Germana Giannone

Correlation of Serum TNF-α Levels and Histologic Liver Injury Scores in Pediatric Nonalcoholic Fatty Liver Disease

We tested the power of tumor necrosis factor (TNF)-alpha and/or leptin in predicting the degree of liver involvement in children with nonalcoholic fatty liver disease (NAFLD). We measured serum levels of TNF-alpha and leptin and computed NAFLD activity score (NAS) (NAS >or= 5, diagnostic of nonalcoholic steatohepatitis [NASH]) in 72 consecutive biopsy-proven NAFLD cases (training and validation sets, 36 cases each). Univariate analysis evaluated variables significantly associated with a diagnostic NAS. Receiver operating characteristic (ROC) curve analysis assessed the diagnostic value of selected variables in predicting a NAS of 5 or more.TNF-alpha (P < .0001), leptin (P = .001); triglycerides (P = .013), and alkaline phosphatase (P = .046) levels were significantly associated with a NAS of 5 or more. TNF-alpha and leptin levels predicted the risk of NAS of 5 or more. ROC analyses defined cutoff values for TNF-alpha, leptin, and risk score. They identified 90%, 83%, and 83% of the cases, respectively, with a NAS of 5 or more (true-positive cases) from the validation set.TNF-alpha alone or combined with leptin in a simple risk score can accurately predict a NAS of 5 or more. TNF-alpha seems to be a specific laboratory marker of NASH.

Association of serum interleukin-8 levels with the degree of fibrosis in infants with chronic liver disease.

Objective: Biliary atresia is a neonatal obstructive cholangiopathy characterized by a destructive, obliterative process affecting both the intrahepatic and extrahepatic ducts of the biliary tree that uniquely presents in the first months of life. The consequence of progressive inflammatory and sclerotic reaction is the development of obstructive jaundice. To determine the proinflammatory cytokine profile in children with biliary atresia, we measured circulating levels of interleukin (IL)-1β, IL-6, tumor necrosis factor-α and IL-8. Methods: Twelve children, five males and seven females, with biliary atresia were studied. In addition, four patients with progressive familial intrahepatic cholestasis and three with Alagille syndrome were also included. Five patients with neonatal hepatitis were studied as controls of a liver disease without portal fibrosis. Serum concentration of total and conjugated bilirubin, γ-glutamyl transferase and glutamic-pyruvic transaminase were measured by routine methods in all patients at time of sampling for the study. The degree of fibrosis in liver biopsies was scored using the histologic activity index. Results: In our study IL-8 was detectable in 11 of 12 patients with biliary atresia with a median level of 262 pg/ml and a highly statistically significant difference (P < 0.0001) from controls. In patients with progressive familial intrahepatic cholestasis or with Alagille syndrome serum IL-8 levels were similarly elevated. In patients with neonatal hepatitis, IL-8 levels were marginally increased. Serum IL-8 levels were significantly correlated (Rs = 0.725, P < 0.0001) with the histologic activity index. Conclusions: Although further studies are needed to determine the role of IL-8 in portal inflammation, our results suggest that increased production of IL-8 may be a mechanism leading to the progressive portal inflammation and fibrosis in patients with chronic liver disease.

The Response to Gonadotropin Releasing Hormone (GnRH) Stimulation Test Does Not Predict the Progression to True Precocious Puberty in Girls With Onset of Premature Thelarche in the First Three Years of Life

