylomicronemia remains to be defined. EXPERT OPINION Emerging pharmacologic therapies for chylomicronemia show promise, particularly apo C-III antagonists. However, these treatments are still investigational. Further study of their efficacy and safety in patients with both rare FCS and more common multifactorial chylomicronemia is needed.
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Affiliation(s)
- Isabel Shamsudeen
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert A Hegele
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Williams L, Baker-Smith CM, Bolick J, Carter J, Kirkpatrick C, Ley SL, Peterson AL, Shah AS, Sikand G, Ware AL, Wilson DP. Nutrition interventions for youth with dyslipidemia an national lipid association clinical perspective. J Clin Lipidol 2022; 16:776-796. [DOI: 10.1016/j.jacl.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 11/29/2022]
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Cheng Y, Li T, Tan P, Du Y, Huang Z, Shi H, Cai T, Chen Y, Fu W. Efficacy and safety of the apolipoprotein C-III inhibitor Volanesorsen: a systematic evaluation and meta-analysis. Endocrine 2022; 76:253-262. [PMID: 35298785 DOI: 10.1007/s12020-022-03025-8] [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] [Received: 12/27/2021] [Accepted: 02/19/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Familial celiac disease syndrome (FCS) is a form of hypertriglyceridemia (HTG) caused by the accumulation of celiac particles. Currently, volanesorsen is considered to be used to treat patients with FCS and HTG to improve symptoms. To evaluate the effect of volanesorsen on lipid metabolism in patients with FCS, we performed a systematic evaluation and meta-analysis. METHODS A systematic search of PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library was conducted, and the bibliographies of original articles were checked manually. The quality of the studies was assessed using the Cochrane Risk of Bias tool. RESULTS Four randomized, controlled trials involving 246 patients were analyzed in this study. Patients treated with volanesorsen showed (MD = -78.85%; 95% CI = -96.04 to -61.65, P = 0.67, I2 = 0%) decrease in TG and (MD = -80.08%; 95% CI = -90.02 to -71.54, P = 0.25, I2 = 29%) decrease in ApoC-III levels compared to patients in the placebo group showing a significant decrease. In addition, HDL-C increased (MD = 46.01% 95% CI = 41.03 to 50.99, P = 0.41, I2 = 0%), NHDL-C decreased (MD = -32.12%; 95% CI = -44.39 to -19.85, P = 0.11, I2 = 55%), VLDL-C decreased (MD = -65.88%; 95% CI = -83.97 to -47.79, P = 0.71, I2 = 0%), apo A1 increased (MD = 13.12%; 95% CI = 7.83 to 18.40, P = 0.72, I2 = 0%), and apoB increased (MD = 7.94 %; 95% CI = -1.90 to 17.78, P = 0.54, I2 = 0%) all suggest that volanesorsen has an overall FCS with a therapeutic effect. However, LDL-C increased (MD = 99.59%; 95% CI = 69.19 to 130.00, P = 0.61, I2 = 0%) and apo B48 decreased (MD = 82.89%; 95% CI = -100.88 to -64.91, P = 0.42, I2 = 0%), showing an inverse effect, suggesting that volanesorsen's did not target all proteins of lipid metabolism.
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Affiliation(s)
- Yonglang Cheng
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Tongxi Li
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Peng Tan
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Yichao Du
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Zhiwei Huang
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hao Shi
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Tianying Cai
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Yifan Chen
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Wenguang Fu
- Department of General Surgery (Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
- Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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Aguilar-Salinas CA, Gómez-Díaz RA, Corral P. New Therapies for Primary Hyperlipidemia. J Clin Endocrinol Metab 2022; 107:1216-1224. [PMID: 34888679 DOI: 10.1210/clinem/dgab876] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
Primary hyperlipidemias include a heterogeneous set of monogenic and polygenic conditions characterized by a strong family aggregation, severe forms of hypercholesterolemia and/or hypertriglyceridemia, appearance early on life, and a high risk of cardiovascular events and/or recurrent pancreatitis. In real life, a small proportion of the primary hyperlipidemia cases is recognized and treated properly. Our goal is to present an update of current and upcoming therapies for patients with primary hyperlipidemia. Recently, new lipid-lowering medications have obtained authorization from the U.S. Food and Drug Administration and the European Medicines Agency. These drugs target metabolic pathways, including (adenosine 5'-triphosphates)-citrate lyase (bempedoic acid), proprotein convertase subtilisin/kexin 9 (inclisiran), apolipoprotein CIII (volanesorsen), and angiopoietin-like 3 (volanesorsen), that have additive effects with the actions of the currently available therapies (i.e., statins, ezetimibe or fibrates). We discuss the potential clinical indications for the novel medications. To conclude, the addition of these new medications to the therapeutic options for primary hyperlipidemia patients may increase the likelihood of achieving the treatment targets. Also, it could be a safer alternative for patients with side effects for the currently available drugs.
