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Abstract
Hypertriglyceridemia is increasingly identified in children and adolescents, owing to improved screening and higher prevalence of childhood obesity. Hypertriglyceridemia can result from either increased triglyceride (TG) production or reduced TG clearance. The etiologic origin can be primary (genetic) or secondary, but it is often multifactorial. Management is challenging because of the interplay of genetic and secondary causes and lack of evidence-based guidelines. Lifestyle changes and dietary interventions are most important, especially in hypertriglyceridemia associated with obesity. Dietary restriction of fat remains the mainstay of management in primary hypertriglyceridemia. When fasting TG concentration is increased above 500 mg/dL (5.65 mmol/L), fibrates may be used to prevent pancreatitis. Omega-3 fatty acids are often used as an adjunctive therapy. When the fasting TG concentration is less than 500 mg/dL (5.65 mmol/L) and if the non-high-density lipoprotein cholesterol level is above 145 mg/dL (3.76 mmol/L), statin treatment can be considered.
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Affiliation(s)
- Badhma Valaiyapathi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Bhuvana Sunil
- Department of Pediatrics, Harlem Hospital Center, New York, NY
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL
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Abstract
An 11-year-old girl presented with palmar and tuberoeruptive xanthomas, and elevated triglycerides and total cholesterol levels. She had an apolipoprotein E2/E2 genotype. A diagnosis of type III dyslipidaemia was made and the patient started on niacin, fenofibrate and salmon oil. At age 18, her lipid levels were well controlled with fenofibrate once weekly. At age 21, the fenofibrate was discontinued and her lipid profile has been normal for the last 4 years. This case history may be consistent with a transient dyslipidaemia.
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Ashraf AP, Beukelman T, Pruneta-Deloche V, Kelly DR, Garg A. Type 1 hyperlipoproteinemia and recurrent acute pancreatitis due to lipoprotein lipase antibody in a young girl with Sjogren's syndrome. J Clin Endocrinol Metab 2011; 96:3302-7. [PMID: 21880794 PMCID: PMC3205898 DOI: 10.1210/jc.2011-1113] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Type 1 hyperlipoproteinemia (T1HLP) in childhood is most often due to genetic deficiency of lipoprotein lipase (LPL) or other related proteins. OBJECTIVE The aim was to report a case of marked hypertriglyceridemia and recurrent acute pancreatitis due to the presence of LPL autoantibody in a young girl who was subsequently diagnosed with Sjögren's syndrome. SUBJECT AND METHODS A 9-yr-old African-American girl presented with acute pancreatitis and serum triglycerides of 4784 mg/dl. Strict restriction of dietary fat reduced serum triglycerides, but she continued to experience recurrent pancreatitis. Approximately 18 months thereafter, she developed transient pauciarticular arthritis with elevated serum antinuclear antibody (>1:1280). Minor salivary gland biopsy revealed chronic sialadenitis with a dense periductal lymphocytic aggregate suggestive of Sjögren's syndrome. Genomic DNA was analyzed for LPL, GPIHBP1, APOA5, APOC2, and LMF1. Immunoblotting was performed to detect serum LPL autoantibody. RESULTS The patient had no disease-causing variants in LPL, GPIHBP1, APOA5, APOC2, or LMF1. Immunoblotting revealed serum LPL antibody. The patient responded to immunosuppressive therapy for Sjögren's syndrome with resolution of hypertriglyceridemia. CONCLUSIONS Unexplained T1HLP in childhood could be secondary to LPL deficiency induced by autoantibodies. Therefore, diagnosis of autoimmune T1HLP should be entertained if clinical features are suggestive of an autoimmune process.
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Affiliation(s)
- Ambika P Ashraf
- Division of Pediatric Endocrinology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, Goldberg AC, Howard WJ, Jacobson MS, Kris-Etherton PM, Lennie TA, Levi M, Mazzone T, Pennathur S. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2011; 123:2292-333. [PMID: 21502576 DOI: 10.1161/cir.0b013e3182160726] [Citation(s) in RCA: 1241] [Impact Index Per Article: 95.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fujita K, Maeda N, Kozawa J, Murano K, Okita K, Iwahashi H, Kihara S, Ishigami M, Omura M, Nakamura T, Shirai K, Yamamura T, Funahashi T, Shimomura I. A case of adolescent hyperlipoproteinemia with xanthoma and acute pancreatitis, associated with decreased activities of lipoprotein lipase and hepatic triglyceride lipase. Intern Med 2010; 49:2467-72. [PMID: 21088351 DOI: 10.2169/internalmedicine.49.4058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Lipoprotein lipase (LPL) and hepatic triglyceride lipase (HTGL) enhance the hydrolysis of triglycerides (TG) transported by chylomicron (CM) and very-low-density lipoprotein (VLDL). We report a case of severe hyperchylomicronemia with high levels of remnant lipoprotein and total cholesterol (T-Chol) in a 15-year-old boy. Precise examination of the lipid profile showed decreased activities of both LPL and HTGL, although the protein mass for LPL and HTGL were maintained. In addition, bezafibrate treatment effectively ameliorated hypertriglyceridemia in this case. This is the first case of hyperchylomicronemia with decreased activities and unaffected protein masses for both LPL and HTGL, without overt immuno-dysfunction.
