Genetic landscape of pediatric acute liver failure of indeterminate origin.

BACKGROUND AIMS Pediatric acute liver failure (PALF) is a life-threatening condition. In Europe, main causes are viral infections (12-16%) and inherited metabolic diseases (14-28%). Yet, in up to 50% of cases the underlying etiology remains elusive, challenging clinical management, including liver transplantation. We systematically studied indeterminate PALF cases referred for genetic evaluation by whole-exome sequencing (WES), and analyzed phenotypic and biochemical markers, and the diagnostic yield of WES in this condition. METHODS With this international, multicenter observational study, patients (0-18 y) with indeterminate PALF were analyzed by WES. Data on the clinical and biochemical phenotype were retrieved and systematically analyzed. RESULTS In total, 260 indeterminate PALF patients from 19 countries were recruited between 2011 and 2022, of whom 59 had recurrent PALF (RALF). WES established a genetic diagnosis in 37% of cases (97/260). Diagnostic yield was highest in children with PALF in the first year of life (46%), and in children with RALF (64%). Thirty-six distinct disease genes were identified. Defects in NBAS (n=20), MPV17 (n=8) and DGUOK (n=7) were the most frequent findings. When categorizing, most frequent were mitochondrial diseases (45%), disorders of vesicular trafficking (28%) and cytosolic aminoacyl-tRNA synthetase deficiencies (10%). One-third of patients had a fatal outcome. Fifty-six patients received liver transplants. CONCLUSION This study elucidates a large contribution of genetic causes in PALF of indeterminate origin with an increasing spectrum of disease entities. The high proportion of diagnosed cases and potential treatment implications argue for exome or in future rapid genome sequencing in PALF diagnostics

