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Kadohisa M, Okamoto T, Iwanaga K, Yamamoto M, Uebayashi EY, Ogawa E, Okajima H, Hatano E. Living Donor Liver Transplantation for Congenital Portosystemic Shunt Presenting With Hyperinsulinemic Hypoglycemia. Pediatr Transplant 2024; 28:e14871. [PMID: 39370668 DOI: 10.1111/petr.14871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/03/2024] [Accepted: 09/23/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND A congenital portosystemic shunt (CPSS) is defined as abnormal vascular communications between the portal vein and the systemic vein. Encephalopathy, hepatopulmonary syndrome, and portopulmonary hypertension are manifestations in patients with CPSS. Hyperinsulinemic hypoglycemia is also one of the manifestations of CPSS. Hyperinsulinemic hypoglycemia secondary to CPSS is caused by a lack of hepatic first-pass elimination of insulin, which is secreted from pancreatic beta cells. CASE PRESENTATION A 7-month-old boy had hypergalactosemia detected by newborn mass screening. Enhanced abdominal computed tomography showed the absence of the portal vein trunk and extrahepatic portosystemic communication between the superior mesenteric vein and the inferior vena cava. He had suffered from uncontrollable hyperinsulinemic hypoglycemia under protein and lactose restriction. We performed living donor liver transplantation (LDLT) using a left lateral segment graft from his father. The postoperative course was uneventful and the hypoglycemic attacks disappeared. CONCLUSION We believe that uncontrolled hyperinsulinemic hypoglycemia secondary to CPSS is an indication of LDLT.
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Affiliation(s)
- Masashi Kadohisa
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Tatsuya Okamoto
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Kougorou Iwanaga
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Yamamoto
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Elena Yukie Uebayashi
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Eri Ogawa
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Kanazawa, Japan
| | - Etsuro Hatano
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Kyoto University Hospital, Kyoto, Japan
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Hospital, Kyoto, Japan
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Justino H. The Significance of Congenital Portosystemic Shunts in Congenital Heart Disease and the Bizarre Phenomenon of Alternating Portosystemic and Systemic-Portal Shunting. Interv Cardiol Clin 2024; 13:307-318. [PMID: 38839165 DOI: 10.1016/j.iccl.2024.03.006] [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: 06/07/2024]
Abstract
Congenital portosystemic shunts (CPSSs) are rare vascular anomalies characterized by abnormal connections between the portal/splanchnic veins and the systemic veins. CPSSs often occur as an isolated congenital anomaly, but they can also coexist with congenital heart disease (CHD). Owing to their myriad consequences on multiple organ systems, familiarity with CPSS is of tremendous importance to the care of patients with CHD. The rationale and timing for interventions to embolize CPSS in this scenario are discussed. Specific shunt embolization techniques are beyond the scope of this article.
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Affiliation(s)
- Henri Justino
- Division of Cardiology, Department of Pediatrics, Rady Children's Hospital and University of California, San Diego, USA.
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Steg Saban O, Weissbach T, Achiron R, Pekar Zlotin M, Haberman Y, Anis Heusler A, Kassif E, Weiss B. Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study. Arch Dis Child 2023; 108:910-915. [PMID: 37474281 DOI: 10.1136/archdischild-2023-325424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Congenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of IHPSS diagnosed prenatally is rarely reported. We present a cohort of children prenatally diagnosed with IHPSS and report their natural course and outcome. METHODS AND DESIGN This was a retrospective study of all fetal cases diagnosed by ultrasound with IHPSS between 2006 and 2019 at a single tertiary centre which were prospectively followed up at the paediatric gastroenterology unit. The postnatal outcome was compared between patients with a single versus multiple intrahepatic shunts. RESULTS Twenty-six patients (70.3% boys) were included in the study, of them, eight (30.8%) patients had multiple intrahepatic shunts. The median gestational age at diagnosis was 29.5 weeks. Growth restriction affected 77% of the cohort. Postnatally, spontaneous shunt closure occurred in 96% of patients at a median age of 7.5 months (IQR 2.2-20 months). Failure to thrive (FTT) and mild developmental delay were observed in eight (30.8%) and seven (26.9%) patients, respectively. FTT was significantly more prevalent in patients with multiple shunts compared with patients with a single shunt (62.5% vs 16.7%, p=0.02); however, the rate of shunt closure and age at time of closure were similar between these groups. All patients survived with limited to no sequelae. CONCLUSIONS IHPSS usually close spontaneously by 2 years of age. Children with prenatally detected IHPSS may develop FTT and mild developmental delay. Close surveillance at a paediatric gastroenterology unit may be beneficial.
