1
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Aitokari L, Hiltunen P, Huhtala H, Kurppa K, Kivelä L. Measurement practices of alanine aminotransferase in children: Temporal changes and etiology for increased values. J Pediatr Gastroenterol Nutr 2024; 78:1383-1388. [PMID: 38477384 DOI: 10.1002/jpn3.12167] [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: 12/19/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
Data on alanine aminotransferase (ALT) measurement practices and diagnoses associated with increased values are limited. We evaluated these issues by collecting ALT measurements from 1- to 16-year-old patients investigated in 1992-2018 in a tertiary center. Diagnoses were gathered in 2008-2018. Altogether 145,092 measurements from 28,118 children were taken 42% undergoing repeated testing. Testing increased from 21/1000 to 81/1000 children and the prevalence of elevated values fluctuated between 18% and 26%. An increase was seen especially in emergency care and departments of rheumatology, gastroenterology, hemato-oncology, and psychiatry. Common acute causes associated with elevated ALT were infections (45%), hemato-oncologic conditions (17%), and external reasons (13%), whereas autoimmune diseases (28%), psychiatric conditions (14%), and metabolic-dysfunction associated steatotic liver disease (10%) were common chronic causes. In conclusion, ALT testing increased 3.9-fold while the proportion of increased values remained stable, indicating that increased testing was justified. However, in some departments the testing efficiency was low.
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Affiliation(s)
- Linnea Aitokari
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Valkeakoski Social and Healthcare Center, Wellbeing Services County of Pirkanmaa, Valkeakoski, Finland
| | - Pauliina Hiltunen
- Department of Pediatrics, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- The University Consortium of Seinäjoki, Seinäjoki, Finland
| | - Laura Kivelä
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric Research, University of Oslo, Oslo, Norway
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Giordano M, Iacoviello O, Santangelo L, Martino M, Torres D, Carbone V, Scavia G, Loconsole D, Chironna M, Cristofori F, Francavilla R. Gastrointestinal involvement in STEC-associated hemolytic uremic syndrome: 10 years in a pediatric center. Pediatr Nephrol 2024; 39:1885-1891. [PMID: 38189960 PMCID: PMC11026196 DOI: 10.1007/s00467-023-06258-5] [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: 04/25/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND The gastrointestinal (GI) tract represents one of the main targets of typical hemolytic uremic syndrome (HUS) in children. In this observational study, we tried to establish (1) the main features of GI complications during STEC-HUS and (2) the relationship between Escherichia coli serotypes and Shiga toxin (Stx) variants with hepatopancreatic involvement. METHODS A total of 79 STEC-HUS patients were admitted to our pediatric nephrology department between January 2012 and June 2021. Evidence of intestinal, hepatobiliary, and pancreatic involvements was reported for each patient, alongside demographic, clinical, and laboratory features. Frequency of gastrointestinal complications across groups of patients infected by specific E. coli serotypes and Stx gene variants was evaluated. RESULTS Six patients developed a bowel complication: two developed rectal prolapse, and four developed bowel perforation which resulted in death for three of them and in bowel stenosis in one patient. Acute pancreatitis was diagnosed in 13 patients. An isolated increase in pancreatic enzymes and/or liver transaminases was observed in 41 and 15 patients, respectively. Biliary sludge was detected in three, cholelithiasis in one. Forty-seven patients developed direct hyperbilirubinemia. Neither E. coli serotypes nor Shiga toxin variants correlated with hepatic or pancreatic involvement. CONCLUSIONS During STEC-HUS, GI complications are common, ranging from self-limited elevation of laboratory markers to bowel perforation, a severe complication with a relevant impact on morbidity and mortality. Hepatopancreatic involvement is frequent, but usually short-lasting and self-limiting.
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Affiliation(s)
- Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy.
| | - Onofrio Iacoviello
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Luisa Santangelo
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Marida Martino
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Diletta Torres
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Vincenza Carbone
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Gaia Scavia
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela Loconsole
- Department of Biomedical Sciences and Human Oncology, Hygiene Section, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Chironna
- Department of Biomedical Sciences and Human Oncology, Hygiene Section, University of Bari "Aldo Moro", Bari, Italy
| | - Fernanda Cristofori
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Ruggiero Francavilla
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
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Mehta S, John T, Feld JJ, Shah H, Mullaithilaga N, Campigotto A, Leung K, Kamath BM, Ling SC, Science M, Ng VL. Severe acute hepatitis of unknown etiology in a large cohort of children. Hepatol Commun 2023; 7:e0272. [PMID: 37756118 PMCID: PMC10531196 DOI: 10.1097/hc9.0000000000000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/18/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND We evaluated the proportion, clinical features, and outcomes of previously healthy children presenting to a large Canadian quaternary pediatric center with severe acute hepatitis of unknown etiology. METHODS All patients with serum alanine aminotransferase (ALT) > 500 U/L or aspartate aminotransferase (AST) > 500 U/L between June 1, 2018, and May 31, 2022, at The Hospital for Sick Children, were identified. Subjects with only AST > 500 U/L were excluded. Clinical characteristics, investigations, and outcomes for patients without clear etiology for ALT > 500 U/L (severe acute hepatitis of unknown etiology) for our study period and from October 1 to May 31 of each year 2018-2021 were reviewed. RESULTS Of 977 patients with ALT/AST> 500 U/L, 720 had only ALT > 500 U/L. We excluded age below 6 months (n = 99) or above 16 years (n = 66), known pre-existing liver conditions (n = 66), and ALT > 500 U/L in already admitted patients (n = 151). Among the remaining 338 children with ALT > 500 U/L at presentation, an etiology was identified in 303 subjects. 33 (9.8%) children [median age 6.1 y (range 0.5-15.5); 61% male] were confirmed as severe acute hepatitis of unknown etiology. Twenty patients (60.6%) were tested for blood adenovirus by PCR, and 1 (5%) was positive (serotype B7). Liver tissue specimens from 18 patients revealed no evidence of viral inclusions or adenovirus. Twelve (36.3%) presented with pediatric acute liver failure, with 8 (24.2%) requiring liver transplantation. There were no deaths. Hepatitis-associated aplastic anemia occurred in 5 (15%) patients. CONCLUSIONS Of children presenting with severe acute hepatitis to a quaternary children's hospital over a 48-month period, 9.8% had unknown etiology with no change over time. Liver transplantation remains an important treatment strategy for those presenting with pediatric acute liver failure phenotype. The frequency of cases associated with human adenovirus infection was noncontributory.
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Affiliation(s)
- Sagar Mehta
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomisin John
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nisa Mullaithilaga
- Department of Paediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Campigotto
- Department of Laboratory Medicine, Division of Microbiology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Leung
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Binita M. Kamath
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Simon C. Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Science
- Department of Paediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky L. Ng
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Costa JM, Pinto SM, Santos-Silva E, Moreira-Silva H. Incidental hypertransaminasemia in children-a stepwise approach in primary care. Eur J Pediatr 2023; 182:1601-1609. [PMID: 36697884 PMCID: PMC9877494 DOI: 10.1007/s00431-023-04825-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/27/2023]
Abstract
Children with elevated liver enzymes are occasionally discovered through laboratory work-up from different clinical scenarios. Although the majority will have transient and/or benign conditions, a subgroup will have underlying liver disorders. The differential diagnosis is broad and therefore, a systematic approach is of utmost importance. In this article, we reviewed the most recent and relevant literature to provide a comprehensive overview of the main disease processes that cause hypertransaminasemia in children. Ultimately, we propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes in asymptomatic children. The first step is to obtain a complete history along with a thorough physical examination to exclude red flags, which should dictate urgent consultation with a paediatric gastroenterologist or hepatologist. Conclusion: Hypertransaminasemia is a challenging scenario in the primary care setting. The aetiology can be broad, ranging from hepatic and extrahepatic to transient versus chronic liver disease. Timely referral to a specialised centre is of paramount importance for conducting targeted research and to not miss the chance of identifying a progressive, but still asymptomatic, treatable liver disease. What is Known: • Elevated liver enzyme is a challenging scenario in the primary care setting. • There are few studies guiding the evaluation of asymptomatic hypertransaminasemia in the paediatric population and a standardised approach is lacking. What is New: • We propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes.
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Affiliation(s)
- Joana Meneses Costa
- Valbom Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Sara Martins Pinto
- Nascente Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal
- Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, UCIBIO, Universidade do Porto, Porto, Portugal
| | - Helena Moreira-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal.
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Alonso‐Peña M, Espinosa‐Escudero R, Herraez E, Briz O, Cagigal ML, Gonzalez‐Santiago JM, Ortega‐Alonso A, Fernandez‐Rodriguez C, Bujanda L, Calvo Sanchez M, D´Avola D, Londoño M, Diago M, Fernandez‐Checa JC, Garcia‐Ruiz C, Andrade RJ, Lammert F, Prieto J, Crespo J, Juamperez J, Diaz‐Gonzalez A, Monte MJ, Marin JJG. Beneficial effect of ursodeoxycholic acid in patients with acyl-CoA oxidase 2 (ACOX2) deficiency-associated hypertransaminasemia. Hepatology 2022; 76:1259-1274. [PMID: 35395098 PMCID: PMC9796151 DOI: 10.1002/hep.32517] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS A variant (p.Arg225Trp) of peroxisomal acyl-CoA oxidase 2 (ACOX2), involved in bile acid (BA) side-chain shortening, has been associated with unexplained persistent hypertransaminasemia and accumulation of C27-BAs, mainly 3α,7α,12α-trihydroxy-5β-cholestanoic acid (THCA). We aimed to investigate the prevalence of ACOX2 deficiency-associated hypertransaminasemia (ADAH), its response to ursodeoxycholic acid (UDCA), elucidate its pathophysiological mechanism and identify other inborn errors that could cause this alteration. METHODS AND RESULTS Among 33 patients with unexplained hypertransaminasemia from 11 hospitals and 13 of their relatives, seven individuals with abnormally high C27-BA levels (>50% of total BAs) were identified by high-performance liquid chromatography-mass spectrometry. The p.Arg225Trp variant was found in homozygosity (exon amplification/sequencing) in two patients and three family members. Two additional nonrelated patients were heterozygous carriers of different alleles: c.673C>T (p.Arg225Trp) and c.456_459del (p.Thr154fs). In patients with ADAH, impaired liver expression of ACOX2, but not ACOX3, was found (immunohistochemistry). Treatment with UDCA normalized aminotransferase levels. Incubation of HuH-7 hepatoma cells with THCA, which was efficiently taken up, but not through BA transporters, increased reactive oxygen species production (flow cytometry), endoplasmic reticulum stress biomarkers (GRP78, CHOP, and XBP1-S/XBP1-U ratio), and BAXα expression (reverse transcription followed by quantitative polymerase chain reaction and immunoblot), whereas cell viability was decreased (tetrazolium salt-based cell viability test). THCA-induced cell toxicity was higher than that of major C24-BAs and was not prevented by UDCA. Fourteen predicted ACOX2 variants were generated (site-directed mutagenesis) and expressed in HuH-7 cells. Functional tests to determine their ability to metabolize THCA identified six with the potential to cause ADAH. CONCLUSIONS Dysfunctional ACOX2 has been found in several patients with unexplained hypertransaminasemia. This condition can be accurately identified by a noninvasive diagnostic strategy based on plasma BA profiling and ACOX2 sequencing. Moreover, UDCA treatment can efficiently attenuate liver damage in these patients.