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Affiliation(s)
- Carlos A Aguilar-Salinas
- Direction of Nutrition Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - Rita A Gómez-Díaz
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Pablo Corral
- Pharmacology Department, School of Medicine, FASTA University, Mar del Plata, Buenos Aires, Argentina
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30
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Wilson DP, Williams L, Kavey REW. Hypertriglyceridemia in Youth. J Pediatr 2022; 243:200-207. [PMID: 34929246 DOI: 10.1016/j.jpeds.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/01/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Don P Wilson
- Pediatric Cardiovascular Health and Risk Prevention Program, Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX.
| | - Lauren Williams
- Pediatric Cardiovascular Health and Risk Prevention Program, Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX
| | - Rae-Ellen W Kavey
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY
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Marogi EP, Ohiomoba RO, Stone NJ. Eruptive Xanthomas: Importance of Recognition to Reduce Delay of Effective Triglyceride Reduction. Am J Med 2022; 135:444-447. [PMID: 34732347 DOI: 10.1016/j.amjmed.2021.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/20/2021] [Accepted: 09/28/2021] [Indexed: 02/03/2023]
Abstract
Eruptive xanthomas are localized lipid deposits in the dermis and an important early clue to severe hypertriglyceridemia. These small erythematous or yellow papules that localize to the extensor surfaces of extremities, buttocks, and the back are often overlooked during routine visits secondary to poor familiarity and limited skin examinations. We present 3 cases of patients with eruptive xanthomas and severe hypertriglyceridemia who underwent skin biopsy and waited weeks to years before receiving effective treatment. We suggest the following to minimize the delay between presentation and effective management. First, perform a comprehensive skin examination. Second, be mindful of the association between metabolic syndrome or diabetes with severe hypertriglyceridemia. Third, evaluate the Four D's of secondary hypertriglyceridemia: Diet/Lifestyle, Drugs/Medications, and Diseases/Disorders of metabolism. Finally, initiate effective treatment promptly after recognition. This includes beginning with a minimal fat diet and appropriate pharmacological intervention to control triglycerides as outlined in recent guidelines.
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Affiliation(s)
- Emily P Marogi
- Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | - Neil J Stone
- Departments of Medicine (Cardiology) and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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Mszar R, Webb GB, Kulkarni VT, Ahmad Z, Soffer D. Genetic Lipid Disorders Associated with Atherosclerotic Cardiovascular Disease: Molecular Basis to Clinical Diagnosis and Epidemiologic Burden. Med Clin North Am 2022; 106:325-348. [PMID: 35227434 DOI: 10.1016/j.mcna.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Genetic lipid disorders, ranging from common dyslipidemias such as familial hypercholesterolemia, lipoprotein (a), and familial combined hyperlipidemia to rare disorders including familial chylomicronemia syndrome and inherited hypoalphalipoproteinemias (ie, Tangier and fish eye diseases), affect millions of individuals in the United States and tens of millions around the world and are often undiagnosed in the general population. Clinicians should take into consideration the potential of inherited lipid disorders or syndromes when severe derangements in lipid parameters are observed. Patients' combined genotype and phenotype should be evaluated in conjunction with a host of environmental factors impacting their risk of atherosclerotic cardiovascular disease.
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Affiliation(s)
- Reed Mszar
- Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Gayley B Webb
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivek T Kulkarni
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zahid Ahmad
- Division of Nutrition and Metabolic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniel Soffer
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Childhood Hypertriglyceridemia: Is It Time for a New Approach? Curr Atheroscler Rep 2022; 24:265-275. [PMID: 35107763 DOI: 10.1007/s11883-022-01000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG) is widely prevalent in youth. There is an unmet need for effective medications in the management of HTG in youth. The purpose of this review is to summarize the approach to HTG in acute and chronic settings, and highlight emerging therapies targeted at specific genes, proteins, and enzymes to selectively alter triglyceride (TG) metabolism. RECENT FINDINGS Genetic and lifestyle factors play a significant role in the pathophysiology of HTG. Severe elevation of TG poses a risk of acute pancreatitis, while mild-to-moderate HTG increases the risk for premature atherosclerotic cardiovascular disease (ASCVD) and, increasingly, has been linked with non-alcoholic fatty liver disease. Although a variety of therapeutic agents are in development, strict adherence to a heart healthy lifestyle, including dietary changes, remain the cornerstone of management for youth with HTG. In addition to lifestyle changes, pharmacological interventions, including fibrates, omega 3 fatty acids, and statins may be considered for management of moderate-to-severe HTG. In view of its association with premature cardiovascular disease (CVD), non-high-density-lipoprotein-C (non-HDL-C) is an important target for therapy in children with moderate HTG. Management of HTG is dependent on its etiology, concomitant symptoms, and degree of TG elevation. The last two decades have seen remarkable changes in drug development, specifically those that act through the lipoprotein lipase complex, including new targeted treatments such as inhibitors of apolipoprotein C3 and angiopoietin-like protein 3.
