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Farrell PR, DesPain AW, Farmer P, Farrell LM, Greenfield B, Rogers ME, Hornung L, Kim E, Pearman R, Neway B, Thompson T, Heubi JE, Sehgal S, Amoury R, Abu-El-Haija M. Faster discharge with lactated ringers than normal saline in first 72 h of acute pancreatitis: A multicenter randomized trial. J Pediatr Gastroenterol Nutr 2024; 78:360-368. [PMID: 38374568 PMCID: PMC10883603 DOI: 10.1002/jpn3.12082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 11/02/2023] [Accepted: 11/21/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS. STUDY DESIGN A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP). RESULTS We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02). CONCLUSION The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs.
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Affiliation(s)
- Peter R Farrell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Angelica W DesPain
- Division of Emergency Medicine, The Children's Hospital of San Antonio, San Antonio, Texas, USA
| | - Peter Farmer
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leslie M Farrell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bryan Greenfield
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Emergency Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Michael E Rogers
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Esther Kim
- Division of Critical Care Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Ryan Pearman
- Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
| | - Beemnet Neway
- Department of Pediatrics, NewYork Presbyterian-Weill Cornell Medical Center, New York City, New York, USA
| | - Tyler Thompson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James E Heubi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sona Sehgal
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Health System, Washington, District of Columbia, USA
| | - Rana Amoury
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of the King's Daughters, Children's Specialty Group, Norfolk, Virginia, USA
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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2
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Kamath BM, Alonso EM, Heubi JE, Karpen SJ, Sundaram SS, Shneider BL, Sokol RJ. Fat Soluble Vitamin Assessment and Supplementation in Cholestasis. Clin Liver Dis 2022; 26:537-553. [PMID: 35868689 DOI: 10.1016/j.cld.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Malnutrition in children with chronic cholestasis is a prevalent issue and a major risk factor for adverse outcomes. Fat soluble vitamin (FSV) deficiency is an integral feature of cholestatic disease in children, often occurring within the first months of life in those with neonatal cholestasis and malnutrition. This review focuses on FSVs in cholestasis, with particular emphasis on a practical approach to surveillance and supplementation that includes approaches that account for differing local resources. The overarching strategy suggested is to incorporate recognition of FSV deficiencies in cholestatic children in order to develop practical plans for close monitoring and aggressive FSV repletion. Routine attention to FSV assessment and supplementation in cholestatic infants will reduce long periods of inadequate levels and subsequent adverse clinical sequalae.
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Affiliation(s)
- Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; University of Toronto, Canada
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Siragusa Transplant Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue Box 57, Chicago, IL 60611, USA
| | - James E Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Center for Clinical and Translational Science and Training, University of Cincinnati/Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
| | - Saul J Karpen
- Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1760 Haygood Drive Northeast, HSRB E204, Atlanta, GA 30322, USA
| | - Shikha S Sundaram
- Pediatric Liver Transplant Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, University of Colorado School of Medicine, Children's Hospital Colorado, Box B290, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Benjamin L Shneider
- Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Colorado Clinical and Translational Sciences Institute, University of Colorado Denver, University of Colorado School of Medicine, Children's Hospital Colorado, Box B290, 13123 East 16th Avenue, Aurora, CO 80045, USA
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3
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Leung DH, Sorensen LG, Ye W, Hawthorne K, Ng VL, Loomes KM, Fredericks EM, Alonso EM, Heubi JE, Horslen SP, Karpen SJ, Molleston JP, Rosenthal P, Sokol RJ, Squires RH, Wang KS, Kamath BM, Magee JC. Neurodevelopmental Outcomes in Children With Inherited Liver Disease and Native Liver. J Pediatr Gastroenterol Nutr 2022; 74:96-103. [PMID: 34694263 PMCID: PMC8673857 DOI: 10.1097/mpg.0000000000003337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate neurodevelopmental status among children with inherited cholestatic liver diseases with native liver and variables predictive of impairment. METHODS Participants with Alagille syndrome (ALGS), progressive familial intrahepatic cholestasis (PFIC), and alpha 1 antitrypsin deficiency (A1AT) enrolled in a longitudinal, multicenter study and completed the Wechsler Preschool and Primary Scale of Intelligence-III or Intelligence Scale for Children-IV. Full Scale Intelligence Quotient (FSIQ) was analyzed continuously and categorically (>100, 85-99, 70-84, <70). Univariate linear regression was performed to study association between FSIQ and risk factors, stratified by disease. RESULTS Two hundred and fifteen completed testing (ALGS n = 70, PFIC n = 43, A1AT n = 102); median age was 7.6 years (3.0-16.9). Mean FSIQ in ALGS was lower than A1AT (94 vs 101, P = 0.01). Frequency of FSIQ < 85 (>1 standard deviation [SD] below average) was highest in ALGS (29%) versus 18.6% in PFIC and 12.8% in A1AT, and was greater than expected in ALGS based on normal distribution (29% vs 15.9%, P = 0.003). ALGS scored significantly lower than test norms in almost all Wechsler composites; A1AT scored lower on Working Memory and Processing Speed; PFIC was not different from test norms. Total bilirubin, alkaline phosphatase, albumin, hemoglobin, and parental education were significantly associated with FSIQ. CONCLUSIONS Patients with ALGS are at increased risk of lower FSIQ, whereas our data suggest A1AT and PFIC are not. A1AT and ALGS appear vulnerable to working memory and processing speed deficits suggestive of attention/executive function impairment. Malnutrition, liver disease severity, and sociodemographic factors appear related to FSIQ deficits, potentially identifying targets for early interventions.
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Affiliation(s)
- Daniel H. Leung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lisa G. Sorensen
- Department of Child & Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Wen Ye
- Department of Biostatistics, University of Michigan
| | | | - Vicky L. Ng
- Transplant and Regenerative Medicine Center, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Emily M. Fredericks
- CS Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Estella M. Alonso
- Ann and Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL
| | - James E. Heubi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Simon P. Horslen
- Division of Gastroenterology and Hepatology, Seattle Children's, Seattle, WA
| | - Saul J. Karpen
- Pediatrics, Emory University, Children's Healthcare Atlanta, Atlanta, GA
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, IN
| | - Philip Rosenthal
- Pediatrics and Surgery, University of California San Francisco, San Francisco, CA
| | - Ronald J. Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | | | | | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John C. Magee
- Surgery, University of Michigan School of Medicine, Ann Arbor, MI
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4
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Zhao J, Setchell KDR, Gong Y, Sun Y, Zhang P, Heubi JE, Fang L, Lu Y, Xie X, Gong J, Wang JS. Genetic spectrum and clinical characteristics of 3β-hydroxy-Δ 5-C 27-steroid oxidoreductase (HSD3B7) deficiency in China. Orphanet J Rare Dis 2021; 16:417. [PMID: 34627351 PMCID: PMC8501698 DOI: 10.1186/s13023-021-02041-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/19/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Biallelic variants in HSD3B7 cause 3β-hydroxy-Δ5-C27-steroid oxidoreductase (HSD3B7) deficiency, a life-threatening but treatable liver disease. The goal of this study was to obtain detailed information on the correlation between the genotype and phenotype of HSD3B7 deficiency and to report on responses to primary bile acid therapy. METHODS The medical records of a cohort of 39 unrelated patients with genetically and biochemically confirmed HSD3B7 deficiency were examined to determine whether there exist genotype-phenotype relationships in this bile acid synthesis disorder. RESULTS In all, 34 of the 44 variants identified in HSD3B7 were novel. A total of 32 patients presented early with neonatal cholestasis, and 7 presented after 1-year of age with liver failure (n = 1), liver cirrhosis (n = 3), cholestasis (n = 1), renal cysts and abnormal liver biochemistries (n = 1), and coagulopathy from vitamin K1 deficiency and abnormal liver biochemistries (n = 1). Renal lesions, including renal cysts, renal stones, calcium deposition and renal enlargement were observed in 10 of 35 patients. Thirty-three patients were treated with oral chenodeoxycholic acid (CDCA) resulting in normalization of liver biochemistries in 24, while 2 showed a significant clinical improvement, and 7 underwent liver transplantation or died. Remarkably, renal lesions in 6 patients resolved after CDCA treatment, or liver transplantation. There were no significant correlations between genotype and clinical outcomes. CONCLUSIONS In what is the largest cohort of patients with HSD3B7 deficiency thus far studied, renal lesions were a notable clinical feature of HSD3B7 deficiency and these were resolved with suppression of atypical bile acids by oral CDCA administration.
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Affiliation(s)
- Jing Zhao
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Kenneth D R Setchell
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ying Gong
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, China
| | - Yinghua Sun
- Department of Ultrasonography, Children's Hospital of Fudan University, Shanghai, China
| | - Ping Zhang
- Center for Molecular Medicine, Pediatrics Research Institute, Children's Hospital of Fudan University, Shanghai, China
| | - James E Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lingjuan Fang
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Yi Lu
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Xinbao Xie
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Jingyu Gong
- Department of Pediatrics, Jinshan Hospital of Fudan University, Shanghai, China
| | - Jian-She Wang
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
- Shanghai Key Laboratory of Birth Defect, Shanghai, China.
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5
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Hertel PM, Bull LN, Thompson RJ, Goodrich NP, Ye W, Magee JC, Squires RH, Bass LM, Heubi JE, Kim GE, Ranganathan S, Schwarz KB, Bozic MA, Horslen SP, Clifton MS, Turmelle YP, Suchy FJ, Superina RA, Wang KS, Loomes KM, Kamath BM, Sokol RJ, Shneider BL. Mutation Analysis and Disease Features at Presentation in a Multi-Center Cohort of Children With Monogenic Cholestasis. J Pediatr Gastroenterol Nutr 2021; 73:169-177. [PMID: 34016879 PMCID: PMC8373673 DOI: 10.1097/mpg.0000000000003153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To advance our understanding of monogenic forms of intrahepatic cholestasis. METHODS Analyses included participants with pathogenic biallelic mutations in adenosine triphosphate (ATP)-binding cassette subfamily B member 11 (ABCB11) (bile salt export pump; BSEP) or adenosine triphosphatase (ATPase) phospholipid transporting 8B1 (ATP8B1) (familial intrahepatic cholestasis; FIC1), or those with monoallelic or biallelic mutations in adenosine triphosphate (ATP)-binding cassette subfamily B member 4 (ABCB4) (multidrug resistance; MDR3), prospectively enrolled in the Longitudinal Study of Genetic Causes of Intrahepatic Cholestasis (LOGIC; NCT00571272) between November 2007 and December 2013. Summary statistics were calculated to describe baseline demographics, history, anthropometrics, laboratory values, and mutation data. RESULTS Ninety-eight participants with FIC1 (n = 26), BSEP (n = 53, including 8 with biallelic truncating mutations [severe] and 10 with p.E297G or p.D482G [mild]), or MDR3 (n = 19, including four monoallelic) deficiency were analyzed. Thirty-five had a surgical interruption of the enterohepatic circulation (sEHC), including 10 who underwent liver transplant (LT) after sEHC. Onset of symptoms occurred by age 2 years in most with FIC1 and BSEP deficiency, but was later and more variable for MDR3. Pruritus was nearly universal in FIC1 and BSEP deficiency. In participants with native liver, failure to thrive was common in FIC1 deficiency, high ALT was common in BSEP deficiency, and thrombocytopenia was common in MDR3 deficiency. sEHC was successful after more than 1 year in 7 of 19 participants with FIC1 and BSEP deficiency. History of LT was most common in BSEP deficiency. Of 102 mutations identified, 43 were not previously reported. CONCLUSIONS In this cohort, BSEP deficiency appears to be correlated with a more severe disease course. Genotype-phenotype correlations in these diseases are not straightforward and will require the study of larger cohorts.
