1
|
Ibba A, Loche S. Diagnosis of GH Deficiency Without GH Stimulation Tests. Front Endocrinol (Lausanne) 2022; 13:853290. [PMID: 35250894 PMCID: PMC8894314 DOI: 10.3389/fendo.2022.853290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
Growth hormone deficiency (GHD) is the most commonly affected pituitary hormone in childhood with a prevalence of 1 in 4000-10000 live births. GH stimulation testing (GHST) is commonly used in the diagnostic workup of GHD. However, GHD can be diagnosed in some clinical conditions without the need of GHST. The diagnosis of GHD in newborns does not require stimulation testing. Likewise infants/children with delayed growth and/or short stature associated with neuroradiological abnormalities and one or more additional pituitary hormone deficiencies may not need GHST. This review summarizes the current evidence on the diagnosis of GHD without stimulation tests.
Collapse
|
2
|
Polidori N, Castorani V, Mohn A, Chiarelli F. Deciphering short stature in children. Ann Pediatr Endocrinol Metab 2020; 25:69-79. [PMID: 32615685 PMCID: PMC7336267 DOI: 10.6065/apem.2040064.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/16/2020] [Indexed: 01/15/2023] Open
Abstract
Short stature is a common reason for referral to pediatric endocrinologists. Multiple factors, including genetic, prenatal, postnatal, and local environmental factors, can impair growth. The majority of children with short stature, which can be defined as a height less than 2 standard deviation score below the mean, are healthy. However, in some cases, they may have an underlying relevant disease; thus, the aim of clinical evaluation is to identify the subset of children with pathologic conditions, for example growth hormone deficiency or other hormonal abnormalities, Turner syndrome, inflammatory bowel disease, or celiac disease. Prompt identification and management of these children can prevent excessive short stature in adulthood. In addition, a thorough clinical assessment may allow evaluation of the severity of short stature and likely growth trajectory to identify the most effective interventions. Consequently, appropriate diagnosis of short stature should be performed as early as possible and personalized treatment should be started in a timely manner. An increase in knowledge and widespread availability of genetic and epigenetic testing in clinical practice in recent years has empowered the diagnostic process and appropriate treatment for short stature. Furthermore, novel treatment approaches that can be used both as diagnostic tools and as therapeutic agents have been developed. This article reviews the diagnostic approach to children with short stature, discusses the main causes of short stature in children, and reports current therapeutic approaches and possible future treatments.
Collapse
Affiliation(s)
- Nella Polidori
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy,Address for correspondence: Francesco Chiarelli, MD, PhD Department of Pediatrics, University of Chieti, Via dei Vestini, 5, I-66100 Chieti, Italy Tel: +39-0871-358015 Fax: +39-0871-574538 E-mail:
| |
Collapse
|
3
|
Soliman AT, Laham M, Jour C, Shaat M, Souikey F, Itani M, Al-Safi A, Karmallah A, Qudaisat A, Alarabi Z, Hassan A, Quraan E, Al-Naimi N, Alsaadi RK, De Sanctis V. Linear growth of children with celiac disease after the first two years on gluten- free diet: a controlled study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:20-27. [PMID: 31544803 PMCID: PMC7233684 DOI: 10.23750/abm.v90i8-s.8515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 01/01/2023]
Abstract
