Study of carnitine's metabolism and alterations in intermediary metabolism in children's malignant diseases

Introduction: Insufficiency or deficiency of carnitine has been found in a number of physiological and pathological situations. Individual studies in cancer patients showed a secondary carnitine deficiency, which may be the result of metabolic changes arising directly or indirectly from chemotherapy or from the actual process of the tumor itself. A decrease in oxidation of fat is expected when deficiency of carnitine occurs. Consequently beta-oxidation is reduced and as result glycolysis increases, favoring the growth of tumor cells, which draw energy from glycolysis. Aim: This thesis was designed to study the alterations of carnitine and its fractions in children with acute leukemia, the probability of insufficiency of carnitine which could arise in these patients, the degree and duration of this insufficiency as their impact in the clinic process and final outcomes of patients. Patients’ characteristics such as age and sex, somatometric features, peripheral blood parameters, serum biochemistry and risk groups for the disease were also examined. Comparison with healthy controls from the same geographical area was also performed. Patients and methods The study population included forty children and adolescents (12 females and 28 males) diagnosed with acute leukemia in the Pediatric Hematology/Oncology Department of our Hospital. The patients received treatment according the BFM-ALL and AML protocols. Thirty seven patients were diagnosed with ALL (Acute Lymphoblastic Leukemia) and three patients with AML (Acute Myelogenous Leukemia). Serum samples and somatometric parameters were examined in four different phases of the disease: Phase A: at the diagnosis, phase B: one year after initiation of chemotherapy, phase C: at the end of therapy and phase D: months to years following completion of therapy. The SPSS 15.0 software package was used for the calculations. P < 0.05 was considered as statistically significant. Results The mean values of acylcarnitines, free carnitine, total carnitine, and ratio acyl/free per phase for patients and contol group appears in table 1. Comparison between all phases was performed regarding the values of Carnitine free, total and ratio acyl /free. Statistically significant decline in values of carnitine free and total has been observed between phase A and phase B (P=0.023) and (P=0.023) respectively. Statistically significant changes also were observed between the phase B and D for both free (P=0.054) and total carnitine (P= 0.035). Between the other phases statistically significant changes were not observed. The ratio acyl/free was not statistically significant changed between the phases. Statistically significant correlations were found between the alanine and lactate in phase A (P = 0.000), phase C (P = 0.009) and phase D (P = 0.000). A statistically significant correlation between the alanine and lactate with free fatty acids was observed only in phase D (P = 0.001 and P = 0.000) respectively. Conclusions: In the present study insufficiency of carnitine was not observed although a statistically significant decrease in carnitine levels was found within different phases of the disease especially during induction and consolidation treatment (phase A-B) for both free & total carnitine (p=0.023). The decrease in carnitine levels free and total was transient and was reversed after the end of chemotherapy p= 0.054 and 0.035 respectively. The abatement found is not correlated with nutritional status, age, gender, risk group of the disease, or hemoglobin levels. Patients with higher BMI z-score after the first year of treatment tend to have a better disease course and prognosis. Long term follow up of these patients may allow a more precise correlation of the decrease in levels of carnitine found in our study with late effects of leukemia and chemotherapy. Further studies may elucidate the impact of this decrease in carnitine’s levels in prognosis and final outcome of the disease as well as the potential benefit from supplementation of carnitine during chemotherapy.