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Affiliation(s)
- Paula M. Hertel
- Texas Children’s Hospital, Baylor College of Medicine, Houston TX
| | - Laura N. Bull
- University of California, San Francisco, San Francisco CA
| | | | | | - Wen Ye
- University of Michigan Hospitals and Health Centers, Ann Arbor MI
| | - John C. Magee
- University of Michigan Hospitals and Health Centers, Ann Arbor MI
| | | | - Lee M. Bass
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago IL
| | - James E. Heubi
- Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Grace E. Kim
- University of California, San Francisco, San Francisco CA
| | | | | | - Molly A. Bozic
- Indiana University-Riley Hospital for Children, Indianapolis IN
| | | | | | | | - Frederick J. Suchy
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora CO
| | | | - Kasper S. Wang
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles CA
| | | | | | - Ronald J. Sokol
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora CO
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6
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Teckman J, Rosenthal P, Hawthorne K, Spino C, Bass LM, Murray KF, Kerkar N, Magee JC, Karpen S, Heubi JE, Molleston JP, Squires RH, Kamath BM, Guthery SL, Loomes KM, Sherker AH, Sokol RJ. Longitudinal Outcomes in Young Patients with Alpha-1-Antitrypsin Deficiency with Native Liver Reveal that Neonatal Cholestasis is a Poor Predictor of Future Portal Hypertension. J Pediatr 2020; 227:81-86.e4. [PMID: 32663593 PMCID: PMC7686087 DOI: 10.1016/j.jpeds.2020.07.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To identify predictors of portal hypertension, liver transplantation, and death in North American youth with alpha-1-antitrypsin (AAT) deficiency, and compare with patients with AAT deficiency elsewhere. STUDY DESIGN The Childhood Liver Disease Research Network Longitudinal Observational Study of Genetic Causes of Intrahepatic Cholestasis is a prospective, cohort study of pediatric cholestatic liver diseases, including AAT deficiency, enrolling PIZZ and PISZ subjects 0-25 years of age seen since November 2007 at 17 tertiary care centers in the US and Canada. Data from standard-of-care baseline and annual follow-up visits were recorded from medical records, history, physical examination, and laboratory studies. Participants with portal hypertension were identified based on data collected. RESULTS We enrolled 350 participants (60% male) with a native liver; 278 (79%) entered the cohort without portal hypertension and 18 developed portal hypertension during follow-up. Thirty participants required liver transplantation; 2 patients died during 1077 person-years of follow-up. There was no difference in participants with or without preceding neonatal cholestasis progressing to transplantation or death during the study (12% vs 7%; P = .09), or in experiencing portal hypertension (28% vs 21%; P = .16); the hazard ratio for neonatal cholestasis leading to portal hypertension was P = .04. Development of portal hypertension was associated with a reduced height Z-score. CONCLUSIONS Portal hypertension in youth with AAT deficiency impacts growth measures. Progression to liver transplantation is slow and death is rare, but the risk of complications and severe liver disease progression persists throughout childhood. A history of neonatal cholestasis is a weak predictor of severe disease.
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Affiliation(s)
- Jeffrey Teckman
- Pediatrics and Biochemistry, Saint Louis University, Cardinal Glennon Children’s Medical Center, Saint Louis, MO
| | - Philip Rosenthal
- Pediatrics and Surgery, University of California San Francisco, San Francisco, CA
| | | | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, MI
| | - Lee M. Bass
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen F. Murray
- Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Nanda Kerkar
- Pediatric Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Magee
- Surgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Saul Karpen
- Pediatrics, Emory University, Children’s Healthcare Atlanta, Atlanta, GA
| | - James E. Heubi
- Pediatric Gastroenterology and Hepatology, Children’s Hospital Medical Center, Cincinnati, OH
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, IN
| | | | - Binita M. Kamath
- Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen L. Guthery
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Utah, and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Averell H. Sherker
- National Institute of Diabetes, Digestive and Kidney Disease, National Institutes of Health, Baltimore, MD
| | - Ronald J. Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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7
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Kamath BM, Ye W, Goodrich NP, Loomes KM, Romero R, Heubi JE, Leung DH, Spinner NB, Piccoli DA, Alonso EM, Guthery SL, Karpen SJ, Mack CL, Molleston JP, Murray KF, Rosenthal P, Squires JE, Teckman J, Wang KS, Thompson R, Magee JC, Sokol RJ. Outcomes of Childhood Cholestasis in Alagille Syndrome: Results of a Multicenter Observational Study. Hepatol Commun 2020; 4:387-398. [PMID: 33313463 PMCID: PMC7049675 DOI: 10.1002/hep4.1468] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/19/2019] [Indexed: 01/04/2023] Open
Abstract
Alagille syndrome (ALGS) is an autosomal dominant multisystem disorder with cholestasis as a defining clinical feature. We sought to characterize hepatic outcomes in a molecularly defined cohort of children with ALGS‐related cholestasis. Two hundred and ninety‐three participants with ALGS with native liver were enrolled. Participants entered the study at different ages and data were collected retrospectively prior to enrollment, and prospectively during the study course. Genetic analysis in 206 revealed JAGGED1 mutations in 91% and NOTCH2 mutations in 4%. Growth was impaired with mean height and weight z‐scores of <−1.0 at all ages. Regression analysis revealed that every 10 mg/dL increase in total bilirubin was associated with a decrease in height z‐score by 0.10 (P = 0.03) and weight z‐score by 0.15 (P = 0.007). Total bilirubin was higher for younger participants (P = 0.03) with a median of 6.9 mg/dL for those less than 1 year old compared with a median of 1.3 mg/dL for participants 13 years or older. The median gamma glutamyl transferase also dropped from 612 to 268 in the same age groups. After adjusting for age, there was substantial within‐individual variation of alanine aminotransferase. By 20 years of age, 40% of participants had developed definite portal hypertension. Estimated liver transplant–free survival at the age of 18.5 years was 24%. Conclusions: This is the largest multicenter natural history study of cholestasis in ALGS, demonstrating a previously underappreciated burden of liver disease with early profound cholestasis, a second wave of portal hypertension later in childhood, and less than 25% of patients reaching young adulthood with their native liver. These findings will promote optimization of ALGS management and development of clinically relevant endpoints for future therapeutic trials.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | - Wen Ye
- Department of Surgery University of Michigan Ann Arbor MI
| | | | - Kathleen M Loomes
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Rene Romero
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - James E Heubi
- Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Daniel H Leung
- Baylor College of Medicine Texas Children's Hospital Houston TX
| | - Nancy B Spinner
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - David A Piccoli
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital Northwestern University Chicago IL
| | | | - Saul J Karpen
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Karen F Murray
- Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Philip Rosenthal
- Department of Pediatrics University of California, San Francisco San Francisco CA
| | - James E Squires
- Department of Gastroenterology and Hepatology UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Jeffrey Teckman
- Department of Pediatrics Saint Louis University School of Medicine St. Louis MO
| | - Kasper S Wang
- Department of Surgery Children's Hospital Los Angeles Los Angeles CA
| | - Richard Thompson
- Institute of Liver Studies King's College London London United Kingdom
| | - John C Magee
- Department of Surgery University of Michigan Ann Arbor MI
| | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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8
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Loomes KM, Spino C, Goodrich NP, Hangartner TN, Marker AE, Heubi JE, Kamath BM, Shneider BL, Rosenthal P, Hertel PM, Karpen SJ, Molleston JP, Murray KF, Schwarz KB, Squires RH, Teckman J, Turmelle YP, Alonso EM, Sherker AH, Magee JC, Sokol RJ. Bone Density in Children With Chronic Liver Disease Correlates With Growth and Cholestasis. Hepatology 2019; 69:245-257. [PMID: 30063078 PMCID: PMC6324969 DOI: 10.1002/hep.30196] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/24/2018] [Indexed: 12/13/2022]
Abstract
Osteopenia and bone fractures are significant causes of morbidity in children with cholestatic liver disease. Dual-energy X-ray absorptiometry (DXA) analysis was performed in children with intrahepatic cholestatic diseases who were enrolled in the Longitudinal Study of Genetic Causes of Intrahepatic Cholestasis in the Childhood Liver Disease Research Network. DXA was performed on participants aged >5 years (with native liver) diagnosed with bile acid synthetic disorder (BASD), alpha-1 antitrypsin deficiency (A1AT), chronic intrahepatic cholestasis (CIC), and Alagille syndrome (ALGS). Weight, height, and body mass index Z scores were lowest in CIC and ALGS. Total bilirubin (TB) and serum bile acids (SBA) were highest in ALGS. Bone mineral density (BMD) and bone mineral content (BMC) Z scores were significantly lower in CIC and ALGS than in BASD and A1AT (P < 0.001). After anthropometric adjustment, bone deficits persisted in CIC but were no longer noted in ALGS. In ALGS, height-adjusted and weight-adjusted subtotal BMD and BMC Z scores were negatively correlated with TB (P < 0.001) and SBA (P = 0.02). Mean height-adjusted and weight-adjusted subtotal BMC Z scores were lower in ALGS participants with a history of bone fractures. DXA measures did not correlate significantly with biliary diversion status. Conclusion: CIC patients had significant bone deficits that persisted after adjustment for height and weight and generally did not correlate with degree of cholestasis. In ALGS, low BMD and BMC reference Z scores were explained by poor growth. Anthropometrically adjusted DXA measures in ALGS correlate with markers of cholestasis and bone fracture history. Reduced bone density in this population is multifactorial and related to growth, degree of cholestasis, fracture vulnerability, and contribution of underlying genetic etiology.
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Affiliation(s)
- Kathleen M. Loomes
- Division of GI, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Thomas N. Hangartner
- Department of Biomedical, Industrial & Human Factors Engineering, Wright State University, Dayton, OH
| | - Amanda E. Marker
- Department of Biomedical, Industrial & Human Factors Engineering, Wright State University, Dayton, OH
| | - James E. Heubi
- Division of GI, Hepatology and Nutrition, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Binita M. Kamath
- Division of GI, Hepatology and Nutrition, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Benjamin L. Shneider
- Division of Pediatric GI, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Philip Rosenthal
- Division of GI, Hepatology and Nutrition, UCSF, San Francisco, CA
| | - Paula M. Hertel
- Division of Pediatric GI, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Saul J. Karpen
- Division of GI, Hepatology and Nutrition, Emory University SOM, Atlanta, GA
| | - Jean P. Molleston
- Division of GI, Hepatology and Nutrition, Indiana University, Riley Hospital for Children, Indianapolis, IN
| | - Karen F. Murray
- Division of GI and Hepatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA
| | | | - Robert H. Squires
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Jeffrey Teckman
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Saint Louis University School of Medicine
| | | | | | | | - John C. Magee
- Department of Surgery, University of Michigan SOM, Ann Arbor, MI
| | - Ronald J. Sokol
- Section of Pediatric GI, Hepatology and Nutrition, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
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9
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Ahmad O, Nogueira J, Heubi JE, Setchell KDR, Ashraf AP. Bile Acid Synthesis Disorder Masquerading as Intractable Vitamin D-Deficiency Rickets. J Endocr Soc 2018; 3:397-402. [PMID: 30746501 PMCID: PMC6364623 DOI: 10.1210/js.2018-00314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/26/2018] [Indexed: 11/19/2022] Open
Abstract
Vitamin D-deficiency rickets, not responding to large treatment doses of oral vitamin D, suggest rare receptor mutations, malabsorption, or hepatobiliary dysfunction. We present a set of twins of Hispanic origin who presented with refractory vitamin D-deficiency rickets and failure to thrive (FTT) at 6 months of age. On follow-up, mild elevations in serum alanine transaminases and normal aspartate aminotransferase were noted. Subsequently, patients manifested fat-soluble vitamin deficiencies. More targeted evaluations revealed a diagnosis of 3β-hydroxy-Δ5-C27-steroid oxidoreductase deficiency. Treatment with oral bile acid replacement with cholic acid resolved rickets and promoted weight gain. Bile acid synthesis disorders should be suspected in refractory rickets in infancy, particularly in a clinical setting of FTT, even in the absence of substantial abnormalities in liver-function tests.