Background: Celiac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs especially growth. Gluten free diet (GFD) is required to achieve remission and prevent abnormal growth. Study reports on growth of children with celiac disease on long-term GFD are not consistent. Objective: We evaluated the effect of GFD on growth of children with the classical form of CD (diagnosed by serology and small intestine mucosal biopsy) on log-term GFD (>2 years). Methods: We studied growth parameters (weight gain/day, BMI and BMI-SDS, height growth velocity, Ht-SDS) and lab data in 30 prepubertal children, aged 7.4±2.6 years, with CD, who were on GFD since the age of 3.2±1.6 years of age (>2 years on GFD) for duration of 1 year. The anthropometric data of 30 randomly selected normal, age and sex matched, children were used as control. Lab investigations of CD children included complete blood count (CBC), renal and liver functions (aspartate transaminase - AST, alanine aminotransferase - ALT, and alkaline phosphatase- ALP, serum albumin, fasting blood glucose, vitamin D, and thyroid function and antibodies. Results: The weight gain per day was on average or above, for age and sex, in 27 children and below average in 3. Two out of those 3 children had slow linear growth (decreased Ht-SDS by -0.56 and -0.1, over one year). BMI-SDS was normal in 26/30 patients (>-1.5). BMI-SD changed from -0.36±1.1 to -0.33±1.1 during the year of treatment. BMI-SDS decreased in 9 children during the follow up period that was explained by their fast-linear growth (increased Ht-SDS) in seven of them. The Ht-SDS was <-2 in four out of 30 children at the beginning of the study (2 years after being on GFD) and in 2 children after a year of follow-up (catch-up growth). Ht-SDS remained normal or increased in 28/30 children during the year of treatment (-0.38 ±1.2 to -0.22±1.1), with a positive trend: 0.15±0.4 SDS. Only one patient crossed down 1 Ht-SDS during the year of follow up, with low weight gain/day and decreased BMI-SDS that can be explained by poor compliance with GFD. Ht-SDS and BMI-SDS increased significantly in the CD group versus controls during the year of follow-up. All patients had normal serum albumin, liver enzyme and hemoglobin levels. 33.3% of patients had low serum ferritin level and 33.3% had a vitamin D deficiency. Conclusions: Most of our children with CD grew normally both in height and weight during GFD. Significant catch-up growth occurred in some of them after 2 years of being on GFD. Those with low BMI-SDS and/or Ht-SDS needed further management, including reinforcement on the importance of GFD and investigations on factors affecting growth pattern. Measuring weight gain /day appears to be a sensitive indicator for monitoring growth in these children. Vitamin D and iron status should be monitored, and deficiencies corrected. (www.actabiomedica.it)
Collapse
|
4
|
Fang Y, Qiu J, Jiang ZB, Xu SR, Zhou ZH, He RL. Increased serum levels of miR-214 in patients with PCa with bone metastasis may serve as a potential biomarker by targeting PTEN. Oncol Lett 2018; 17:398-405. [PMID: 30655780 DOI: 10.3892/ol.2018.9522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 01/03/2018] [Indexed: 12/13/2022] Open
Abstract
MicroRNAs (miRNAs/miRs) are identified to serve key functions in the progression of various tumors. miR-214 is aberrantly expressed in various types of cancer. In the present study, the function of miR-214 and its feasibility as a potential non-invasive biomarker for patients with prostate cancer (PCa) in a hyperplasia group and a control group were investigated. First, RNA was isolated from the serum of 75 patients with PCa with bone metastasis, 65 patients with PCa with no bone metastasis and 70 healthy controls. The level of miR-214 expression was significantly upregulated in the serum of the bone metastasis group compared with the healthy control and non-bone metastasis groups. Expression levels of alkaline phosphatase (ALP), bone sialoprotein (BSP), collagen type I pyridine crosslinking peptide (ICTP) were also evaluated. The results indicated that serum levels of BSP, ALP and ICTP were increased in the bone metastasis group compared with that in the non-bone metastasis group, hyperplasia group and the control group (P<0.05). The expression level of miR-214 is positively associated with poorly differentiated tumors in patients with PCa with a Gleason score >7 (P<0.05). Western blot analysis demonstrated that phosphatase and tensin homolog (PTEN) was a target gene of miR-214. Additionally, silencing of PTEN significantly increased the invasive ability of PC3 cells even when miR-214 expression was inhibited. In summary, serum miR-214 expression may serve as a potential novel non-invasive biomarker for PCa screening through targeting PTEN.
