Genetic landscape of pediatric acute liver failure of indeterminate origin

BACKGROUND AND AIMS

Pediatric acute liver failure (PALF) is a life-threatening condition. In Europe, the main causes are viral infections (12%-16%) and inherited metabolic diseases (14%-28%). Yet, in up to 50% of cases the underlying etiology remains elusive, challenging clinical management, including liver transplantation. We systematically studied indeterminate PALF cases referred for genetic evaluation by whole-exome sequencing (WES), and analyzed phenotypic and biochemical markers, and the diagnostic yield of WES in this condition.

APPROACH AND RESULTS

With this international, multicenter observational study, patients (0-18 y) with indeterminate PALF were analyzed by WES. Data on the clinical and biochemical phenotype were retrieved and systematically analyzed.

RESULTS

In total, 260 indeterminate PALF patients from 19 countries were recruited between 2011 and 2022, of whom 59 had recurrent PALF. WES established a genetic diagnosis in 37% of cases (97/260). Diagnostic yield was highest in children with PALF in the first year of life (41%), and in children with recurrent acute liver failure (64%). Thirty-six distinct disease genes were identified. Defects in NBAS (n=20), MPV17 (n=8), and DGUOK (n=7) were the most frequent findings. When categorizing, the most frequent were mitochondrial diseases (45%), disorders of vesicular trafficking (28%), and cytosolic aminoacyl-tRNA synthetase deficiencies (10%). One-third of patients had a fatal outcome. Fifty-six patients received liver transplantation.

CONCLUSIONS

This study elucidates a large contribution of genetic causes in PALF of indeterminate origin with an increasing spectrum of disease entities. The high proportion of diagnosed cases and potential treatment implications argue for exome or in future rapid genome sequencing in PALF diagnostics.

Inflammatory fibroid polyp of the anus in a 12-month-old girl: Case report and review of the literature

Inflammatory fibroid polyp (IFP) is a rare, usually solitary and intraluminal polypoid benign tumour that can affect any part of the gastrointestinal (GI) tract. Its aetiology is unknown and clinical presentation depends on the site of involvement. We present the case of a 12-month-old girl with IFP and review all reported cases of IFP in children and adolescents <18 years. A 12-month-old girl presented with rectal bleeding. The patient underwent colonoscopy which revealed an anus polyp. Surgical resection was performed and histopathological examination of the specimen showed features of IFP. A literature review of 20 cases (including ours) between 1966 and January 2022 is also presented. To our knowledge, this is the youngest reported patient with IFP and the first in the anal area.

Changes in Shear Wave Elastography after Lumacaftor/Ivacaftor Treatment in Children with Cystic Fibrosis

BACKGROUND

Lumacaftor/Ivacaftor (LUM/IVA) is an approved combination therapy for cystic fibrosis (CF) patients homozygous for F508del.

OBJECTIVE

This study aimed to detect changes in liver stiffness measurement (LSM) in patients under this treatment.

METHODS

The study population consisted of CF patients homozygous for F508del, 6 to 11 years old, who had been treated for six months with LUM/IVA. Shear wave elastography (SWE) was performed in all of them, before and 6 months after the commencement of treatment.

RESULTS

Thirty-one patients were included in the study. LSM values after treatment were significantly higher than the values before treatment (medians and interquartile ranges of LSM values before and after treatment: 5.6, 5.3-6.3 kPa and, 6.4, 6.0-7.6 kPa, respectively, p<0.001).

CONCLUSION

SWE can detect early changes in LSM in some CF patients treated with LUM/IVA.

Seroprevalence of Hepatitis C in Children Without Identifiable Risk-Factors: A Systematic Review and Meta-Analysis

OBJECTIVES

Hepatitis C virus (HCV) remains a major public health burden for >30 years since its discovery. It is estimated that >80 million people have been already infected. Direct-acting antiviral (DAA) treatment is now approved for young children over the age of 3 years. Treating children before the development of high-risk behaviors is optimal. Thus, assessing the current epidemiology of HCV in children becomes important and may promote awareness.

METHODS

Articles describing the prevalence of hepatitis C in children, were systematically reviewed. To assess HCV infection prevalence in the general population, studies discussing high-risk groups alone were excluded.

RESULTS

Data from 58 studies were analyzed. National data was scarce. An overall prevalence of HCV in children of 0.87% was found, ranging from 0.34% in Europe to 3.02% in Africa. Prevalence of viremic infection is important and data synthesis from available data indicated that HCV viremia was detected in 56.8% of children. The prevalence of HCV according to sex was described in 25 studies but no difference between sexes was detected. HCV prevalence was significantly higher in children older than 10 years (0.97%) when compared to those ages under 10 years old (0.75%, P < 0.001).

CONCLUSIONS

Considering probable underdiagnosis of HCV infection in children, this information reveals that prevalence is substantial. One may argue that future strategies aiming towards HCV elimination, may need to include antiviral treatment of pre-adolescent children as well.