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Affiliation(s)
- Osman Ahmad
- Division of Gastroenterology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Janaina Nogueira
- Division of Gastroenterology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - James E Heubi
- Department of Gastroenterology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kenneth D R Setchell
- Department of Gastroenterology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology and Metabolism, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
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10
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Abstract
Zellweger spectrum disorders (ZSDs) are a subgroup of peroxisomal biogenesis disorders with a generalized defect in peroxisome function. Liver disease in ZSDs has been associated with the lack of peroxisomal β-oxidation of C27-bile acid intermediates to form primary C24-bile acids, which prevents normal physiologic feedback and leads to accumulation of hepatotoxic bile acid intermediates. Primary bile acid therapy, oral cholic acid (CA), as adjunctive treatment for ZSDs, restores physiologic feedback inhibition on bile acid synthesis and inhibits formation of hepatotoxic bile acid intermediates. Our patient is a Caucasian male diagnosed with moderately severe ZSD at age 5 months, and he received long-term CA therapy from age 16 months through 19 years old. CA treatment was well tolerated, with no reports of adverse events. His liver biopsy prior to CA therapy showed cholestasis, periportal inflammation, and bridging fibrosis. Following 5 months of CA therapy, his liver biopsy showed improvement in inflammation and no change in fibrosis. Serum liver enzymes during CA therapy improved compared to pre-therapy levels but frequently were above the upper limit of normal. At age 19 years, following several years with clinical cirrhosis with severe portal hypertension, he presented with worsening jaundice, and he was diagnosed with hepatocellular cancer (HCC). Early-onset advanced liver disease associated with ZSD and natural disease progression that is not completely suppressed with CA treatment likely caused HCC in our patient. Greater awareness is needed of the possibility of development of HCC in patients with moderately severe ZSD who survive past childhood.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition and Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Warren P Bishop
- Division of Pediatric Gastroenterology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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11
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Abstract
Inborn errors of bile acid metabolism are rare causes of neonatal cholestasis and liver disease in older children and adults. The diagnosis should be considered in the context of hyperbilirubinemia with normal serum bile acids and made by urinary liquid secondary ionization mass spectrometry or DNA testing. Cholic acid is an effective treatment of most single-enzyme defects and patients with Zellweger spectrum disorder with liver disease.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA.
| | - Kenneth D R Setchell
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
| | - Kevin E Bove
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
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12
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Abstract
Zellweger spectrum disorders (ZSDs), a subgroup of peroxisomal biogenesis disorders, have a generalized defect in peroxisome function. Liver disease in ZSDs has been linked to accumulation of C27-bile acid intermediates due to the lack of peroxisomal β-oxidation of these intermediates to form primary C24-bile acids. Oral treatment with primary bile acid, cholic acid (CA), inhibits formation of hepatotoxic C27-bile acids by restoring normal physiologic feedback inhibition on bile acid synthesis. We present the long-term CA treatment and liver-related outcomes for 3 pediatric patients with ZSDs who have received CA treatment for ≥15 years. Ongoing CA treatment was associated with stabilized liver function, as shown by serum biochemistries and liver histopathology, and no treatment-related adverse effects were observed. All 3 patients have attended regular school with classroom accommodations and attained a good quality of life. Our patient outcomes suggest that early and ongoing CA therapy may sustain liver function in patients with ZSDs.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kevin E Bove
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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13
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Galloway D, Mezoff E, Zhang W, Byrd M, Cole C, Aban I, Kocoshis S, Setchell KD, Heubi JE. Serum Unconjugated Bile Acids and Small Bowel Bacterial Overgrowth in Pediatric Intestinal Failure: A Pilot Study. JPEN J Parenter Enteral Nutr 2018; 43:263-270. [PMID: 30035316 DOI: 10.1002/jpen.1316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/02/2018] [Accepted: 05/17/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND We determined qualitative and quantitative serum unconjugated bile acid (SUBA) levels among children with history of intestinal failure (IF) and suspected small bowel bacterial overgrowth (SBBO). METHODS This was a single-center, case-control pilot study conducted at Cincinnati Children's Hospital Medical Center. Children with history of IF and suspected SBBO were enrolled as subjects. Age-matched children without IF or suspected SBBO served as controls. All participants underwent small bowel fluid sampling for microbial culture analysis. Additionally, serum fractionated and total bile acids were measured by liquid chromatography-mass spectrometry at enrollment and following treatment for SBBO. RESULTS SUBA concentrations were elevated in IF subjects (median 1.16 μM, range 0.43-10.65 μM) compared with controls (median 0.10 μM, range 0.05-0.18 μM, P = 0.001). Among SUBA, chenodeoxycholic acid (CDCA) was significantly elevated in subjects (median 0.8 μM, range 0-7.08 μM) compared with controls (median 0 μM, range 0-0.03 μM, P = 0.012). When controls were excluded from analysis, IF subjects with positive aspirates for SBBO demonstrated higher concentration of CDCA (median 7.36 μM, range 1.1-8.28 μM) compared with IF subjects with negative aspirates (median 0.18 μM, range 0-1.06 μM, P = 0.017). Treatment for SBBO did not alter SUBA concentration. CONCLUSIONS SUBA concentrations are elevated in children with history of IF and presumed SBBO compared with non-IF controls. CDCA was more prevalent in IF subjects with positive aspirates for SBBO compared with IF subjects with negative aspirates. The determination of SUBA concentration may be a useful surrogate to small bowel fluid aspiration in the diagnosis of SBBO in children with history of IF.
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Affiliation(s)
- David Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ethan Mezoff
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Wujuan Zhang
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melissa Byrd
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Inmaculada Aban
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Samuel Kocoshis
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kenneth Dr Setchell
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James E Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Leung DH, Heltshe SL, Borowitz D, Gelfond D, Kloster M, Heubi JE, Stalvey M, Ramsey BW. Effects of Diagnosis by Newborn Screening for Cystic Fibrosis on Weight and Length in the First Year of Life. JAMA Pediatr 2017; 171:546-554. [PMID: 28437538 PMCID: PMC5731827 DOI: 10.1001/jamapediatrics.2017.0206] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Since the implementation of universal newborn screening (NBS) for cystic fibrosis (CF), the timing and magnitude of growth deficiency or its association with correlates of disease among infants with CF who underwent NBS has not been well described. OBJECTIVE To examine incremental weight gain, linear growth, and clinical features in the first year of life among infants with CF who underwent NBS. DESIGN, SETTING, AND PARTICIPANTS The Baby Observational and Nutrition Study (BONUS), a multicenter, longitudinal, observational cohort study, was conducted during regular CF clinic visits in the first 12 months of life at 28 US Cystic Fibrosis Foundation-accredited Care Centers from January 7, 2012, through May 31, 2015. Participants included 231 infants younger than 3.5 months who underwent NBS and had confirmed CF, with a gestational age of at least 35 weeks, birth weight of at least 2.5 kg, and toleration of full oral feeds. Of these, 222 infants (96.1%) had follow-up beyond 6 months of age and 215 (93.1%) completed 12 months of follow-up. EXPOSURE Cystic fibrosis. MAIN OUTCOME AND MEASURES Attained weight and length for age and World Health Organization normative z scores at ages 1 to 6 and 8, 10, and 12 months (defined a priori). RESULTS Of the 231 infants enrolled, 110 infants (47.6%) were female and 121 (52.4%) were male, with a mean (SD) age of 2.58 (0.69) months. BONUS infants had lower than mean birth weights (mean z score, -0.15; 95% CI, -0.27 to -0.04) and higher birth lengths (mean z score, 0.44; 95% CI, 0.26 to 0.62). They achieved normal weight by 12 months, a significant improvement over a prescreening cohort of newborns with CF from 20 years before the contemporary cohort (mean z score increase, 0.57; 95% CI, 0.37-0.77). However, length was lower than the mean at 12 months (mean z score, -0.56; 95% CI, -0.70 to -0.42). Only 30 infants (13.6%) were at less than the 10th percentile of weight for age, whereas 53 (23.9%) were at less than the 10th percentile of length for age at more than half their visits. Male sex, pancreatic insufficiency, meconium ileus, histamine blocker use, and respiratory Pseudomonas aeruginosa infection were associated with lower weight or length during the first year. Insulinlike growth factor 1 levels were significantly lower among low-length infants. Persistently low-weight infants consumed significantly more calories, and weight and length z scores were negatively correlated with caloric intake. CONCLUSIONS AND RELEVANCE Since initiation of universal NBS for CF, significant improvement has occurred in nutritional status, with normalization of weight in the first year of life. However, length stunting remains common.
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Affiliation(s)
- Daniel H. Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Sonya L. Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Drucy Borowitz
- Department of Pediatrics, University of Buffalo, Buffalo, New YorkCystic Fibrosis Foundation, Bethesda, Maryland
| | - Daniel Gelfond
- Division of Gastroenterology/Nutrition, Department of Pediatrics, University of Rochester, Rochester, New York
| | - Margaret Kloster
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - James E. Heubi
- Division of Gastroenterology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael Stalvey
- Department of Pediatrics, University of Alabama at Birmingham
| | - Bonnie W. Ramsey
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle
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15
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Heubi JE, Schaeffer D, Ahrens RC, Sollo N, Strausbaugh S, Graff G, Jain R, Witte S, Forssmann K. Safety and Efficacy of a Novel Microbial Lipase in Patients with Exocrine Pancreatic Insufficiency due to Cystic Fibrosis: A Randomized Controlled Clinical Trial. J Pediatr 2016; 176:156-161.e1. [PMID: 27297209 DOI: 10.1016/j.jpeds.2016.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/12/2016] [Accepted: 05/12/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of a novel microbial lipase (NM-BL) in a liquid formulation for the treatment of exocrine pancreatic insufficiency (EPI) in patients with cystic fibrosis (CF) in a phase IIa proof-of-concept study. STUDY DESIGN We conducted a double-blind, randomized, placebo controlled crossover study in patients with cystic fibrosis and exocrine pancreatic insufficiency. Adolescent and adult patients with CF were randomized to receive NM-BL or placebo for 1 week as replacement for their usual pancreatic enzyme formulation. They were subsequently crossed-over to the alternate study treatment. The coefficient of fat absorption was evaluated as the primary endpoint. Symptoms and adverse events were evaluated as secondary endpoints. RESULTS A total of 35 patients were randomized into the study and 22 patients completed both treatment periods. During treatment with NM-BL, the coefficient of fat absorption was significantly greater (72.7%) compared with placebo (53.8%) with a difference between groups of 18.8% (P < .001). Subjective assessment of stool fat and stool consistency also improved under treatment with NM-BL. Adverse events were mostly gastrointestinal in nature and were more common in the group receiving NM-BL. CONCLUSIONS Currently available pancreatic enzyme products are limited because of the lack of liquid formulations and being largely porcine based. The novel microbial lipase NM-BL was safe and effective in this short term trial. The trial provided clinical proof-of-concept for this novel microbial lipase as a treatment for EPI in CF. A larger phase 2 dose ranging trial is warranted. TRIAL REGISTRATION ClinicalTrials.gov: NCT01710644.