Collapse
Affiliation(s)
- Yi Fang
- Department of Anesthesiology, Changsha Central Hospital, Changsha, Hunan 410000, P.R. China
| | - Jun Qiu
- Oncology Department Two, Mawangdui Hospital of Hunan People's Hospital, Changsha, Hunan 410016, P.R. China
| | - Zong-Bin Jiang
- Department of Pain Medicine, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Sheng-Rong Xu
- Department of Pain Medicine, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Zeng-Hua Zhou
- Department of Pain Medicine, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Rui-Lin He
- Department of Pain Medicine, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| |
Collapse
|
5
|
Laurikka P, Nurminen S, Kivelä L, Kurppa K. Extraintestinal Manifestations of Celiac Disease: Early Detection for Better Long-Term Outcomes. Nutrients 2018; 10:E1015. [PMID: 30081502 PMCID: PMC6115849 DOI: 10.3390/nu10081015] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/25/2018] [Accepted: 07/31/2018] [Indexed: 12/11/2022] Open
Abstract
Population-based screening studies have shown celiac disease to be one of the most common chronic gastrointestinal diseases. Nevertheless, because of the diverse clinical presentation, the great majority of patients remain unrecognized. Particularly difficult to identify are the multifaceted extraintestinal symptoms that may appear at variable ages. Although the pathogenesis and long-term outcome of these manifestations are still poorly established, there is some evidence that unrecognized celiac disease predisposes to severe complications if not diagnosed and prevented with an early-initiated gluten-free diet. Therefore, it is of utmost importance that physicians of different disciplines learn to recognize celiac disease in individuals with non-gastrointestinal symptoms. In the future, more studies are needed to clarify the factors affecting development and prognosis of the extraintestinal manifestations.
Collapse
Affiliation(s)
- Pilvi Laurikka
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, 33014 Tampere, Finland.
- Department of Internal Medicine, Hospital District of South Ostrobothnia, 60200 Seinäjoki, Finland.
| | - Samuli Nurminen
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
| | - Laura Kivelä
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
| | - Kalle Kurppa
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, 33014 Tampere, Finland.
| |
Collapse
|
6
|
Blum WF, Alherbish A, Alsagheir A, El Awwa A, Kaplan W, Koledova E, Savage MO. The growth hormone-insulin-like growth factor-I axis in the diagnosis and treatment of growth disorders. Endocr Connect 2018; 7:R212-R222. [PMID: 29724795 PMCID: PMC5987361 DOI: 10.1530/ec-18-0099] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/03/2018] [Indexed: 01/11/2023]
Abstract
The growth hormone (GH)-insulin-like growth factor (IGF)-I axis is a key endocrine mechanism regulating linear growth in children. While paediatricians have a good knowledge of GH secretion and assessment, understanding and use of measurements of the components of the IGF system are less current in clinical practice. The physiological function of this axis is to increase the anabolic cellular processes of protein synthesis and mitosis, and reduction of apoptosis, with each being regulated in the appropriate target tissue. Measurement of serum IGF-I and IGF-binding protein (IGFBP)-3 concentrations can complement assessment of GH status in the investigation of short stature and contribute to prediction of growth response during GH therapy. IGF-I monitoring during GH therapy also informs the clinician about adherence and provides a safety reference to avoid over-dosing during long-term management.
Collapse
Affiliation(s)
| | | | - Afaf Alsagheir
- King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
| | - Ahmed El Awwa
- Department of Pediatric Endocrinology & DiabetesHamad Medical Center, Doha, Qatar
| | | | | | - Martin O Savage
- William Harvey Research InstituteBarts and the London School of Medicine & Dentistry, London, UK
| |
Collapse
|
7
|
Valitutti F, Trovato CM, Montuori M, Cucchiara S. Pediatric Celiac Disease: Follow-Up in the Spotlight. Adv Nutr 2017; 8:356-361. [PMID: 28298278 PMCID: PMC5347098 DOI: 10.3945/an.116.013292] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The follow-up of celiac disease (CD) is challenging due to the scarcity of published data and the lack of standardized evidence-based protocols. The worldwide frequency and methods of CD follow-up appear to be heavily influenced by expert opinions of the individual physicians who assess children with CD. The aim of this review was to summarize the available studies on CD follow-up in children. We conducted a literature search with the use of PubMed, Medline, and Embase (from 1900 to 15 December 2016) for terms relevant to this review, including CD, follow-up, dietary adherence or dietary compliance, nutrition, comorbidities, complications, and quality of life. The aims of follow-up are as follows: to ensure strict adherence to a gluten-free diet, to ensure nutritional adequacy, to improve quality of life, and to prevent disease complications. For the correct evaluation of children with CD at follow-up, a clinical and biochemical evaluation is necessary on a regular basis. It is advisable to assess compliance, nutrition, comorbidities, or possible complications once a year at the referral center. Laboratory tests might be useful for a thorough evaluation of any patient with CD to rule out a micronutrient deficiency (full blood count, ferritin, folic acid, vitamin B-6, and vitamin B-12) and possible cardiovascular risk factors (glucose, LDL cholesterol, triglycerides). Biochemical evaluation is essential when there are clinical problems and should be customized on the basis of the specific clinical suspicion. Associated autoimmune thyroiditis should also be screened for yearly by measuring thyroid-stimulating hormone and thyroid autoantibody concentrations, regardless of symptoms, because hypothyroidism is often subtle and methods for early treatment are available and desirable. Although evidence-based recommendations for follow-up of pediatric patients with CD have not yet been established, we advise a yearly follow-up visit as the safest approach.