Εισαγωγή: Ανεπάρκεια ή έλλειψη καρνιτίνης έχει βρεθεί σε μια σειρά παθολογικών και φυσιολογικών καταστάσεων. Μεμονωμένες μελέτες, σε ασθενείς με καρκίνο έδειξαν ότι υπάρχει δευτεροπαθής έλλειψη καρνιτίνης, η οποία μπορεί να είναι αποτέλεσμα των μεταβολικών αλλαγών που προέρχονται έμμεσα ή άμεσα από την χημειοθεραπεία ή και από την ίδια τη νεοπλασματική διεργασία. Η ανεπάρκεια καρνιτίνης οδηγεί σε ελάττωση της καύσης των λιπών με πιθανό επακόλουθο ελαττωμένη β-οξείδωση, αύξηση της γλυκόλυσης, ευόδωση της ανάπτυξης των καρκινικών κυττάρων που αναπτύσσονται αντλώντας ενέργεια από την γλυκόλυση. Σκοπός: Η παρούσα διατριβή σχεδιάστηκε με σκοπό να μελετηθούν οι μεταβολές της καρνιτίνης και των κλασμάτων της σε παιδιά με οξεία λευχαιμία, η ανεπάρκεια που πιθανά προκύπτει σ’ αυτούς τους ασθενείς, ο βαθμός και η διάρκεια αυτής της ανεπάρκειας όπως και οι συνέπειες της στην κλινική πορεία- έκβαση των ασθενών. Ασθενείς- μέθοδοι: Η μελέτη διεξήχθη στην Παιδιατρική Κλινική Αιματολογίας-Ογκολογίας του Τμήματος Ιατρικής του Πανεπιστημίου Κρήτης. Τον πληθυσμό της μελέτης απετέλεσαν 40 παιδιά, 37 με Οξεία Λεμφοβλαστική (ΟΛΛ) και 3 με Οξεία Μυελογενή Λευχαιμία (ΟΜΛ). Οι παραπάνω ασθενείς μελετήθηκαν διαχρονικά σε 4 φάσεις της νόσου. Η φάση Α συμπίπτει με την διάγνωση της λευχαιμίας, η φάση Β περίπου 1 χρόνο μετά την έναρξη της χημειοθεραπείας (πιο εντατική φάση θεραπείας με πολυπαραγοντική χημειοθεραπεία), η φάση C που συμπίπτει με το τέλος της χημειοθεραπείας και η φάση D (2,4 + 1,668) έτη μετά το τέλος της χημειοθεραπείας. Σε κάθε μία από τις φάσεις αυτές μελετήθηκαν οι τιμές της καρνιτίνης και των κλασμάτων της στον ορό των ασθενών. Η σύγκριση των τιμών έγινε τόσο με τις φυσιολογικές τιμές για την ηλικία τους ανά φάση αλλά και με τιμές μαρτύρων από την ίδια γεωγραφική περιοχή. Σε 25 από τους ασθενείς μελετήθηκαν επίσης οι τιμές της αλανίνης, του γαλακτικού οξέος και των ελεύθερων λιπαρών οξέων σε τρεις φάσεις της νόσου στη φάση Α (διάγνωση της λευχαιμίας) στη φάση C που συμπίπτει με το τέλος της χημειοθεραπείας και στη η φάση D (3 + 0,9) χρόνια μετά το τέλος της χημειοθεραπείας. Η στατιστική ανάλυση έγινε με το πρόγραμμα SPSS 15.0 . Το επίπεδο στατιστικής σημαντικότητας θεωρήθηκε το 0,05. Αποτελέσματα: Οι τιμές της ακυλιωμένης, ελεύθερης, και ολικής καρνιτίνης και του λόγου ακυλ/ελεύθερη των ασθενών αλλά και των μαρτύρων φαίνονται στον πίνακα 1. Οι τιμές της ελεύθερης, ολικής καρνιτίνης και του λόγου ακυλ/ελεύθερη έγινε μεταξύ όλων των φάσεων. Στατιστικά σημαντική απόκλιση βρέθηκε στις τιμές τόσο της ελεύθερης όσο και της ολικής καρνιτίνης ανάμεσα στη φάση Α και φάση Β, p=0,023 και p=0,023 αντίστοιχα. Επίσης στατιστικά σημαντική διαφορά παρατηρήθηκε μεταξύ των φάσεων Β και D p=0,054 και p=0,035 αντίστοιχα. Μεταξύ των άλλων φάσεων δεν παρατηρήθηκαν στατιστικά σημαντικές διαφορές. Ο λόγος ακυλ/ ελεύθερη δεν μεταβλήθηκε στατιστικά σημαντικά μεταξύ των φάσεων. Στατιστικά σημαντικές συσχετίσεις βρέθηκαν μεταξύ της αλανίνης και του γαλακτικού στη φάση Α (P = 0.000), στη φάση C (P = 0.009) και στην φάση D ( P = 0.000). Στατιστικά σημαντική συσχέτιση μεταξύ της αλανίνης και γαλακτικού οξέος με τα ελεύθερα λιπαρά οξέα παρατηρήθηκε μόνο στη φάση D (P = 0.001 και P = 0.000) αντίστοιχα. Συμπεράσματα: Στην παρούσα μελέτη ανεπάρκεια καρνιτίνης δεν παρατηρήθηκε, ωστόσο διαπιστώθηκε στατιστικά σημαντική μείωση των επιπέδων καρνιτίνης μεταξύ των διαφόρων φάσεων της νόσου και συγκεκριμένα μεταξύ της φάσης Α (διάγνωση) και Β (τέλος εντατικής χημειοθεραπείας) τόσο για την ελεύθερη όσο και την ολική καρνιτίνη (p=0.023). H μείωση αυτή είναι παροδική και αποκαθίσταται μετά το τέλος της χημειοθεραπείας τόσο για την ελεύθερη όσο και για την ολική καρνιτίνη (p=0.054) και (p=0.035) αντίστοιχα, ενώ δεν συσχετίζεται με την θρέψη, την ηλικία, το φύλο, την ομάδα κινδύνου της νόσου ή με τα επίπεδα αιμοσφαιρίνης. Επιπρόσθετα ασθενείς με υψηλότερο ΒΜΙ z-score μετά τον πρώτο χρόνο χημειοθεραπείας τείνουν να έχουν καλύτερη πορεία νόσου και τελική έκβαση. Μακροχρόνια παρακολούθηση αυτών των ασθενών πιθανά να οδηγήσει σε συσχέτιση της μείωσης των επιπέδων καρνιτίνης με απώτερες επιπλοκές της νόσου και της χημειοθεραπείας. Περαιτέρω μελέτες θα αποσαφηνίσουν το ρόλο της πτώσης των επιπέδων καρνιτίνης στην πρόγνωση και τελική έκβαση καθώς και το ενδεχόμενο πιθανής ωφέλειας των ασθενών αυτών από τη συμπληρωματική χορήγηση καρνιτίνης κατά τη διάρκεια της χημειοθεραπείας