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Affiliation(s)
- Marta Alonso‐Peña
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain,Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive DiseasesValdecilla Research Institute (IDIVAL)Marqués de Valdecilla University HospitalSantanderSpain
| | - Ricardo Espinosa‐Escudero
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain
| | - Elisa Herraez
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain,Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain
| | - Oscar Briz
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain,Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain
| | - Maria Luisa Cagigal
- Pathological Anatomy ServiceHospital Universitario Marqués de ValdecillaSantanderSpain
| | - Jesus M. Gonzalez‐Santiago
- Department of Gastroenterology and HepatologyUniversity Hospital of SalamancaInstitute for Biomedical ResearchSalamancaSpain
| | - Aida Ortega‐Alonso
- Liver Unit, Gastroenterology ServiceInstitute of Biomedical Research of MálagaSchool of MedicineUniversity Hospital Virgen de la VictoriaMálagaSpain
| | | | - Luis Bujanda
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Department of Liver and Gastrointestinal DiseasesBiodonostia Health Research InstituteDonostia University HospitalUniversity of the Basque CountrySan SebastianSpain
| | | | - Delia D´Avola
- Department of MedicineClinica Universidad de Navarra and Center for Applied Medical ResearchUniversity of NavarraPamplonaSpain
| | - Maria‐Carlota Londoño
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Liver UnitHospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain,Institute of Biomedical Research of Barcelona (IDIBAPS)BarcelonaSpain
| | - Moises Diago
- Valencia University General HospitalValenciaSpain
| | - Jose C. Fernandez‐Checa
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Institute of Biomedical Research of Barcelona (IDIBAPS)BarcelonaSpain,Consejo Superior de Investigaciones Científicas (CSIC)MadridSpain,Research Center for Alcoholic Liver and Pancreatic Diseases (ALPD) and CirrhosisKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Carmen Garcia‐Ruiz
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Institute of Biomedical Research of Barcelona (IDIBAPS)BarcelonaSpain,Consejo Superior de Investigaciones Científicas (CSIC)MadridSpain,Research Center for Alcoholic Liver and Pancreatic Diseases (ALPD) and CirrhosisKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Raul J. Andrade
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Liver Unit, Gastroenterology ServiceInstitute of Biomedical Research of MálagaSchool of MedicineUniversity Hospital Virgen de la VictoriaMálagaSpain
| | - Frank Lammert
- Department of Medicine IISaarland University Medical CenterHomburgGermany,Health SciencesHannover Medical SchoolHannoverGermany
| | - Jesus Prieto
- Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain,Department of MedicineClinica Universidad de Navarra and Center for Applied Medical ResearchUniversity of NavarraPamplonaSpain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive DiseasesValdecilla Research Institute (IDIVAL)Marqués de Valdecilla University HospitalSantanderSpain
| | - Javier Juamperez
- Pediatric Hepatology and Liver Transplantation UnitVall d’Hebron University HospitalUniversitat Autónoma de BarcelonaBarcelonaSpain
| | - Alvaro Diaz‐Gonzalez
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive DiseasesValdecilla Research Institute (IDIVAL)Marqués de Valdecilla University HospitalSantanderSpain
| | - Maria J. Monte
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain,Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain
| | - Jose J. G. Marin
- Experimental Hepatology and Drug TargetingInstitute for Biomedical ResearchUniversity of SalamancaSalamancaSpain,Center for the Study of Liver and Gastrointestinal Diseases (CIBEREHD)Carlos III National Institute of HealthMadridSpain
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Furthner D, Weghuber D, Dalus C, Lukas A, Stundner-Ladenhauf HN, Mangge H, Pixner T. Nonalcoholic Fatty Liver Disease in Children with Obesity: Narrative Review and Research Gaps. Horm Res Paediatr 2022; 95:167-176. [PMID: 34351306 DOI: 10.1159/000518595] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the leading hepatic disease in children, ranging from steatosis to steatohepatitis and fibrosis. Age, sex, hormonal levels, pubertal stages, genetic risk- and epigenetic factors are among the many influencing factors. Appearing predominantly in children with obesity, but not exclusively, it is the liver's manifestation of the metabolic syndrome but can also exist as an isolated entity. SUMMARY Pediatric NAFLD differs from the adult phenotype. This narrative review on NAFLD in children with obesity provides an overview of the current knowledge on risk factors, screening, and diagnostic methods, as well state-of-the-art treatment. The recent discussion on the proposition of a new nomenclature - Metabolic [Dysfunction-] Associated Liver Disease - is featured, and current gaps of knowledge are discussed. KEY MESSAGES Currently, there is no international consensus on screening and monitoring of pediatric NAFLD. With lifestyle interventions being the cornerstone of treatment, no registered pharmacological treatment for pediatric NAFLD is available. Development and validation of additional noninvasive biomarkers, scores and imaging tools suitable to subcategorize, screen and monitor pediatric patients are necessary. With a variety of upcoming and promising agents, clear recommendations for pediatric nonalcoholic steatohepatitis trials are urgently needed.
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Affiliation(s)
- Dieter Furthner
- Department of Pediatric and Adolescent Medicine, Salzkammergutklinikum Voecklabruck, Voecklabruck, Austria.,Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria
| | - Daniel Weghuber
- Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria.,University Children's Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Christopher Dalus
- Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria.,University Children's Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Lukas
- Department of Pediatric and Adolescent Medicine, Salzkammergutklinikum Voecklabruck, Voecklabruck, Austria.,Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria
| | | | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Thomas Pixner
- Department of Pediatric and Adolescent Medicine, Salzkammergutklinikum Voecklabruck, Voecklabruck, Austria.,Obesity Research Unit, Paracelsus Medical University, Salzburg, Austria
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7
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Arnal IR, Andrade JR, Hally MM, Baviera LCB, Tirado DG, Martín SHC, de la Calle Navarro E, Álvarez AMV. Diagnostic action against hypertransaminasemia in paediatrics: Consensus document of Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), Asociación Española de Pediatría de Atención Primaria (AEPap) and Sociedad Española de Pediatría de Atención Primaria (SEPEAP). ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:448.e1-448.e11. [DOI: 10.1016/j.anpede.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/07/2022] [Indexed: 02/07/2023] Open
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8
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Actuación diagnóstica ante hipertransaminasemia en pediatría: documento de consenso de Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), Asociación Española de Pediatría de Atención Primaria (AEPap) y Sociedad Española de Pediatría de Atención Primaria (SEPEAP). An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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9
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Mandato C, Vajro P. Isolated aspartate aminotransferase elevation: Is it liver disease or what else? Acta Paediatr 2022; 111:459-461. [PMID: 34935200 DOI: 10.1111/apa.16213] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Claudia Mandato
- Section of Pediatrics Dipartimento di Medicina, Chirurgia e Odontoiatria ‘Scuola Medica Salernitana’ Baronissi (Salerno) Italy
| | - Pietro Vajro
- Section of Pediatrics Dipartimento di Medicina, Chirurgia e Odontoiatria ‘Scuola Medica Salernitana’ Baronissi (Salerno) Italy
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10
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Kamin W, Adams O, Kardos P, Matthys H, Meister N, Strassburg CP. Liver Involvement in Acute Respiratory Infections in Children and Adolescents - Results of a Non-interventional Study. Front Pediatr 2022; 10:840008. [PMID: 35425729 PMCID: PMC9001984 DOI: 10.3389/fped.2022.840008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In children and adults with acute respiratory tract infections (ARTI), elevations of serum liver enzyme activities are frequently observed in clinical practice. However, epidemiological data particularly in the pediatric population are very limited. The aim of this study was to assess the incidence of hepatic involvement, to identify the viruses and to analyze risk factors in children and adolescents with ARTI in a real-world setting. METHODS We report on a prospective, multicenter, non-interventional study with 1,010 consecutive patients aged 1-17 years with ARTI who consulted a physician within 5 days after onset of symptoms. Laboratory blood tests and PCR virus detection in nasopharyngeal lavage were performed at first presentation and after 3-7 days. Patients with elevated activities of serum liver enzymes (ASAT, ALAT, and γ-GT) were determined in local laboratories and values were normalized by dividing by the individual upper limit of the normal range (ULN). The resulting index (<1 means below ULN, >1 means above ULN) allowed to compare results from laboratories with different reference ranges. RESULTS Laboratory test results of 987 patients were available at first visit. 11.1% (95% CI: 9.2-13.3%) exhibited an elevation of ASAT, ALAT, and/or γ-GT activities. Virus DNA or RNA was identified in nasopharyngeal lavages of 63% of the patients. 12.2% of patients with positive PCR and 9.7% of those with negative PCR (p = 0.25) had elevated serum liver enzyme activities. The highest rates were observed in patients with a positive result for influenza B virus (24.4%) followed by human metapneumovirus (14.6%), and human coronavirus (others than SARS-CoV-2) (13.6%). The rate of children and adolescents with ARTI and elevation of serum liver enzyme activities correlated with the virus species and with overweight of the patients but did not differ in patients with or without previous medication intake. CONCLUSION Elevated enzyme activities are present in about 10% of children and adolescents with ARTI. In our cohort, these elevations were mild to moderate; probably resulting from an inflammation process with hepatic involvement.