Collapse
Affiliation(s)
- Francesco Valitutti
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Chiara Maria Trovato
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Monica Montuori
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
8
|
Snyder J, Butzner JD, DeFelice AR, Fasano A, Guandalini S, Liu E, Newton KP. Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children. Pediatrics 2016; 138:peds.2015-3147. [PMID: 27565547 DOI: 10.1542/peds.2015-3147] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/11/2022] Open
Abstract
Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.
Collapse
Affiliation(s)
- John Snyder
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's National Health Systems, Washington, District of Columbia;
| | - J Decker Butzner
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, Alberta, Canada
| | - Amy R DeFelice
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, New York-Presbyterian Hospital, Columbia University, New York, New York
| | - Alessio Fasano
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Stefano Guandalini
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, Chicago, Illinois
| | - Edwin Liu
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; and
| | - Kimberly P Newton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital and University of California San Diego School of Medicine, San Diego, California
| |
Collapse
|
9
|
Nurminen S, Kivelä L, Taavela J, Huhtala H, Mäki M, Kaukinen K, Kurppa K. Factors associated with growth disturbance at celiac disease diagnosis in children: a retrospective cohort study. BMC Gastroenterol 2015; 15:125. [PMID: 26438321 PMCID: PMC4595273 DOI: 10.1186/s12876-015-0357-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/25/2015] [Indexed: 12/22/2022] Open
Abstract
Background Impaired growth is a well-known complication in celiac disease, but factors associated with it are poorly known. We investigated this issue in a large cohort of children. Methods 530 children with biopsy-proven celiac disease were included. The participants were divided into two groups on the basis of the presence (n = 182) or absence (n = 348) of growth disturbance at diagnosis. Histological, serological and clinical characteristics were compared between children with growth failure and those with normal growth. Further, patients with growth failure as the sole clinical presentation were compared to those with poor growth and concomitant other symptoms. Results Children with growth failure were younger (p < 0.001) and had lower hemoglobin (p = 0.016) and higher celiac antibody (p < 0.001), alanine aminotransferase (p = 0.035) and thyroid-stimulating hormone values (p = 0.013) than those with normal growth. Significantly associated with growth failure at diagnosis were age <3 years (OR 4.3 (95 % CI 2.5-7.5) vs older age), diagnosis before the year 2000 and in 2000–09 (OR 3.1 (1.8-5.4) and OR 1.8 (1.1-2.8) vs diagnosis in 2010–2013), presence of total and subtotal villous atrophy (OR 4.2 (2.5-7.0) and OR 2.0 (1.3-3.2) vs partial atrophy), severe symptoms (OR 3.4 (1.8-6.7) vs mild symptoms) and vomiting (OR 3.1 (1.5-6.3). The presence of abdominal pain reduced the risk (OR 0.5 (0.3-0.7)), while there was no effect of gender, diarrhea, constipation, other chronic diseases and celiac disease in the family. Children evincing poor growth as the sole clinical presentation were older (p < 0.001) and had higher hemoglobin (P < 0.001) and total iron (p = 0.010) values and lower TG2ab values (p = 0.009) than those with growth disturbance and other symptoms. Conclusions In particular young age and severe clinical and histological presentation were associated with growth disturbance at celiac disease diagnosis. Children with only poor growth are markedly different from those with other concomitant symptoms, suggesting different pathogenic mechanisms.
