Determinants of premature atherosclerosis in children with end-stage renal disease.

Cardiovascular disease is a major cause of morbidity and mortality in young adults with end-stage renal disease (ESRD), but its basis is still not well understood. We therefore evaluated the determinants of atherosclerosis in children with ESRD. A total of 37 children with ESRD (with 31 who had undergone transplantation) were examined and compared to a control group comprising 22 healthy children. The common carotid intima-media thickness (CIMT) was measured by ultrasound as a marker of preclinical atherosclerosis. The association of CIMT with anthropometrical data, blood pressure, plasma lipid levels, and other biochemical parameters potentially related to cardiovascular disease was evaluated. Children with ESRD had significantly higher CIMT, blood pressure, and levels of lipoprotein (a), urea, creatinine, ferritin, homocysteine, and serum uric acid as well as significantly lower values of apolipoprotein A. The atherogenic index of plasma (log(triglycerides/HDL cholesterol)) was also higher in patients with ESRD; however, this difference reached only borderline significance. In addition, a negative correlation was found between CIMT and serum albumin and bilirubin in the ESRD group, and this correlation was independent of age and body mass index. In the control group, a significant positive correlation was observed between CIMT and ferritin levels. Factors other than traditional cardiovascular properties, such as the anti-oxidative capacity of circulating blood, may be of importance during the early stages of atherosclerosis in children with end-stage renal disease.

Variants of CARD15, TNFA and PTPN22 and susceptibility to Crohn's disease in the Czech population: high frequency of the CARD15 1007fs.

Crohn's disease (CD) has been shown to be associated with the variants in the CARD15 gene as well as in other genes involved in the immune response. The frequencies of the variants profoundly differ among populations and so does the associated risk. We examined the associations of variants in the CARD15, TNFA and PTPN22 genes with pediatric-onset and adult-onset CD in the Czech population. Genotype, phenotype and allelic frequencies were compared between 345 patients with CD (136 pediatric-onset and 209 adult-onset patients) and 501 unrelated healthy controls. At least one minor allele of the CARD15 gene was carried by 46% patients and only 21% control subjects (OR = 3.2, 95% CI 2.4-4.4). In a multiple logistic regression model, the strongest association with CD was found for the 1007fs variant (OR = 4.6, 95% CI 3.0-7.0), followed by p.G908R (OR = 2.9, 95% CI 1.5-5.7) and p.R702W (OR = 1.7, 95% CI 1.0-2.9), while no independent association was found for the remaining variants in the CARD15 gene (p.268S, p.955I and p.289S), for the p.R620W variant in the PTPN22 gene or for the g.-308G>A variant in the TNFA gene. The age at CD onset was strongly modified by positivity for the 1007fs allele: it was present in 42% pediatric-onset and only 25% adult-onset patients. In conclusion, we report a high frequency of the minor allele of the CARD15 1007fs polymorphism in the Czech population and a strong effect of this allele on the age at disease onset.

Apolipoprotein E/intrauterine undernutrition interaction and hypercholesterolemia in children.

The inconsistency of data regarding intrauterine programming of cardiovascular risk factors may be largely caused by genetic predisposition and later lifestyle. We analyzed whether low birth weight and apolipoprotein E (Apo E) polymorphism participate in the onset of hypercholesterolemia in children. Our approach was based on hypothesis that genetically enhanced susceptibility of different individuals might influence the effects of intrauterine programming. Two groups were selected from 2000 children at the beginning of an ongoing study: high-cholesterol group (HCG, n=67) and low-cholesterol group as a control (LCG, n=72). Both groups were divided into tertilles according to birth weight and we compared birth weight and apo E gene polymorphism between and within groups. The birth weight in HCG was 0.3 kg lower than the controls (p<0.001). The frequency of apoE4 was 31 % in HCG and only 10 % in LCG. The frequency of apoE4+ genotypes was not significantly different between tertilles based on birth weight in HCG. We suppose that intrauterine undernutrition, demonstrated by a lower birth weight, participates in the development of hypercholesterolemia already in childhood. The effects of low birth weight and the candidate gene - apoE, are synergic.

[Trichobezoar-Rapunzel syndrome--case report]. / Trichobezoár-Rapunzelin syndrom--kazuistika.

Bezoars consist of swallowed foreign materials or indigestible organic matter and form a mass in gastrointestinal tract, usually in stomach. Trichobezoars are formed by swallowed hair, they are rare, and occur often in patients with psychiatric disorders. They may present with malabsorption, weight loss, abdominal pain, and signs of gastrointestinal obstruction or even perforation. Gastric trichobezoar with a tail reaching small intestine is called Rapunzel syndrom. Authors present a case of Rapunzel syndrome in a 13-year-old girl with only a short history of mild abdominal pain in who a gastric trichobezoar weighting 700g and measuring 24 x 16 x 10 cm was removed from laparotomy.

Intrauterine undernutrition and programming as a new risk of cardiovascular disease in later life.