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Affiliation(s)
- Wolfgang Kamin
- Children's Hospital, Evangelic Hospital, Hamm, Germany.,Faculty of Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Ortwin Adams
- Institute for Virology, Heinrich-Heine University, Düsseldorf, Germany
| | - Peter Kardos
- Group Practice and Centre for Pneumology, Allergy and Sleep Medicine at Red Cross Maingau Hospital, Frankfurt am Main, Germany
| | - Heinrich Matthys
- Department of Pneumology, University Hospital, Freiburg, Germany
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Lee Y, Yi DY, Lee YM, Choi SY, Choi YJ, Lee KJ. A Multicenter Study of Real-world Practice for Management of Abnormal Liver Function Tests in Children with Acute Infectious Diseases. J Korean Med Sci 2021; 36:e310. [PMID: 34873882 PMCID: PMC8648609 DOI: 10.3346/jkms.2021.36.e310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/14/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Abnormal liver function tests (LFTs) are commonly seen in pediatric patients with acute infectious diseases. Few studies and no definite clinical guidelines for these conditions are available. The present study aimed to elucidate the causes and factors associated with prolongation of liver enzyme elevation. We also investigated actual real-world practices in Korea. METHODS A retrospective study was performed on all patients younger than 18 years, who visited six tertiary teaching hospitals around Korea in 2018 for acute infectious diseases and showed alanine aminotransferase (ALT) levels above 60 IU/L without other specific conditions that could cause ALT elevation. We categorized the infections that cause LFT elevation into six groups: respiratory infection, gastrointestinal infection, urinary tract infection, other febrile disease, Epstein-Barr virus infection, and cytomegalovirus infection. We collected data on the medical specialty of the attending physician who followed up the subject, follow-up duration, percentage of follow-up loss, and their investigation. RESULTS A total of 613 patients were enrolled in this study, half of whom (50.7%) were younger than 12 months. The mean initial aspartate aminotransferase and ALT values were 171.2 ± 274.1 and 194.9 ± 316.1 IU/L (range 23-2,881, 60-2,949 IU/L), respectively; however, other LFTs were within the normal range. Respiratory infection was the most common diagnosis (45.0%), and rhinovirus was the most commonly identified pathogen (9.8%). The follow-up rate was higher with pediatric gastroenterologists (90.5%) and non-gastroenterology pediatricians (76.4%) than with pediatric residents and emergency doctors. Older age was related to better ALT recovery (odds ratio [OR] of age for month = 1.003; 95% confidence interval [CI], 1.001-1.004; P = 0.004), while the number of infection episodes (OR = 0.626; 95% CI, 0.505-0.777; P < 0.001) was associated with poor ALT recovery. Abdominal sonography was the most commonly used diagnostic tool (36.9%), followed by the hepatotropic virus workup. The modalities of hepatitis workup were significantly differently applied by physicians based on their specialties and institutions. CONCLUSION Abnormal liver function test after a systemic infection was common in respiratory infection and under the age of 1 year. Age, number of infections, and initial results of LFTs were related to ALT recovery time. Inter-physician, inter-institution, and inter-specialty variances were observed in real-world practice.
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Affiliation(s)
- Yoon Lee
- Department of Pediatrics, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Dae Yong Yi
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Yoo Min Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of medicine, Bucheon, Korea
| | - So Yoon Choi
- Department of Pediatrics, Kosin Gospel Hospital, Kosin University College of Medicine, Busan, Korea
- Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - You Jin Choi
- Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Kyung Jae Lee
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea.
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Gunzer S, Kraus A, Buchroth I, Grüneberg M, Westermann C, Biskup S, Reunert J, Grünewald I, Marquardt T. Hypertransaminasemia and liver fibrosis associated with haptoglobin retention and anhaptoglobinemia in a paediatric patient. Liver Int 2021; 41:2427-2432. [PMID: 34358398 DOI: 10.1111/liv.15029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 12/13/2022]
Abstract
Cryptogenic elevation of transaminases in childhood can in a few instances be linked to rare hereditary causes. In this paper, a 7-year old girl is reported who was diagnosed with elevated transaminases of unknown origin since infancy. A liver biopsy showed bridging fibrosis, pale eosinophilic intracytoplasmic hepatocellular inclusions and enlarged endoplasmic reticulum cisternae in the hepatocytes. Whole-exome sequencing revealed a homozygous in-frame deletion of 3 base pairs in the haptoglobin gene. The patient is anhaptoglobinemic measured by standard laboratory turbidometry, which was confirmed by Western Blotting and thereby shown to affect both protein chains of haptoglobin. A polyclonal antibody revealed haptoglobin retention in hepatocytes suggesting a defect in haptoglobin secretion. A novel, previously unknown haptoglobin storage disease is suspected to be the reason for the elevated liver enzymes and tissue abnormalities in this patient. The pathophysiology appears to be similar to endoplasmic reticulum storage diseases like alpha-1-antitrypsin-deficiency.
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Affiliation(s)
- Sophia Gunzer
- Department of General Paediatrics, Metabolic Diseases, University Children's Hospital Muenster, Muenster, Germany
| | - Andreas Kraus
- Institute for Experimental Immunology and Imaging, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Inka Buchroth
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | - Marianne Grüneberg
- Department of General Paediatrics, Metabolic Diseases, University Children's Hospital Muenster, Muenster, Germany
| | - Cordula Westermann
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | | | - Janine Reunert
- Department of General Paediatrics, Metabolic Diseases, University Children's Hospital Muenster, Muenster, Germany
| | - Inga Grünewald
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | - Thorsten Marquardt
- Department of General Paediatrics, Metabolic Diseases, University Children's Hospital Muenster, Muenster, Germany
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Colucci A, Rocco MC, De Anseris AGE, Nazzaro L, Vajro P, Mandato C. Pediatric vs. adult NAFLD to MAFLD transition: a welcome but tangled path. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The term non-alcoholic fatty liver disease (NAFLD) appears unfitting both in adults and in children. As obesity and metabolic syndrome play a relevant pathogenic role, an international group of adults’ liver disease experts has proposed to rename this condition metabolic (dysfunction)-associated fatty liver disease (MAFLD). While this new more appropriate and useful definition has mostly been met with good reactions in adults, it may present a tangled path in pediatrics. Here we further stress the recommendations of the North American and the European Societies for Pediatric Gastroenterology, Hepatology and Nutrition that a hyperechogenic liver in a child affected by obesity or overweight with chronically elevated liver enzymes should not be assumed to have NAFLD only. Especially in those patients who are not in the classic age range or who have particularly severe laboratory anomalies, other genetic, metabolic (inborn errors of metabolism, IEM), endocrine, intestinal and hepatic pediatric-onset conditions, should in fact be excluded, particularly when response to a weight loss trial is not available. The term pediatric fatty liver disease (PeFLD) with three subtypes (1. contextual diagnosis of an IEM; 2. Metabolic (dysfunction)-associated fatty liver; 3. unknown cause of fatty liver) has recently been proposed aiming to separate true MAFLD from IEM and/or the other above mentioned conditions, which may be rare when considered individually but represent a large group when considered collectively. Although the cost-effectiveness ratio of this attitude is still indeterminate, it is likely that the advantage of the early identification of a specifically treatable pediatric-onset liver disease associated to/mimicking MAFLD would be rewarding.
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Affiliation(s)
- Angelo Colucci
- Pediatrics Section, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi (Salerno), Italy
| | - Maria Chiara Rocco
- Pediatrics Section, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi (Salerno), Italy
| | | | - Lucia Nazzaro
- Pediatrics, AOU San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi (Salerno), Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children’s Hospital, 80129 Naples, Italy
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Paglia P, Nazzaro L, De Anseris AGE, Lettieri M, Colantuono R, Rocco MC, Siano MA, Biffaro N, VAJRO P. Atypically Protracted Course of Liver Involvement in Kawasaki Disease. Case Report and Literature Review. Pediatr Rep 2021; 13:357-362. [PMID: 34287369 PMCID: PMC8293418 DOI: 10.3390/pediatric13030044] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/26/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
Hypertransaminasemia in patients with Kawasaki disease (KD) is reported to be transient. Here, we describe a child with an atypically protracted course of liver tests abnormalities and review the inherent literature. The patient was hospitalized at age 7-months for isolated hypertransaminasemia detected during a classical KD diagnosed 3 months before, and persistent since then. KD clinical evolution had been favorable, with rapid response to acetylsalicylic acid and intravenous immunoglobulins. Liver enzymes however remained persistently elevated with a fluctuating pattern (ALT > AST levels; peak of AST 186 IU/L and ALT 240 IU/L). During follow-up, the main causes of liver dysfunction had to be excluded through appropriate and extensive laboratory investigations. Transaminases values become steadily normal only 7 months after the acute presentation of KD. Conclusions: Our report shows that an atypically protracted courses of KD-related hypertransaminasemia above the previously reported temporal limits should be taken into account during the stepwise diagnostic approach to the patient's liver dysfunction. Insidious acetylsalycilic acid-hepatotoxicity warrants consideration in the differential diagnosis.
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Affiliation(s)
- Pamela Paglia
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Lucia Nazzaro
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
| | - Anna Giulia Elena De Anseris
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
| | - Milena Lettieri
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
- Department of Translational Medical Sciences, Section of Pediatrics, “Federico II” University, 80131 Naples, Italy
| | - Rossella Colantuono
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Maria Chiara Rocco
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Maria Anna Siano
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Nicola Biffaro
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
| | - Pietro VAJRO
- Chair of Pediatrics and Residency Program of Pediatrics, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (P.P.); (M.L.); (R.C.); (M.C.R.); (M.A.S.); (N.B.)
- Pediatrics Units of San Giovanni di Dio e Ruggi d’Aragona University Hospital, 84131 Salerno, Italy; (L.N.); (A.G.E.D.A.)