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Thajer A, Skacel G, de Gier C, Greber-Platzer S. The Effect of a Fat-Restricted Diet in Four Patients with Familial Chylomicronemia Syndrome: A Long-Term Follow-Up Study. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111078. [PMID: 34828789 PMCID: PMC8619212 DOI: 10.3390/children8111078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/17/2021] [Accepted: 11/17/2021] [Indexed: 06/13/2023]
Abstract
(1) Background: Familial chylomicronemia syndrome (FCS) is a very rare autosomal recessive disorder characterized by severely elevated triglycerides and clinical symptoms in early childhood mainly presenting with abdominal pain, acute pancreatitis and hepatosplenomegaly. Primary treatment is a lifelong very strict low-fat diet, which might be challenging in pediatric patients. So far, data about children with FCS are rare. The aim of this study was to show the familial chylomicronemia syndrome traffic light table for pediatric patients and to assess the dietary fat intake and impact on triglycerides in children with FCS. (2) Methods: We performed a retrospective analysis in four children (50% male) affected by FCS from the Department of Pediatrics and Adolescent Medicine, Medical University of Vienna between January 2002 and September 2020. (3) Results: The four patients presented with classical FCS symptoms and showed baseline triglycerides (TG) exceeding 30,000 mg/dL in two patients, 10,000 mg/dL and 2400 mg/dL in one patient each. After diagnosis, fat percentage of total daily caloric intake was decreased and resulted immediately in triglyceride reduction. In all patients, FCS was genetically confirmed by mutations in genes encoding lipoprotein lipase. Acute pancreatitis and hepatosplenomegaly disappeared under the fat-restricted diet. A FCS traffic light table was developed as a dietary tool for affected families. (4) Conclusions: A restriction of dietary fat between 10% to 26% of the total daily caloric intake was feasible and effective in the long-term treatment of genetically confirmed FCS in children and could reduce the risk for acute pancreatitis. The dietary tool, the pediatric FCS traffic light table and the age-appropriate portion sizes for patients between 1 to 18 years, supports children and their parents to achieve and adhere to the lifelong strict low-fat diet.
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35
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Khan TZ, Schatz U, Bornstein SR, Barbir M. Hypertriglyceridaemia: contemporary management of a neglected cardiovascular risk factor. Glob Cardiol Sci Pract 2021; 2021:e202119. [PMID: 34805377 PMCID: PMC8587207 DOI: 10.21542/gcsp.2021.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/30/2021] [Indexed: 11/05/2022] Open
Abstract
Hypertriglyceridaemia represents one of the most prevalent lipid abnormalities, however it is often eclipsed by focus on LDL cholesterol and is frequently overlooked by clinicians, despite it being an important cardiovascular risk factor. For most patients, hypertriglyceridaemia arises from a combination of environmental factors and multiple genetic variations with small effects. Even in cases with apparent familial clustering of hypertriglyceridaemia, a monogenetic cause is rarely identified. Common secondary causes include obesity, uncontrolled diabetes, alcohol, and various commonly used drugs. Correction of these factors, along with lifestyle optimisation, should be prioritised prior to commencing medication. The goal of drug treatment is to reduce the risk of cardiovascular disease in those with moderate hypertriglyceridaemia and the risk of pancreatitis in those with severe hypertriglyceridaemia. Recent and ongoing trials demonstrate the important role of triglycerides (TG) in determining residual risk in patients with cardiovascular disease (CVD) already established on statin therapy. Novel and emerging data on omega-3 fatty acids (high-dose icosapent ethyl) and the selective PPAR modulator pemafibrate are eagerly awaited and may provide further clarity for clinicians in determining which patients will benefit from TG lowering and help inform clinical guidelines. There are numerous novel therapies on the horizon that reduce TG by decreasing the activity of proteins that inhibit lipoprotein lipase such as apolipoprotein C-III (including Volanesorsen which was recently approved in Germany) and ANGPTL 3/4 which may offer promise for the future.
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Affiliation(s)
- Tina Z. Khan
- Department of Cardiology, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust Hospital, Hill End Road, Harefield UB9 6JH, United Kingdom
| | - Ulrike Schatz
- University Hospital Carl Gustav Carus, Fetscher Street 74, Dresden 01307, Germany
| | - Stefan R. Bornstein
- University Hospital Carl Gustav Carus, Fetscher Street 74, Dresden 01307, Germany
| | - Mahmoud Barbir
- Department of Cardiology, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust Hospital, Hill End Road, Harefield UB9 6JH, United Kingdom
- University Hospital Carl Gustav Carus, Fetscher Street 74, Dresden 01307, Germany
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36
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Tünnemann-Tarr A, Scharnagl H, Katzmann JL, Stürzebecher P, Laufs U. Familial chylomicronemia syndrome due to a heterozygous deletion of the chromosome 8 treated with the apoCIII inhibitor volanesorsen: A case report. Medicine (Baltimore) 2021; 100:e27573. [PMID: 34678899 PMCID: PMC8542157 DOI: 10.1097/md.0000000000027573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/07/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Familial chylomicronemia syndrome is a congenital, severe form of hypertriglyceridemia associated with increased risk of acute pancreatitis. Treatment options are limited. PATIENT CONCERNS A 52-year-old woman was referred with recurrent pancreatitis and severe hypertriglyceridemia to our lipid clinic. DIAGNOSIS Laboratory examination showed elevated serum triglyceride concentrations of 8090 mg/dL (90 mmol/L). Lipid electrophoresis showed a type V phenotype with positive chylomicrons. Genetic investigation revealed a novel heterozygous large deletion of the lipoprotein lipase gene on chromosome 8. A familial chylomicronemia syndrome was diagnosed. Other causes of hypertriglyceridemia were excluded. INTERVENTIONS Fibrates and diet did not lower triglyceride levels. Therefore, treatment with the apolipoprotein CIII (apoCIII) inhibitor volanesorsen was initiated. OUTCOMES After 3 months of treatment, a 90% reduction of triglycerides was observed. ApoCIII concentrations were reduced by 90% in the total and by 61% in the chylomicron-free serum. Treatment was well tolerated with only minor local reaction after the first application. The platelet count was monitored weekly and did not decrease <150 cells/μL. LESSONS This case report shows that inhibition of apoCIII potently reduces serum triglycerides in patients with heterozygous monogenetic deletion of the lipoprotein lipase gene. Follow-up will show the effect on recurrent episodes of pancreatitis.