PlGF and sFlt-1 levels in patients with non-transfusion-dependent thalassemia: Correlations with markers of iron burden and endothelial dysfunction

BACKGROUND

Levels of the angiogenic cytokines placental growth factor (PlGF) and soluble Fms-like tyrosine kinase-1 (sFlt-1) and the angiogenic balance, expressed by sFlt-1/PlGF ratio, are perturbed in sickle-cell disease and iron overload, but they have not been evaluated in non-transfusion-dependent thalassemia (NTDT).

PATIENTS AND METHODS

We measured levels of PlGF, sFlt-1 and vWF:antigen in patients with NTDT of beta-thalassemia genotype, and correlated them with erythrocytic indices and markers of iron overload, inflammation, and tissue hypoxia. Thirty-four NTDT patients with mean hemoglobin level of 8.4 g/dL were included in the study along with 20 apparently healthy individuals who served as controls.

RESULTS

Ferritin, LDH, and hs-CRP were higher in patients as compared to controls. We found significant differences between patients and controls in regard to levels of PlGF (52.2 vs 17.2 pg/mL, P < .001), sFlt-1/PlGF (2 vs 4.7, P < .001), and vWF:antigen (88 vs 77.1 IU/dL, P < .01). There was a strong correlation of ferritin with PlGF (r = .653, P < .001) and with vWF:antigen (r = .503, P = .003).

CONCLUSIONS

In this study, we demonstrated an association between increased PlGF and iron overload and the degree of tissue hypoxia in patients with NTDT. High vWF:antigen expressing endothelial damage may be associated with specific NTDT comorbidities.

Plasma neutrophil gelatinase-associated lipocalin levels are markedly increased in patients with non-transfusion-dependent thalassemia: Lack of association with markers of erythropoiesis, iron metabolism and renal function

BACKGROUND

Neutrophil Gelatinase-Associated Lipocalin (NGAL) (known as NGAL, Lipocalin 2, Siderocalin, Uterocalin, proteinase-3 and 24p3) is a mammalian small 25-kD peptide that belongs to the lipocalin superfamily, which consists of about 20 small lipoproteins. NGAL was initially discovered as an antibacterial factor of natural immunity and an acute-phase protein. NGAL is also an iron trafficking protein, a member of the non-transferrin-bound iron (NTBI) pool and an alternative to the transferrin-mediated iron-delivery pathway. Of note, NTBI, which is elevated in thalassemic patients, induces cellular toxicity. In this study we investigated the possible association of NGAL with parameters of erythropoiesis, iron metabolism and renal injury in patients with non-transfusion-dependent thalassemia (thalassemia intermedia or TI).

PATIENTS AND METHODS

Thirty-five patients with TI, 13 men and 22 women, aged 8-63 years, were included in the study, while, 20 healthy individuals served as controls. Plasma NGAL levels were determined using an immunoenzymatic technique. Erythroid marrow activity was estimated by measuring soluble transferrin receptors (sTfR) levels with a turbidimetric technique. NTBI levels were determined using electrothermal atomic absorption spectrometry. Cystatin C, β2-microglobulin and hs-CRP concentrations were measured by means of immunonephelometric techniques.

RESULTS

The main results of the study showed: a) NGAL levels were significantly higher in patients with TI compared to controls (139.1 ± 86.1 vs 51.2 ± 11.8 μg/L, p<0.0001), without significant effect of splenectomy or hydroxyurea on NGAL levels. Only 4 patients had NGAL levels within the control group range, b) no correlation was found between NGAL levels and either the parameters of erythropoiesis Hb, Hb F, reticulocytes and sTfR (p>0.66, p>0.67, p>0.63 and p>0.81 respectively), or with those of iron metabolism ferritin and NTBI (p>0.90 and p>0.95 respectively).

CONCLUSIONS

The increased NGAL levels reported for the first time in TI patients in this study are in agreement with the elevated expression of NGAL observed in TI mouse models. We postulate that the induction of NGAL in these patients may represent either a survival response, facilitating the survival of the less damaged thalassemic erythroid precursors, or a consequence of the abnormal iron regulation in TI.

Use of therapeutic surfactant lavage in a preterm infant with massive pulmonary hemorrhage

We report a case of a premature infant presenting with recurrent pulmonary hemorrhage in which we performed a therapeutic lavage with diluted surfactant after an acute episode of bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10×2 mL) allowed rapid improvement in oxygenation and reduction of required mean airway pressures during high frequency oscillatory ventilation. This observation may suggest that surfactant lavage could be beneficial in massive pulmonary hemorrhage in infants. A randomized controlled trial might be needed to clarify the potential benefit of this therapeutic intervention on outcome of infants suffering from this life-threatening complication.

Adhesion molecules and high-sensitivity C-reactive protein levels in patients with sickle cell beta-thalassaemia

BACKGROUND AND AIM

  The primary symptoms of sickle cell disease (SCD) arise from vaso-occlusive crises. The pathogenesis of these crises is complex phenomenon where endothelial activation and damage has a major role. Chronic inflammation also plays an important role in the pathophysiology of SCD. We aimed to investigate endothelial activation in Caucasian Greek patients with SCD by means of measuring adhesion molecules and markers of inflammation.