- Correspondence: ; Tel.: +39-339-236-1008
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Putri RR, Casswall T, Hagman E. Prevalence of increased transaminases and its association with sex, age, and metabolic parameters in children and adolescents with obesity - a nationwide cross-sectional cohort study. BMC Pediatr 2021; 21:271. [PMID: 34107897 PMCID: PMC8188660 DOI: 10.1186/s12887-021-02747-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/28/2021] [Indexed: 01/18/2023] Open
Abstract
Background Childhood obesity increases the risk of non-alcoholic fatty liver disease marked by elevated alanine aminotransferase (ALT). This study investigated the prevalence of increased ALT in children and adolescents with obesity, and its associations with sex, age, degree of obesity, and metabolic parameters. Methods Individuals between 5 and 17.99 years of age enrolled in the Swedish Childhood Obesity Treatment Register (BORIS) before March 2020 were included. Mildly increased ALT was defined by ALT 27–51 U/L (males) and 23–43 U/L (females), while markedly increased ALT by levels above. Multiple logistic regression models were used for statistical analysis. Results Among 11,776 individuals (age 11.0 ± 3.3 years, 53.5% males), the prevalence of mildly and markedly increased ALT were 37.9 and 10.6%, respectively. A sex-age interaction was found, where increasing age strengthened the odds of markedly increased ALT in males (OR, 99% CI: 1.34, 1.29–1.4 for each year) while the corresponding pattern in females with was minuscule (1.09, 1.02–1.10). Compared to class I obesity, class II and III obesity had greater odds ratios for mildly increased ALT (class II obesity OR, 99% CI: 1.51, 1.35–1.70; class III obesity OR, 99% CI: 2.17, 1.66–2.61) and for markedly increased ALT (class II obesity OR, 99% CI: 1.82, 1.51–2.20; class III obesity OR, 99% CI 3.38, 2.71–4.23). Dyslipidemia was associated with both mildly and markedly increased ALT, all p < 0.001. Prevalence of impaired fasting glucose was 19.1% in normal ALT group, 20.4% in mildly increased ALT group, and 29.0% in markedly increased ALT group. Conclusions The risk of markedly increased ALT increased exponentially with age among boys, but not among girls. Higher degree of obesity was observed in individuals with mildly and markedly increased ALT. Further, metabolic derangements were more prevalent among individuals with mildly and markedly increased ALT.
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Affiliation(s)
- Resthie R Putri
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Blickagången 6A, 141 57 Huddinge, Stockholm, Sweden
| | - Thomas Casswall
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Blickagången 6A, 141 57 Huddinge, Stockholm, Sweden
| | - Emilia Hagman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Blickagången 6A, 141 57 Huddinge, Stockholm, Sweden.
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Fernández Ventureira V, Ros Arnal I, Rodríguez Martínez G, García Rodríguez B, García Romero R, Ubalde Sainz E. Evaluation of liver function tests in the paediatric patient. An Pediatr (Barc) 2021; 94:359-365. [PMID: 34090632 DOI: 10.1016/j.anpede.2020.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/04/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Although changes in liver function tests can be non-specific in numerous clinical conditions, they can be the first sign of a potentially serious disease in an asymptomatic patient. MATERIAL AND METHODS Retrospective cohort study, performed by reviewing the records of children of a reference hospital central laboratory with alanine aminotransferase enzyme (ALT) elevation during a 6-month aleatory period. RESULTS 572 blood tests with serum ALT elevation corresponding to 403 patients have been assessed during the period studied. 98 patients were excluded for presenting abnormal liver test before the study period of comorbidity that could produce ALT elevation. The remaining 305 patients, 22.6% were diagnosed with a medical condition during the first blood test that explained the ALT elevation, although only 33.3% of them were followed up until verifying their normalisation. Final study sample consists of 236 patients with abnormal liver test without apparent liver disease. Adequate follow-up was found only in 29% of them. From this group, 9 patients (13%) were diagnosed with liver disease. The rest of the samples were not properly monitored. In patients with higher serum ALT levels, follow-up was early and more appropriate. CONCLUSIONS In our area, most children without apparent liver disease are no properly monitored. Therefore, an opportunity to diagnosis and treat a potential liver disease was lost in a great number of children. All children with unexplained hypertransaminasaemia must be studied.
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Affiliation(s)
| | - Ignacio Ros Arnal
- Unidad de Gastroenterología y Nutrición Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Ruth García Romero
- Unidad de Gastroenterología y Nutrición Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Eduardo Ubalde Sainz
- Unidad de Gastroenterología y Nutrición Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Bongiovanni A, Spina M, Papale M, Brambilla I, Licari A, Parisi GF, Leonardi S. Hypertransaminasemia in children is not always as simple as it seems. Minerva Pediatr (Torino) 2021; 73:281-283. [PMID: 34047150 DOI: 10.23736/s2724-5276.19.05514-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Annarita Bongiovanni
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Massimo Spina
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Maria Papale
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Amelia Licari
- Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - Giuseppe F Parisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy -
| | - Salvatore Leonardi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Ben Houmich T, Admou B. Celiac disease: Understandings in diagnostic, nutritional, and medicinal aspects. Int J Immunopathol Pharmacol 2021; 35:20587384211008709. [PMID: 33878915 PMCID: PMC8064516 DOI: 10.1177/20587384211008709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Celiac disease (CD) is characterized by clinical polymorphism, with classic, asymptomatic or oligosymptomatic, and extra-intestinal forms, which may lead to diagnostic delay and exposure to serious complications. CD is a multidisciplinary health concern involving general medicine, pediatric, and adult gastroenterology, among other disciplines. Immunology and pathology laboratories have a fundamental role in diagnosing and monitoring CD. The diagnosis consists of serological testing based on IgA anti-transglutaminase (TG2) antibodies combined with IgA quantification to rule out IgA deficiency, a potential misleading factor of CD diagnosis. Positive TG2 serology should be corroborated by anti-endomysium antibody testing before considering an intestinal biopsy. Owing to multiple differential diagnoses, celiac disease cannot be confirmed based on serological positivity alone, nor on isolated villous atrophy. In children with classical signs or even when asymptomatic, with high levels of CD-linked markers and positive HLA DQ2 and/or DQ8 molecules, the current trend is to confirm the diagnosis on basis of the non-systematic use of the biopsy, which remains obligatory in adults. The main challenge in managing CD is the implementation and compliance with a gluten-free diet (GFD). This explains the key role of the dietitian and the active participation of patients and their families throughout the disease-management process. The presence of the gluten in several forms of medicine requires the sensitization of physicians when prescribing, and particularly when dispensing gluten-containing formulations by pharmacists. This underlines the importance of the contribution of the pharmacist in the care of patients with CD within the framework of close collaboration with physicians and nutritionists.
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Affiliation(s)
- Taoufik Ben Houmich
- Laboratory of Immunology, Center of Clinical Research, University Hospital Mohammed VI, Marrakech, Morocco
| | - Brahim Admou
- Laboratory of Immunology, Center of Clinical Research, University Hospital Mohammed VI, Marrakech, Morocco.,Bioscience Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
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KEÇELİ BAŞARAN M, ÇİÇEK T. Causes of hypertransaminasemia in children, single-center experience. FAMILY PRACTICE AND PALLIATIVE CARE 2021. [DOI: 10.22391/fppc.787707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Siano MA, Mandato C, Nazzaro L, Iannicelli G, Ciccarelli GP, Barretta F, Mazzaccara C, Ruoppolo M, Frisso G, Baldi C, Tartaglione S, Di Salle F, Melis D, Vajro P. Hepatic Presentation of Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency (MADD): Case Report and Systematic Review. Front Pediatr 2021; 9:672004. [PMID: 34041209 PMCID: PMC8143529 DOI: 10.3389/fped.2021.672004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022] Open
Abstract
Diagnosis of pediatric steatohepatitis is a challenging issue due to a vast number of established and novel causes. Here, we report a child with Multiple Acyl-CoA Dehydrogenase Deficiency (MADD) presenting with an underrated muscle weakness, exercise intolerance and an atypically severe steatotic liver involvement. A systematic literature review of liver involvement in MADD was performed as well. Our patient is a 11-year-old otherwise healthy, non-obese, male child admitted for some weakness/asthenia, vomiting and recurrent severe hypertransaminasemia (aspartate and alanine aminotransferases up to ×20 times upper limit of normal). Hepatic ultrasound showed a bright liver. MRI detected mild lipid storage of thighs muscles. A liver biopsy showed a micro-macrovacuolar steatohepatitis with minimal fibrosis. Main causes of hypertransaminasemia were ruled out. Serum aminoacids (increased proline), acylcarnitines (increased C4-C18) and a large excretion of urinary glutaric acid, ethylmalonic, butyric, isobutyric, 2-methyl-butyric and isovaleric acids suggested a diagnosis of MADD. Serum acylcarnitines and urinary organic acids fluctuated overtime paralleling serum transaminases during periods of illness/catabolic stress, confirming their recurrent nature. Genetic testing confirmed the diagnosis [homozygous c.1658A > G (p.Tyr553Cys) in exon 12 of the ETFDH gene]. Lipid-restricted diet and riboflavin treatment rapidly ameliorated symptoms, hepatic ultrasonography/enzymes, and metabolic profiles. Literature review (37 retrieved eligible studies, 283 patients) showed that liver is an extramuscular organ rarely involved in late-onset MADD (70 patients), and that amongst 45 patients who had fatty liver only nine had severe presentation. Conclusion: MADD is a disorder with a clinically heterogeneous phenotype. Our study suggests that MADD warrants consideration in the work-up of obesity-unrelated severe steatohepatitis.