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Affiliation(s)
| | - Hubert Scharnagl
- Klinisches Institut für Medizinische und Chemische Labordiagnostik, Medizinische Universität Graz, Graz, Austria
| | - Julius L. Katzmann
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paulina Stürzebecher
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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Clinical Management of Hypertriglyceridemia in the Prevention of Cardiovascular Disease and Pancreatitis. Curr Atheroscler Rep 2021; 23:72. [PMID: 34515873 PMCID: PMC8436578 DOI: 10.1007/s11883-021-00962-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
Purpose of Review Hypertriglyceridemia (HTG) is common and is a significant contributor to atherosclerosis and pancreatitis risk. Specific HTG treatments have had variable success in reducing atherosclerosis risk. Novel therapies for severe HTG treatment and pancreatitis risk reduction are likely to be available soon. These novel therapies are expected to have broader applications for more moderate HTG and atherosclerosis risk reduction as well. Recent Findings NHANES 2012 data has confirmed a reduction in average triglyceride (TG) levels in the US population. Dietary modification and weight reduction when needed remain the core treatment elements for all individuals with HTG, while statin therapy is a foundational pharmacologic care for atherosclerotic cardiovascular disease (ASCVD) event risk reduction. In addition, the REDUCE-IT study provides evidence for additional benefit from the use of high-dose icosapent ethyl (IPE) on top of background medical therapy in adults with moderate HTG and ASCVD or type 2 diabetes mellitus (T2D) and additional ASCVD risk factors. However, treatment with eicosapentaenoic acid (EPA) combined with docosahexanoic acid (DHA) did not reduce ASCVD in a similar population studied in the STRENGTH trial. Furthermore, novel therapeutics targeting PPAR-ɑ, as well as ApoC-III and AngPTL3, effectively lower TG levels in individuals with moderate and severe HTG, respectively. These treatments may have applicability for reducing risk from ASCVD among individuals with chylomicronemia; in addition, ApoC-III and AngPTL3 treatments may have a role in treating individuals with the rare monogenic familial chylomicronemia syndrome (FCS) at risk for acute pancreatitis (AP). Summary Residual ASCVD risk in individuals treated with contemporary care may be due in part to non-LDL lipid abnormalities including HTG. The findings from REDUCE-IT, but not STRENGTH, confirm that consumption of high-dose EPA may reduce ASCVD risk, while combination therapy of EPA plus DHA does not reduce ASCVD in a similar population. TG lowering likely reduces ASCVD risk in individuals with HTG, but ASCVD risk is multifactorial; the added benefit of IPE to contemporary preventive therapy is the consequence of differential non-TG biologic properties between the two fatty acids. Acute pancreatitis is more difficult to study prospectively since it is less common; however, TG lowering is likely critical for the care of at-risk individuals. Additional benefit from novel therapy that has an impact on this otherwise refractory condition is anticipated.
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Choi J, Kim H, Jun J, Ryu J, Lee HY. Recurrent Pancreatitis in a Pregnant Woman with Severe Hypertriglyceridemia Successfully Managed by Multiple Plasmapheresis. J Atheroscler Thromb 2021; 29:1108-1116. [PMID: 34219115 PMCID: PMC9252624 DOI: 10.5551/jat.62734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypertriglyceridemia (HTG) is a state of increased serum triglyceride (TG) affected by multigenetic and multifactorial causes. Serum TG concentration can be markedly elevated if exposed to precipitating factors, such as estrogen hormone and pregnancy. We report the case of a patient with severe HTG who suffered from recurrent pancreatitis during the second trimester of pregnancy conceived within vitro fertilization-embryo transfer (IVF-ET) and was successfully controlled by multiple sessions of plasmapheresis.
A 24-year-old pregnant woman was admitted because of a sudden onset of severe abdominal pain at 26 weeks of gestation conceived by IVF-ET. She has experienced recurrent pancreatitis despite low-fat diet and dyslipidemia medications allowed in pregnancy. At admission, serum amylase and lipase were elevated to 347 and 627 U/L, respectively, along with fasting TG to 4809 mg/dL. A clinical diagnosis of HTG-induced acute pancreatitis was made, and plasmapheresis was performed. After plasmapheresis, serum TG, amylase, and lipase levels decreased to 556 mg/dL, 60 U/L, and 69 U/L, respectively, along with subsequent pain relief. The patient underwent a total of nine sessions of plasmapheresis to retain serum TG lower than 1,000 mg/dL during pregnancy, with no further recurrence of acute pancreatitis. After delivery, the serum TG level was maintained below 500 mg/dL with a combination treatment of fenofibrate, statin, and ezetimibe. Although severe HTG is usually asymptomatic, if exposed to precipitating factors, it can cause acute pancreatitis, a fatal complication. Early application of plasmapheresis may be a useful option in HTG-induced acute pancreatitis intractable to medical treatment; however, its indications, risks, and benefits should be carefully evaluated.