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Affiliation(s)
- Koichi Fujita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Nagasaka H, Kikuta H, Chiba H, Murano T, Harashima H, Ohtake A, Senzaki H, Sasaki N, Inoue I, Katayama S, Shirai K, Kobayashi K. Two cases with transient lipoprotein lipase (LPL) activity impairment: evidence for the possible involvement of an LPL inhibitor. Eur J Pediatr 2003; 162:132-138. [PMID: 12655414 DOI: 10.1007/s00431-002-1133-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2002] [Accepted: 10/30/2002] [Indexed: 11/29/2022]
Abstract
UNLABELLED Two independent severe hypertriglyceridemic infants with transiently impaired lipoprotein lipase (LPL) activity were observed and the causes were explored. Both infants were female, born prematurely with low birth weight and developed hypertriglyceridemia (Fredrickson type V hyperlipidemia: high VLDL and low LDL/HDL) a few months after birth. While mass levels of their post-heparin plasma LPL and apoprotein C-II (apo C-II), a physiological activator of LPL, were normal, their post-heparin plasma LPL activities were remarkably impaired. Both of their mothers' post-heparin plasma LPL activities were slightly or moderately impaired as well, without a decrease in the LPL mass level. No mutations in the genes for LPL and apo C-II were detected in either patient. In an in vitro study with their serum at onset, we could not detect any distinct circulating inhibitors for LPL. There was no data supporting infection or autoimmune diseases, which might have an impact on LPL activity, during the follow-up period. Levels of their plasma triglyceride (TG) and total cholesterol (TC) were decreased quickly by a dietary intervention with medium-chain triglyceride (MCT) milk and kept normal even after stopping the intervention at around age 1 year. However, their low post-heparin LPL activity persisted and returned to normal at around age 2 years. Their low HDL cholesterol levels persisted even after recovery of the TG and TC levels, although lecithin:cholesterol acyltransferase (LCAT) and cholesterol-ester-transfer protein (CETP), two key enzymes of HDL metabolism, were normal throughout the course. The exact reasons why their post-heparin LPL activities were impaired for a certain period and why their HDL cholesterol levels have remained low are still unclear. CONCLUSION Transiently impaired LPL activity with no defect in LPL enzyme induced severe hypertriglyceridemia in infants. The transient occurrence of inhibitor(s) for LPL was proposed.
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Affiliation(s)
- H Nagasaka
- Department of Pediatrics, Hokkaido University School of Medicine, Kita-ku N. 15 W.7, 060-8638, Sapporo, Japan.
- Department of Pediatrics, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan.
| | - H Kikuta
- Department of Pediatrics, Hokkaido University School of Medicine, Kita-ku N. 15 W.7, 060-8638, Sapporo, Japan
| | - H Chiba
- Department of Clinical Laboratory, Hokkaido University Hospital, 060-8648, Sapporo, Japan
| | - T Murano
- Department of Laboratory Medicine, Toho University Sakura Hospital, Sakura, Sakura City, 285-0841, Chiba, Japan
| | - H Harashima
- Department of Pediatrics, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - A Ohtake
- Department of Pediatrics, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - H Senzaki
- Department of Pediatrics, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - N Sasaki
- Department of Pediatrics, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - I Inoue
- Fourth Department of Internal Medicine, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - S Katayama
- Fourth Department of Internal Medicine, Saitama Medical College, Moroyama-cho, 350-0495, Saitama, Japan
| | - K Shirai
- Department of Laboratory Medicine, Toho University Sakura Hospital, Sakura, Sakura City, 285-0841, Chiba, Japan
| | - K Kobayashi
- Department of Pediatrics, Hokkaido University School of Medicine, Kita-ku N. 15 W.7, 060-8638, Sapporo, Japan
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