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Affiliation(s)
- Maria Anna Siano
- Postgraduate School of Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Claudia Mandato
- Unit of Pediatrics 1, AORN Santobono-Pausilipon, Naples, Italy
| | - Lucia Nazzaro
- Pediatric Clinic, AOU "S. Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy
| | - Gennaro Iannicelli
- Pediatric Clinic, AOU "S. Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy
| | - Gian Paolo Ciccarelli
- Postgraduate School of Pediatrics, Faculty of Medicine University of Naples Federico II, Naples, Italy
| | - Ferdinando Barretta
- Department of Molecular Medicine and Medical Biotechnology, Faculty of Medicine University of Naples Federico II, Naples, Italy.,CEINGE-Biotecnologie Avanzate s.c.a r.l., Naples, Italy
| | - Cristina Mazzaccara
- Department of Molecular Medicine and Medical Biotechnology, Faculty of Medicine University of Naples Federico II, Naples, Italy.,CEINGE-Biotecnologie Avanzate s.c.a r.l., Naples, Italy
| | - Margherita Ruoppolo
- Department of Molecular Medicine and Medical Biotechnology, Faculty of Medicine University of Naples Federico II, Naples, Italy.,CEINGE-Biotecnologie Avanzate s.c.a r.l., Naples, Italy
| | - Giulia Frisso
- Department of Molecular Medicine and Medical Biotechnology, Faculty of Medicine University of Naples Federico II, Naples, Italy.,CEINGE-Biotecnologie Avanzate s.c.a r.l., Naples, Italy
| | - Carlo Baldi
- Pathology Unit, AOU "S. Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy
| | | | - Francesco Di Salle
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Daniela Melis
- Postgraduate School of Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy.,Pediatric Clinic, AOU "S. Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy
| | - Pietro Vajro
- Postgraduate School of Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy.,Pediatric Clinic, AOU "S. Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy.,Postgraduate School of Pediatrics, Faculty of Medicine University of Naples Federico II, Naples, Italy
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22
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Luo Y, Lin H. Inflammation initiates a vicious cycle between obesity and nonalcoholic fatty liver disease. IMMUNITY INFLAMMATION AND DISEASE 2020; 9:59-73. [PMID: 33332766 PMCID: PMC7860600 DOI: 10.1002/iid3.391] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 12/14/2022]
Abstract
Low‐level of chronic inflammation activation is characteristic of obesity. Nonalcoholic fatty liver disease (NAFLD) is closely linked to obesity and is an emerging health problem, it originates from abnormal accumulation of triglycerides in the liver, and sometimes causes inflammatory reactions that could contribute to cirrhosis and liver cancer, thus its pathogenesis needs to be clarified for more treatment options. Once NAFLD is established, it contributes to systemic inflammation, the low‐grade inflammation is continuously maintained during NAFLD causing impaired resolution of inflammation in obesity, which subsequently exacerbates its severity. This study focuses on the effects of obesity‐induced inflammations, which are the underlying causes of the disease progression and development of more severe inflammatory and fibrotic stages. Understanding the relationship between obesity and NAFLD could help in establishing attractive therapeutic targets or diagnostic markers in obesity‐induced inflammation response and provides new approaches for the prevention and treatment of NAFLD in obesity.
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Affiliation(s)
- Yunfei Luo
- Department of Pathophysiology, Schools of Basic Sciences, Jiangxi Provincial Key Laboratory of Tumor Pathogens and Molecular Pathology, Nanchang University, Nanchang, China
| | - Hui Lin
- Department of Pathophysiology, Schools of Basic Sciences, Jiangxi Provincial Key Laboratory of Tumor Pathogens and Molecular Pathology, Nanchang University, Nanchang, China
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23
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Tanaka N, Kimura T, Fujimori N, Ichise Y, Sano K, Horiuchi A. Non-alcoholic fatty liver disease later diagnosed as myotonic dystrophy. World J Hepatol 2020; 12:685-692. [PMID: 33033573 PMCID: PMC7522559 DOI: 10.4254/wjh.v12.i9.685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/24/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Myotonic dystrophy (MD) is sometimes accompanied by metabolic/endocrine disorders, including dyslipidemia, central obesity, and hypogonadism. Due to considerable individual differences in the severity and progression of myopathy, MD patients with minimal-to-mild muscle symptoms might be followed as having other diseases, such as non-alcoholic fatty liver disease (NAFLD).
CASE SUMMARY A 40-year-old non-obese man without a history of regular ethanol consumption was referred to our hospital due to persistent liver dysfunction and hyperlipidemia. His body mass index was 23.4 kg/m2. Liver histology demonstrated macrovesicular steatosis, ballooned hepatocytes with eosinophilic inclusion bodies, and perisinusoidal fibrosis, leading to the diagnosis of non-alcoholic steatohepatitis (NASH). Although he had no discernable muscle pain or weakness, persistently high serum creatine kinase (CK) and myoglobin levels as well as the presence of frontal baldness, a hatched face, history of cataract surgery, and grip myotonia indicated the possibility of MD. Southern blotting of the patient’s DNA revealed the presence of CTG repeats, confirming the diagnosis.
CONCLUSION When gastroenterologists encounter NAFLD/NASH patients, serum CK should be verified. If hyperCKemia, frontal baldness, a hatched face, history of cataract surgery, and grip myotonia are noted, the possibility of MD may be considered.
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Affiliation(s)
- Naoki Tanaka
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Takefumi Kimura
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Naoyuki Fujimori
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Yasuyuki Ichise
- Digestive Disease Center, Showa Inan General Hospital, Komagane 399-4117, Japan
| | - Kenji Sano
- Department of Pathology, Iida Municipal Hospital, Iida 395-8502, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane 399-4117, Japan
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24
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Johansen MJ, Gade J, Stender S, Frithioff-Bøjsøe C, Lund MAV, Chabanova E, Thomsen HS, Pedersen O, Fonvig CE, Hansen T, Holm JC. The Effect of Overweight and Obesity on Liver Biochemical Markers in Children and Adolescents. J Clin Endocrinol Metab 2020; 105:5588552. [PMID: 31617910 DOI: 10.1210/clinem/dgz010] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/20/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Elevated plasma concentrations of liver enzymes are routinely used as markers of liver injury in adults and children. Currently, the age- and sex-specific effects of adiposity on pediatric liver enzyme concentrations are unclear. METHODS We included participants from 2 cohorts of Danish children and adolescents: 1858 from a population-based cohort and 2155 with overweight or obesity, aged from 6 to 18 years. Age- and sex-specific percentile curves were calculated for fasting plasma concentrations of alanine transaminase (ALT), aspartate transaminase (AST), lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT), bilirubin, and alkaline phosphatase (ALP) in both cohorts. Hepatic fat content was assessed by proton magnetic resonance spectroscopy in 458 participants. RESULTS Concentrations of ALT, AST, LDH, and ALP decreased with age in both girls and boys, while GGT and bilirubin were comparable across age groups in girls and increased slightly with age in boys. Children and adolescents with overweight or obesity exhibited higher concentrations of ALT in all age groups. Concentrations of ALT, and to a lesser degree GGT, increased with age in boys with overweight or obesity. Optimal ALT cut-points for diagnosing hepatic steatosis (liver fat content > 5%) was 24.5 U/L for girls (sensitivity: 55.6%, specificity: 84.0%), and 34.5 U/L for boys (sensitivity: 83.7%, specificity: 68.2%). CONCLUSIONS Pediatric normal values of liver enzymes vary with both age and sex. Overweight and obesity is associated with elevated biochemical markers of liver damage. These findings emphasize the need for prevention and treatment of overweight and obesity in children and adolescents. (J Clin Endocrinol Metab XX: 0-0, 2019).
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Affiliation(s)
- Magnus J Johansen
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Department of Radiology, Herlev Gentofte Hospital, Herlev, Denmark
| | - Julie Gade
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Department of Radiology, Herlev Gentofte Hospital, Herlev, Denmark
| | - Stefan Stender
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Christine Frithioff-Bøjsøe
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten A V Lund
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik S Thomsen
- Department of Radiology, Herlev Gentofte Hospital, Herlev, Denmark
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
| | - Oluf Pedersen
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cilius E Fonvig
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Department of Pediatrics, Kolding Hospital a part of Lillebaelt Hospital, Kolding, Denmark
| | - Torben Hansen
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- University of Southern Denmark, Faculty of Health Sciences, Odense, Denmark
| | - Jens-Christian Holm
- The Children's Obesity Clinic, European Centre of Management (COM/EASO), Department of Pediatrics, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
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25
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Hsu D, Josyabhatla R, Monteiro IM. Case 3: Persistent Elevated Transaminase Levels in a 9-year-old Boy. Pediatr Rev 2019; 40:643-646. [PMID: 31792049 DOI: 10.1542/pir.2018-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Diane Hsu
- Department of Pediatrics, Rutgers New Jersey Medical School, Newark, NJ
| | - Rohit Josyabhatla
- Department of Pediatrics, Rutgers New Jersey Medical School, Newark, NJ
| | - Iona M Monteiro
- Department of Pediatrics, Rutgers New Jersey Medical School, Newark, NJ
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26
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Xie ES, Pai N, Batthish M. Limited GPA and Alpha-1 Antitrypsin Deficiency in a Pediatric Patient. J Rheumatol 2019; 46:543-544. [PMID: 30824654 DOI: 10.3899/jrheum.180979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Elaine S Xie
- Department of Family Medicine, University of Toronto, Toronto
| | - Nikhil Pai
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital, and Assistant Professor, Department of Pediatrics, McMaster University, Hamilton
| | - Michelle Batthish
- Division of Rheumatology, McMaster Children's Hospital, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
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27
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Troisi J, Belmonte F, Bisogno A, Pierri L, Colucci A, Scala G, Cavallo P, Mandato C, Di Nuzzi A, Di Michele L, Delli Bovi AP, Guercio Nuzio S, Vajro P. Metabolomic Salivary Signature of Pediatric Obesity Related Liver Disease and Metabolic Syndrome. Nutrients 2019; 11:nu11020274. [PMID: 30691143 PMCID: PMC6412994 DOI: 10.3390/nu11020274] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022] Open
Abstract
Pediatric obesity-related metabolic syndrome (MetS) and nonalcoholic fatty liver disease (NAFLD) are increasingly frequent conditions with a still-elusive diagnosis and low-efficacy treatment and monitoring options. In this study, we investigated the salivary metabolomic signature, which has been uncharacterized to date. In this pilot-nested case-control study over a transversal design, 41 subjects (23 obese patients and 18 normal weight (NW) healthy controls), characterized based on medical history, clinical, anthropometric, and laboratory data, were recruited. Liver involvement, defined according to ultrasonographic liver brightness, allowed for the allocation of the patients into four groups: obese with hepatic steatosis ([St+], n = 15) and without hepatic steatosis ([St–], n = 8), and with (n = 10) and without (n = 13) MetS. A partial least squares discriminant analysis (PLS-DA) model was devised to classify the patients’ classes based on their salivary metabolomic signature. Pediatric obesity and its related liver disease and metabolic syndrome appear to have distinct salivary metabolomic signatures. The difference is notable in metabolites involved in energy, amino and organic acid metabolism, as well as in intestinal bacteria metabolism, possibly reflecting diet, fatty acid synthase pathways, and the strict interaction between microbiota and intestinal mucins. This information expands the current understanding of NAFLD pathogenesis, potentially translating into better targeted monitoring and/or treatment strategies in the future.