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Affiliation(s)
- JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - JongKwan Jun
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine
| | - JiKon Ryu
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
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39
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Huang L, Gao L, Chen C. Role of Medium-Chain Fatty Acids in Healthy Metabolism: A Clinical Perspective. Trends Endocrinol Metab 2021; 32:351-366. [PMID: 33832826 DOI: 10.1016/j.tem.2021.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/22/2022]
Abstract
Medium-chain fatty acids (MCFAs) serve not only as an energy source but also regulate glucose and lipid metabolism. The unique transport and rapid metabolism of MCFAs provide additional clinical benefits over other substrates such as long-chain fatty acids (LCFAs) and have prompted interest in the use of MCFAs for treating metabolic and neurological disorders. This review focuses on the metabolic role of MCFAs in modulating cellular signaling and regulating key circulating metabolites and hormones. The potential of MCFAs in treating various metabolic diseases in a clinical setting has also been analyzed.
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Affiliation(s)
- Lili Huang
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Lin Gao
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Chen Chen
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia.
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40
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Okazaki H, Gotoda T, Ogura M, Ishibashi S, Inagaki K, Daida H, Hayashi T, Hori M, Masuda D, Matsuki K, Yokoyama S, Harada-Shiba M. Current Diagnosis and Management of Primary Chylomicronemia. J Atheroscler Thromb 2021; 28:883-904. [PMID: 33980761 PMCID: PMC8532063 DOI: 10.5551/jat.rv17054] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.
PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes (
LPL
,
LMF1
,
GPIHBP1
,
APOC2
, and
APOA5
). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).
The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive. The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life. Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease. Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.
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Affiliation(s)
- Hiroaki Okazaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo
| | - Takanari Gotoda
- Department of Metabolic Biochemistry, Faculty of Medicine, Kyorin University
| | - Masatsune Ogura
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Jichi Medical University
| | - Kyoko Inagaki
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Nippon Medical School
| | - Hiroyuki Daida
- Faculty of Health Science, Juntendo University, Juntendo University Graduate School of Medicine
| | - Toshio Hayashi
- School of Health Sciences, Nagoya University Graduate School of Medicine
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University
| | - Daisaku Masuda
- Department of Cardiology, Health Care Center, Rinku Innovation Center for Wellness Care and Activities (RICWA), Rinku General Medical Center
| | - Kota Matsuki
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine
| | | | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute
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Treatment of chylomicronemia. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2021; 33 Suppl 2:75-79. [PMID: 34006359 DOI: 10.1016/j.arteri.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/25/2021] [Indexed: 02/03/2023]
Abstract
Fasting chylomicronaemia appears in type V (multifactorial chylomicronaemia syndrome, MCS), and in type I (familial chylomicronaemia syndrome, FCS). MCS needs to be treated as in any general hypertriglyceridaemia: low-calorie diet, avoid sugar and alcohol, reduce body weight, control of diabetes and, in some cases, common lipid lowering-drugs, such as fibrates or omega-3 fatty acids. For type I HLP, FCS, patients should adhere to a strict very low fat diet, usually less than 15-20 g per day. In spite of this, many patients with FCS suffer from recurrent abdominal pain and/or acute pancreatitis. Volanesorsen, an antisense oligonucleotide against apolipoprotein C-III, is the only drug approved to control the disease. As shown in the APPROACH study, the administration of volanesorsen at a weekly dose of 285 mg induced at three month a reduction of triglycerides of 77% (primary end-point) and a reduction of 1712 mg/dL from the baseline. Among patient receiving volanesorsen, 77% reached a fasting triglyceride value below 750 mg/dL. The most frequent side effects were a skin reaction at injection site and low platelet levels, which should be monitored.
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42
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Kuthiroly S, Yesodharan D, Radhakrishnan N, Ganapathy A, Mannan AU, Hoffmann MM, Nampoothiri S. Lipoprotein Lipase Deficiency. Indian J Pediatr 2021; 88:147-153. [PMID: 32472350 DOI: 10.1007/s12098-020-03305-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To analyse the clinical and molecular spectrum of Lipoprotein Lipase (LPL) deficiency and to highlight the effect of a cost-effective indigenous diet for management of this disorder. METHODS This is a single-centre retrospective study. Fifteen patients from 14 kindreds with severe hypertriglyceridemia (more than 1000 mg/dl) were evaluated for a period of 12.5 y at Amrita Institute of Medical Sciences, Kerala, India. RESULTS Thirteen of 15 patients were referred after incidental detection of lipemic plasma, 1/15 had chylothorax in the neonatal period and 1/15 had pancreatitis. The mean age of presentation was 7 mo (ranging from 2 d to 4 y), and 20% of the patients had a positive history of consanguinity. Hepatomegaly (15/15), splenomegaly (9/15) and lipemia retinalis (14/15) were common findings. Lipemia retinalis was a useful non-invasive diagnostic tool. All the patients were subjected to diet modification and followed up at regular intervals. Fourteen of 15 complied with the diet, resulting in a dramatic improvement in the fasting lipid profile; only 1/15 developed pancreatitis. Genetic screening analysis was offered to 14/15 patients (1/15 was lost to follow-up); six different variants were identified, of which two were novel variants. CONCLUSIONS Lipemic serum, chylothorax and recurrent pancreatitis in children should raise the suspicion of Lipoprotein Lipase deficiency. Early diagnosis and prompt initiation of a stringent fat-restricted diet are the keys to success for the management of LPL deficiency and prevention of pancreatitis.
