Vitamin A concentration in the liver decreases with age in patients with cystic fibrosis

The Effect of Retinol Acetate on Liver Fibrosis Depends on the Temporal Features of the Development of Pathology

Background

The effect of vitamin A on the manifestations of liver fibrosis is controversial and establishing the causes of its multidirectional influence is an urgent problem. In the work, the functional characteristics of the liver with Cu-induced fibrosis were determined after the restoration of vitamin A to the control level at the F0/F1 stage.

Methods

In animals with liver fibrosis, classical indicators of physiology, functional activity of the liver, histological, and hematological characteristics were determined; the content of calcium and ROS was determined in bone marrow cells.

Results

It was shown that in the liver with Cu-induced fibrosis, the restoration of vitamin A content to control values after per os injections of a retinol acetate solution at a dose of 0.10 mg (300 IU)/100 g of body weight in the early stages of this pathology development (Fо/F1) was accompanied by: a decrease in the number of immunocompetent cells in the bloodstream to control values; normalization of the amount of calcium ions and ROS in bone marrow cells; restoration to the control level of activity of alkaline phosphatase; an increase in the number of binuclear hepatocytes; and restoration of the dynamics of body weight growth in experimental animals, even against the background of the ongoing action of the hepatotoxic factor.

Conclusion

We came to the conclusion that the multidirectional action of vitamin A, which occurs in liver fibrosis, depends not only on the concentration of vitamin A in the liver but also on temporal characteristics of cellular and metabolic links involved in the adaptive response formation. It was suggested that knowledge of the initial temporal metabolic characteristics and the amount of vitamin A in the liver, taking into account the stages of fibrosis development, can be an effective way to restore the altered homeostatic parameters of the body.

Might Routine Vitamin A Monitoring in Cystic Fibrosis Patients Reduce Virus-Mediated Lung Pathology?

Cystic fibrosis (CF) is an autosomal recessive gene disorder that affects tens of thousands of patients worldwide. Individuals with CF often succumb to progressive lung disease and respiratory failure following recurrent infections with bacteria. Viral infections can also damage the lungs and heighten the CF patient's susceptibility to bacterial infections and long-term sequelae. Vitamin A is a key nutrient important for immune health and epithelial cell integrity, but there is currently no consensus as to whether vitamin A should be monitored in CF patients. Here we evaluate previous literature and present results from a CF mouse model, showing that oral vitamin A supplements significantly reduce lung lesions that would otherwise persist for 5-6 weeks post-virus exposure. Based on these results, we encourage continued research and suggest that programs for the routine monitoring and regulation of vitamin A levels may help reduce virus-induced lung pathology in CF patients.

ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis

BACKGROUND

Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members.

RESULTS

The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended.

CONCLUSION

Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.

Vitamin A intake and serum retinol levels in children and adolescents with cystic fibrosis

BACKGROUND

Pancreatic insufficient cystic fibrosis (CF) patients receive vitamin A supplementation according to CF-specific recommendations to prevent deficiencies. Whether current recommendations are optimal for preventing both deficiency and toxicity is a subject of debate. We assessed the longitudinal relation between serum retinol levels and appropriate variables.

METHODS

We studied vitamin A intake, and the long-term effects of vitamin A intake, coefficient of fat absorption (CFA) and immunoglobulin G (IgG) on serum retinol levels in 221 paediatrics CF patients during a seven-year follow up period.

RESULTS

Total vitamin A intake, derived from 862 dietary assessments, exceeded the tolerable upper intake level in 30% of the assessments, mainly up to age six. Although CF patients failed to meet the CF-specific recommendations, serum retinol deficiency was found in only 17/862 (2%) of the measurements. Longitudinally, we observed no association to serum retinol levels for total vitamin A intake, CFA, gender or age but serum retinol levels were associated with serum IgG levels. Each g/L increase in serum IgG level would result in a 2.49% (95% CI -3.60 to -1.36%) reduction in serum retinol levels.

CONCLUSION

In this large sample of children and adolescents with CF, serum retinol deficiency was rare despite lower than the CF-specific recommendations. However, the TUL was commonly exceeded. A reduction in CF-specific vitamin A supplementation recommendations should therefore be considered. Moreover, serum retinol levels were not associated with vitamin A intake, CFA, gender or age, although a decreased serum retinol was associated with an increased serum IgG.

Individualized vitamin A supplementation for patients with cystic fibrosis

BACKGROUND & AIMS

To determine the vitamin A status and appropriate supplementation dosage of cystic fibrosis (CF) patients who received vitamin A supplementation based on annual serum retinol measurements.