Collapse
Affiliation(s)
- Samuli Nurminen
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Laura Kivelä
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Juha Taavela
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Heini Huhtala
- School of Health Sciences, University of Tampere, Tampere, Finland.
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Katri Kaukinen
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
| | - Kalle Kurppa
- School of Medicine, University of Tampere, FIN-33014, Tampere, Finland. .,Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| |
Collapse
|
10
|
Bruins MJ. The clinical response to gluten challenge: a review of the literature. Nutrients 2013; 5:4614-41. [PMID: 24284613 PMCID: PMC3847752 DOI: 10.3390/nu5114614] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/01/2013] [Accepted: 11/06/2013] [Indexed: 02/07/2023] Open
Abstract
The aim of this review was to identify, evaluate and summarize all relevant studies reporting on the clinical response to gluten challenge by adult or pediatric patients with suspected or diagnosed coeliac disease (CD) on a gluten-free diet. We evaluated the effect of gluten challenge on changes in symptoms, intestinal mucosa histology, and serum antibodies. A systematic electronic search was performed for studies published as of 1966 using PubMed and Scopus databases. In the reviewed studies, doses ranged from 0.2 to 30 g/day of wheat gluten or comprised a gluten-containing diet. The onset of symptoms upon gluten intake varied largely from days to months and did not parallel serum antibody or histological changes. Within 3 months of gluten challenge, 70%-100% of pediatric CD patients became positive for AGA-IgA and EMA-IgA antibodies and 50%-70% for AGA-IgG. A limited number of trials suggest that no more than half of adult patients developed positive AGA-IgA, EMA-IgA, tTG-IgA or DGP-IgA/IgG titers. Approximately 50%-100% of pediatric and adult patients experienced mucosal relapse of gluten provocation within 3 months, which was preceded by increased mucosal intra-epithelial lymphocytes within several days of challenge. A 3-month high-dose gluten challenge should be suitable to diagnose the majority of CD patients. In some cases prolonged challenge may be needed to verify diagnosis. Combination testing for antibodies and mucosal histology may fasten the diagnosis.
Collapse
Affiliation(s)
- Maaike J Bruins
- DSM Biotechnology Center, Alexander Fleminglaan 1, Delft 2613AX, The Netherlands.
| |
Collapse
|
11
|
Bone mineralization in celiac disease. Gastroenterol Res Pract 2012; 2012:198025. [PMID: 22737164 PMCID: PMC3378976 DOI: 10.1155/2012/198025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/12/2012] [Accepted: 04/03/2012] [Indexed: 01/31/2023] Open
Abstract
Evidence indicates a well-established relationship between low bone mineral density (BMD) and celiac disease (CD), but data on the pathogenesis of bone derangement in this setting are still inconclusive. In patients with symptomatic CD, low BMD appears to be directly related to the intestinal malabsorption. Adherence to a strict gluten-free diet (GFD) will reverse the histological changes in the intestine and also the biochemical evidence of calcium malabsorption, resulting in rapid increase of BMD. Nevertheless, GFD improves BMD but does not normalize it in all patients, even after the recovery of intestinal mucosa. Other mechanisms of bone injury than calcium and vitamin D malabsorption are thought to be involved, such as proinflammatory cytokines, parathyroid function abnormalities, and misbalanced bone remodeling factors, most of all represented by the receptor activator of nuclear factor B/receptor activator of nuclear factor B-ligand/osteoprotegerin system. By means of dual-energy X-ray absorptiometry (DXA), it is now rapid and easy to obtain semiquantitative values of BMD. However, the question is still open about who and when submit to DXA evaluation in CD, in order to estimate risk of fractures. Furthermore, additional information on the role of nutritional supplements and alternative therapies is needed.