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Affiliation(s)
- Shwetha Kuthiroly
- Department of Pediatric Genetics, Amrita Institute of Medical Sciences & Research Centre, Aims Ponekkara PO, Cochin, Kerala, 682041, India
| | - Dhanya Yesodharan
- Department of Pediatric Genetics, Amrita Institute of Medical Sciences & Research Centre, Aims Ponekkara PO, Cochin, Kerala, 682041, India
| | - Natasha Radhakrishnan
- Department of Ophthalmology, Amrita Institute of Medical Sciences & Research Centre, Aims Ponekkara PO, Cochin, Kerala, 682041, India
| | - Aparna Ganapathy
- Strand Life Sciences, Hebbal PO, Bangalore, Karnataka, 560024, India
| | - Ashraf U Mannan
- Strand Life Sciences, Hebbal PO, Bangalore, Karnataka, 560024, India
| | - Michael M Hoffmann
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Centre & Faculty of Medicine - University of Freiburg, Freiburg im Breisgau, Germany
| | - Sheela Nampoothiri
- Department of Pediatric Genetics, Amrita Institute of Medical Sciences & Research Centre, Aims Ponekkara PO, Cochin, Kerala, 682041, India.
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Susheela AT, Vadakapet P, Pillai L, Thampi S. Familial chylomicronemia syndrome: a case report. J Med Case Rep 2021; 15:5. [PMID: 33419463 PMCID: PMC7791813 DOI: 10.1186/s13256-020-02609-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 11/30/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Familial chylomicronemia is an extremely rare disease. Lipoprotein lipase deficiency, lipoprotein defect or lipoprotein receptor defect are the main genetic causes of familial chylomicronemia. CASE PRESENTATION We report a rare case of hypertriglyceridemia which was diagnosed at 24 days after birth. A newborn south east Asian baby born for G3P2A1 mother was presented with hematuria at 24 days at the hospital. The patient's family history is significant for pink blood in an elder sibling who died within a few months of birth without a proper diagnosis. Physical examination was not significant for any findings. Urinalysis revealed numerous RBC in the urine. Blood draw to perform renal function test revealed a characteristic pink blood. Baby's blood was normal and red in color at the time of birth. During the present visit, although most of the blood test were not able to be carried out by the regular laboratory instruments, the patient's lipid profile was alarmingly high with triglyceride levels over 4000 mg/dL. Due to a very high triglyceride level in a neonate and a significant familial history, a genetic cause of hypertriglyceridemia is suspected. Upon diagnosis, baby was discontinued of breast feeding completely and was given a special diet devoid of triglyceride and containing medium chain fatty acid diet and was also started with fenofibrate. After a month and a half, follow up tests were conducted which showed the triglyceride level was reduced to 1300 and a reversal of the blood color from pink to red. Since the imported diet was extremely expensive for the family, the patient was put on skimmed milk with medium-chain triglyceride (MCT) oil. With 6 weeks of treatment, baby's condition has improved and is thriving well. CONCLUSIONS Our case reports an extremely rare and fatal condition and illustrated the significance of timely diagnosis and intervention for saving the life of the baby.
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Affiliation(s)
- Ammu Thampi Susheela
- Loyola-MacNeal Hospital, 3249 S Oak Park Ave, Berwyn, IL, 60402, USA. .,Edward Hines, Jr. VA Hospital/Loyola University Medical Center, 5000 5th Ave, Hines, IL, 60141, USA.
| | - Padmesh Vadakapet
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
| | - Lekshmi Pillai
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
| | - Susheela Thampi
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
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Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG), a form of dyslipidemia characterized by elevated plasma of triglycerides (TG), is associated with an increased risk for acute pancreatitis. Moreover, HTG has recently been shown to be linked to the development of atherosclerotic cardiovascular disease (ASCVD); therefore, there is a great interest in better understanding the pathophysiology of HTG and improving its clinical management. In this review, we briefly describe TG metabolism, recent guidelines for the clinical management of HTG and provide an overview of the current and potential new therapies for HTG. RECENT FINDINGS Screening patients for HTG is valuable for not only identifying patients with extreme TG elevations, who are at risk for pancreatitis, but also for managing ASCVD risk in patients with more moderate forms of HTG. Therefore, the most recent USA guidelines for cardiovascular diseases recommend using TG as a risk enhancer test, leading to a more aggressive treatment of patients with intermediate risk. Currently, there are several available approaches for reducing plasma TG, which include lifestyle changes, fibrates and omega-3 fatty acid treatment. The addition of eicosapentaenoic acid (EPA) on top of statins has recently been shown to significantly reduce ASCVD events. Nevertheless, there is an unmet need for more effective treatment options. Several new therapies based on newly identified targets in TG metabolism, such as apolipoprotein C-III and angiopoietin-like 3 protein, are currently under development. SUMMARY The clinical management of HTG is important in the prevention and treatment of acute pancreatitis and also impacts on how ASCVD risk is managed. More work needs to be done to establish the mechanism for the ability of how EPA lowers ASCVD and how to best integrate it with other lipid-lowering therapies. The efficacy and safety of the novel therapies for HTG should be established soon in the ongoing late-stage clinical trials.