METHODS

Vitamin A food intake, supplementation dosage, and serum retinol levels were obtained for 32 CF patients >4 years of age (4.3-27.3 years old) who had pancreatic insufficiency and mild-to-moderate lung disease (percent predicted of forced expiratory volume in 1 s > 40%). These measurements were compared with the dietary reference intake for healthy children and adults (D-A-CH dietary recommendations), US and German CF recommendations, and serum retinol concentrations from National Health and Nutrition Examination Survey (NHANES) data.

RESULTS

Total vitamin A intake from food and supplementation was 315% ± 182% of D-A-CH recommendations, with 65% from supplements. The range of the prescribed vitamin A supplementation dosage was 0-20,000 IU/day (median 5500 IU), and it was consistent with CF recommendations in 28% of participants. A quarter of all patients did not need any vitamin A supplementation. The total vitamin A intake exceeded the recommended upper limit of intake in 69% of subjects. The mean (range) serum retinol was 38.6 μg/dl (22.1-59.1 μg/dl). All subjects had serum retinol levels above 20 μg/dl and below 72 μg/dl (95th percentile of NHANES reference range).

CONCLUSION

Individualized vitamin A supplementation of 0-20,000 IU/day based on annual serum retinol measurements may prevent deficiency and high serum retinol levels, but it may lead to vitamin A intake above the tolerable upper intake level.

Vitamin A intake and elevated serum retinol levels in children and young adults with cystic fibrosis

BACKGROUND

Individuals with cystic fibrosis (CF) and pancreatic insufficiency (PI) are at risk for fat-soluble vitamin deficiency, including vitamin A. Recent evidence suggests current practices of vitamin A intake results in elevated serum retinol.

METHODS

Serum retinol was assessed in 78 subjects (8 to 25 years old) with CF and PI by high performance liquid chromatography, and compared to the U.S. National Health and Nutrition Examination Survey (NHANES) data of subjects of similar age and gender. Vitamin A intake, anthropometry and FEV(1) were measured, and their relationship to serum retinol status was assessed.

RESULTS

Median (range) serum retinol was 80 microg/dL (33 to 208) in subjects with CF; 58% were above the NHANES reference range (30 to 72 microg/dL). Total vitamin A intake from diet and supplements was high (608+431% Recommended Dietary Allowance). Serum retinol was not correlated with vitamin A intake, age or gender, and was inversely correlated with weight and height z scores (r=-0.28, p<0.05) in the subjects with CF.

CONCLUSIONS

Both vitamin A intake and serum retinol were elevated in subjects with CF and PI, corroborating recent evidence of elevated serum retinol in preadolescent children with CF. These findings indicate the need for further study of dosing and monitoring care practices of vitamin A, to ensure adequacy and to avoid toxicity.

Elevated vitamin A intake and serum retinol in preadolescent children with cystic fibrosis

BACKGROUND

Persons with cystic fibrosis (CF) and pancreatic insufficiency (PI) are at risk of vitamin A deficiency because of steatorrhea, despite pancreatic enzyme replacement. Long-standing vitamin A supplementation may increase the risk of vitamin A toxicity.

OBJECTIVE

The aim was to describe the vitamin A intake and serum retinol concentrations of preadolescent children with CF, PI, and mild-to-moderate pulmonary disease, who were cared for under current practice recommendations.

DESIGN

This cross-sectional study evaluated children aged 8.0-11.9 y with CF and PI from 13 US CF centers. Dietary and supplemental vitamin A intakes were compared with the Dietary Reference Intakes (DRIs) for healthy children, CF recommendations, and data from the National Health and Nutrition Examination Survey (NHANES), 1999-2000. Serum retinol concentrations were compared with NHANES data.

RESULTS

The 73 subjects with CF had a dietary vitamin A intake of 816 +/- 336 microg retinol activity equivalents (165 +/- 69% of the recommended dietary allowance), which was similar to the NHANES value. The supplement intake provided 2234 +/- 1574 microg retinol activity equivalents/d and exceeded recommendations in 21% of the subjects with CF. Total preformed retinol intake exceeded the DRI tolerable upper intake level in 78% of the subjects with CF. The serum retinol concentration was 52 +/- 13 microg/dL (range: 26-98 microg/dL), which was significantly higher than the NHANES value (37 +/- 10 microg/dL; range: 17-63 microg/dL; P < 0.001).

CONCLUSION

Although supplementation helps to prevent vitamin A deficiency in children with CF and PI, their high vitamin A intakes and serum retinol concentrations suggest that usual care may result in excessive vitamin A intake and possible toxicity that would increase the risk of CF-associated liver and bone complications.