Collapse
|
12
|
Blazina S, Bratanic N, Campa AS, Blagus R, Orel R. Bone mineral density and importance of strict gluten-free diet in children and adolescents with celiac disease. Bone 2010; 47:598-603. [PMID: 20601293 DOI: 10.1016/j.bone.2010.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 05/23/2010] [Accepted: 06/10/2010] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Low bone mineral density (BMD) is common in children and adolescents with celiac disease. Strict gluten-free diet (GFD) improves bone mineralization, even in 1 year. The effect of occasional gluten intake is not known. The aims of this study were to compare BMD and prevalence of low BMD in children and adolescents on strict and not strict GFD. METHODS We measured BMD in 55 children and adolescents (strict GFD) with negative endomysium antibodies (EMA) in the last 2 years and in 19 (not strict GFD) with positive EMA at the time of the study. Lumbar, left hip and total body BMD were measured by dual-energy X-ray absorptiometry. Four-day weighted dietary protocols were obtained by means of a self-completed questionnaire of total food and beverage intake. Energy and calcium intake were calculated using nutrition data software. EMA, tissue transglutaminase antibodies, serum calcium, phosphate, 25-hydroxy vitamin D, intact parathormone, albumin, urea and creatinine levels were determined in all patients. RESULTS BMD in patients on strict GFD was significantly higher than in patients on not strict GFD (lumbar p=0.01; total body p=0.005). There were significantly more patients with total body BMD below -1.0 in not strictly compliant group (71% compared to 38%; p=0.03). Calcium intake and vitamin D levels were below recommendations in both groups. CONCLUSION Children and adolescents on not strict GFD are at increased risk for low BMD. We therefore recommend that BMD should be evaluated in patients with positive EMA. In addition, patients on strict GFD are at risk for low BMD because of low calcium intake or vitamin D deficiency. Therefore, strict GFD with recommended calcium intake and vitamin D supplementation during winter and spring should be encouraged in all children and adolescents with celiac disease.
Collapse
Affiliation(s)
- Stefan Blazina
- University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana, Slovenia.
| | | | | | | | | |
Collapse
|
13
|
Abstract
Chronic inflammation and malabsorption in celiac disease (CD) can cause bone metabolism alterations and bone mineral loss in children and adults. Bone status before and after gluten-free diet, epidemiology of fractures, and possible treatment options for CD-related osteoporosis are presented. Controversial aspects of this complication of CD are discussed. The relationship between bone derangements and celiac disease (CD) was recognized almost 50 years ago, but many questions are still open. We are now aware that osteoporosis is a relatively frequent atypical presentation of CD, especially in adults, and that undiagnosed CD can be the cause of osteoporosis and related fractures. Chronic inflammatory intestinal diseases, including CD, can affect bone and mineral metabolism because of alterations in both systemic and local regulatory factors. The pathogenetic processes are still controversial, but two main mechanisms seem to be involved: intestinal malabsorption and the presence of chronic inflammation. This review analyzes the published data on bone involvement in children, adolescents, and adults either before or after a gluten-free diet. Special attention is paid to the epidemiology of fractures in celiac patients, considering that fractures are a major complication of osteoporosis and an important problem in the management of a chronic disease like CD. The usefulness of screening osteoporotic patients systematically for CD is still an open question, but some rules can be given. Finally, the current treatment options for children and adults are discussed. Recommendations for future clinical research are proposed.
Collapse
Affiliation(s)
- M-L Bianchi
- Bone Metabolism Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy.