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Affiliation(s)
- Jacopo Troisi
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
- Theoreo srl, Via degli Ulivi 3, 84090 Montecorvino Pugliano (SA), Italy.
- European Biomedical Research Institute of Salerno (EBRIS), Via S. de Renzi, 3, 84125 Salerno, Italy.
- Hosmotic srl, Via R. Bosco 178, 80069 Vico Equense (NA), Italy.
| | - Federica Belmonte
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Antonella Bisogno
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Luca Pierri
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Angelo Colucci
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
- Theoreo srl, Via degli Ulivi 3, 84090 Montecorvino Pugliano (SA), Italy.
| | - Giovanni Scala
- Hosmotic srl, Via R. Bosco 178, 80069 Vico Equense (NA), Italy.
| | - Pierpaolo Cavallo
- Department of Physics, University of Salerno, 84084 Fisciano (Salerno), Italy.
| | - Claudia Mandato
- Department of Pediatrics, Children's Hospital Santobono-Pausilipon, 80129 Naples, Italy.
| | - Antonella Di Nuzzi
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Laura Di Michele
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Anna Pia Delli Bovi
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Salvatore Guercio Nuzio
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Pietro Vajro
- Department of Medicine and Surgery and Dentistry, "Scuola Medica Salernitana", Pediatrics Section University of Salerno, 84081 Baronissi (Salerno), Italy.
- European Laboratory of Food Induced Intestinal Disease (ELFID), University of Naples Federico II, 80100 Naples, Italy.
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28
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Alfani R, Vassallo E, De Anseris AG, Nazzaro L, D'Acunzo I, Porfito C, Mandato C, Vajro P. Pediatric Fatty Liver and Obesity: Not Always Justa Matter of Non-Alcoholic Fatty Liver Disease. CHILDREN-BASEL 2018; 5:children5120169. [PMID: 30551665 PMCID: PMC6306738 DOI: 10.3390/children5120169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/10/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
Obesity-related non-alcoholic fatty liver disease (NAFLD) represents the most common cause of pediatric liver disease due to overweight/obesity large-scale epidemics. In clinical practice, diagnosis is usually based on clinical features, blood tests, and liver imaging. Here, we underline the need to make a correct differential diagnosis for a number of genetic, metabolic, gastrointestinal, nutritional, endocrine, muscular, and systemic disorders, and for iatrogenic/viral/autoimmune hepatitis as well. This is all the more important for patients who are not in the NAFLD classical age range and for those for whom a satisfactory response of liver test abnormalities to weight loss after dietary counseling and physical activity measures cannot be obtained or verified due to poor compliance. A correct diagnosis may be life-saving, as some of these conditions which appear similar to NAFLD have a specific therapy. In this study, the characteristics of the main conditions which require consideration are summarized, and a practical diagnostic algorithm is discussed.
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Affiliation(s)
- Renata Alfani
- Pediatrics Residency Joint Programs, University of Naples Federico II, 80131 Naples, Italy.
- Pediatrics Residency Joint Programs, University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Edoardo Vassallo
- Pediatrics Residency Joint Programs, University of Naples Federico II, 80131 Naples, Italy.
- Pediatrics Residency Joint Programs, University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Anna Giulia De Anseris
- Clinical Pediatrics Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy.
| | - Lucia Nazzaro
- Clinical Pediatrics Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy.
| | - Ida D'Acunzo
- Pediatrics Residency Joint Programs, University of Naples Federico II, 80131 Naples, Italy.
- Pediatrics Residency Joint Programs, University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Carolina Porfito
- Pediatrics Residency Joint Programs, University of Naples Federico II, 80131 Naples, Italy.
- Pediatrics Residency Joint Programs, University of Salerno, 84081 Baronissi (Salerno), Italy.
| | - Claudia Mandato
- Children's Hospital Santobono-Pausilipon, Department of Pediatrics, 80129 Naples, Italy.
| | - Pietro Vajro
- Pediatrics Residency Joint Programs, University of Naples Federico II, 80131 Naples, Italy.
- Pediatrics Residency Joint Programs, University of Salerno, 84081 Baronissi (Salerno), Italy.
- Clinical Pediatrics Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi D'Aragona, 84131 Salerno, Italy.
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, Pediatrics Section, University of Salerno, 84081 Baronissi (Salerno), Italy.
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29
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Incidental hypertransaminasemia in children: Potential delay in diagnosis of muscle disease. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2018. [DOI: 10.1016/j.epag.2018.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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30
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Bussler S, Vogel M, Pietzner D, Harms K, Buzek T, Penke M, Händel N, Körner A, Baumann U, Kiess W, Flemming G. New pediatric percentiles of liver enzyme serum levels (alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase): Effects of age, sex, body mass index, and pubertal stage. Hepatology 2018; 68:1319-1330. [PMID: 28926121 DOI: 10.1002/hep.29542] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 08/23/2017] [Accepted: 09/17/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED The present study aims to clarify the effects of sex, age, body mass index (BMI), and puberty on transaminase serum levels in children and adolescents and to provide new age- and sex-related percentiles for alanine aminotransferase (ALT), aspartate aminotransferase (AST), and γ-glutamyltransferase (GGT). Venous blood and anthropometric data were collected from 4,126 cases. Excluded were cases of participants with potential hepatotoxic medication, with evidence of potential illness at the time of blood sampling and non-normal BMI (BMI <10th or >90th). The resulting data (N = 3,131 cases) were used for the calculations of ALT, AST, and GGT percentiles. Age- and sex-related reference intervals were established by using an LMS method of Cole-type method. Serum levels of transaminases follow age-specific patterns and relate to the onset of puberty. This observation is more pronounced in girls than in boys. ALT percentiles showed similar-shaped patterns in both sexes. Multivariate regression confirmed significant effects of puberty and BMI-SDS (β = 2.21) on ALT. Surprisingly, AST serum levels were negatively influenced by age (β = -1.42) and BMI-SDS (β = -0.15). GGT percentiles revealed significant sex-specific differences, correlated positively with age (β = 0.37) and showed significant association with BMI-SDS (β = 1.16). CONCLUSION Current reference values of ALT, AST, and GGT serum levels were calculated for children between 11 months and 16.0 years, using modern analytical and statistical methods. This study extends the current knowledge about transaminases by revealing influences of age, sex, BMI, and puberty on serum concentrations of all three parameters and has for these parameters one of the largest sample sizes published so far. (Hepatology 2017).
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Affiliation(s)
- Sarah Bussler
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Mandy Vogel
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Diana Pietzner
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Kristian Harms
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Theresa Buzek
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Melanie Penke
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Norman Händel
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Antje Körner
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Ulrich Baumann
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Wieland Kiess
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Gunter Flemming
- Hospital for Children and Adolescents, Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
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31
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Pierri L, Saggese P, Guercio Nuzio S, Troisi J, Di Stasi M, Poeta M, Savastano R, Marchese G, Tarallo R, Massa G, Ciccone V, Ziegenhardt D, Cavallo P, Bergheim I, Weisz A, Vajro P. Relations of gut liver axis components and gut microbiota in obese children with fatty liver: A pilot study. Clin Res Hepatol Gastroenterol 2018; 42:387-390. [PMID: 29773420 DOI: 10.1016/j.clinre.2018.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Luca Pierri
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy.
| | - Pasquale Saggese
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi (Sa), Italy
| | - Salvatore Guercio Nuzio
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy
| | - Jacopo Troisi
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy; Laboratory of Metabolomics Theoreo, 84090 Montecorvino Pugliano (Sa), Italy
| | - Martina Di Stasi
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy
| | - Marco Poeta
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy
| | - Riccardo Savastano
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", 84131 Salerno, Italy
| | - Giovanna Marchese
- Genomix4life Srl, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi (Sa), Italy
| | - Roberta Tarallo
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi (Sa), Italy
| | - Grazia Massa
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy
| | - Vincenzo Ciccone
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", 84131 Salerno, Italy
| | - Doreen Ziegenhardt
- Department of Nutritional Sciences, Molecular Nutritional Science, University of Vienna, Althanstr, 14 (UZA2), 1090 Vienna, Austria
| | - Pierpaolo Cavallo
- Department of Physics, University of Salerno, 84084 Fisciano (Sa), Italy
| | - Ina Bergheim
- Department of Nutritional Sciences, Molecular Nutritional Science, University of Vienna, Althanstr, 14 (UZA2), 1090 Vienna, Austria
| | - Alessandro Weisz
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi (Sa), Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", 84131 Salerno, Italy
| | - Pietro Vajro
- Pediatrics, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via Allende, 84081 Baronissi (Sa), Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", 84131 Salerno, Italy; European Laboratory of Food Induced Intestinal Diseases (ELFID), University of Naples Federico II, 80100 Naples, Italy
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Abstract
The liver and kidneys are often similarly affected by a single disease. This is the case in metabolic, immunological, toxic, and infectious diseases, and in the different congenital malformation syndromes. Also, an enzymatic defect in an otherwise healthy liver or the consequences of advanced liver disease by itself can cause kidney disease as a secondary phenomenon. In this review, we describe numerous pathogenic mechanisms leading to dysfunction or malformations of the liver and kidneys in children. We encourage multidisciplinary management for optimal care. A combined liver-kidney transplantation is sometimes needed.