Vitamin A levels in patients with CF are influenced by the inflammatory response

BACKGROUND

Serum vitamin A, normally depressed in inflammatory conditions, is frequently low in people with CF. Vitamin A is important in respiratory epithelial regeneration and repair. We hypothesised that serum vitamin A would be associated with inflammation and disease severity.

METHODS

Serum vitamin A (as retinol), C-reactive protein (CRP), vitamin E, 25-hydroxy vitamin D (25OHD), 1,25-dihydroxy vitamin D (1,25(OH)(2)D), weight, and lumbar spine bone mineral density (LSBMD) were measured in 138 subjects with CF (5-56 years) and 138 control subjects (5-48 years). FEV(1), presence of CF liver disease (CFLD) and hospital admissions were recorded in those with CF.

RESULTS

Serum vitamin A level was lower in CF subjects than in controls (mean, 95% CI: 1.29, 1.0-1.37 vs. 1.80, 1.7-1.87 micromol/l, p < 0.0001), and inversely correlated with CRP (r(s) = -0.37, p < 0.0001). CF subjects with low vitamin A (45%) level had poorer FEV(1), weight z-score, LSBMD z-score, and higher CRP compared with those with normal levels. In the CF group CRP, vitamin E, 1,25(OH)(2)D, presence of CFLD, admissions, and age were associated with vitamin A level.

CONCLUSIONS

Serum vitamin A is negatively associated with CRP in subjects with CF, consistent with normal population studies. It is important to distinguish between low serum vitamin A associated with the inflammatory response and that due to poor nutritional stores. The role of vitamin A in CF warrants further study, in the contexts both of chronic recurrent inflammatory disease and acute pulmonary exacerbation.

Plasma retinol binding protein for monitoring the acetaminophen-induced hepatotoxicity

Retinol-binding protein (RBP) is a specific transport protein which carries retinol in the circulation. RBP concentration in plasma and liver of rats following a large dose of acetaminophen (APAP) intraperitoneally was examined. The RBP concentration in plasma decreased significantly at 12 hr after the APAP administration, while the plasma albumin concentration was affected a little. Western blot and northern blot analyses showed marked changes in RBP but not in albumin. Thus, RBP was suggested to be more sensitive for the acute drug-induced hepatotoxicity than albumin. The decrease of RBP concentration in plasma was suggested to be caused by the dysfunction of RBP synthesis in the liver.

Nutrition in patients with cystic fibrosis: a European Consensus

This document is the result of an European Consensus conference which took place in Artimino, Tuscany, Italy, in March 2001 involving 33 experts on nutrition in patients with cystic fibrosis, organised by the European Cystic Fibrosis Society, and sponsored by Axcan-Scandipharm, Baxter, Dr Falk Pharma, Fresenius, Nutricia, SHS International, Solvay Pharmaceuticals (major sponsor). The purpose of the conference was to develop a consensus document on nutrition in patients with cystic fibrosis based on current evidence.

Normal annual increase of bone mineral density during two years in patients with cystic fibrosis

OBJECTIVES

To determine prospectively for 2 years the change in bone mineral density (BMD) in patients with cystic fibrosis (CF) and to correlate clinical data and routine biochemical parameters of bone metabolism and infection with BMD.

METHODS

Fifty-four patients with CF, aged 6 to 33 years, were included. BMD was measured using dual-energy x-ray absorptiometry in lumbar spine (LS) and femoral neck (FN). Anthropometric data and biochemical markers of bone metabolism and infection were measured. The number of intravenous antibiotic courses per year (ivAC) and pulmonary function were assessed.

RESULTS

The patients had normal anthropometric data and normal growth, but 36% and 33% of the patients had BMD z score <-1 standard deviation in LS and in FN, respectively. Nevertheless, BMD increased at a normal rate during the 2 years and was correlated to weight and lung function. Intact parathyroid hormone was positively correlated with the increase of BMD in both LS and FN during childhood. Blood sedimentation rate, serum concentration of immunoglobulin G, and ivAC were negatively correlated with BMD in FN. Patients with 2 more severe CF transmembrane conductance regulator mutations had significantly lower BMD in FN than other genetic combinations.

CONCLUSION

The study suggests that low BMD in CF is multifactorial and depends on infection and nutritional parameters. Differences in BMD of LS and FN suggested higher susceptibility to infection in FN at all ages. Longitudinal studies starting early before bacterial colonization would be valuable to determine the relative role of infection in the development of BMD in CF.

A comparison of nutrient intake between infants and toddlers with and without cystic fibrosis

OBJECTIVE

To compare the micronutrient and energy intake of infants and toddlers with cystic fibrosis (CF) to the intake of matched control children and dietary reference index (DRI) levels.

DESIGN

A two-group comparison study. Nutrient and energy intakes were measured via 3-day diet diaries. Anthropometric data were collected within 1 week of study enrollment.