Systematic Review and Meta-analysis of Histological Gastric Biopsy Aspects According to the Updated Sydney System in Children

Objectives: A descriptive and comparative study of gastric histological aspects according to the updated Sydney classification (USC), obtained from Helicobacter pylori-positive versus H pylori-negative children referred for upper gastrointestinal endoscopy. Methods: The Prisma method was used to perform a systematic review and meta-analysis. Selection criteria were based on following key words USC, H pylori, children, endoscopy, or biopsy. Publication biases were assessed according to the Newcastle-Ottawa Scale, and a meta-regression analysis was done. The study was registered on the PROSPERO platform. Results: Between 1994 and 2017, 1238 references were found; 97 studies were retained for the systematic review with a total number of 25,867 children; 75 studies were selected for the meta-analysis concerning 5990 H pylori-infected and 17,782 uninfected children. H pylori-positive versus H pylori-negative children, according to the USC, showed significantly higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, and of lymphoid follicles, and gastric mucosa atrophy, whereas, intestinal metaplasia showed a significantly higher RR only in antral biopsies. The meta-regression analysis showed that H pylori-positive versus H pylori-negative children had significantly higher risk only for corpus activity according to age, recurrent abdominal pain, and geographical area of low H pylori prevalence. Conclusions: H pylori infection in children was associated with higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, lymphoid follicles, and rare gastric mucosa atrophy, whereas, rare intestinal metaplasia was only significantly higher in the antral area

Management of Helicobacter pylori infection in paediatric patients in Europe: results from the EuroPedHp Registry

Purpose: The EuroPedHp-registry aims to monitor guideline-conform management, antibiotic resistance, and eradication success of 2-week triple therapy tailored to antibiotic susceptibility (TTT) in Helicobacter pylori-infected children. Methods: From 2017 to 2020, 30 centres from 17 European countries reported anonymized demographic, clinical, antibiotic susceptibility, treatment, and follow-up data. Multivariable logistic regression identified factors associated with treatment failure. Results: Of 1605 patients, 873 had follow-up data (53.2% female, median age 13.0 years, 7.5% with ulcer), thereof 741 (85%) treatment naïve (group A) and 132 (15%) after failed therapy (group B). Resistance to metronidazole was present in 21% (A: 17.7%, B: 40.2%), clarithromycin in 28.8% (A: 25%, B: 51.4%), and both in 7.1% (A: 3.8%, B: 26.5%). The majority received 2-week tailored triple therapy combining proton pump inhibitor (PPI), amoxicillin with clarithromycin (PAC) or metronidazole (PAM). Dosing was lower than recommended for PPI (A: 49%, B: 41%) and amoxicillin (A: 6%, B: 56%). In treatment naïve patients, eradication reached 90% (n = 503, 95% CI 87–93%) and 93% in compliant children (n = 447, 95% CI 90–95%). Tailored triple therapy cured 59% patients after failed therapy (n = 69, 95% CI 48–71%). Treatment failure was associated with PAM in single clarithromycin resistance (OR = 2.47, 95% CI 1.10–5.53), with PAC in single metronidazole resistance (OR = 3.44, 95% CI 1.47–8.08), and with low compliance (OR = 5.89, 95% CI 2.49–13.95). Conclusions: Guideline-conform 2-weeks therapy with PPI, amoxicillin, clarithromycin or metronidazole tailored to antibiotic susceptibility achieves primary eradication of ≥ 90%. Higher failure rates in single-resistant strains despite tailored treatment indicate missed resistance by sampling error.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Event-free survival of maralixibat-treated patients with Alagille syndrome compared to a real-world cohort from GALA