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Affiliation(s)
- Anna Wolska
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Zhi-Hong Yang
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Alan T. Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
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Tripathi M, Wong A, Solomon V, Yassine HN. THE PREVALENCE OF PROBABLE FAMILIAL CHYLOMICRONEMIA SYNDROME IN A SOUTHERN CALIFORNIA POPULATION. Endocr Pract 2020; 27:71-76. [PMID: 33475504 DOI: 10.4158/ep-2020-0135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To estimate the prevalence of probable familial chylomicronemia syndrome (FCS) in a major Southern California Academic Center as well as to provide a systematic review of past FCS studies and management recommendations. METHODS Electronic medical records were queried based on single fasting plasma triglyceride (TG) levels of ≥880 mg/dL and at least 1 episode of acute pancreatitis. After the exclusion of secondary causes (diabetes, alcohol misuse, gallbladder disease, chronic kidney disease, uncontrolled hypothyroidism, estrogen, and drug use) and responses to lipid-lowering treatment, probable patients with FCS were identified. A systematic review of all published literature on the prevalence and management guidelines for FCS was then presented and discussed. RESULTS Out of 7 699 288 charts queried, 138 patients with TG levels of ≥880 mg/dL and documented evidence of at least 1 episode of acute pancreatitis were identified. Nine patients did not have any documented secondary causes of chylomicronemia. Four of the 9 patients had >20% decrease in TG levels after lipid-lowering treatment, 2 patients were not responsive to lipid-lowering medication, and data on lipid-lowering medications were missing in 3 patients. CONCLUSION Our study estimates the prevalence of probable FCS at a range of 0.26 to 0.66 per million. Using the recommended criteria, probable FCS cases can be identified to allow early diagnosis and management.
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Affiliation(s)
- Mrinali Tripathi
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - April Wong
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Victoria Solomon
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hussein N Yassine
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Abstract
Hypertriglyceridemia is one of the most common lipid abnormalities encountered in clinical practice. Many monogenic disorders causing severe hypertriglyceridemia have been identified, but in most patients triglyceride elevations result from a combination of multiple genetic variations with small effects and environmental factors. Common secondary causes include obesity, uncontrolled diabetes, alcohol misuse, and various commonly used drugs. Correcting these factors and optimizing lifestyle choices, including dietary modification, is important before starting drug treatment. The goal of drug treatment is to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia and cardiovascular disease in those with moderate hypertriglyceridemia. This review discusses the various genetic and acquired causes of hypertriglyceridemia, as well as current management strategies. Evidence supporting the different drug and non-drug approaches to treating hypertriglyceridemia is examined, and an easy to adopt step-by-step management strategy is presented.
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Affiliation(s)
- Vinaya Simha
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
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47
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Gallo A, Béliard S, D'Erasmo L, Bruckert E. Familial Chylomicronemia Syndrome (FCS): Recent Data on Diagnosis and Treatment. Curr Atheroscler Rep 2020; 22:63. [PMID: 32852651 DOI: 10.1007/s11883-020-00885-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Familial chylomicronemia syndrome (FCS) is a rare recessive genetic disorder often underdiagnosed with potentially severe clinical consequences. In this review, we describe the clinical and biological characteristics of the disease together with its main complication, i.e., acute pancreatitis. We focused the paper on new diagnostic tools, progress in understanding the role of two key proteins (apolipoprotein CIII (apo CIII) and angiopoietin-like3 (ANGPTL-3)), and new therapeutic options. RECENT FINDINGS Recently, a new diagnostic tool has been proposed by European experts to help identify these patients. This tool with two recently identified parameters (low LDL and low body mass index) can help identify patients who should be genetically tested or who may have the disease when genetic testing is not available. FCS is caused by homozygous or compound heterozygous mutations of lipoprotein lipase, apolipoprotein C-II, apolipoprotein A-V, glycosylphosphatidylinositol anchored high-density lipoprotein-binding protein 1, and lipase maturation factor. Two proteins have been identified as important player in the metabolism of triglyceride-rich lipoprotein and its regulation. These two proteins are therapeutic target. Antisense oligonucleotide targeting apo CIII has been shown to significantly decrease triglyceride levels even in FCS and is the first available treatment for these patients. Further development might identify new compounds with reduced risk to develop severe thrombocytopenia. ANGPTL-3 inhibitors have not yet been tested in FCS patients but exert significant hypotriglyceridemic effect in the more frequent and less severe polygenic forms. Beyond these two new targets, microsomal triglyceride transfer protein (MTTP) inhibitors could also be part of the armamentarium, if on-going trials confirm their efficacy. New clinical tools and simple criteria can help select patients with possible FCS and identify patients who should have a genetic testing. Identifying patients with FCS is a major issue since these patients have a high risk to suffer severe episodes of acute pancreatitis and may now benefit from new therapeutic options including antisense oligonucleotide targeting apo CIII.