SUBJECTS/SETTING

A clinical sample of 35 infants and toddlers with CF (mean=18.6, SD=8.1 months) matched to a community sample of 34 healthy controls.

STATISTICAL ANALYSES PERFORMED

Children with CF and controls were compared on anthropometric and nutrient data using independent sample t tests. Mean nutrient and energy intake for children in each group were compared with the age-appropriate DRI for targeted nutrients using percentages.

RESULTS

Children with CF and controls were similar on measures of growth (height, weight, or weight-for-height percentile). Four children with CF were at or below the 10th percentile for weight-for-height, compared with one control child. Children with CF and controls did not differ on average daily protein, calcium, zinc, and energy intake. Overall, children met or exceeded DRI levels for nutrient intakes. A notable exception was iron, for which mean intakes were lower for control children. Toddlers with CF consumed only 89% of the RDA per day for energy.

APPLICATIONS/CONCLUSIONS

Infants and toddlers with CF are likely obtaining adequate micronutrient intakes from food. Interventions to increase total energy intake in infants and toddlers with CF are needed. Dietitians may want to focus more on calorie intake and percent calories from fat than on micronutrient intake in their nutrition counseling in young children with CF.

Role of electroretinography in the assessment of retinal function as an indicator of vitamin A status

Hypovitaminosis A is associated with exocrine pancreatic insufficiency in cystic fibrosis. Peripheral retinal dysfunction is an early finding of vitamin A deficiency. We evaluated serum retinol and zinc as well as visual adaptation in 41 patients with cystic fibrosis, receiving generous pancreatic enzyme and micronutrient supplementation. Forty-one normal individuals matched for age and sex served as controls. Peripheral retinal function was measured by clinical electroretinography using an Electrophysiologic Personal Interfaced Computer and applying a standard protocol. Serum retinol in cystic fibrosis was significantly lower than that of the control group (0.30+/-0.01 versus 0.39+/-0.02 mg/l, p<0.001). Serum zinc concentrations were normal in the cystic fibrosis group (1.21+/-0.03 mg/l) and significantly higher than that of the control group (1.02+/-0.01 mg/l, p<0.001). The overall visual adaptation, however, was found to be normal and comparable in the two groups. It is concluded that, in cystic fibrosis, despite appropriate vitamin A supplementation, retinol serum concentration may be low. As serum retinol does not reflect vitamin A status, evaluation of visual adaptation may be a more appropriate way to monitor for vitamin A deficiency in cystic fibrosis.

Night blindness precipitated by isotretinoin in the setting of hypovitaminosis A

A 16-year-old male developed night blindness 2 weeks after starting isotretinoin at a dose of 20 mg per day for cystic acne. He also had cystic fibrosis, complicated by hepatic cirrhosis. Despite long-term oral vitamin A supplementation, serum vitamin A levels were found to be 0.3 mumol/L (normal range 0.9-2.5 mumol/L). Oral vitamin A replacement was instituted with resolution of his visual symptoms in 6 months. Isotretinoin therapy was successfully continued with no deterioration in liver function. Isotretinoin has been reported to cause deterioration in night vision. In vitro evidence suggests isotretinoin may interfere with the processing of endogenous vitamin A in the retina. This case highlights the need for careful monitoring of serum vitamin A status in patients with malabsorptive states on isotretinoin therapy.

Natural history of liver disease in cystic fibrosis

The median age of the population with cystic fibrosis (CF) has increased worldwide, which has led to the suggestion that the prevalence of liver disease would increase. The aim of this study was to evaluate the natural history of CF-associated liver disease over a 15-year period in a well-controlled population of patients with CF. During the years 1976 through 1993, 124 patients were followed up by yearly liver function tests (LFTs). Fifteen patients were followed up with liver biopsies throughout the whole study period. More than 50% of the patients had pathological LFTs in infancy, later being normalized. Approximately 25% of children 4 years of age or older had biochemical markers of liver disease during the study period. In about 10% of the patients, cirrhosis or advanced fibrosis was confirmed at biopsy and 4% of patients had cirrhosis with clinical liver disease. Severe liver disease developed mainly during prepuberty and puberty. Of the 15 patients prospectively followed up with liver biopsies, only 3 had progressive fibrosis. No specific risk factor was identified, but deficiency of essential fatty acids was found more often in patients with marked steatosis (P <.05). No patient developed clinical liver disease in adulthood and the histological changes in the liver biopsies were usually not progressive. Liver disease was no more frequent at the end of the study period although the median age of the patient population had increased. Modern treatment might positively influence liver disease because it seemed less common, less progressive, and less serious than previously reported.