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Affiliation(s)
- Or Steg Saban
- Pediatrics B Department, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Weissbach
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Reuven Achiron
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Marina Pekar Zlotin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Yitzhak Shamir Medical Center Assaf Harofeh, Tzrifin, Israel
| | - Yael Haberman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology and Nutrition Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Anis Heusler
- Department of OBGYN, Laniado Hospital, Netanya, Israel
- The Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Eran Kassif
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Batia Weiss
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology and Nutrition Unit, Sheba Medical Center, Tel Hashomer, Israel
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van Albada ME, Shah P, Derks TGJ, Fuchs S, Jans JJM, McLin V, van der Doef HPJ. Abnormal glucose homeostasis and fasting intolerance in patients with congenital porto-systemic shunts. Front Endocrinol (Lausanne) 2023; 14:1190473. [PMID: 37664849 PMCID: PMC10471981 DOI: 10.3389/fendo.2023.1190473] [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: 03/20/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023] Open
Abstract
In physiological glucose homeostasis, the liver plays a crucial role in the extraction of glucose from the portal circulation and storage as glycogen to enable release through glycogenolysis upon fasting. In addition, insulin secreted by the pancreas is partly eliminated from the systemic circulation by hepatic first-pass. Therefore, patients with a congenital porto-systemic shunt present a unique combination of (a) postabsorptive hyperinsulinemic hypoglycaemia (HH) because of decreased insulin elimination and (b) fasting (ketotic) hypoglycaemia because of decreased glycogenolysis. Patients with porto-systemic shunts therefore provide important insight into the role of the portal circulation and hepatic function in different phases of glucose homeostasis.
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Affiliation(s)
- Mirjam E. van Albada
- Department of Pediatric Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pratik Shah
- Department of Pediatric Endocrinology, The Royal London Childrens Hospital, Barts Health National Health Service (NHS) Trust and William Harvey Research Institute, Queen Mary University London, London, United Kingdom
| | - Terry G. J. Derks
- Department of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Sabine Fuchs
- Department of Metabolic Diseases, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Judith J. M. Jans
- Department of Genetics, Section Metabolic Diagnostics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Valérie McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Obstetrics, and Gynecology, University of Geneva, Geneva, Switzerland
| | - Hubert P. J. van der Doef
- Department of Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Fujiwara A, Kanda S, Ueno K, Fujie H, Sekine N. Reactive hypoglycemia owing to an intrahepatic congenital portosystemic shunt in an older patient. Diabetol Int 2023; 14:298-303. [PMID: 37397900 PMCID: PMC10307763 DOI: 10.1007/s13340-023-00627-z] [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: 11/21/2022] [Accepted: 03/02/2023] [Indexed: 07/04/2023]
Abstract
An 85-year-old woman was admitted to our hospital because of hypoglycemia and impairment of consciousness several hours after breakfast. Because the hypoglycemia predominantly occurred 2-4 h after meals, we diagnosed reactive hypoglycemia. An oral glucose tolerance test showed prolonged hyperinsulinemia following the postprandial hyperglycemia, with a subsequent rapid decrease in blood glucose concentration. The post-stimulus plasma C-peptide concentration was relatively low compared to the plasma insulin concentration. Abdominal computed tomography revealed an intrahepatic congenital portosystemic shunt (CPSS). On the basis of these findings, we concluded that the reactive hypoglycemia was induced by the CPSS, via a reduction in hepatic insulin extraction. Treatment with an alpha-glucosidase inhibitor resolved the reactive hypoglycemia. CPSS comprises anomalous vascular connections between the portal vein and the systemic venous circulation, and reactive hypoglycemia is a rare complication of this malformation, which has most frequently been reported in children, with only a few cases reported in adults. However, this case indicates that even in adult patients, imaging studies should be conducted to rule out CPSS as the cause of the reactive hyperglycemia.
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Affiliation(s)
- Akiko Fujiwara
- Department of Diabetology and Endocrinology, JCHO Tokyo Shinjuku Medical Center, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo, 162-8543 Japan
- Department of Diabetes and Metabolic Diseases, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Shuhei Kanda
- Department of Diabetology and Endocrinology, JCHO Tokyo Shinjuku Medical Center, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo, 162-8543 Japan
| | - Keisuke Ueno
- Department of Diabetology and Endocrinology, JCHO Tokyo Shinjuku Medical Center, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo, 162-8543 Japan
| | - Hajime Fujie
- Department of Gastroenterology, JCHO Tokyo Shinjuku Medical Center, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo, 162-8543 Japan
| | - Nobuo Sekine
- Department of Diabetology and Endocrinology, JCHO Tokyo Shinjuku Medical Center, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo, 162-8543 Japan
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Robinson EB, Jordan G, Katz D, Sundaram SS, Boster J, Brigham D, Ladd P, Chan CM, Shay RL, Ochmanek E, Annam A. Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach. JPGN REPORTS 2023; 4:e279. [PMID: 37181921 PMCID: PMC10174742 DOI: 10.1097/pg9.0000000000000279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/21/2022] [Indexed: 05/16/2023]
Abstract
Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.