Study of endothelial adhesion molecules in patients with haemoglobinopathies

Hemoglobinopathies are the most common single gene disorders worldwide, characterised by decreased (Thalassaemias) or abnormal (i.e. Sickle Cell Disease) globin chain synthesis. The role of endothelial activation in Sickle Cell Disease has been shown through many studies. However, there are only few in vitro studies concerning Thalassaemia. The purpose of this study was to determine the levels of certain endothelial activation markers which possibly interfere in the pathophysiology of Sickle Cell Disease and Thalassaemias. We included in our study 35 patients with Thalassaemia Intermedia (TI) and 28 patients with Sickle Cell Disease (SCD), selected from the Laboratory of Human Genetics of Athens University (Choremio Laboratory) and the First Department of Internal Medicine of the Medical School of Athens. 20 healthy individuals were included in the control group. Immuno-enzymatic assays, performed in the Biochemistry Laboratory of “Aghia Sophia” Children’s Hospital, were used to measure the serum levels of sICAM-1, sVCAM-1, thrombomoduline (sTM), P and E selectin, as well as the levels of two inflammation markers, CRP and serum amyloid (SAA). We used STATGRAFICS PLUS 5.1 for Windows (Graphic Software System) for the statistic analysis of our results. In the group of patients with SCD in steady state, the levels of endothelial activation markers were increased, confirming the activation and malfunction of the endothelium layer. Levels of CRP and SAA were also increased, reflecting the inflammation state of these patients. Treatment with hydroxyuria helped decrease the levels of sICAM, sVCAM και sΤΜ, but not significantly, whereas venesections did not result in any change. Furthermore, we did not observe any correlation of the levels of the above mentioned molecules with the degree of patients’ anemia. In the group of patients with TI, the levels of endothelial activation markers were increased, showing, as in the SCD group, endothelial activation. Levels of CRP and SAA were also increased, as a result of chronic inflammation of these patients. Treatment with hydroxyuria or splenectomy did not decrease the levels of the above mentioned molecules. Finally, as in the SCD group, we did not observe any correlation with the degree of patients’ anemia. As a conclusion, the results of this study confirm the role of endothelial activation in the pathophysiology of SCD and indicate that similar mechanisms, which have previously been described in patients with β-Thalassaemia Major, are implied in the pathogenesis of TI.Οι αιμοσφαιρινοπάθειες αποτελούν αυτοσωμικά κληρονομικά νοσήματα που προκαλούν κυρίως ποσοτικές (Μεσογειακά Σύνδρομα) αλλά και ποιοτικές (πχ ρεπανοκυτταρική Νόσος) διαταραχές της σύνθεσης των πολυπεπτιδικών αλυσίδων της αιμοσφαιρίνης. Ο ρόλος του ενεργοποιημένου ενδοθηλίου στη ρεπανοκυτταρική Νόσο έχει αποδειχτεί μέσα από πολυάριθμες μελέτες. Σε ό,τι αφορά τα Μεσογειακά Σύνδρομα, οι αντίστοιχες μελέτες είναι πιο περιορισμένες και παραμένουν κυρίως σε εργαστηριακό επίπεδο. Σκοπός της παρούσας μελέτης ήταν ο προσδιορισμός των επιπέδων των μορίων-δεικτών ενεργοποίησης του ενδοθηλίου που πιθανά να εμπλέκονται στην παθοφυσιολογία της ρεπανοκυτταρικής Νόσου και των Μεσογειακών Συνδρόμων και η μελέτη των μεταξύ τους συσχετίσεων. Στη μελέτη περιελήφθησαν 35 ασθενείς με Ενδιάμεση Μεσογειακή Αναιμία (ΕΜΑ) και 28 ασθενείς με ρεπανοκυτταρική Νόσο ( Ν), προερχόμενοι από τη Μονάδα Αναιμιών του Εργαστηρίου Ιατρικής Γενετικής του Πανεπιστημίου Αθηνών (Χωρέμειο Εργαστήριο) και της Α Παθολογικής Κλινικής του Πανεπιστημίου Αθηνών. Συμμετείχαν επίσης 20 υγιείς μάρτυρες. Μελετήθηκαν τα επίπεδα στον ορό των sICAM-1, sVCAM-1, θρομβομοντουλίνης (sTM), P και E σελεκτίνης, όπως και τα επίπεδα των CRP και S-αμυλοειδούς (SAA) ως δείκτες φλεγμονης. Ο προσδιορισμός των επιπέδων των μορίων έγινε με ανοσοενζυματικές μεθόδους στο Εργαστήριο Βιοχημείας του Νοσοκομείου Παίδων « Αγία Σοφία ». Για τη στατιστική επεξεργασία των αποτελεσμάτων χρησιμοποιήθηκε το πρόγραμμα STATGRAFICS PLUS 5.1 for Windows (Graphic Software System). Στους ασθενείς με Ν τα επίπεδα των μορίων προσκόλλησης του ενδοθηλίου στον ορό, σε συνθήκες ηρεμίας («steady state»), βρέθηκαν αυξημένα σε σχέση με τους υγιείς μάρτυρες, επιβεβαιώνοντας την ενεργοποίηση και τη δυσλειτουργία του ενδοθηλίου ακόμα και στους ασθενείς που βρίσκονται εκτός περιόδου ενεργού κρίσης. Αυξημένα βρέθηκαν επίσης τα επίπεδα CRP και SAA, αντικατοπτρίζοντας το φλεγμονώδη χαρακτήρα της νόσου. Η λήψη υδροξυουρίας πιθανά να βελτιώνει το βιολογικό προφίλ των ασθενών, καθώς στην αντίστοιχη ομάδα τα επίπεδα sICAM, sVCAM και sΤΜ βρέθηκα ελαττωμένα, αλλά όχι σε στατιστικά σημαντικό επίπεδο, ενώ οι θεραπευτικού χαρακτήρα αφαιμάξεις δεν επέφεραν κάποια αλλαγή στην έκφραση των παραπάνω μορίων προσκόλλησης. Τέλος, τα επίπεδα των μορίων προσκόλλησης του ενδοθηλίου δε βρέθηκαν να συσχετίζονται με το βαθμό αναιμίας των ασθενών. Όπως και στους ασθενείς με Ν, έτσι και στους ασθενείς με ΕΜΑ παρατηρήθηκε αύξηση των επιπέδων των μορίων προσκόλλησης του ενδοθηλίου στον ορό σε σχέση με τους υγιείς μάρτυρες. Επιπλέον, τόσο η CRP όσο και το SAA βρέθηκαν αυξημένα σε σχέση με τον υγιή πληθυσμό, ως αποτέλεσμα της χρόνιας φλεγμονής η οποία παρατηρείται σε αυτούς τους ασθενείς. Σε σχέση με τη θεραπεία, δεν παρατηρούνται στατιστικά σημαντικές διαφορές στα επίπεδα των μορίων αυτών μεταξύ των ασθενών που λαμβάνουν υδροξυουρία και εκείνων που δεν υπόκεινται στην ίδια αγωγή, όπως επίσης δεν παρατηρήθηκε στατιστικά σημαντική διαφορά στα επίπεδα των αντίστοιχων μορίων στους ασθενείς που έχουν υποβληθεί σε σπληνεκτομή. Τέλος, όπως και στους πάσχοντες από Ν, τα επίπεδα των μορίων προσκόλλησης του ενδοθηλίου δε βρέθηκαν να συσχετίζονται με το βαθμό αναιμίας των ασθενών. Συμπερασματικά, τα αποτελέσματα της παρούσας μελέτης επιβεβαιώνουν τη συμμετοχή του ενεργοποιημένου ενδοθηλίου στην παθοφυσιολογία της Ν, ενώ αποδεικνύουν ότι παρόμοιες παθοφυσιολογικές διαταραχές, οι οποίες έχουν ήδη περιγραφεί νωρίτερα στους ασθενείς με μείζονα μεσογειακή αναιμία, ισχύουν και για τους ασθενείς με ΕΜΑ