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Affiliation(s)
- James E Heubi
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | | | - Richard C Ahrens
- Roy J and Lucille A Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Natalie Sollo
- University of Kansas School of Medicine-Wichita/Via Christi Research, Wichita, KS
| | | | - Gavin Graff
- Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Raksha Jain
- The University of Texas Southwestern Medical Center, Dallas, TX
| | - Stephan Witte
- Nordmark Arzneimittel GmbH & Co. KG, Uetersen, Germany
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16
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Mouzaki M, Bass LM, Sokol RJ, Piccoli DA, Quammie C, Loomes KM, Heubi JE, Hertel PM, Scheenstra R, Furuya K, Kutsch E, Spinner NB, Robbins KN, Venkat V, Rosenthal P, Beyene J, Baker A, Kamath BM. Early life predictive markers of liver disease outcome in an International, Multicentre Cohort of children with Alagille syndrome. Liver Int 2016. [PMID: 26201540 PMCID: PMC5401769 DOI: 10.1111/liv.12920] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Liver disease in Alagille syndrome is highly variable. Many of the patients presenting with severe cholestasis early in life improve spontaneously; 10-20%, however, have progressive disease. It is currently not possible to predict long-term hepatic outcomes in Alagille syndrome. This international, multicentre study was aimed at identifying early life predictors of liver disease outcome. METHODS Retrospective clinical, laboratory and radiographic data from a cohort of 144 Alagille syndrome patients, whose long-term hepatic outcomes had been determined a priori based on previously published criteria, were collected. RESULTS Sixty-seven patients had mild and 77 had severe hepatic outcome. Univariate analysis demonstrated that cholestasis and fibrosis on biopsy, as well as the presence of xanthomata were significantly different between the groups (P < 0.05 for all). Mixed model analysis revealed that total serum bilirubin and serum cholesterol were also associated with outcome (P = 0.001 and P = 0.002, respectively). Graphical representation of the data revealed a change in total bilirubin levels between 12 and 24 months of age in the mild group. Recursive partitioning identified a threshold for total bilirubin of 3.8 mg/dl (65 mmol/L) in that age-frame that differentiated between outcomes. A multivariable logistic regression model was developed using fibrosis, xanthomata and the total bilirubin cut-off of 3.8 mg/dl (65 mmol/L), which generated an area under the ROC curve of 0.792. CONCLUSIONS The long-term hepatic outcomes of patients with Alagille syndrome can be predicted based on serum total bilirubin between the ages of 12-24 months combined with fibrosis on liver biopsy and the presence of xanthomata on physical examination.
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Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, University of Toronto
| | - Lee M. Bass
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago
| | - Ronald J. Sokol
- Division of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - David A. Piccoli
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia
| | - Claudia Quammie
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, University of Toronto
| | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia
| | - James E. Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital, Cincinnati
| | - Paula M. Hertel
- Division of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Rene Scheenstra
- Division of Gastroenterology, Hepatology and Nutrition, Beatrix Children’s Hospital, University Medical Center, Groningen Netherlands
| | - Katryn Furuya
- Division of Gastroenterology, Hepatology and Nutrition, Nemours/AI. duPont Hospital for Children, Delaware
| | - Erika Kutsch
- Division of Gastroenterology, Hepatology and Nutrition, Nemours/AI. duPont Hospital for Children, Delaware
| | - Nancy B. Spinner
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Kristen N. Robbins
- Division of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Veena Venkat
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Pittsburgh, Pittsburgh, University of Pittsburgh
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology and Nutrition, UCSF Benioff Children’s Hospital, San Francisco
| | - Joseph Beyene
- Clinical Epidemiology & Biostatistics, McMaster University, Hamilton
| | - Alastair Baker
- King’s Paediatric Liver Centre, King’s College Hospital, London UK
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, University of Toronto
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17
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Brehm BJ, Summer SS, Khoury JC, Filak AT, Lieberman MA, Heubi JE. Health Status and Lifestyle Habits of US Medical Students: A Longitudinal Study. Ann Med Health Sci Res 2016; 6:341-347. [PMID: 28540101 PMCID: PMC5423333 DOI: 10.4103/amhsr.amhsr_469_15] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Evidence shows that physicians and medical students who engage in healthy lifestyle habits are more likely to counsel patients about such behaviors. Yet medical school is a challenging time that may bring about undesired changes to health and lifestyle habits. Aims: This study assessed changes in students' health and lifestyle behaviors during medical school. Subjects and Methods: In a longitudinal study, students were assessed at both the beginning and end of medical school. Anthropometric, metabolic, and lifestyle variables were measured at a clinical research center. Data were collected from 2006 to 2011, and analyzed in 2013–2014 with SAS version 9.3. Pearson's correlations were used to assess associations between variables and a generalized linear model was used to measure change over time. Results: Seventy-eight percent (97/125) of participants completed both visits. At baseline, mean anthropometric and clinical measures were at or near healthy values and did not change over time, with the exception of increased diastolic blood pressure (P = 0.01), high-density lipoprotein-cholesterol (P < 0.001), and insulin (P < 0.001). Self-reported diet and physical activity habits were congruent with national goals, except for Vitamin D and sodium. Dietary intake did not change over time, with the exceptions of decreased carbohydrate (percent of total energy) (P < 0.001) and sodium (P = 0.04) and increased fat (percent of total energy) and Vitamin D (both P < 0.01). Cardiovascular fitness showed a trend toward declining, while self-reported physical activity increased (P < 0.001). Conclusions: Students' clinical measures and lifestyle behaviors remain generally healthy throughout medical school; yet some students exhibit cardiometabolic risk and diet and activity habits not aligned with national recommendations. Curricula that include personal health and lifestyle assessment may motivate students to adopt healthier practices and serve as role models for patients.
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Affiliation(s)
- B J Brehm
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
| | - S S Summer
- Clinical Translational Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A T Filak
- Department of Medical Education, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - M A Lieberman
- Department of Molecular Genetics, Biochemistry and Microbiology, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - J E Heubi
- Center for Clinical and Translational Science and Training, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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18
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Coburn-Miller C, Casey S, Luong Q, Cameron N, Hocevar-Trnka J, Leung DH, Gelfond D, Heubi JE, Ramsey B, Borowitz D. Standardization of Research-Quality Anthropometric Measurement of Infants and Implementation in a Multicenter Study. Clin Transl Sci 2015; 8:330-3. [PMID: 26053284 DOI: 10.1111/cts.12283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Malnutrition is one of the earliest clinical manifestations of cystic fibrosis (CF) and is associated with poorer pulmonary and cognitive outcomes and survival later in life. Infant growth can be a responsive measure for clinical research in this age group if obtained and characterized accurately. We report here the methods to standardize and implement research-quality anthropometric measurement of infants with cystic fibrosis in the Baby Observational Nutrition Study multicenter trial.
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Affiliation(s)
| | - Susan Casey
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Quynh Luong
- Therapeutics Development Network Coordinating Center, Seattle, Washington, USA
| | - Natalia Cameron
- Therapeutics Development Network Coordinating Center, Seattle, Washington, USA
| | - Jasna Hocevar-Trnka
- Therapeutics Development Network Coordinating Center, Seattle, Washington, USA
| | - Daniel H Leung
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | - James E Heubi
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Bonnie Ramsey
- Seattle Children's Hospital, Seattle, Washington, USA.,Therapeutics Development Network Coordinating Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Drucy Borowitz
- Women and Children's Hospital of Buffalo, Buffalo, New York, USA.,State University of New York at Buffalo, Buffalo, New York, USA
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19
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Heubi JE, Setchell KD, Jha P, Buckley D, Zhang W, Rosenthal P, Potter C, Horslen S, Suskind D. Treatment of bile acid amidation defects with glycocholic acid. Hepatology 2015; 61:268-74. [PMID: 25163551 PMCID: PMC4280294 DOI: 10.1002/hep.27401] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/10/2014] [Indexed: 12/07/2022]
Abstract
UNLABELLED Bile acid amidation defects were predicted to present with fat/fat soluble vitamin malabsorption with minimal cholestasis. We identified and treated five patients (one male, four females) from four families with defective bile acid amidation due to a genetically confirmed deficiency in bile acid CoA:amino acid N-acyl transferase (BAAT) with the conjugated bile acid, glycocholic acid (GCA). Fast atom bombardment-mass spectrometry analysis of urine and bile at baseline revealed predominantly unconjugated cholic acid and absence of the usual glycine and taurine conjugated primary bile acids. Treatment with 15 mg/kg GCA resulted in total duodenal bile acid concentrations of 23.3 ± 19.1 mmol/L (mean ± SD) and 63.5 ± 4.0% of the bile acids were secreted in bile in the conjugated form, of which GCA represented 59.6 ± 9.3% of the total biliary bile acids. Unconjugated cholic acid continued to be present in high concentrations in bile because of partial intestinal deconjugation of orally administered GCA. Serum total bile acid concentrations did not significantly differ between pretreatment and posttreatment samples and serum contained predominantly unconjugated cholic acid. These findings confirmed efficient intestinal absorption, hepatic extraction, and biliary secretion of the administered GCA. Oral tolerance tests for vitamin D2 (1,000 IU vitamin D2/kg) and tocopherol (100 IU/kg tocopherol acetate) demonstrated improvement in fat-soluble vitamin absorption after GCA treatment. Growth improved in 3/3 growth-delayed prepubertal patients. CONCLUSION Oral glycocholic acid therapy is safe and effective in improving growth and fat-soluble vitamin absorption in children and adolescents with inborn errors of bile acid metabolism due to amidation defects.
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Affiliation(s)
- James E. Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
,Division of Clinical and Translational Research Center, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Kenneth D.R. Setchell
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Pinky Jha
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Donna Buckley
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
,Division of Clinical and Translational Research Center, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Wujuan Zhang
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA
| | - Carol Potter
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Ohio State University, Columbus, OH
| | - Simon Horslen
- Division of Gastroenterology and Nutrition, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - David Suskind
- Division of Gastroenterology and Nutrition, Seattle Children’s Hospital, University of Washington, Seattle, WA
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20
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Setchell KDR, Brown NM, Zimmer-Nechemias L, Wolfe B, Jha P, Heubi JE. Metabolism of secoisolariciresinol-diglycoside the dietary precursor to the intestinally derived lignan enterolactone in humans. Food Funct 2014; 5:491-501. [PMID: 24429845 DOI: 10.1039/c3fo60402k] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Secoisolariciresinol-diglycoside (SDG), a natural dietary lignan of flaxseeds now available in dietary supplements, is converted by intestinal bacteria to the mammalian lignans enterodiol and enterolactone. High levels of these lignans in blood and urine are associated with reduced risk of many chronic diseases. Our objective was to determine the bioavailability and pharmacokinetics of SDG in purified flaxseed extracts under dose-ranging and steady-state conditions, and to examine whether differences in secoisolariciresinol-diglycoside purity influence bioavailability. Pharmacokinetic studies were performed on healthy postmenopausal women after oral intake of 25, 50, 75, 86 and 172 mg of secoisolariciresinol-diglycoside. Extracts differing in secoisolariciresinol-diglycoside purity were compared, and steady-state lignan concentrations measured after daily intake for one week. Blood and urine samples were collected at timed intervals and secoisolariciresinol, enterodiol and enterolactone concentrations measured by mass spectrometry. Secoisolariciresinol-diglycoside was efficiently hydrolyzed and converted to secoisolariciresinol. Serum concentrations increased rapidly after oral intake, peaking after 5-7 h and disappearing with a plasma elimination half-life of 4.8 h. Maximum serum concentrations of the biologically active metabolites, enterodiol and enterolactone were attained after 12-24 h and 24-36 h, respectively, and the half-lives were 9.4 h and 13.2 h. Linear dose-responses were observed and secoisolariciresinol bioavailability correlated (r(2) = 0.835) with cumulative lignan excretion. There were no significant differences in the pharmacokinetics of extracts differing in purity, and steady-state serum lignan concentrations were obtained after one-week of daily dosing. In conclusion, this study defines the pharmacokinetics of secoisolariciresinol-diglycoside and shows it is first hydrolyzed and then metabolized in a time-dependent sequence to secoisolariciresinol, enterodiol and ultimately enterolactone, and these metabolites are efficiently absorbed.
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Affiliation(s)
- Kenneth D R Setchell
- Division of Pathology, Clinical Mass Spectrometry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA.