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Affiliation(s)
- Eduardo Bent Robinson
- From the Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory Jordan
- From the Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Danielle Katz
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
| | - Shikha S. Sundaram
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Julia Boster
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Dania Brigham
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
| | - Christine M. Chan
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Rebecca L. Shay
- Division of Neonatology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Emily Ochmanek
- Division of Interventional Radiology, Department of Radiology, University of New Mexico, Albuquerque, NM, USA
| | - Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, Aurora, CO, USA
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Presentation, Management, and Outcome of Congenital Portosystemic Shunts in Children: The Boston Children's Hospital Experience. J Pediatr Gastroenterol Nutr 2022; 75:81-87. [PMID: 35442217 DOI: 10.1097/mpg.0000000000003450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Congenital portosystemic shunts (CPSS) are rare vascular malformations. We describe presentations, complications, associations, and outcomes of CPSS at Boston Children's Hospital (BCH). METHODS This was a retrospective review of children with CPSS at BCH from 2000 to 2020. RESULTS Twenty-nine patients had CPSS (17 girls): 14 extrahepatic (EH) and 15 intrahepatic (IH). At diagnosis, 15 were ≤5 days, 7 <1 year, and 7 >1 year (range 1-19). Median follow-up duration was 5.2 years (interquartile range [IQR] 1.6-10.9) in EH and 2.2 years (0.2-4.2) in IH CPSS. The most common presentation was antenatal ultrasound 13 (45%) followed by hyperammonemia 10 (34%), whereas 6 (21%) were asymptomatic. Complications were noted in 17 (12/14 EH vs 6/15 IH, P = 0.008). Associated anomalies were present in 25 (14/14 EH vs 11/15 IH, P = 0.10). Spontaneous closure was observed in 8 (28%) patients with IH CPSS, all <12 months of age. Ten patients underwent shunt closure 3 (30%) by interventional radiology (IR) and 5 (50%) by surgery, whereas 2 (20%) required both. After therapeutic closure; 8 had improvement, 1 had portal hypertension, and 1 had sepsis and thrombosis. The remaining 11 patients, 8 (42%) were followed without closure: 6 of 8 (75%) EH versus 2 of 11 (18%) IH ( P = 0.02), 2 lost follow-up and 1 with complicated EH CPSS died, unsuitable for therapeutic closure. CONCLUSIONS CPSS may be asymptomatic or present with complications. Spontaneous closure of IH shunts may occur in infancy, thus therapeutic closure may be deferred until age ≥ 2 years. IR and surgical closure of CPSS are associated with improvement in the majority of cases.
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Miyazaki T, Ozeki M, Sasai H, Ohnishi H. Propranolol for infantile hemangiomas with hyperinsulinemic hypoglycemia. Pediatr Int 2021; 63:724-725. [PMID: 34042227 DOI: 10.1111/ped.14471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Taichi Miyazaki
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Michio Ozeki
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideo Sasai
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
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Abstract
Congenital portosystemic shunts are increasingly recognized in several settings and at any age. The following are some of the most common presentations: prenatal ultrasound, neonatal cholestasis, incidental finding on abdominal imaging, or systemic complications such as unexplained cardiopulmonary or neurological disease, or the presence of liver nodules in a noncirrhotic liver. The purpose of the present review is to summarize clinical presentation and current recommendations for management, and highlight areas of future research. Illustrative examples from the veterinary literature complement our current lack of knowledge of this rare malformation often masquerading as a multisystem disease.
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Weigert A, Bierwolf J, Reutter H, Gembruch U, Woelfle J, Ganschow R, Mueller A. Congenital intrahepatic portocaval shunts and hypoglycemia due to secondary hyperinsulinism: a case report and review of the literature. J Med Case Rep 2018; 12:336. [PMID: 30415638 PMCID: PMC6231275 DOI: 10.1186/s13256-018-1881-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/11/2018] [Indexed: 01/13/2023] Open
Abstract
Background Congenital portosystemic shunts present with various associated complications, such as other congenital malformations, hyperammonemia, or hepatopulmonary syndrome. Few cases of associated hypoglycemia have been reported so far and our case, to the best of our knowledge, describes the most severe extent of hypoglycemia. Case presentation We describe the case of a newborn Arab boy with two intrahepatic portosystemic shunts, resulting in severe and persistent hypoglycemia, due to which one of the shunts was closed by interventional radiology whereas the other shunt had already closed spontaneously. Conclusions Because he showed elevated levels for insulin and prolonged high insulin levels in an oral glucose tolerance test, our case supports the theory that portocaval shunts cause a reduced hepatic insulin reduction due to the high blood volume bypassing the liver. This case provides further insights into glucose regulation mechanisms of the liver and we suggest a consistent screening for hypoglycemia in patients with congenital portosystemic shunts.
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Affiliation(s)
- Alexander Weigert
- Clinic of General Pediatrics, University Hospital Bonn, Bonn, Germany. .,Universitätskliniken Bonn - Zentrum für Kinderheilkunde, Adenauerallee 119, 53113, Bonn, Germany.
| | - Jeanette Bierwolf
- Clinic of General Pediatrics, University Hospital Bonn, Bonn, Germany
| | - Heiko Reutter
- Department of Neonatology and Pediatric Intensive Care, University Hospital Bonn, Bonn, Germany.,Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Joachim Woelfle
- Clinic of General Pediatrics, University Hospital Bonn, Bonn, Germany.,Pediatric Endocrinology Division, Children's Hospital, University of Bonn, Bonn, Germany
| | - Rainer Ganschow
- Clinic of General Pediatrics, University Hospital Bonn, Bonn, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care, University Hospital Bonn, Bonn, Germany
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