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Guirat Dhouib N, Khaled MB, Ouederni M, Besbes H, Mellouli F, Bejaoui M. Hypertransaminasemia revealing a clinically silent muscular dystrophy in a child with sickle cell disease. Ann Hematol 2018; 97:2261-2262. [PMID: 29754272 DOI: 10.1007/s00277-018-3360-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Naouel Guirat Dhouib
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia.
| | - Monia Ben Khaled
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Monia Ouederni
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Habib Besbes
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Fethi Mellouli
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Mohamed Bejaoui
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center, Tunis, Tunisia
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Vajro P, Zielinska K, Ng BG, Maccarana M, Bengtson P, Poeta M, Mandato C, D'Acunto E, Freeze HH, Eklund EA. Three unreported cases of TMEM199-CDG, a rare genetic liver disease with abnormal glycosylation. Orphanet J Rare Dis 2018; 13:4. [PMID: 29321044 PMCID: PMC5763540 DOI: 10.1186/s13023-017-0757-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 12/29/2017] [Indexed: 01/21/2023] Open
Abstract
Background TMEM199 deficiency was recently shown in four patients to cause liver disease with steatosis, elevated serum transaminases, cholesterol and alkaline phosphatase and abnormal protein glycosylation. There is no information on the long-term outcome in this disorder. Results We here present three novel patients with TMEM199-CDG. All three patients carried the same set of mutations (c.13-14delTT (p.Ser4Serfs*30) and c.92G > C (p.Arg31Pro), despite only two were related (siblings). One mutation (c.92G > C) was described previously whereas the other was deemed pathogenic due to its early frameshift. Western Blot analysis confirmed a reduced level of TMEM199 protein in patient fibroblasts and all patients showed a similar glycosylation defect. The patients presented with a very similar clinical and biochemical phenotype to the initial publication, confirming that TMEM199-CDG is a non-encephalopathic liver disorder. Two of the patients were clinically assessed over two decades without deterioration. Conclusion A rising number of disorders affecting Golgi homeostasis have been published over the last few years. A hallmark finding is deficiency in protein glycosylation, both in N- and O-linked types. Most of these disorders have signs of both liver and brain involvement. However, the present and the four previously reported patients do not show encephalopathy but a chronic, non-progressive (over decades) liver disease with hypertransaminasemia and steatosis. This information is crucial for the patient/families and clinician at diagnosis, as it distinguishes it from other Golgi homeostasis disorders, in having a much more favorable course.
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Affiliation(s)
- Pietro Vajro
- Unit of Pediatrics, Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, (Sa), Italy
| | | | - Bobby G Ng
- Human Genetics Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
| | - Marco Maccarana
- Section for Matrix Biology, Department of Experimental Medical Sciences, Lund University, Lund, Sweden
| | - Per Bengtson
- Division of Clinical Chemistry, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Marco Poeta
- Unit of Pediatrics, Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, (Sa), Italy
| | - Claudia Mandato
- Children's Hospital "Santobono-Pausilipon", 1st Division of Pediatrics, Naples, Italy
| | - Elisa D'Acunto
- Unit of Pediatrics, Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, (Sa), Italy
| | - Hudson H Freeze
- Human Genetics Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
| | - Erik A Eklund
- Division of Pediatrics, Lund University, Lund, Sweden.
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Genetic analysis of 55 northern Vietnamese patients with Wilson disease: seven novel mutations in ATP7B. J Genet 2017; 96:933-939. [DOI: 10.1007/s12041-017-0857-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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37
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Yang CH, Perumpail BJ, Yoo ER, Ahmed A, Kerner JA. Nutritional Needs and Support for Children with Chronic Liver Disease. Nutrients 2017; 9:nu9101127. [PMID: 29035331 PMCID: PMC5691743 DOI: 10.3390/nu9101127] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 12/31/2022] Open
Abstract
Malnutrition has become a dangerously common problem in children with chronic liver disease, negatively impacting neurocognitive development and growth. Furthermore, many children with chronic liver disease will eventually require liver transplantation. Thus, this association between malnourishment and chronic liver disease in children becomes increasingly alarming as malnutrition is a predictor of poorer outcomes in liver transplantation and is often associated with increased morbidity and mortality. Malnutrition requires aggressive and appropriate management to correct nutritional deficiencies. A comprehensive review of the literature has found that infants with chronic liver disease (CLD) are particularly susceptible to malnutrition given their low reserves. Children with CLD would benefit from early intervention by a multi-disciplinary team, to try to achieve nutritional rehabilitation as well as to optimize outcomes for liver transplant. This review explains the multifactorial nature of malnutrition in children with chronic liver disease, defines the nutritional needs of these children, and discusses ways to optimize their nutritional.
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Affiliation(s)
- Christine H Yang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucile Packard Children's Hospital, Palo Alto, Stanford, CA 94304, USA.
| | - Brandon J Perumpail
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA 19129, USA.
| | - Eric R Yoo
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - John A Kerner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucile Packard Children's Hospital, Palo Alto, Stanford, CA 94304, USA.
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Valentini D, Alisi A, di Camillo C, Sartorelli MR, Crudele A, Bartuli A, Nobili V, Villani A. Nonalcoholic Fatty Liver Disease in Italian Children with Down Syndrome: Prevalence and Correlation with Obesity-Related Features. J Pediatr 2017; 189:92-97.e1. [PMID: 28662945 DOI: 10.1016/j.jpeds.2017.05.077] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the prevalence of overweight/obesity in a cohort of Italian children with Down syndrome (DS) and to investigate the correlation of both obesity and DS with nonalcoholic fatty liver disease (NAFLD). STUDY DESIGN We enrolled 280 children with DS (age range 5-18 years), who were referred to the DS outpatient clinic of the Bambino Gesù Children's Hospital in Rome. For all children, we collected the clinical history and measured anthropometric variables. Eighty-four of 280 children with DS were selected to undergo liver ultrasound scanning to evaluate the presence of NAFLD. RESULTS Italian children with DS exhibited a prevalence of 19.64% for overweight and 12.14% for obesity. The prevalence of NAFLD in nonobese (45%) and overweight/obese (82%) children with DS is greater than in the European pediatric nonobese (5.7%) or obese population (33%). Moreover, the severity of liver brightness on ultrasound scan correlated positively with body mass index, triglycerides, low-density lipoprotein-cholesterol, and leptin levels and negatively with adiponectin. CONCLUSIONS We demonstrated that, independently from the obese phenotype, children with DS display a greater risk to develop NAFLD than the general pediatric population.
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Affiliation(s)
- Diletta Valentini
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy.
| | - Anna Alisi
- Liver Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara di Camillo
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | | | - Annalisa Crudele
- Liver Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Bartuli
- Rare Diseases and Medical Genetic Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
| | - Valerio Nobili
- Hepato-Metabolic Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Institute for Research and Health Care (IRCCS), Rome, Italy
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Congenital Hypothyroidism: An Unusual Combination of Biochemical Abnormalities. Case Rep Pediatr 2016; 2016:2678578. [PMID: 27994903 PMCID: PMC5138475 DOI: 10.1155/2016/2678578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 11/18/2022] Open
Abstract
A forty-five-day-old female infant presented with prolonged jaundice with clinical features suggestive of congenital hypothyroidism (CHT). On investigations, the infant was noted to have indirect hyperbilirubinemia (13.8 mg/dl) with increased levels of AST (298 IU/dl) and ALT (174 IU/dl) in the serum. The child had low levels of free T3 (<1 pg/ml) and free T4 (0.4 ng/dl) secondary to thyroid agenesis detected on radionuclide scan and ultrasonography of the neck and raised levels of TSH (>500 microIU/ml) in the serum. The combination of indirect hyperbilirubinemia and raised levels of hepatic transaminases has not been reported in babies with CHT. Following institution of oral thyroxin therapy, the serum bilirubin levels ameliorated (2.9 mg/dl) considerably by 15 days of therapy and the serum levels of AST (40 IU/dl) and ALT (20 IU/dl) got normalized. The case demonstrates that raised levels of hepatic transaminases can occur in infants with CHT and these can resolve just with thyroxin therapy, obviating the need for extensive investigative laboratory work-up.
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40
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Clemente MG, Mandato C, Poeta M, Vajro P. Pediatric non-alcoholic fatty liver disease: Recent solutions, unresolved issues, and future research directions. World J Gastroenterol 2016; 22:8078-8093. [PMID: 27688650 PMCID: PMC5037077 DOI: 10.3748/wjg.v22.i36.8078] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) in children is becoming a major health concern. A “multiple-hit” pathogenetic model has been suggested to explain the progressive liver damage that occurs among children with NAFLD. In addition to the accumulation of fat in the liver, insulin resistance (IR) and oxidative stress due to genetic/epigenetic background, unfavorable lifestyles, gut microbiota and gut-liver axis dysfunction, and perturbations of trace element homeostasis have been shown to be critical for disease progression and the development of more severe inflammatory and fibrotic stages [non-alcoholic steatohepatitis (NASH)]. Simple clinical and laboratory parameters, such as age, history, anthropometrical data (BMI and waist circumference percentiles), blood pressure, surrogate clinical markers of IR (acanthosis nigricans), abdominal ultrasounds, and serum transaminases, lipids and glucose/insulin profiles, allow a clinician to identify children with obesity and obesity-related conditions, including NAFLD and cardiovascular and metabolic risks. A liver biopsy (the “imperfect” gold standard) is required for a definitive NAFLD/NASH diagnosis, particularly to exclude other treatable conditions or when advanced liver disease is expected on clinical and laboratory grounds and preferably prior to any controlled trial of pharmacological/surgical treatments. However, a biopsy clearly cannot represent a screening procedure. Advancements in diagnostic serum and imaging tools, especially for the non-invasive differentiation between NAFLD and NASH, have shown promising results, e.g., magnetic resonance elastography. Weight loss and physical activity should be the first option of intervention. Effective pharmacological treatments are still under development; however, drugs targeting IR, oxidative stress, proinflammatory pathways, dyslipidemia, gut microbiota and gut liver axis dysfunction are an option for patients who are unable to comply with the recommended lifestyle changes. When morbid obesity prevails, bariatric surgery should be considered.
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Serdaroğlu F, Koca T, Dereci S, Akçam M. The etiology of hypertransaminasemia in Turkish children. Bosn J Basic Med Sci 2016; 16:151-6. [PMID: 26894285 PMCID: PMC4852998 DOI: 10.17305/bjbms.2016.982] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 01/29/2016] [Accepted: 01/30/2016] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to investigate the causes of elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in children. We analyzed the medical records for children aged 3 months to 18 years who presented to the hospital with ALT >45 IU/L and/or AST >50 IU/L, between 2012 and 2014, for various reasons, including those not related to liver disease. In total, 281 children met the study criteria. This group comprised of 125 (44.5%) females and 156 (55.5%) males. At the presentation, the most common patient complaint was fatigue (53.4%), while 15.7% of the patients reported no symptoms. The most common findings on the physical examination were jaundice and hepatomegaly. In 15% of the cases, the findings were normal. According to the diagnosis, the most common cause of the elevated transaminases were infections (34%), with hepatitis A virus (HAV) infection as the leading cause (18.9%). Drug-induced liver injury (DILI) was the cause in 18.1% of the cases and non-alcoholic fatty liver disease (NAFLD) in 11.1%. The highest transaminase levels were associated with HAV infection, while DILI and NAFLD caused only slightly elevated transaminases. Overall, our results show that the elevated transaminases in children are most often caused by infections, DILI, and NAFLD. In a majority of cases, elevated ALT and AST indicate liver disease, however, they could also be associated with conditions other than liver damage. Additionally, the elevated enzymes can be detected in completely healthy individuals.