| | | |
Collapse
|
14
|
Abstract
OBJECTIVE To describe a patient with osteoporosis who was treated with alendronate and developed hypocalcemia, which ultimately led to the diagnosis of celiac sprue. METHODS We present the clinical and laboratory findings in a patient with osteoporosis, in whom hypocalcemia developed after treatment with alendronate. This patient was subsequently diagnosed with celiac sprue. The pertinent literature regarding orally administered bisphosphonate-induced hypocalcemia is reviewed. RESULTS A 79-year-old man who was diagnosed with osteoporosis was treated with alendronate. He was subsequently found to have asymptomatic hypocalcemia (serum calcium concentration, 8.3 mg/dL), which resolved after alendronate therapy was discontinued. He was then treated with calcium, vitamin D, and calcitonin nasal spray, which did not cause hypocalcemia. Because of his reduced bone density, however, he was subsequently referred for endocrine consultation. Evaluation at that time showed normal levels of serum calcium, phosphorus, creatinine, alkaline phosphatase, 25-hydroxyvitamin D, thyrotropin, and parathyroid hormone as well as 24-hour urine calcium excretion. An endomysial antibody titer was dramatically elevated. Upper endoscopy showed villous atrophy, and small bowel biopsy confirmed the presence of villous blunting and chronic inflammation, consistent with celiac sprue. He was treated with a gluten-free diet and then subsequently treated with orally administered risedronate, which he tolerated well without evidence of hypocalcemia. CONCLUSION To the best of our knowledge, this is the first report of orally administered bisphosphonate-induced hypocalcemia, which subsequently led to the diagnosis of previously unrecognized, otherwise asymptomatic celiac sprue. Patients with unexplained hypocalcemia should be screened for celiac sprue, even in the absence of gastrointestinal symptoms.
Collapse
Affiliation(s)
- Shon E Meek
- Division of Endocrinology, Mayo Clinic College of Medicine, Jacksonville, Florida 32224-1865, USA
| | | |
Collapse
|
15
|
Demerjian-Somogyi N, Palazzo E, Cohen-Solal M. Osteoporosis in patients with inflammatory bowel disease. Joint Bone Spine 2005; 72:354-6. [PMID: 16214067 DOI: 10.1016/j.jbspin.2004.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Accepted: 12/27/2004] [Indexed: 11/27/2022]
|
16
|
Abstract
BACKGROUND Celiac disease (CD) has a wide clinical spectrum from malabsorption syndrome to extra intestinal presentations. A total of 45 children with CD presented with mainly chronic diarrhea (n :23), anemia (n: 12), and short stature (n: 10) were evaluated in this study. The aim was to find common parameters of CD with various presentations. METHODS Basic anthropometric, biochemical and hematological parameters in cases with CD with various presentations were compared. RESULTS It was found that children with CD presenting with chronic diarrhea were younger. There was no significant difference in hemoglobin levels in children with CD presenting with anemia. Children with CD with short stature had significantly lower serum vitamin B(12) levels and lower levels of height standard deviation scores, bone age delay, and alkaline phosphatase. CONCLUSIONS It was concluded that children, especially infants with chronic diarrhea with CD, may not be affected with generalized malabsorption. Anemia and short stature are frequent findings in cases with CD whether they are main presenting symptoms or not. Children with CD presenting with short stature may have lower levels of vitamin B(12) than other presentations.
Collapse
Affiliation(s)
- Tumay Doganci
- Department of Gastroenterology, Children's Hospital, Ankara, Turkey.