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21
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Brown NM, Galandi SL, Summer SS, Zhao X, Heubi JE, King EC, Setchell KDR. S-(-)equol production is developmentally regulated and related to early diet composition. Nutr Res 2014; 34:401-9. [PMID: 24916553 DOI: 10.1016/j.nutres.2014.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/26/2014] [Accepted: 03/31/2014] [Indexed: 10/25/2022]
Abstract
S-(-)7-hydroxy-3-(4'-hydroxyphenyl)-chroman, or S-(-)equol, a biologically active intestinally derived bacterial metabolite of the soy isoflavones daidzin/daidzein, is not produced in neonatal life. Because its synthesis is dependent on equol-producing bacteria, we hypothesized that early nutrition may influence equol production. This prospective 2.5-year study determined the frequency of S-(-)equol production in healthy infants (n = 90) fed breast milk, soy infant formula, or cow's milk formula in their first year. Urinary S-(-)equol and daidzein were quantified by mass spectrometry after a standardized 3.5-day soy isoflavone challenge. Infants were tested at 6, 9, 12, 18, 24, and 36 months of age, and 3-day diet records were obtained at each visit to explore the effect of early and postweaning (>12 months) macronutrient and micronutrient dietary composition and S-(-)equol production. Use of antibiotics was also recorded. At age 6 months, none of the breast-fed infants produced S-(-)equol, whereas 3.8% and 6.0%, respectively, of soy and cow's milk formula-fed infants were equol producers. By age 3 years, 50% of the formula-fed infants were equol producers, compared with 25% of breast-fed infants. Use of antibiotics was prevalent among infants and may have impacted the stability of S-(-)equol production. No significant differences among the groups were observed in postweaning dietary intakes of total energy, carbohydrate, fiber, protein, fat, saturated fatty acids, or polyunsaturated fatty acids and the propensity to make S-(-)equol. In conclusion, S-(-)equol production is developmentally regulated and initially related to diet composition with the proportion of equol producers increasing over the first 3 years of life, with a trend for formula feeding favoring S-(-)equol production.
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Affiliation(s)
- Nadine M Brown
- Division of Clinical Mass Spectrometry, Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie L Galandi
- Division of Clinical Mass Spectrometry, Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Suzanne S Summer
- Center for Clinical and Translational Science and Training, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Xueheng Zhao
- Division of Clinical Mass Spectrometry, Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - James E Heubi
- Center for Clinical and Translational Science and Training, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Eileen C King
- Department of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kenneth D R Setchell
- Division of Clinical Mass Spectrometry, Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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22
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Jandacek RJ, Heubi JE, Buckley DD, Khoury JC, Turner WE, Sjödin A, Olson JR, Shelton C, Helms K, Bailey TD, Carter S, Tso P, Pavuk M. Reduction of the body burden of PCBs and DDE by dietary intervention in a randomized trial. J Nutr Biochem 2014; 25:483-8. [PMID: 24629911 DOI: 10.1016/j.jnutbio.2014.01.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 12/26/2013] [Accepted: 01/13/2014] [Indexed: 12/28/2022]
Abstract
Serum polychlorinated biphenyls (PCBs) in Anniston, AL, residents have been associated with hypertension and diabetes. There have been no systematic interventions to reduce PCB body burdens in Anniston or other populations. Our objective was to determine the efficacy of 15 g/day of dietary olestra to reduce PCBs in Anniston residents. Blood PCBs and 1,1-bis-(4-chlorophenyl)-2,2-dichloroethene were measured at baseline and 4-month intervals in a double-blind, placebo-controlled, 1-year trial. Participants with elevated serum PCBs were randomized into two groups of 14 and received potato crisps made with olestra or vegetable oil (VO). Elimination rates during the study period were compared with 5-year prestudy rates. Eleven participants in the olestra group and 12 in the VO group completed the study. Except for one participant in the VO group, reasons for dropout were unrelated to treatments. The elimination rate of 37 non-coplanar PCB congeners during the 1-year trial was faster during olestra consumption compared to the pretrial period (-0.0829 ± 0.0357 and -0.00864 ± 0.0116 year(-1), respectively; P=.04), but not during VO consumption (-0.0413 ± 0.0408 and -0.0283 ± 0.0096 year(-1), respectively; P=.27). The concentration of PCBs in two olestra group participants decreased by 27% and 25% during the trial. There was no significant time by group interaction in change from baseline. However, group main effects for total PCBs and PCB 153 were of borderline significance. This pilot study has demonstrated that olestra can safely reduce body burdens of PCBs and supports a larger intervention trial that may also determine whether reduction in PCBs will reduce the risk of hypertension and diabetes.
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Affiliation(s)
| | - James E Heubi
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Donna D Buckley
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jane C Khoury
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Wayman E Turner
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andreas Sjödin
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Kim Helms
- Jacksonville State University, Jacksonville, Alabama
| | - Tina D Bailey
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Patrick Tso
- Jacksonville State University, Jacksonville, Alabama
| | - Marian Pavuk
- Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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Tsevat J, Lindsell CJ, Parr WD, Kues JR, Kissela BM, Heubi EC, Flessa JW, Heubi JE. Beyond project-focused consultation to investigator-focused consultation: the CCTST Integration Committee model. Clin Transl Sci 2014; 7:3-5. [PMID: 24456418 DOI: 10.1111/cts.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Joel Tsevat
- Center for Clinical and Translational Science and Training, University of Cincinnati, Cincinnati, Ohio, USA
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24
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25
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Setchell KDR, Brown NM, Summer S, King EC, Heubi JE, Cole S, Guy T, Hokin B. Dietary factors influence production of the soy isoflavone metabolite s-(-)equol in healthy adults. J Nutr 2013; 143:1950-8. [PMID: 24089421 PMCID: PMC3827640 DOI: 10.3945/jn.113.179564] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
S-(-)equol, an intestinally derived metabolite of the soy isoflavone daidzein, is proposed to enhance the efficacy of soy diets. Adults differ in their ability to produce equol when consuming soy foods for reasons that remain unclear. Therefore, we performed a comprehensive dietary analysis of 143 macro- and micronutrients in 159 healthy adults in the United States (n = 89) and Australia (n = 70) to determine whether the intake of specific nutrients favors equol production. Three-d diet records were collected and analyzed using Nutrition Data System for Research software and S-(-)equol was measured in urine by mass spectrometry. Additionally, in a subset of equol producers and nonproducers (n = 10/group), we examined the long-term stability of equol producer status by retesting 12, 18, and 24 mo later. Finally, the effect of oral administration of the antibiotic metronidazole (500 mg/d for 7 d) on equol production was examined in 5 adults monitored during a 4-mo follow-up period. Equol producers accounted for 30.3% and 28.6% of the United States and Australian participants, respectively (overall frequency, 29.6%). No significant differences were observed for total protein, carbohydrate, fat, saturated fat, or fiber intakes between equol producers and nonproducers. However, principal component analysis revealed differences in several nutrients, including higher intakes of polyunsaturated fatty acids (P = 0.039), maltose (P = 0.02), and vitamins A (P = 0.01) and E (P = 0.035) and a lower intake of total cholesterol (P = 0.010) in equol producers. During a 2-y period, equol producer status remained unchanged in all nonproducers and in 80% of equol producers, whereas metronidazole abolished equol production in only 20% of participants. In conclusion, these findings suggest that major differences in the macronutrient content of the diet appear not to influence equol production, but subtle differences in some nutrients may influence the ability to produce equol, which was a relatively stable phenomenon.
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Affiliation(s)
- Kenneth D. R. Setchell
- Divisions of Clinical Mass Spectrometry, Department of Pathology,University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH,To whom correspondence should be addressed. E-mail:
| | - Nadine M. Brown
- Divisions of Clinical Mass Spectrometry, Department of Pathology
| | | | | | - James E. Heubi
- Clinical Translational Research Center,Gastroenterology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; and,University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH
| | - Sidney Cole
- Sanitarium Health and Wellbeing Company, Berkeley Vale, New South Wales, Australia; and
| | - Trish Guy
- Sanitarium Health and Wellbeing Company, Berkeley Vale, New South Wales, Australia; and
| | - Bevan Hokin
- The Department of Pathology, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
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26
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Currier RL, Schneider MR, Heubi JE. Taking Journal Clubs off Autopilot: A Case Study of Teaching Literature Evaluation Skills to Preclinical MD/PhD Students. Med Sci Educ 2013; 23:572-577. [PMID: 24634798 PMCID: PMC3949766 DOI: 10.1007/bf03341682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Researchers designed learner-directed journal clubs to develop literature evaluation skills in preclinical students. Sessions balanced student-led discussion with structured objectives and faculty support. During the pilot with preclinical MD/PhD students, self-rated mastery improved over all 17 measured objectives. Six exercises have since been incorporated into the full medical school curriculum.
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Affiliation(s)
| | | | - James E Heubi
- University of Cincinnati College of Medicine, Cincinnati, OH, USA ; Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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27
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Heubi JE. 50 Years ago in The Journal Of Pediatrics: Technique for peroral small intestinal biopsy in children. J Pediatr 2013; 163:784. [PMID: 23973237 DOI: 10.1016/j.jpeds.2013.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/16/2022]
Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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28
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Ramprasath VR, Jones PJ, Buckley DD, Woollett LA, Heubi JE. Effect of dietary sphingomyelin on absorption and fractional synthetic rate of cholesterol and serum lipid profile in humans. Lipids Health Dis 2013; 12:125. [PMID: 23958473 PMCID: PMC3765565 DOI: 10.1186/1476-511x-12-125] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/15/2013] [Indexed: 12/30/2022] Open
Abstract
Background Diets enriched with sphingolipids may improve blood lipid profiles. Studies in animals have shown reductions in cholesterol absorption and alterations in blood lipids after treatment with sphingomyelin (SM). However, minimal information exists on effect of SM on cholesterol absorption and metabolism in humans. The objective was to assess the effect of SM consumption on serum lipid concentrations and cholesterol metabolism in healthy humans. Methods Ten healthy adult males and females completed a randomized crossover study. Subjects consumed controlled diets with or without 1 g/day SM for 14 days separated by at least 4 week washout period. Serum lipid profile and markers of cholesterol metabolism including cholesterol absorption and synthesis were analyzed. Results Serum triglycerides, total, LDL- and VLDL- cholesterol were not affected while HDL cholesterol concentrations were increased (p = 0.043) by SM diet consumption. No change in cholesterol absorption and cholesterol fractional synthesis rate was observed with supplementation of SM compared to control. Intraluminal cholesterol solubilization was also not affected by consumption of SM enriched diet. Conclusions In humans, 1 g/day of dietary SM does not alter the blood lipid profile except for an increased HDL-cholesterol concentration and has no effect on cholesterol absorption, synthesis and intraluminal solubilization compared to control. Trial registration Clinicaltrials.gov # NCT00328211
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29
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Appleman SS, Kalkwarf HJ, Dwivedi A, Heubi JE. Bone deficits in parenteral nutrition-dependent infants and children with intestinal failure are attenuated when accounting for slower growth. J Pediatr Gastroenterol Nutr 2013; 57:124-30. [PMID: 23518489 PMCID: PMC4303576 DOI: 10.1097/mpg.0b013e318291fec5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the present study was to determine whether bone mineral content (BMC) and density (BMD) of infants and children with parenteral nutrition (PN)-dependent intestinal failure (IF) is lower than healthy controls, and investigate potential causes of lower BMC and BMD. METHODS We performed a cross-sectional study comparing infants and children with PN-dependent IF with duos of age-, sex-, and race-matched controls. Lumbar spine BMC and BMD were measured by dual-energy x-ray absorptiometry, and serum cytokines, aluminum, insulin-like growth factor-1 (IGF-1), IGF-binding protein 3 (IGF-BP3), parathyroid hormone, 25-hydroxy vitamin D, and 1,25-dihydroxy vitamin D were measured. Generalized estimating equation models accounting for matching were used for comparisons. RESULTS BMC was 15% and BMD was 12% lower in IF participants than in controls (P ≤ 0.004). Group differences were attenuated to 3% and 7% and were not statistically significant (P = 0.40 and P = 0.07) when adjusted for length and weight; length- and weight-for-age were lower in IF than in control participants (12.5% vs 63%; 29.5% vs 54%, P ≤ 0.03). IF participants had higher serum aluminum (23 vs 7 μg/L, P < 0.0001), IGF-1 (97 vs 64 ng/mL, P = 0.04), and 25-hydroxy vitamin D concentrations (40 vs 30 ng/mL, P = 0.0005), and lower IGF-BP3 (1418 vs 1812 ng/mL, P < 0.0001) and parathyroid hormone concentrations (51 vs 98 pg/mL, P = 0.0002) than controls. There was no difference in serum cytokine concentrations (P ≥ 0.09). CONCLUSIONS Growth retardation is a significant problem for patients with PN-dependent IF. Additional investigation is needed to elucidate the cause and its effect on bone mass and density, especially the role of IGF-1 resistance and aluminum toxicity.