Background and Aims: Alagille syndrome (ALGS) is characterized by chronic cholestasis with associated pruritus and extrahepatic anomalies. Maralixibat, an ileal bile acid transporter inhibitor, is an approved pharmacologic therapy for cholestatic pruritus in ALGS. Since long-term placebo-controlled studies are not feasible or ethical in children with rare diseases, a novel approach was taken comparing 6-year outcomes from maralixibat trials with an aligned and harmonized natural history cohort from the Global ALagille Alliance (GALA) study. Approach and Results: Maralixibat trials comprise 84 patients with ALGS with up to 6 years of treatment. GALA contains retrospective data from 1438 participants. GALA was filtered to align with key maralixibat eligibility criteria, yielding 469 participants. Serum bile acids could not be included in the GALA filtering criteria as these are not routinely performed in clinical practice. Index time was determined through maximum likelihood estimation in an effort to align the disease severity between the two cohorts with the initiation of maralixibat. Event-free survival, defined as the time to first event of manifestations of portal hypertension (variceal bleeding, ascites requiring therapy), surgical biliary diversion, liver transplant, or death, was analyzed by Cox proportional hazards methods. Sensitivity analyses and adjustments for covariates were applied. Age, total bilirubin, gamma-glutamyl transferase, and alanine aminotransferase were balanced between groups with no statistical differences. Event-free survival in the maralixibat cohort was significantly better than the GALA cohort (HR, 0.305; 95% CI, 0.189–0.491; p &lt; 0.0001). Multiple sensitivity and subgroup analyses (including serum bile acid availability) showed similar findings. Conclusions: This study demonstrates a novel application of a robust statistical method to evaluate outcomes in long-term intervention studies where placebo comparisons are not feasible, providing wide application for rare diseases. This comparison with real-world natural history data suggests that maralixibat improves event-free survival in patients with ALGS.</p

Event-free survival of maralixibat-treated patients with Alagille syndrome compared to a real-world cohort from GALA

Background and Aims: Alagille syndrome (ALGS) is characterized by chronic cholestasis with associated pruritus and extrahepatic anomalies. Maralixibat, an ileal bile acid transporter inhibitor, is an approved pharmacologic therapy for cholestatic pruritus in ALGS. Since long-term placebo-controlled studies are not feasible or ethical in children with rare diseases, a novel approach was taken comparing 6-year outcomes from maralixibat trials with an aligned and harmonized natural history cohort from the Global ALagille Alliance (GALA) study. Approach and Results: Maralixibat trials comprise 84 patients with ALGS with up to 6 years of treatment. GALA contains retrospective data from 1438 participants. GALA was filtered to align with key maralixibat eligibility criteria, yielding 469 participants. Serum bile acids could not be included in the GALA filtering criteria as these are not routinely performed in clinical practice. Index time was determined through maximum likelihood estimation in an effort to align the disease severity between the two cohorts with the initiation of maralixibat. Event-free survival, defined as the time to first event of manifestations of portal hypertension (variceal bleeding, ascites requiring therapy), surgical biliary diversion, liver transplant, or death, was analyzed by Cox proportional hazards methods. Sensitivity analyses and adjustments for covariates were applied. Age, total bilirubin, gamma-glutamyl transferase, and alanine aminotransferase were balanced between groups with no statistical differences. Event-free survival in the maralixibat cohort was significantly better than the GALA cohort (HR, 0.305; 95% CI, 0.189–0.491; p &lt; 0.0001). Multiple sensitivity and subgroup analyses (including serum bile acid availability) showed similar findings. Conclusions: This study demonstrates a novel application of a robust statistical method to evaluate outcomes in long-term intervention studies where placebo comparisons are not feasible, providing wide application for rare diseases. This comparison with real-world natural history data suggests that maralixibat improves event-free survival in patients with ALGS.</p