| | | |
Collapse
|
17
|
Plank C, Konrad M, Dörr HG, Dötsch J. Growth failure in a girl with Fanconi syndrome and growth hormone deficiency. Nephrol Dial Transplant 2004; 19:1910-2. [PMID: 15199197 DOI: 10.1093/ndt/gfh241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christian Plank
- Klinik fur Kinder und Jugendliche, Friedrich-Alexander-University Erlangen, Erlangen, Germany
| | | | | | | |
Collapse
|
18
|
Barera G, Beccio S, Proverbio MC, Mora S. Longitudinal changes in bone metabolism and bone mineral content in children with celiac disease during consumption of a gluten-free diet. Am J Clin Nutr 2004; 79:148-54. [PMID: 14684411 DOI: 10.1093/ajcn/79.1.148] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A gluten-free diet (GFD) rapidly corrects the bone mineral deficit of children with untreated celiac disease. The mechanisms underlying such changes are still poorly understood. OBJECTIVE In a longitudinal study, we monitored changes in bone metabolism during consumption of a GFD. DESIGN We studied 22 white patients with celiac disease (11 girls) aged 10.5 +/- 1.0 y at the time of diagnosis. We compared bone metabolism and bone mass values in these patients with those in 428 healthy white children aged 11.3 +/- 0.2 y. Bone-specific alkaline phosphatase (a bone formation index) and N-terminal telopeptide of type I collagen (NTx; a bone resorption marker) were measured at the time of diagnosis and after 2, 6, and 12 mo of the GFD. Bone mineral content was measured at the lumbar spine and for the whole skeleton. RESULTS The bone mineral content of patients was significantly lower than that of control subjects at the time of diagnosis but not after 1 y of the GFD. Serum bone-specific alkaline phosphatase concentrations of patients were significantly lower than those of control subjects at the time of diagnosis (P = 0.0064) and increased gradually and significantly during the GFD (ANOVA F = 4.71; P = 0.024). Conversely, patients with untreated disease had significantly higher urinary concentrations of NTx than did healthy control subjects (P < 0.0001). Urinary concentrations of NTx were not significantly affected by treatment (P = 0.37). CONCLUSIONS The rate of bone metabolism is altered in children with untreated celiac disease, and these alterations may be the cause of osteopathy. Remarkable changes occur after the initiation of a GFD, and they result in a more balanced equilibrium.
Collapse
Affiliation(s)
- Graziano Barera
- Department of Pediatrics, Scientific Institute H San Raffaele, Milan, Italy
| | | | | | | |
Collapse
|
19
|
Affiliation(s)
- Anders Juul
- Department of Growth and Reproduction, University of Copenhagen, Blegdamsvej 9 Rigshopitalet, Section 5064, Copenhagen 2100, Denmark.
| |
Collapse
|
20
|
Magnusson P, Sharp CA, Farley JR. Different distributions of human bone alkaline phosphatase isoforms in serum and bone tissue extracts. Clin Chim Acta 2002; 325:59-70. [PMID: 12367767 DOI: 10.1016/s0009-8981(02)00248-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In vitro, bone alkaline phosphatase (BALP) is released from the osteoblast membrane with its glycosylphosphatidylinositol (GPI) anchor still attached (i.e., in an anchor-intact form); however, in vivo, BALP circulates as a variable mixture of anchorless isoforms, which can be identified by high-performance liquid chromatography (HPLC). Previous studies have shown that the relative abundance of these BALP isoforms in serum may be clinically useful for the diagnosis and management of metabolic bone disease. METHODS In the current studies, we describe a method for the determination of anchorless BALP isoforms in extracts of bone and we present novel data on the conversion of anchor-intact to anchorless BALP by incubation with endogenous circulating GPI-specific phospholipase D (GPI-PLD). RESULTS A 72-h extraction with 0.1% Triton X-100 released approximately 90% of the BALP activity from powdered bone. An average of 19% of this activity was anchorless, but essentially all of the activity could be converted to the anchorless form by incubation with partially purified GPI-PLD from human serum. Using HPLC, we detected four BALP isoforms (B/I, B1x, B1, and B2) in these GPI-PLD-treated extracts of bone. An additional BALP fraction was also detected in the samples during the initial phase of GPI-PLD treatment. CONCLUSIONS The abundance of the BALP isoforms differed between bone and serum, particularly for the B/I isoform, which comprised, on average, 18% of the BALP in GPI-PLD-treated extracts of healthy bone tissue, but only 6% of the total BALP activity in serum from healthy individuals. Based on our recent finding of differences in the number of sialic acid residues between the BALP isoforms, we hypothesize that this difference between BALP isoforms in serum and extracts of bone is due to the different patterns of glycosylation, which results in different biological half-lives in the circulation. A preliminary application of our method to the extraction of BALP isoforms from a small number of human bone samples suggests that the method should be useful for studies of human skeletal site-specific and metabolic bone disease-specific differences in the amounts and distributions of the BALP isoforms in bone.
Collapse
Affiliation(s)
- Per Magnusson
- Department of Biomedicine and Surgery, Bone and Mineral Metabolic Unit, Division of Clinical Chemistry, Linköping University Hospital, SE-581-85 Linköping, Sweden.
| | | | | |
Collapse
|