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Affiliation(s)
- Stephanie S. Appleman
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Heidi J. Kalkwarf
- General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Alok Dwivedi
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH
| | - James E. Heubi
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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30
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Setchell KDR, Heubi JE, Shah S, Lavine JE, Suskind D, Al-Edreesi M, Potter C, Russell DW, O'Connell NC, Wolfe B, Jha P, Zhang W, Bove KE, Knisely AS, Hofmann AF, Rosenthal P, Bull LN. Genetic defects in bile acid conjugation cause fat-soluble vitamin deficiency. Gastroenterology 2013; 144:945-955.e6; quiz e14-5. [PMID: 23415802 PMCID: PMC4175397 DOI: 10.1053/j.gastro.2013.02.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/29/2013] [Accepted: 02/06/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS The final step in bile acid synthesis involves conjugation with glycine and taurine, which promotes a high intraluminal micellar concentration to facilitate lipid absorption. We investigated the clinical, biochemical, molecular, and morphologic features of a genetic defect in bile acid conjugation in 10 pediatric patients with fat-soluble vitamin deficiency, some with growth failure or transient neonatal cholestatic hepatitis. METHODS We identified the genetic defect that causes this disorder using mass spectrometry analysis of urine, bile, and serum samples and sequence analysis of the genes encoding bile acid-CoA:amino acid N-acyltransferase (BAAT) and bile acid-CoA ligase (SLC27A5). RESULTS Levels of urinary bile acids were increased (432 ± 248 μmol/L) and predominantly excreted in unconjugated forms (79.4% ± 3.9%) and as sulfates and glucuronides. Glycine or taurine conjugates were absent in the urine, bile, and serum. Unconjugated bile acids accounted for 95.7% ± 5.8% of the bile acids in duodenal bile, with cholic acid accounting for 82.4% ± 5.5% of the total. Duodenal bile acid concentrations were 12.1 ± 5.9 mmol/L, which is too low for efficient lipid absorption. The biochemical profile was consistent with defective bile acid amidation. Molecular analysis of BAAT confirmed 4 different homozygous mutations in 8 patients tested. CONCLUSIONS Based on a study of 10 pediatric patients, genetic defects that disrupt bile acid amidation cause fat-soluble vitamin deficiency and growth failure, indicating the importance of bile acid conjugation in lipid absorption. Some patients developed liver disease with features of a cholangiopathy. These findings indicate that patients with idiopathic neonatal cholestasis or later onset of unexplained fat-soluble vitamin deficiency should be screened for defects in bile acid conjugation.
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Affiliation(s)
- Kenneth D. R. Setchell
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - James E. Heubi
- Division of Gastroenterology and Nutrition, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Sohela Shah
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143
| | - Joel E. Lavine
- Department of Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital/Columbia University, NY, NY 10032
| | - David Suskind
- Department of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington Medical School of Medicine, Seattle, WA 98105
| | - Mohammed Al-Edreesi
- Pediatric Specialty Services Division, Dhahran Health Center, Saudi Aramco, Dhahran, Saudi Arabia
| | - Carol Potter
- Department of Gastroenterology and Nutrition, Nationwide Children's Hospital, The Ohio State University, Columbus, OH 43205
| | - David W. Russell
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Nancy C. O'Connell
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Brian Wolfe
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Pinky Jha
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Wujuan Zhang
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Kevin E. Bove
- Department of Pathology and Laboratory Medicine, Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Alex S. Knisely
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Alan F. Hofmann
- Department of Medicine, University of California San Diego, San Diego, CA 92093-063
| | - Philip Rosenthal
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143,Departments of Pediatrics and Surgery, University of California, San Francisco Medical Center, San Francisco, CA 94143
| | - Laura N. Bull
- UCSF Liver Center Laboratory and Institute for Human Genetics, University of California, San Francisco Medical Center, San Francisco, CA 94143
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Kalkwarf HJ, Zemel BS, Yolton K, Heubi JE. Bone mineral content and density of the lumbar spine of infants and toddlers: influence of age, sex, race, growth, and human milk feeding. J Bone Miner Res 2013; 28:206-12. [PMID: 22887693 PMCID: PMC3527676 DOI: 10.1002/jbmr.1730] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 07/20/2012] [Accepted: 07/23/2012] [Indexed: 11/11/2022]
Abstract
Little is known about factors that affect bone mass and density of infants and toddlers and the means to assess their bone health owing to challenges in studying this population. The objectives of this study were to describe age, sex, race, growth, and human milk feeding effects on bone mineral content (BMC) and areal density (aBMD) of the lumbar spine, and determine precision of BMC and aBMD measurements. We conducted a cross-sectional study of 307 healthy participants (63 black), ages 1 to 36 months. BMC and aBMD of the lumbar spine were measured by dual-energy X-ray absorptiometry. Duplicate scans were obtained on 76 participants for precision determination. Age-specific Z-scores for aBMD, weight, and length (BMDZ, WAZ, LAZ) were calculated. Information on human milk feeding duration was ascertained by questionnaire. Between ages 1 and 36 months, lumbar spine BMC increased about fivefold and aBMD increased twofold (p < 0.0001). BMC was greater (5.8%) in males than in females (p = 0.001), but there was no difference in aBMD (p = 0.37). There was no difference in BMC or aBMD between whites and blacks (p ≥ 0.16). WAZ and LAZ were positively associated with BMDZ (r = 0.34 and 0.24, p < 0.001). Duration of human milk feeding was negatively associated with BMDZ in infants <12 months of age (r = -0.42, p < 0.001). Precision of BMC and aBMD measurements was good, 2.20% and 1.84%, respectively. Dramatic increases in BMC and aBMD of the lumbar spine occur in the first 36 months of life. We provide age-specific values for aBMD of healthy infants and toddlers that can be used to evaluate bone deficits. Future studies are needed to identify the age when sex and race differences in aBMD occur, and how best to account for delayed or accelerated growth in the context of bone health assessment of infants and toddlers.
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Affiliation(s)
- Heidi J Kalkwarf
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Ramprasath VR, Jones PJH, Buckley DD, Woollett LA, Heubi JE. Decreased plasma cholesterol concentrations after PUFA-rich diets are not due to reduced cholesterol absorption/synthesis. Lipids 2012; 47:1063-71. [PMID: 22965757 DOI: 10.1007/s11745-012-3708-8] [Citation(s) in RCA: 22] [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] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 07/30/2012] [Indexed: 12/18/2022]
Abstract
Plasma cholesterol concentrations increase with consumption of high saturated fatty acid (SFA) and decrease with high polyunsaturated fatty acid (PUFA) diets, leading to shifts in lipid levels consistent with reduction in heart disease risk. Direct measurements of cholesterol absorption, one of the key regulators of plasma cholesterol levels, have not been performed in humans after consumption of high PUFA diets. Thus, cholesterol absorption and fractional synthesis rates (FSRs) were measured in 16 healthy adults (8 males and 9 females) using a randomized cross-over study with a diet containing high (PUFA/SFA) P/S ratio (2:1) and a low P/S ratio (0.5:1). Cholesterol absorption and fractional cholesterol synthetic rates were measured using stable isotopes after 20 days of dietary intervention. Diet did not affect cholesterol absorption or synthesis. There was a significant decrease in plasma cholesterol concentrations (P < 0.02), specifically LDL-cholesterol (P < 0.02), without a change in HDL-cholesterol or triacylglycerol concentrations. Intraluminal cholesterol solubilization and plasma sterol (cholesterol biosynthetic intermediates and plant sterols) levels were not affected by diet. Thus, consumption of diets with a high P/S ratio reduces plasma total and LDL-cholesterol concentrations independent of shifts in cholesterol absorption or synthesis.
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Affiliation(s)
- Vanu R Ramprasath
- Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, R3T 2N2, Canada
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Hicks PD, Hawthorne KM, Berseth CL, Marunycz JD, Heubi JE, Abrams SA. Total calcium absorption is similar from infant formulas with and without prebiotics and exceeds that in human milk-fed infants. BMC Pediatr 2012; 12:118. [PMID: 22871243 PMCID: PMC3439330 DOI: 10.1186/1471-2431-12-118] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 08/02/2012] [Indexed: 12/04/2022] Open
Abstract
Background 1) To evaluate calcium absorption in infants fed a formula containing prebiotics (PF) and one without prebiotics (CF). 2) To compare calcium absorption from these formulas with a group of human milk-fed (HM) infants. Methods A dual tracer stable isotope method was used to assess calcium absorption in infants exclusively fed CF (n = 30), PF (n = 25) or HM (n = 19). Analysis of variance was used to analyze calcium intake, fractional calcium absorption, and the amount of calcium absorbed. Results Calcium intake (Mean ± SEM) for PF was 534 ± 17 mg/d and 557 ± 16 mg/d for CF (p = 0.33). Fractional calcium absorption was 56.8 ± 2.6 % for PF and 59.2 ± 2.3 % for CF (p = 0.49). Total calcium absorbed for PF was 300 ± 14 mg/d and 328 ± 13 mg/d for CF (p = 0.16). For HM infants calcium intake was 246 ± 20 mg/d, fractional calcium absorption was 76.0 ± 2.9 % and total calcium absorbed was 187 ± 16 mg/d (p <0.001, compared to either PF or CF). Conclusions Despite lower fractional calcium absorption of CF and PF compared to HM, higher calcium content in both led to higher total calcium absorption compared to HM infants. No significant effect of prebiotics was observed on calcium absorption or other markers of bone mineral metabolism.
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Prada CE, Kaul A, Hopkin RJ, Page KI, Nathan JD, Bartholomew DW, Cohen MB, Heubi JE, Leslie ND, Burrow TA. Recurrent pancreatitis in ornithine transcarbamylase deficiency. Mol Genet Metab 2012; 106:482-4. [PMID: 22728053 DOI: 10.1016/j.ymgme.2012.06.005] [Citation(s) in RCA: 2] [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] [Received: 04/22/2012] [Revised: 06/07/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
Abstract
Ornithine transcarbamylase (OTC) deficiency is a urea cycle defect with varying frequency and severity of episodes of hyperammonemia. We report three patients with OTC deficiency with recurrent pancreatitis. The pathogenesis of acute pancreatitis in this patient population requires further elucidation. Pancreatitis significantly affected dietary/metabolic management and increased frequency of hospitalizations.
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Affiliation(s)
- Carlos E Prada
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, USA
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Dawodu A, Zalla L, Woo JG, Herbers PM, Davidson BS, Heubi JE, Morrow AL. Heightened attention to supplementation is needed to improve the vitamin D status of breastfeeding mothers and infants when sunshine exposure is restricted. Matern Child Nutr 2012; 10:383-97. [PMID: 22708508 DOI: 10.1111/j.1740-8709.2012.00422.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Although exclusively breastfed infants are at increased risk of vitamin D (vit D) deficiency if vit D supplementation is lacking and sun exposure is limited, assessment of both risk factors in the first year of life is lacking. We evaluated the contribution of vit D intake and sunlight exposure to vit D status in 120 healthy, breastfeeding mother-infant dyads, who were followed up for 1 year. Vitamin D intake and skin sunlight exposure were evaluated using questionnaires. Serum 25-hydroxyvitamin D, parathyroid hormone (PTH) and alkaline phosphatase levels were determined post-natally in mothers at 4 weeks and in infants at 4, 26 and 52 weeks. Vitamin D supplementation was low (<20%) and sunlight exposure was common (93%) in study infants. At 4 weeks, 17% of mothers were vit D deficient (<50 nmol L(-1)) and 49% were insufficient (50-<75 nmol L(-1)), while 18% of infants were severely vit D deficient (<25 nmol L(-1)) and 77% were deficient (<50 nmol L(-1)). At 26 weeks, winter/spring birth season and shorter duration of months of exclusive breastfeeding were protective of vit D deficiency in infants. Vitamin D deficiency in infants decreased to 12% at 52 weeks with sunlight exposure. Serum PTH levels were significantly higher in severely vit D deficient than sufficient infants. Vitamin D deficiency was widespread in early post-partum breastfeeding mothers and infants, and declined to one in eight infants at 52 weeks due mostly to sunshine exposure. When sunlight exposure is limited or restricted, intensified vit D supplementation of breastfeeding mothers and infants is needed to improve vit D status.