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Affiliation(s)
- Filiz Serdaroğlu
- Department of Pediatrics, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey.
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Ku MC, Kok VC, Lee MY, Hsu SM, Lee PY, Chang CW, Tyan YS, Juan CW. Clinical analysis of contributors to the delayed gallbladder opacification following the use of water-soluble contrast medium. Ther Clin Risk Manag 2016; 12:1357-64. [PMID: 27660453 PMCID: PMC5019449 DOI: 10.2147/tcrm.s116899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Gallbladder opacification (GBO) on computed tomography (CT) imaging may obscure certain pathological or emergent conditions in the gallbladder, such as neoplasms, stones, and hemorrhagic cholecystitis. This study aimed to investigate the clinical contributing factors that could predict the presence of delayed GBO determined by CT. METHODS This study retrospectively evaluated 243 consecutive patients who received enhanced CT or intravenous pyelography imaging and then underwent abdominal CT imaging within 5 days. According to the interval between imaging, the patients were divided into group A (1 day), group B (2 or 3 days), and group C (4 or 5 days). Three radiologists evaluated CT images to determine GBO. Fisher's exact test and multivariate backward stepwise elimination logistic regression were performed. RESULTS Positive GBO was significantly associated with the interval between imaging studies, contrast type, contrast volume, renal function, and hypertransaminasemia (P<0.05). Multivariate backward stepwise elimination logistic regression analysis of the three groups identified contrast type and hypertransaminasemia as independent predictors of GBO in group B patients (odds ratio [OR], 13.52, 95% confidence interval [CI], 1.72-106.38 and OR, 3.43, 95% CI, 1.31-8.98, respectively; P<0.05). Hypertransaminasemia was the only independent predictor of GBO in group C patients with an OR of 7.2 (95% CI, 1.62-31.73). Hypertransaminasemia was noted in three patients (100%) who initially underwent imaging 5 days prior to GBO. CONCLUSION Delayed GBO on CT imaging may be associated with laboratory hypertransaminasemia, particularly in patients receiving contrast medium over a period of ≥4 days. A detailed clinical history, physical examination, and further workup are of paramount importance for investigating the underlying cause behind the hypertransaminasemia.
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Affiliation(s)
- Ming-Chang Ku
- Department of Radiology, Kuang Tien General Hospital, Taichung; Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli
| | - Victor C Kok
- Department of Internal Medicine, Division of Medical Oncology, Kuang Tien General Hospital; Department of Bioinformatics and Medical Engineering, Asia University
| | - Ming-Yung Lee
- Department of Statistics and Informatics Science, Providence University
| | - Soa-Min Hsu
- Department of Radiology, Kuang Tien General Hospital, Taichung
| | - Pei-Yu Lee
- Department of Radiology, Kuang Tien General Hospital, Taichung
| | - Che-Wei Chang
- Department of Radiology, Kuang Tien General Hospital, Taichung
| | - Yeu-Sheng Tyan
- Department of Medical Imaging, Chung Shan Medical University Hospital
| | - Chi-Wen Juan
- Department of Emergency Medicine, Kuang Tien General Hospital; Department of Nursing, HungKuang University, Taichung, Taiwan
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43
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Eğin S, Açıksarı K, Ercan G, Aydın AF, Üstyol EA, Eser M, Tanrıverdi G, Yanar HT. Effects of pentoxifylline on oxidative stress in rats with abdominal compartment syndrome model. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Veropalumbo C, Campanozzi A, De Gregorio F, Correra A, Raia V, Vajro P. Shwachman-Diamond syndrome with autoimmune-like liver disease and enteropathy mimicking celiac disease. Clin Res Hepatol Gastroenterol 2015; 39:e1-4. [PMID: 25129842 DOI: 10.1016/j.clinre.2014.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/16/2014] [Accepted: 06/29/2014] [Indexed: 02/04/2023]
Abstract
Liver abnormalities that normalize during infancy as well an enteropathy are reported in Shwachman-Diamond syndrome (SDS). The pathogenesis of both conditions is unknown. We report two SDS cases with autoimmune-like (antismooth muscle and/or antinuclear antibody positivity) liver disease and antigliadin antibody positive inflammatory enteropathy. Hypertransaminasemia did not resolve after immunosuppressive therapy and/or a gluten-free diet. These transient autoimmune phenomena and gut-liver axis perturbations may have played a role in transient SDS hepatopathy and enteropathy. Our report may stimulate other studies to define the relationship between the SDS genetic defect and intestinal permeability as the pathogenic mechanism underlying SDS related liver and intestinal inflammation.
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Affiliation(s)
| | - Angelo Campanozzi
- Department of Scienze Mediche e del Lavoro, Pediatrics Section, University of Foggia, Foggia, Italy.
| | | | | | - Valeria Raia
- Pediatrics Section, University of Naples "Federico II", Naples, Italy.
| | - Pietro Vajro
- Department of Medicine and Surgery, Chair of Pediatrics, University of Salerno, Baronissi-Salerno, Italy; European Laboratory for Food Induced Disease (ELFID), Naples, Italy.
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45
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Baumann U. Differenzialdiagnostik bei persistierender Erhöhung der Transaminasenkonzentrationen. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3267-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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46
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Wei Z, Huang Y, Liu A, Diao S, Yu Q, Peng Z, Hong M. Mutational characterization of ATP7B gene in 103 Wilson's disease patients from Southern China: identification of three novel mutations. Neuroreport 2014; 25:1075-80. [PMID: 25089800 DOI: 10.1097/wnr.0000000000000216] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Wilson's disease (WD) is an autosomal recessive inheritance disorder of copper metabolism due to mutations in the ATP7B gene. The distribution of ATP7B gene mutations is diverse in different population. This study aimed to examine the genotypes of the ATP7B mutant alleles in WD patients from Southern China. Genomic DNA was extracted from 103 WD patients and 60 healthy patients. Mutations were screened and detected by DNA sequencing. A total of 51 different ATP7B mutations were identified in WD patients, including six homozygous, 51 compound heterozygous, and 39 single heterozygotes. Three mutations were found to be novel, including one missense mutation (c.2549C>T) and two frameshift mutations (c.3851_3876del and c.1057delC). The most frequent mutations are Arg778Leu (18.93%), Ile1148Thr (8.74%), and Pro992Leu (4.37%). Different from the published results of early studies, Ile1148Thr was found to be the second common mutation in our cohort. The highest mutation detection rate was on exon 8 (43.69%), followed by exon 16 (24.27%), and exon 12 (17.48%). The total mutation detection rate on exon 8, 12, and 16 was 85.44%. No ATP7B gene mutation was found in healthy patients. In conclusion, we identified three novel mutations and Ile1148Thr as another hotspot mutation in WD patients from Southern China. Most of the mutations can be detected by screening exon 8, 12, and 16. Our research has further enriched the mutation spectrum of the ATP7B gene in Chinese and may help to develop genetic screening strategies of WD.
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Affiliation(s)
- Zhisheng Wei
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
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Socha P, Vajro P, Lefeber D, Adamowicz M, Tanner S. Search for rare liver diseases: the case of glycosylation defects mimicking Wilson Disease. Clin Res Hepatol Gastroenterol 2014; 38:403-6. [PMID: 24972800 DOI: 10.1016/j.clinre.2014.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 04/19/2014] [Accepted: 04/28/2014] [Indexed: 02/04/2023]
Abstract
Pediatric hepatology appears to be a very specific field of paediatrics which deals mainly with rare diseases although clinical features can be commonly found - like increased activity of transaminases. Some of these rare diseases like Wilson disease are commonly looked for and recently Wilsonian like phenotypes have been described which additionally presented with abnormal glycosylation of the plasma protein transferrin. In a subgroup of those patients with specific additional clinical symptoms (cleft uvula, low blood sugar, rhabdomyolysis and dilated cardiomyopathy) phosphoglucomutase 1 deficiency was identified. We recommend screening for abnormal glycosylation of the plasma protein transferrin in children with unexplained liver injury.
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Affiliation(s)
- Piotr Socha
- Department of Gastroenterology, Hepatology and Nutrition Disorders, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Pietro Vajro
- Department of Medicine and Surgery, Pediatrics Section, University of Salerno, Baronissi (Salerno), Italy
| | - Dirk Lefeber
- Department of Neurology, Laboratory of Genetic, Endocrine and Metabolic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maciej Adamowicz
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Stuart Tanner
- University of Sheffield, UK, Academic Unit of Child Health, Sheffield Children's Hospital, Western Bank, Sheffield, UK
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Lamireau T, McLin V, Nobili V, Vajro P. A practical approach to the child with abnormal liver tests. Clin Res Hepatol Gastroenterol 2014; 38:259-62. [PMID: 24736033 DOI: 10.1016/j.clinre.2014.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 02/18/2014] [Accepted: 02/26/2014] [Indexed: 02/04/2023]
Abstract
The presence of elevated aminotransferases on routine blood tests can reveal liver diseases of various severities. In children, etiologies are more numerous and complex than those usually considered in adults. Information derived from family and personal history, physical examination and basic laboratory data are necessary to reach a timely and correct diagnosis. A stepwise approach is proposed to guide the timing of more specific investigations that are often required.
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Affiliation(s)
- Thierry Lamireau
- Pediatric Gastroenterology Unit, Children's Hospital, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - Valérie McLin
- Pediatric Gastroenterology Unit and Swiss Center for Liver Disease in Children, University Hospitals Geneva, 6, rue Willy Donze, 1211 Geneva 14, Switzerland
| | - Valério Nobili
- Hepatometabolic Unit, Bambino Gesu' Children Hospital, IRCCS, Rome, Italy
| | - Pietro Vajro
- Department of Medicine and Surgery, Pediatric Section, University of Salerno, 84081 Baronissi (SA), Italy
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