CONTEXT Premature thelarche in early childhood may evolve into true precocious puberty. The individuation of cases progressing to precocious puberty is challenging. OBJECTIVE We analyzed the parameters predictive for progression in girls younger than 3 years. DESIGN AND SETTING We conducted a retrospective longitudinal study. PATIENTS AND METHODS A total of 450 girls referred for premature thelarche were initially evaluated, 353 were clinically monitored at 3-month intervals, and 97 underwent endocrine and imaging assessment. Central precocious puberty (CPP) was diagnosed in girls showing LH peak response to GnRH testing >5 mU/mL with tuber cinereum hamartoma at magnetic resonance imaging, or with normal magnetic resonance imaging but progression of puberty during follow-up. MAIN OUTCOME MEASURE We measured the progression to precocious puberty. RESULTS Idiopathic premature thelarche (IPT) was diagnosed in 85 of the 97 girls who underwent extensive evaluation, CPP in nine girls, and peripheral precocious puberty in three girls. The uterus was >34 mm in six (7%) IPT girls and six (66.6%) CPP girls. Basal LH was >0.2 mU/mL in one (1.17%) IPT girl and eight (88.8%) CPP girls. LH peak was >5 mU/mL in 31 (36.4%) IPT girls and nine (100%) CPP girls. LH peak/FSH peak ratio was >1 in six (66.6%) CPP girls. CONCLUSIONS None of the available tests alone allows identification of girls who will progress to precocious puberty. Elevated LH responses to GnRH are common but are not related to progression toward puberty. The combined measurement of basal LH and longitudinal diameter of the uterus represents a reliable screening approach to identify subjects who should undergo GnRH testing.

Serum insulin-like growth factor-I (IGF-I) reference ranges for chemiluminescence assay in childhood and adolescence. Data from a population of in- and out-patients

BACKGROUND Insulin-like growth factor I (IGF-I) measurement is widely used for the diagnosis of disorders of GH secretion and sensitivity, and for monitoring of both GH and IGF-I replacement therapies. However, the lack of appropriate reference values obtained from large and representative samples undermines its practical utility. OBJECTIVE To establish IGF-I reference values for a commonly used enzyme-labeled chemiluminescent immunometric assay in a large population of children aged 0 to 18 years. DESIGN Cross-sectional analysis of serum IGF-I levels from samples collected in the two major Italian Childrens Hospitals. SUBJECTS AND METHODS IGF-I was measured using a solid-phase, enzyme-labeled chemiluminescent immunometric assay in 24403 children (50.6% girls) aged 0 to 18 years. Quantile regression coupled to multivariable fractional polynomials was used to produce age- and sex-specific reference values. MAIN OUTCOME MEASURE Age- and sex-specific IGF-I reference values. RESULTS AND CONCLUSION Reference values for immunometric assay of IGF-I were produced in a large sample of children and adolescents. Prediction equations were provided to automatize their calculations.

Sexual dimorphism in growth and insulin-like growth factor-I in children with type 1 diabetes mellitus

OBJECTIVE Impaired linear growth and reduced IGF-I levels in children with type 1 diabetes (T1DM) have been related to poor metabolic control. The aim of this study was to identify additional factors which may negatively affect growth and IGF system in patients with T1DM. DESIGN Ninety-one T1DM children (54 males, age=: 11.73±3years, disease duration=5.6±2.1years) were studied. All children were on intensive insulin therapy: 62 children were on multiple injection therapy (MI) and 29 children on continuous subcutaneous insulin infusion (CSII). RESULTS Height velocity (HV) SDS and IGF-I levels were higher in females and in pubertal children [HV SDS: females=0.6±2.4 vs males=-0.45±2.3 (p=0.04); IGF-I SDS: females=-1.09±0.58 vs males=-1.4±0.6 (p=0.02); IGF-I/IGFBP-3 molar ratio: females=0.25±0.1 vs males=0.21±0.08 (p=0.04); IGF-I SDS: pre-pubertal=-1.58±0.46 vs pubertal=-1.15±0.65 (p<0.001); IGF-I/IGFBP-3 molar ratio: pre-pubertal=0.16±0.08 vs pubertal=0.26±0.09 (p<0.001)]. No differences between children on CSII or MI therapy were found. IGF-I SDS was positively related to C peptide level (p<0.001), puberty (p<0.001) and female gender (p=0.02) and negatively related to HbA1c (p=0.04). IGF-I/IGFBP-3 molar ratio was positively affected by C peptide level (p<0.001), puberty (p<0.001) and daily insulin dose (p<0.001). CONCLUSIONS Our results indicate that despite intensive insulin therapy, T1DM still negatively affects IGF-I secretion and linear growth. Growth impairment is more severe in males and primarily related to poor glycemic control and loss of the residual beta cell mass.