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Affiliation(s)
- Adekunle Dawodu
- Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA The Perinatal Institute's Center for Interdisciplinary Research in Human Milk and Lactation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Hepatology, Gastroenterology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Woo JG, Summer SS, Morrow AL, Heubi JE. Relationship between maternal diet, plasma lipids and human milk cholesterol and fatty acids. FASEB J 2012. [DOI: 10.1096/fasebj.26.1_supplement.390.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jessica Graus Woo
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOH
| | - Suzanne S Summer
- Clinical Translational Research CenterCincinnati Children's Hospital Medical CenterCincinnatiOH
| | - Ardythe L Morrow
- Perinatal InstituteCincinnati Children's Hospital Medical CenterCincinnatiOH
| | - James E Heubi
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOH
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Setchell KDR, Brown NM, Zhao X, Lindley SL, Heubi JE, King EC, Messina MJ. Soy isoflavone phase II metabolism differs between rodents and humans: implications for the effect on breast cancer risk. Am J Clin Nutr 2011; 94:1284-94. [PMID: 21955647 PMCID: PMC3192476 DOI: 10.3945/ajcn.111.019638] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Human and animal studies have produced conflicting results with regard to the effect of soy isoflavones on breast cancer risk. This may be due to differences in isoflavone metabolism. OBJECTIVE The objective of this study was to determine whether soy isoflavone phase II metabolism differs between humans and rodents. DESIGN Circulating total and unconjugated isoflavone concentrations were determined by mass spectrometry in plasma samples from 7 separate studies: 1) in Sprague-Dawley rats and in 3 strains of mice fed commercial soy-containing diets; 2) in Sprague-Dawley rats gavaged with genistein; 3) in healthy adults who consumed single servings of soy nuts, soy milk, and tempeh; 4) in healthy adults subchronically given soy milk; 5) in healthy women orally administered 50 mg genistein; 6) in healthy women orally administered 20 mg pure S-(-)equol; and 7) in 6-mo-old infants fed soy infant formula and later, at age 3 y, a soy germ isoflavone supplement. RESULTS The proportion of unconjugated genistein in plasma from adults and infants who consumed different soy foods, pure genistein, or an isoflavone supplement was <1% in steady state and <2% at peak concentrations. By contrast, rodents fed soy-containing diets conjugate isoflavones less efficiently. The plasma percentages of unconjugated genistein concentrations in Sprague-Dawley rats and C57BL/6, nude, and transgenic AngptL4B6 mice were 4.0 ± 0.6%, 4.6 ± 0.6%, 11.6 ± 0%, and 30.1 ± 4.3%, respectively, which represent 20, 23, 58, and 150 times that in humans. CONCLUSION The markedly higher circulating concentrations of biologically active (unconjugated) genistein in certain strains of mice cast doubt on the value of the use of these rodents for gaining insight into the effects of isoflavones in humans, especially with regard to the effects on breast tissue.
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Affiliation(s)
- Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, OH 45229, USA.
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Mizukawa B, George A, Pushkaran S, Weckbach L, Kalinyak K, Heubi JE, Kalfa TA. Cooperating G6PD mutations associated with severe neonatal hyperbilirubinemia and cholestasis. Pediatr Blood Cancer 2011; 56:840-2. [PMID: 20949590 PMCID: PMC3023834 DOI: 10.1002/pbc.22744] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 06/15/2010] [Indexed: 11/05/2022]
Abstract
We report a novel glucose-6-phosphate dehydrogenase (G6PD) mutation, which we propose to name G6PD Cincinnati (c.1037A > T, p.N346I), found in combination with G6PD Gastonia (c.637G > T, p.V213L) in an infant who presented with neonatal cholestasis. The G6PD Cincinnati mutation results in a non-conservative amino acid substitution at the tetramer interface disturbing its formation, as seen by native gel electrophoresis and immunoblotting. G6PD Gastonia disrupts dimerization of the enzyme and by itself causes chronic non-spherocytic hemolytic anemia. The G6PD Cincinnati mutation may have aggravated the clinical picture of G6PD Gastonia with the result of severe perinatal hemolysis causing cholestasis and associated liver injury.
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Affiliation(s)
- Benjamin Mizukawa
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alex George
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Suvarnamala Pushkaran
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lana Weckbach
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - KarenAnn Kalinyak
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - James E. Heubi
- Gastroenterology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Theodosia A. Kalfa
- Hematology-Oncology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
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Kohli R, Kirby M, Setchell KDR, Jha P, Klustaitis K, Woollett LA, Pfluger PT, Balistreri WF, Tso P, Jandacek RJ, Woods SC, Heubi JE, Tschoep MH, D'Alessio DA, Shroyer NF, Seeley RJ. Intestinal adaptation after ileal interposition surgery increases bile acid recycling and protects against obesity-related comorbidities. Am J Physiol Gastrointest Liver Physiol 2010; 299:G652-60. [PMID: 20595624 PMCID: PMC2950688 DOI: 10.1152/ajpgi.00221.2010] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Surgical interposition of distal ileum into the proximal jejunum is a bariatric procedure that improves the metabolic syndrome. Changes in intestinal and hepatic physiology after ileal interposition (transposition) surgery (IIS) are not well understood. Our aim was to elucidate the adaptation of the interposed ileum, which we hypothesized, would lead to early bile acid reabsorption in the interposed ileum, thus short circuiting enterohepatic bile acid recycling to more proximal bowel segments. Rats with diet-induced obesity were randomized to IIS, with 10 cm of ileum repositioned distal to the duodenum, or sham surgery. A subgroup of sham rats was pair-fed to IIS rats. Physiological parameters were measured until 6 wk postsurgery. IIS rats ate less and lost more weight for the first 2 wk postsurgery. At study completion, body weights were not different, but IIS rats had reversed components of the metabolic syndrome. The interposed ileal segment adapted to a more jejunum-like villi length, mucosal surface area, and GATA4/ILBP mRNA. The interposed segment retained capacity for bile acid reabsorption and anorectic hormone secretion with the presence of ASBT and glucagon-like-peptide-1-positive cells in the villi. IIS rats had reduced primary bile acid levels in the proximal intestinal tract and higher primary bile acid levels in the serum, suggesting an early and efficient reabsorption of primary bile acids. IIS rats also had increased taurine and glycine-conjugated serum bile acids and reduced fecal bile acid loss. There was decreased hepatic Cyp27A1 mRNA with no changes in hepatic FXR, SHP, or NTCP expression. IIS protects against the metabolic syndrome through short-circuiting enterohepatic bile acid recycling. There is early reabsorption of primary bile acids despite selective "jejunization" of the interposed ileal segment. Changes in serum bile acids or bile acid enterohepatic recycling may mediate the metabolic benefits seen after bariatric surgery.
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Affiliation(s)
- Rohit Kohli
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, USA.
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Affiliation(s)
- James E Heubi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Dorsey J, Buckley D, Summer S, Jandacek RJ, Rider T, Tso P, Narkewicz MR, Heubi JE. Fat malabsorption in cystic fibrosis: comparison of quantitative fat assay and a novel assay using fecal lauric/behenic acid. J Pediatr Gastroenterol Nutr 2010; 50:441-6. [PMID: 20179641 PMCID: PMC2847657 DOI: 10.1097/mpg.0b013e3181b18308] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The gold standard for the diagnosis of fat malabsorption, the 72-hour fat balance study, requires a 3-day collection to generate a coefficient of fat absorption (CFA). We hypothesized that a new test using behenic acid (behenate test) as a nonabsorbable lipid marker may provide a facile means to assess fat absorption. The study proposed to answer 2 questions: first, whether the behenate test correlated with the gold standard and, second, whether the CFA improved when taking pancreatic enzymes during meals instead of taking them before meals. PATIENTS AND METHODS The study compared the behenate test with the gold standard in 15 patients with cystic fibrosis during 3 arms that require 3- to 4-day hospitalization: first, taking pancreatic enzymes before meals; second, taking it during meals; and third, without taking it. RESULTS The mean CFA was 78.3% when pancreatic enzymes were taken during meals and 80.4% when these enzymes were taken before meals. Correlation between the CFA and the behenate test for collections during all 3 arms was r = 0.219 (P = 0.001). CONCLUSIONS Timing of ingestion of pancreatic enzymes does not significantly alter the CFA. Although the CFA correlates with the behenate test, the correlation is not robust enough to justify replacement of the gold standard by this test. It is unclear whether the poor correlation between tests relates to intermeal variability in fat excretion or other factors; however, the behenate test may be suitable as a screening test for the detection of fat malabsorption.
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Affiliation(s)
| | - Donna Buckley
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center; General Clinical Research Center, Cincinnati Children’s Hospital Medical Center
| | - Suzanne Summer
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center; General Clinical Research Center, Cincinnati Children’s Hospital Medical Center
| | | | - Therese Rider
- Department of Pathology, University of Cincinnati College of Medicine
| | - Patrick Tso
- Department of Pathology, University of Cincinnati College of Medicine
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology and Nutrition, and Pediatric Pulmonology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital, Aurora, CO
| | - James E. Heubi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center; General Clinical Research Center, Cincinnati Children’s Hospital Medical Center
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Wooldridge JL, Heubi JE, Amaro-Galvez R, Boas SR, Blake KV, Nasr SZ, Chatfield B, McColley SA, Woo MS, Hardy KA, Kravitz RM, Straforini C, Anelli M, Lee C. EUR-1008 pancreatic enzyme replacement is safe and effective in patients with cystic fibrosis and pancreatic insufficiency. J Cyst Fibros 2009; 8:405-17. [DOI: 10.1016/j.jcf.2009.07.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 07/16/2009] [Accepted: 07/20/2009] [Indexed: 02/02/2023]
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Abstract
OBJECTIVES : In 2001, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition created Teaching and Tomorrow, a novel pediatric subspecialty recruitment program to provide prospective fellows the opportunity to participate in the society's annual meeting and to interact with current trainees and members. The aims of this report are to describe participant survey data from the first 4 years of the program and to explore potential influences of participation on outcomes and proposed career choices. MATERIALS AND METHODS : Pre- and postprogram surveys were administered during opening and closing breakfast meetings, respectively, to ascertain demographics, certainty of career intent, factors influencing choice of specialty, and anticipated benefits from participation. RESULTS : Among 189 applications, 107 (57%) participated and 107 (57%) matriculated into gastroenterology(GI) fellowship. The matriculation rate was similar between participants and nonparticipants. Among applicants who became GI fellows, there was a 42% lower odds of being female than male (OR 0.42; chi = 8.48, P < 0.01). Among participants who completed both pre- and postprogram surveys (n = 91) and who reported certainty about entering GI both before and after, 79% entered GI fellowship. Among participants who reported uncertainty about entering GI both before and after, 8% entered GI. More participants were interested in jobs as clinician-investigators and funded clinical or translational investigators. CONCLUSIONS : In a selected population of pediatric residents with high interest in pediatric gastroenterology, there was no difference in the matriculation rate into pediatric GI fellowship training among those who participated compared with those who did not. However, those who eventually matriculated had a higher odds of being male than female. There was a high retention rate of participants who were initially certain and a modest conversion rate of those who were initially uncertain about pursuing a career in pediatric GI.