It is believed that atherogenesis is a multifactorial process, which could already start in utero. Development of atherosclerosis progresses over decades and leads to the cardiovascular morbidity and mortality in adulthood. At present, we have no exact explanation for all the risk factors acting in the pathogenesis of atherosclerosis. This review should provide an overview about the possible role of intrauterine undernutrition in the development of risk factors for cardiovascular disease. Intrauterine undernutrition leads to changes in fetal growth and metabolism and programs later development of some of these risk factors. A number of experimental and human studies indicates that hypertension as well as impaired cholesterol and glucose metabolism are affected by intrauterine growth. Intrauterine undernutrition plays an important role and acts synergistically with numerous genetic and environmental factors in the development of atherosclerosis. There is evidence that undernutrition of the fetus has permanent effects on the health status of human individuals.

Influence of intrauterine undernutrition on the development of hypercholesterolemia in an animal model.

A low birth weight is a new risk factor for the development of premature atherosclerosis. The effect of intrauterine undernutrition on hypercholesterolemia in later life was studied in an experimental model using the Prague Hereditary Hypercholesterolemic (PHHC) rat. Compared to animals in the control group (Wistar rats), animals with an increased sensitivity to high-cholesterol diet (PHHC rats) display hypercholesterolemia. Only in PHHC animals, individuals undernourished in their intrauterine life (hypotrophic group, HG) had a significantly higher total cholesterol, compared with individuals without food restriction in pregnancy (eutrophic group, EG). Restricted food intake in pregnancy led to smaller nests and a decreased number of pups in each litter. We found no significant diferences in birth weight between HG and EG. In spite of similar birth weights in PHHC and Wistar rats, intrauterine undernutrition caused an increase in cholesterolemia in the HG group of the PHHC rats. The effect of intrauterine undernutrition on the development of hypercholesterolemia will most likely play a role in individuals with geneticaly determined increased susceptibility to a high-cholesterol diet. The use of this model of intrauterine undernutrition for the study of hypercholesterolemia has proved to be feasible.

Metabolism of 13C-labeled linoleic acid in newborn infants during the first week of life.

Linoleic acid metabolism was studied during the first week of life in 10 breast-fed, full-term infants. Uniformly 13C-labeled linoleic acid (1 mg/kg body weight) was given orally. The 13C content was determined in expired CO2 over 6 h and in plasma phospholipid fatty acids over 3 d. Total CO2 production determined by indirect calorimetry was 16.7 +/- 10.6 mL/min (mean +/- SE). Over 6 h 7.4 +/- 0.6% of the ingested 13C-labeled linoleic acid was oxidized to CO2. Plasma phospholipid linoleic acid showed maximal 13C enrichment 24 h after tracer application (delta over baseline 178 +/- 24/1000). Enrichment of dihomo-gamma-linolenic acid increased from d 2 to d 5 of life (p < 0.002), with delta over baseline values of 2.1 +/- 0.5/1000 at 24 h, 3.7 +/- 10.9/1000 at 48 h, and 4.4 +/- 1.0/1000 at 72 h. 13C content of arachidonic acid tended to increase insignificantly. Areas under the curve of plasma tracer concentration over time were calculated for plasma n-6 phospholipid fatty acids. Percentages of total areas under the curve of the investigated n-6 fatty acids were 97.3 +/- 0.8% for linoleic acid, 1.5 +/- 0.6% for dihomo-gamma-linolenic acid, and 1.2 +/- 0.6% for arachidonic acid. The proportion of linoleic acid oxidized to CO2 did not correlate with the estimated conversion to long-chain polyunsaturated metabolites. Breast-fed newborn infants synthesize n-6 long-chain polyunsaturated fatty acids already during the first week of life, but the contribution of endogenous synthesis to the total plasma long-chain polyunsaturated pool is small. A major portion of dihomo-gamma-linolenic acid is converted to arachidonic acid.

The use of stable isotope techniques for nutritional and metabolic research in paediatrics.

Stable isotope methods are increasingly used in paediatrics for clinical diagnosis and research due to marked improvements in analytical technologies and better availability of suitable tracers. The safety of stable isotopes is of major importance for use in children. Large amounts of deuterium well above the doses applied under clinical conditions may induce adverse effects. In contrast, heavier stable isotopes such as 13C, 15N or 18O do not induce adverse effects even at the highest enrichments obtained, and they are safe. Breath tests with measurements of 13CO2 enrichment after oral application of a tracer can reliably evaluate helicobacter pylori infection and gastric emptying kinetics. Combined with an estimation of total CO2 production, 13CO2 breath tests allow estimation of the absorption and oxidation of 13C-labelled substrates, such as medium- and long-chain triglycerides, and demonstrates the beneficial effect of carnitine supplements on fat oxidation in primary carnitine deficiency. The study of metabolic processes may require the sampling of blood for isotopic analyses of metabolites of the applied tracer. Gas chromatography-isotope ratio mass spectrometry can detect tracer in individual components from small plasma samples. The high precision enabled us to utilize the small differences in natural 13C-enrichment between dietary fats to study fatty acid turnover in term infants, in whom the dietary fat source was switched to corn oil with a slightly higher 13C-content. With this approach we demonstrated active conversion of linoleic into arachidonic acid. We also applied biotechnologically produced, U-13C labelled linoleic and alpha-linolenic acids to infants and detected the conversion of these essential fatty acids to their longer chain polyunsaturated derivatives, with an apparent change of conversion activity with age. Moreover, it has become possible to measure tissue protein synthesis from small biopsy samples obtained in situ without surgery, such as forceps biopsies of rectal tumors. These few examples of recent developments demonstrate the great clinical and scientific potential of stable isotope methods in future paediatric applications.