Ovarian hyperandrogenism in adolescents and young women with type I diabetes is primarily related to birth weight and body mass index

OBJECTIVE To clarify the effects of insulin therapy on ovarian androgen production, hyperandrogenism and polycystic ovary syndrome (PCOS) in adolescents and young women with type 1 diabetes (T1D). DESIGN Case-control study. SETTING Childrens research hospital. PATIENT(S) Fifty-four consecutive T1D subjects (age, 15-25 years), without residual endogenous insulin secretion, treated by intensive insulin therapy (multiple injection therapy [MI] or continuous SC insulin infusion [CSII]); and one-hundred fifty age-matched healthy women. INTERVENTION(S) Analysis of the prevalence and risk factors of ovarian hyperandrogenism and PCOS in T1D adolescents and young women. MAIN OUTCOME MEASURE(S) Biometric, glycemic, and metabolic parameters. Evaluation of androgen levels and ovary ultrasound during the early follicular phase of the menstrual cycle. RESULT(S) Androgen levels were significantly higher in T1D subjects than in the control group (T, 68.8 ± 23.4 vs. 46.1 ± 20.8 ng/dL). Four subjects (7.4%) were affected by PCOS according to the Rotterdam criteria. No correlation was evident between HbA1c% and androgen levels. No significant differences were evident between subjects on MI or CSII therapy. Multivariable linear regression analysis showed a direct and independent effect of age and body mass index on T levels. T levels were also negatively affected by birth weight. CONCLUSION(S) Androgen levels are significantly increased in T1D adolescents and young women treated by intensive insulin therapy. The presence and severity of ovarian hyperandrogenism seem to be primarily related to common risk factors such as age, low birth weight, overweight, and obesity.

Indirect methods for TSH reference interval: At last fit for purpose?

To the Editor We read with great interest the article by Katayev et al1 and the companion editorial by Horowitz2 that discuss the production of reliable reference intervals for common tests such as calcium, creatinine, mean corpuscular volume, and thyroid-stimulating hormone (TSH). Katayev et al1 used a computerized version of the technique proposed almost 50 years ago by Hoffmann3 in a large number of results stored in the laboratory information system serving 6 laboratories. According to Katayev et al,1 “The computerized Hoffmann method for the indirect determination of RIs [reference intervals] produced intervals that were remarkably similar to peer-reviewed RIs.” Horowitz2 disagrees and states “… the reference intervals generated in this way are strikingly different from the reference intervals in use….” The articles disagree because TSH is being measured more and more precisely, but different assays show a relevant bias; manufacturers, laboratory professionals, and clinicians rarely appreciate the effect of this bias on the cutoffs quoted in guidelines. In some cases, we agree that TSH could indeed be unfit for purpose.4 Katayev et al1 reported upper reference limits in 2 large sets of data using the ADVIA Centaur analyzer (Siemens Medical Solutions Diagnostics, Tarrytown, NY) of 3.05 and 3.19 mIU/L consistent with that proposed by the American Association of Clinical Endocrinologists (3 mIU/L).5 Since 2000, we have been using the same analyzer and the program GraphROC, which implements the “indirect” method proposed by Kairisto and Poola6 based on the Hoffmann method.7 In synthesis, the distribution is split and the mode (rather than the mean) of the hypothesized health-related distribution is forced to be the same as the mode in the original distribution. The health-related distribution consisted of 2 halves of 2 different gaussian distributions, with the same mode and …

Low Birthweight Increases the Likelihood of Severe Steatosis in Pediatric Non-Alcoholic Fatty Liver Disease