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Affiliation(s)
- Antonio Gallo
- Department of Endocrinology and Cardiovascular Disease Prevention, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Sophie Béliard
- Department of Nutrition, Maladies Métaboliques et Endocrinologie, Hôpital Conception, Marseille, France
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eric Bruckert
- Department of Endocrinology and Cardiovascular Disease Prevention, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France.
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48
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D'Erasmo L, Gallo A, Di Costanzo A, Bruckert E, Arca M. Evaluation of efficacy and safety of antisense inhibition of apolipoprotein C-III with volanesorsen in patients with severe hypertriglyceridemia. Expert Opin Pharmacother 2020; 21:1675-1684. [PMID: 32646313 DOI: 10.1080/14656566.2020.1787380] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Severe hypertriglyceridemia (sHTG) is a complex disorder of lipid metabolism characterized by plasma levels of triglyceride (TG) greater than 885 mg/dl (>10 mmol/L). The treatment of sHTG syndromes is challenging because conventional treatments are often ineffective in reducing TG under the threshold to prevent acute pancreatitis (AP). The inhibition of APOC3, which encodes a protein involved in triglyceride (TG)-rich lipoproteins (TGRLs) removal, has been reported to be a novel target for the treatment of sHTG. Volanesorsen is a second-generation antisense oligonucleotide inhibiting apoC-III transcription/translation that has been recently approved in Europe for Familial Chylomicronemia Syndrome (FCS) treatment. AREAS COVERED This review summarizes the evidences on the efficacy and safety of volanesorsen for the treatment of sHTG syndromes. EXPERT OPINION Volanesorsen effectively reduces TG in sHTG through a mechanism that is mainly LPL-independent, potentially decreasing the risk of AP. Some safety concerns have been raised with the use of volanesorsen, mainly represented by the occurrence of thrombocytopenia. Due to the potential severity of side effects, some caution is needed before affirming the long-term utility of this drug. Despite this, volanesorsen currently remains the only drug that has been demonstrated effective in FCS, which otherwise remains an untreatable disease.
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Affiliation(s)
- Laura D'Erasmo
- Department of Translational and Precision Medicine, Sapienza University of Rome , Rome, Italy.,Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Pitié-Salpêtrière University Hospital , Paris, France
| | - Antonio Gallo
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Pitié-Salpêtrière University Hospital , Paris, France.,Laboratoire d'imagerie Biomédicale, INSERM 1146, - CNRS 7371, Sorbonne University , Paris, France
| | - Alessia Di Costanzo
- Department of Translational and Precision Medicine, Sapienza University of Rome , Rome, Italy
| | - Eric Bruckert
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Pitié-Salpêtrière University Hospital , Paris, France
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome , Rome, Italy
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Acute Pancreatitis After a Meatless Burger in Familial Chylomicronemia Syndrome. Am J Med 2020; 133:e308. [PMID: 31926141 DOI: 10.1016/j.amjmed.2019.12.005] [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: 10/30/2019] [Revised: 11/27/2019] [Accepted: 12/01/2019] [Indexed: 11/20/2022]
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Fox RS, Peipert JD, Vera-Llonch M, Phillips G, Cella D. PROMIS® and Neuro-QoL TM measures are valid measures of health-related quality of life among patients with familial chylomicronemia syndrome. Expert Rev Cardiovasc Ther 2020; 18:231-238. [PMID: 32223345 DOI: 10.1080/14779072.2020.1748011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: FCS significantly affects health-related quality of life (HRQOL). Legacy patient-reported outcome measures are often not sensitive to FCS's impact. NIH PROMIS and Neuro-QoL measures may accurately capture HRQOL in FCS patients. This study assessed a broad range of PROMIS and Neuro-QoL measures covering physical, mental, and social HRQOL to determine their suitability for the FCS population.Methods: Adult FCS patients in the United States (N = 25) were recruited to an online survey study and completed several PROMIS short forms and Neuro-QoL computer adaptive tests.Results: Scores were more than 0.5 standard deviations (SD) worse than the normative mean on 10 of 16 normed measures, and more than 0.75 SDs worse than the normative mean on two measures. Responses at the floor and ceiling were occasionally observed, marginal reliabilities were strong, and significant differences across performance status (ps < 0.05) provided preliminary support for construct validity. The measures correlated with each other strongly and as expected.Conclusion: Results support the ability of PROMIS and Neuro-QoL measures to detect HRQOL impairment among patients with FCS. PROMIS and Neuro-QoL measures captured the functional impact and symptom burden associated with FCS, and the broad range of symptom severity experienced by patients with FCS.
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Affiliation(s)
- Rina S Fox
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Devin Peipert
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Montserrat Vera-Llonch
- Department of Global Health Economics and Outcomes Research, Akcea Therapeutics, Cambridge, MA, USA
| | - Glenn Phillips
- Department of Value and Evidence Generation, Rhythm Pharmaceuticals, Boston, MA, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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