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

We report a case of a premature infant presenting with recurrent pulmonary hemorrhage in which we performed a therapeutic lavage with diluted surfactant after an acute episode of bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10x2 mL) allowed rapid improvement in oxygenation and reduction of required mean airway pressures during high frequency oscillatory ventilation. This observation may suggest that surfactant lavage could be beneficial in massive pulmonary hemorrhage in infants. A randomized controlled trial might be needed to clarify the potential benefit of this therapeutic intervention on outcome of infants suffering from this life-threatening complication

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

We report a case of a premature infant presenting with recurrent pulmonary hemorrhage in which we performed a therapeutic lavage with diluted surfactant after an acute episode of bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10x2 mL) allowed rapid improvement in oxygenation and reduction of required mean airway pressures during high frequency oscillatory ventilation. This observation may suggest that surfactant lavage could be beneficial in massive pulmonary hemorrhage in infants. A randomized controlled trial might be needed to clarify the potential benefit of this therapeutic intervention on outcome of infants suffering from this life-threatening complication

Improvement in Intestinal-Failure-Associated Liver Disease by Using Parenteral Fish Oil as Monotherapy: Case-Based Review of the Literature

Intestinal-failure-associated liver disease (IFALD) is a common complication of prolonged parenteral nutrition (PN). Risk factors for IFALD include clinical features, as well as medical interventions, and its management was initially based on the decrease or interruption of parenteral nutrition while increasing enteral nutrition. However, the tolerance of full enteral nutrition in children with intestinal failure may require prolonged intestinal rehabilitation over a period of years. As a consequence, infants unable to wean from PN are prone to develop end-stage liver disease. We describe the case of an infant receiving long-term PN who was diagnosed with IFALD wherein we were able to reverse IFALD by switching lipid emulsions to fish oil monotherapy. A systemic review of case reports and case series on reversing IFALD using fish oil lipid emulsion follows the case description

Soluble endothelial adhesion molecules and inflammation markers in patients with beta-thalassemia intermedia

The term thalassemia intermedia, indicates a clinical condition of intermediate severity between thalassaemia minor, the asymptomatic carrier, and thalassaemia major, the transfusion-dependent, severe form. Thromboembolic events frequently complicate the outcome of thalassemia intermedia patients, reflecting a hypercoagulable state to which endothelial activation is believed to play an important role. The aim of this study was to evaluate the levels of soluble endothelial adhesion molecules that reflect endothelial activation and dysfunction and levels of chronic inflammation markers in the serum of beta-thalassemia intermedia patients. Thirty-five Greek patients with beta-thalassemia intermedia that have received different types of treatment (Hydroxyurea, splenectomy, untreated), aged 8-63 years, were included in the study. Twenty apparently healthy individuals matched forage and sex, formed the control group. Measurements of sVCAM-1, sICAM-1, sTM, P-selectin, E-selectin and CRP levels were performed using immunoassays. We found that all endothelial adhesion molecules and CRP were significantly increased in patients (p<0.001) and not influenced by treatment. A negative correlation was observed between levels of sICAM-1 and sTM and this finding agrees with the results of studies, which propose this correlation as a predictive marker of increased risk for vascular damage. No correlation was observed between endothelial adhesion molecules and inflammation markers. These findings support the hypothesis that a serious degree of endothelial activation and damage along with a state of chronic inflammation underlie the pathophysiology of beta-thalassemia intermedia. Furthermore, these findings are of particular importance in patients who can otherwise be characterized by a subtle clinical phenotype and may have an important role in their clinical care. (C) 2009 Elsevier Inc. All rights reserved

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

Background and aim The primary symptoms of sickle cell disease (SCD) arise from vaso-occlusive crises. The pathogenesis of these crises is complex phenomenon where endothelial activation and damage has a major role. Chronic inflammation also plays an important role in the pathophysiology of SCD. We aimed to investigate endothelial activation in Caucasian Greek patients with SCD by means of measuring adhesion molecules and markers of inflammation. Subjects and methods Twenty-eight patients with SCD aged 563 years were included in the study. Most of the patients (23/28) were double heterozygotes for sickle cell/beta-thalassaemia, while five patients (5/28) were sickle cell homozygotes. Patients were treated with one/or more of hydroxyurea, therapeutic phlebotomies, blood transfusion or splenectomy. Twenty apparently healthy individuals matched for age and sex formed the control group. Measurements of soluble intercellular adhesion molecule-1, (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), P-selectin, E-selectin, soluble thrombomodulin (sTM) and high-sensitivity C-reactive protein (hs-CRP) levels were performed using immunoassays in both patients and healthy individuals. Results We found that all endothelial adhesion molecules and hs-CRP were significantly increased (P < 0 center dot 001) in patients with SCD compared with controls, while sTM levels did not differ significantly (P > 0 center dot 05) and this increase was not influenced by the treatment. Conclusion Our findings demonstrate the high degree of endothelial activation and damage seen in sickle cell patients even in steady-state condition, as well as the important chronic inflammation underlying the pathophysiology of this widespread disease

Lipids, lipoproteins, apolipoproteins, selected trace elements and minerals in the serum of children on valproic acid monotherapy

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