Objectives:Small for gestational age (SGA) is associated with an increased risk of non-alcoholic fatty liver disease (NAFLD). Our aim was to investigate the correlation of birthweight with the severity of liver damage in a large cohort of children with NAFLD.Methods:Two hundred and eighty-eight consecutive Caucasian Italian overweight/obese children with biopsy-proven NAFLD were included in the study. We examined the relative association of each histological feature of NAFLD with metabolic alterations, insulin-resistance, I148M polymorphism in the patatin-like phospholipase domain-containing protein 3 (PNPLA3) gene, and birthweight relative to gestational age.Results:In the whole NAFLD cohort, 12.2% of patients were SGA, 62.8% appropriate for gestational age (AGA), and 25% large for gestational age (LGA). SGA children had a higher prevalence of severe steatosis (69%) and severe portal inflammation (14%) compared with the AGA and LGA groups. Notably, severe steatosis (>66%) was decreasing from SGA to AGA and LGA, whereas the prevalence of moderate steatosis (33–66%) was similar in three groups. The prevalence of type 1 NAFLD is higher in the LGA group with respect to the other two groups (25% vs.5.2% vs.9.4%), whereas the SGA group shows a higher prevalence of overlap type (85.8%) with respect to the LGA group (51.4%) but not compared with the AGA group (75%). At multivariable regression analysis, SGA at birth increased fourfold the likelihood of severe steatosis (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.43–10.9, P=0.008) and threefold the likelihood of NAFLD Activity Score (NAS)≥5 (OR 2.98, 95% CI 1.06–8.33, P=0.037) independently of homeostasis model assessment of insulin resistance and PNPLA3 genotype. The PNPLA3-CC wild-type genotype was the strongest independent predictor of the absence of significant fibrosis (OR 0.26, 95% CI 0.13–0.52, P=<0.001).Conclusions:In children with NAFLD, the risk of severe steatosis is increased by SGA at birth, independent of and in addition to other powerful risk factors (insulin-resistance and I148M variant of the PNPLA3 gene).

Reduced steroidogenesis in patients with PCDH19‐female limited epilepsy

Patients affected by protocadherin 19 (PCDH19)–female limited epilepsy (PCDH19‐FE) present a remarkable reduction in allopregnanolone blood levels. However, no information is available on other neuroactive steroids and the steroidogenic response to hormonal stimulation. For this reason, we evaluated allopregnanolone, pregnanolone, and pregnenolone sulfate by liquid chromatographic procedures coupled with electrospray tandem mass spectrometry in 12 unrelated patients and 15 age‐matched controls. We also tested cortisol, estradiol, progesterone, and 17OH‐progesterone using standard immunoassays. Apart from estradiol and progesterone, all the considered hormones were evaluated in basal condition and after stimulation with adrenocorticotropic hormone (ACTH). A generalized decrease in blood levels of almost all measured neuroactive steroids was found. When considering sexual development, cortisol and pregnenolone sulfate basal levels were significantly reduced in postpubertal girls affected by PCDH19‐FE. Of interest, ACTH administration did not recover pregnenolone sulfate serum levels but restored cortisol to control levels. In prepubertal girls with PCDH19‐FE, by challenging adrenal function with ACTH we disclosed defects in the production of cortisol, pregnenolone sulfate, and 17OH‐progesterone, which were not apparent in basal condition. These findings point to multiple defects in peripheral steroidogenesis associated with and potentially relevant to PCDH19‐FE. Some of these defects could be addressed by stimulating adrenocortical activity.

ZnT8 antibodies in patients with cystic fibrosis: An expression of secondary beta-cell damage?

Cystic Fibrosis-Related Diabetes (CFRD) is caused by a severe insulin deficiency with associated different degrees of insulin resistance. Data concerning the potential impact of autoimmunity are conflicting. Ninety subjects with cystic fibrosis (CF) were tested for glucose tolerance and autoantibodies against insulin (IAA), glutamic acid decarboxylase (GADA), protein tyrosine phosphatase (IA2) and zinc transporter 8 (Znt8A). Eighty-three subjects showed a normal glucose tolerance (92.2%), 6 subjects (6.6%) impaired glucose tolerance and 1 subject (1.1%) newly diagnosed CFRD. Four subjects were found positive for both IAA and GADA (4.4%), one subject (1.1%) for both IA2 and GADA, and one subject (1.1%) for isolated GADA. Three subjects (3.3%) showed isolated ZnT8A positivity. ZnT8A positivity in CF patients is uncommon and not associated with other autoantibodies. ZnT8A may not represent a specific indicator of a primary autoimmune beta-cell destruction, but possibly the expression of a secondary damage of the pancreatic islets with autoantigen release.