SUBJECTS AND METHODS

Twenty-eight patients with SCD aged 5-63 years were included in the study. Most of the patients (23/28) were double heterozygotes for sickle cell/beta-thalassaemia, while five patients (5/28) were sickle cell homozygotes. Patients were treated with one/or more of hydroxyurea, therapeutic phlebotomies, blood transfusion or splenectomy. Twenty apparently healthy individuals matched for age and sex formed the control group. Measurements of soluble intercellular adhesion molecule-1, (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), P-selectin, E-selectin, soluble thrombomodulin (sTM) and high-sensitivity C-reactive protein (hs-CRP) levels were performed using immunoassays in both patients and healthy individuals.

RESULTS

We found that all endothelial adhesion molecules and hs-CRP were significantly increased (P < 0·001) in patients with SCD compared with controls, while sTM levels did not differ significantly (P > 0·05) and this increase was not influenced by the treatment.

CONCLUSION

Our findings demonstrate the high degree of endothelial activation and damage seen in sickle cell patients even in steady-state condition, as well as the important chronic inflammation underlying the pathophysiology of this widespread disease.

Changes in free radical generation and antioxidant capacity during ultramarathon foot race

BACKGROUND

Exhaustive exercise has been implicated in the generation of reactive oxygen species, resulting in oxidative stress. We studied the effect of a long-distance, endurance exercise on oxidative stress parameters in athletes who participated in the ultramarathon race Spartathlon (246 km).

MATERIALS AND METHODS

This study included 18 runners (16 men and 2 women) aged 42.8 +/- 1.4 years. Blood samples were obtained 24 h before (prerace), at the end (postrace) and 48 h after the end of the race (48 h postrace). We measured oxidative stress indices, including red cell glutathione, malonyldialdehyde and 8-iso-prostaglandin F(2a), as well as the total antioxidant capacity.

RESULTS

8-Iso-prostaglandin F(2a) level increased significantly at the end of the race, compared to prerace levels (up to 914.7 +/- 61.4 pg mL(-1) from 197.6 +/- 8.4 pg mL(-1)), and remained 2.5-fold increased over the baseline 48 h after the race (532.0 +/- 54.2 pg mL(-1), P < 0.000). The total antioxidant capacity of the athletes increased from a baseline of 289.6 +/- 9.0 micromol L(-1) to 358.7 +/- 11.0 micromol L(-1) immediately after the race and remained elevated 48 h later (350.6 +/- 7.6 micromol L(-1)) (P < 0.001).

CONCLUSIONS

Prolonged exercise induces a marked response of oxidative stress biomarkers, which in part is compensated by serum ability to scavenge free radicals. Whether these changes have long-term negative effects in the organism needs further investigation.

Observation of a rare hemoglobin variant [Hb Lulu island, beta107(G9)Gly-->Asp, GGC-->GAC] co-inherited with a beta+-thalassemia mutation [IVS-I-110 (G-->A)] or in the heterozygous state in a Greek-Albanian family

We report clinical, hematological, biochemical, functional and molecular studies carried out on two first cousins from a Greek-Albanian family who have clinical and hematological findings consistent with the diagnosis of thalassemia intermedia. DNA studies determined that they had co-inherited a common Mediterranean beta-thalassemia (thal) mutation, IVS-I-110 (G-->A), in trans to a beta-globin gene mutation at codon 107 (GGC-->GAC), predicted to give rise to a rare unstable beta chain variant Hb Lulu Island or beta107(G9)Gly-->Asp.

Lipids, Lipoproteins, Apolipoproteins, Selected Trace Elements and Minerals in the Serum of Children on Valproic Acid Monotherapy

We evaluated the serum levels of lipids, lipoproteins, apolipoproteins, along with a number of minerals and trace elements such as Ca, Mg, Cu and Zn in a group of children after 6 months of valproic acid monotherapy. Thirty patients with seizures, mean age, 9.8+/-2.6 years and 79 healthy children (controls), mean age, 10.9+/-3.2 years, formed the two styd groups. The patient group was treated with valproic acid (27.9+/-14.8 mg/kg/24 hr). Patients underwent clinical and laboratory evaluations including liver function tests, NH3, lipid, mineral and selected trace element levels before and after six months on valproic acid treatment, whereas controls only one evaluation. Liver function data and NH3 levels were found to be elevated in the group of patients, whereas albumin level was reduced. Triglycerides, total cholesterol, HDL-C, apolipoprotein (ApoA)-1, Apo B and Ca concentrations were found relative to control values, LDL-C, VLDL-C, Mg, Cu, Zn, were measured significantly altered (P<0.0001) compared to controls. The ratios ApoA-1/ApoB, HDL-C/ApoA-1, LDL-C/Apo B, which were closely related to the size of LDL particles, where correlated with Zn/Cu (P<0.001). Serum lipid profile, especially LDL size, indirectly evaluated for the first time and metal levels were found to be significantly changed, after six months on valproic acid monotherapy, suggesting a possible risk of developing coronary heart disease. Since valproic acid is a long-term treatment, it could be recommended that the incorporation of measurements of lipids, lipoproteins, apolipoproteins and trace elements in the "follow up" laboratory testing could be a preventive measure.