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Affiliation(s)
- Rose C Graham
- *Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA daggerCincinnati Children's Medical Center, Cincinnati, OH, USA double daggerChildren's Hospital of Wisconsin, Milwaukee, WI, USA
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Gonzales E, Gerhardt MF, Fabre M, Setchell KDR, Davit-Spraul A, Vincent I, Heubi JE, Bernard O, Jacquemin E. Oral cholic acid for hereditary defects of primary bile acid synthesis: a safe and effective long-term therapy. Gastroenterology 2009; 137:1310-1320.e1-3. [PMID: 19622360 DOI: 10.1053/j.gastro.2009.07.043] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 06/20/2009] [Accepted: 07/09/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Oral bile acid replacement has been shown to be an effective therapy in primary bile acid synthesis defects, but to date there have been no reports of the long-term effects of this therapy. The aim of the study was to evaluate the long-term effectiveness and safety of cholic acid (CA) therapy. METHODS Fifteen patients with either 3beta-hydroxy-Delta(5)-C(27)-steroid oxidoreductase (3beta-HSD) (n = 13) or Delta(4)-3-oxosteroid 5beta-reductase (Delta(4)-3-oxo-R) (n = 2) deficiency confirmed by mass spectrometry and gene sequencing received oral CA and were followed up prospectively. RESULTS CA therapy was started at a median age of 3.9 years (range, 0.3-13.1 years). The median follow-up with treatment was 12.4 years (range, 5.6-15 years). The mean daily dose of CA was initially 13 mg/kg and was 6 mg/kg at last evaluation. During CA therapy, physical examination findings, laboratory test results, and findings on sonography normalized. Mass spectrometry analysis of urine showed that excretion of the atypical metabolites was reduced by 500-fold and 30-fold in 3beta-HSD and Delta(4)-3-oxo-R deficiency, respectively, and total urinary bile acid excretion decreased dramatically. Liver biopsies performed in 14 patients after at least 5 years of CA therapy showed marked improvement, especially in patients with the 3beta-HSD deficiency. CA was well tolerated with all children developing normally, including 2 women having 4 normal pregnancies during treatment. CONCLUSIONS Oral CA therapy is a safe and effective long-term treatment of the most common primary bile acid synthesis defects.
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Affiliation(s)
- Emmanuel Gonzales
- Pediatric Hepatology Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
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Setchell KD, Zhao X, Jha P, Heubi JE, Brown NM. The pharmacokinetic behavior of the soy isoflavone metabolite S-(-)equol and its diastereoisomer R-(+)equol in healthy adults determined by using stable-isotope-labeled tracers. Am J Clin Nutr 2009; 90:1029-37. [PMID: 19710188 PMCID: PMC2744624 DOI: 10.3945/ajcn.2009.27981] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 07/28/2009] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The nonsteroidal estrogen equol occurs as diastereoisomers, S-(-)equol and R-(+)equol, both of which have significant biological actions. S-(-)equol, the naturally occurring enantiomer produced by 20-30% of adults consuming soy foods, has selective affinity for estrogen receptor-beta, whereas both enantiomers modulate androgen action. Little is known about the pharmacokinetics of the diastereoisomers, despite current interest in developing equol as a nutraceutical or pharmaceutical agent. OBJECTIVE The objective was to compare the pharmacokinetics of S-(-)equol and R-(+)equol by using [13C] stable-isotope-labeled tracers to facilitate the optimization of clinical studies aimed at evaluating the potential of these diastereoisomers in the prevention and treatment of estrogen- and androgen-dependent conditions. DESIGN A randomized, crossover, open-label study in 12 healthy adults (6 men and 6 women) compared the plasma and urinary pharmacokinetics of orally administered enantiomeric pure forms of S-(-)[2-13C]equol, R-(+)[2-13C]equol, and the racemic mixture. Plasma and urinary [13C]R-equol and [13C]S-equol concentrations were measured by tandem mass spectrometry. RESULTS Plasma [13C]equol concentration appearance and disappearance curves showed that both enantiomers were rapidly absorbed, attained high circulating concentrations, and had a similar terminal elimination half-life of 7-8 h. The systemic bioavailability and fractional absorption of R-(+)[2-13C]equol were higher than those of S-(-)[2-13C]equol or the racemate. The pharmacokinetics of racemic (+/-)[2-13C]equol were different from those of the individual enantiomers: slower absorption, lower peak plasma concentrations, and lower systemic bioavailability. CONCLUSIONS The high bioavailability of both diastereoisomers contrasts with previous findings for the soy isoflavones daidzein and genistein, both of which have relatively poor bioavailability, and suggests that low doses of equol taken twice daily may be sufficient to achieve biological effects.
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Affiliation(s)
- Kenneth Dr Setchell
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Burke KT, Horn PS, Tso P, Heubi JE, Woollett LA. Hepatic bile acid metabolism in the neonatal hamster: expansion of the bile acid pool parallels increased Cyp7a1 expression levels. Am J Physiol Gastrointest Liver Physiol 2009; 297:G144-51. [PMID: 19389801 PMCID: PMC2711759 DOI: 10.1152/ajpgi.90515.2008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intraluminal concentrations of bile acids are low in newborn infants and increase rapidly after birth, at least partly owing to increased bile acid synthesis rates. The expansion of the bile acid pool is critical since bile acids are required to stimulate bile flow and absorb lipids, a major component of newborn diets. The purpose of the present studies was to determine the mechanism responsible for the increase in bile acid synthesis rates and the subsequent enlargement of bile acid pool sizes (BAPS) during the neonatal period, and how changes in circulating hormone levels might affect BAPS. In the hamster, pool size was low just after birth and increased modestly until 10.5 days postpartum (dpp). BAPS increased more significantly ( approximately 3-fold) between 10.5 and 15.5 dpp. An increase in mRNA and protein levels of cholesterol 7alpha-hydroxylase (Cyp7a1), the rate-limiting step in classical bile acid synthesis, immediately preceded an increase in BAPS. In contrast, levels of oxysterol 7alpha-hydroxylase (Cyp7b1), a key enzyme in bile acid synthesis by the alternative pathway, were relatively elevated by 1.5 dpp. farnesyl X receptor (FXR) and short heterodimeric partner (SHP) mRNA levels remained relatively constant at a time when Cyp7a1 levels increased. Finally, although simultaneous increases in circulating cortisol and Cyp7a1 levels occurred, precocious expression of Cyp7a1 could not be induced in neonatal hamsters with dexamethasone. Thus the significant increase in Cyp7a1 levels in neonatal hamsters is due to mechanisms independent of the FXR and SHP pathway and cortisol.
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Affiliation(s)
- Katie T. Burke
- Departments of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati Medical School, and Mathematical Sciences, University of Cincinnati; and Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, General Clinical Research Center, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Paul S. Horn
- Departments of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati Medical School, and Mathematical Sciences, University of Cincinnati; and Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, General Clinical Research Center, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Tso
- Departments of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati Medical School, and Mathematical Sciences, University of Cincinnati; and Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, General Clinical Research Center, Children's Hospital Medical Center, Cincinnati, Ohio
| | - James E. Heubi
- Departments of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati Medical School, and Mathematical Sciences, University of Cincinnati; and Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, General Clinical Research Center, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Laura A. Woollett
- Departments of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati Medical School, and Mathematical Sciences, University of Cincinnati; and Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, General Clinical Research Center, Children's Hospital Medical Center, Cincinnati, Ohio
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Steinberg SJ, Snowden A, Braverman NE, Chen L, Watkins PA, Clayton PT, Setchell KDR, Heubi JE, Raymond GV, Moser AB, Moser HW. A PEX10 defect in a patient with no detectable defect in peroxisome assembly or metabolism in cultured fibroblasts. J Inherit Metab Dis 2009; 32:109-19. [PMID: 19127411 DOI: 10.1007/s10545-008-0969-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [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] [Received: 05/30/2008] [Revised: 09/10/2008] [Accepted: 10/09/2008] [Indexed: 11/28/2022]
Abstract
Zellweger spectrum disorders (ZSD) are diagnosed by biochemical assay in blood, urine and cultured fibroblasts and PEX gene mutation identification. In most cases studies in fibroblasts corroborate results obtained in body fluids. In 1996 Clayton and colleagues described a 10-year old girl with evidence of a peroxisome disorder, based on elevated bile acid metabolites and phytanate. At the time it was not possible to distinguish whether she had a ZSD or a single peroxisomal protein defect. Studies in our laboratory showed that she also had elevated plasma pipecolate, supporting the former diagnosis. Despite the abnormal metabolites detected in blood (phytanate, bile acid intermediates and pipecolate), analysis of multiple peroxisomal pathways in fibroblasts yielded normal results. In addition, she had a milder clinical phenotype than usually associated with ZSD. Since complementation analysis to determine the gene defect was not possible, we screened this patient following the PEX Gene Screen algorithm (PGS). The PGS provides a template for sequencing PEX gene exons independent of complementation analysis. Two mutations in PEX10 were identified, a frameshift mutation inherited from her father and a de novo missense mutation in a conserved functional domain on the other allele. This case highlights that molecular analysis may be essential to the diagnosis of patients at the milder end of the ZSD spectrum. Furthermore, it supports the concept that some tissues are less affected by certain PEX gene defects than brain and liver.
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Affiliation(s)
- S J Steinberg
- Neurogenetics, Kennedy Krieger Institute, Baltimore, Maryland 21205, USA.
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Perman MJ, Lucky AW, Heubi JE, Azizkhan RG. Severe Symptomatic Hypocalcemia in a Patient With RDEB Treated With Intravenous Zoledronic Acid. ACTA ACUST UNITED AC 2009; 145:95-6. [DOI: 10.1001/archdermatol.2008.536] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
The objective of this study was to determine the impact of glucocorticoid exposure on lumbar spine bone mineral density (BMD) in children while concurrently measuring their calcium intake, serum 25-OH vitamin D levels, and physical activity. Forty-three patients (4-18 years) with renal glomerular diseases, dermatomyositis, inflammatory bowel disease, juvenile rheumatoid arthritis, post-solid organ transplant, and Duchenne muscular dystrophy were studied. All received at least 5 mg per day of prednisone for more than 6 months. The mean BMD z score was 0 +/- 0.2 (range, -3.8 to +3.3) with 2 patients (5%) having z scores less than -2. The mean daily calcium intake was 1147 +/- 145 g, with 1 patient having hypovitaminosis D (<15 ng/mL). The mean physical activity level was 7.8 +/- 0.8 h/wk. The small reductions in BMD observed in our population suggest that screening is likely not warranted in all children with chronic glucocorticoid exposure.
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Affiliation(s)
- Valeria C Cohran
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital, Chicago, Illinois 60614, USA.
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Abstract
Bile acids are synthesized by the liver from cholesterol through a complex series of reactions involving at least 14 enzymatic steps. A failure to perform any of these reactions will block bile acid production with failure to produce "normal bile acids" and, instead, result in the accumulation of unusual bile acids and intermediary metabolites. Failure to synthesize bile acids leads to reduced bile flow and decreased intraluminal solubilization of fat and fat-soluble vitamins. In some circumstances, the intermediates created because of blockade in the bile acid biosynthetic pathway may be toxic to hepatocytes. Nine recognized inborn errors of bile acid metabolism have been identified that lead to enzyme deficiencies and impaired bile acid synthesis in infants, children, and adults. Patients may present with neonatal cholestasis, neurologic disease, or fat and fat-soluble vitamin malabsorption. If untreated, progressive liver disease may develop or reduced intestinal bile acid concentrations may lead to serious morbidity or mortality. This review focuses on a description of the disorders of bile acid synthesis that are directly related to single defects in the metabolic pathway, their proposed pathogenesis, treatment, and prognosis.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229-3039, USA
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