113
Clinica Chimica Acta, 56 (1974) 113-120 0 Elsevier Scientific Publishing Company,
Amsterdam
-~ Printed
in The Netherlands
CCA 6593
BEHAVIOUR
I. TAMIR,
OF SERUM LIPIDS IN CHILDREN
D. HELDENBERG,
0. LEVTOW,
Y. BURSTEIN,
WITH HEPATITIS
S. LUPO and B. WERBIN
Pediatric Metabolic Unit and Department of Pediatrics B, Tel-Aviv Center, University of Tel-Aviv Medical School, Tel-Aviv (Israel)
(Received
A
Medical
April 23,1974)
Summary Serum lipids were estimated in 10 children during the acute phase of hepatitis A and following recovery. Two to 4 days after the appearance of the first symptoms a significant increase in serum lipids (total cholesterol, triglycerides and total phospholipids) was found in all children. This increased concentration persisted throughout the active phase regardless of other liver function tests which showed a gradual improvement. 30 days after the start of the disease all serum lipids returned to normal levels. In serum triglyceride fatty acids a gradual decline in the relative linoleic acid concentration was seen. This may be due to faulty absorption of fat or to increased utilization of carbohydrates during recovery. In the major phospholipid fractions an increase in lecithin and a decrease in lysolecithin was seen in most children. This may indicate a defect in the hydrolysis of lecithin to lysolecithin.
Introduction
The behaviour of serum lipids during the course of chronic liver diseases has been studied extensively [l--3] , but only scant information is available on the changes caused by acute liver disease. Eder et al. [4] described an accumulation of abnormal lipoproteins in the early stages of acute hepatitis and ascribed them to intrahepatic obstruction of biliary radicals. Petersen [5] described the changes in the individual plasma phospholipids. He found an initial rise in plasma total phospholipids and that this increase was due mainly to a rise in the concentration of lecithin. He concluded that the hyperphospholipidemia indicated accelerated synthesis in the liver. This paper presents a study of serum lipids during the acute stage of hepatitis A in children compared to the serum lipids in the same individuals following recovery.
114
TABLE
I
SERUM TITIS
TOTAL
BILIRUBIN,
A (MEAN
SGOT
AND
ALKALINE
Day 2 BiIirubin*
(I.U.) AIkaIine
Day
4.7
(mg/lOO SGOT*
PHOSPHATASE
IN
CHILDREN
WITH
HEPA-
+ 1 S.D.)
t
1.11
7
Day
2.6
+
1.98
1.21
12
Day
-I-
30
0.83
0.42
f 0.18
f 67.91
26.90
2 8.97
6.44
+ 0.84
ml) 263.50
phosphatase
(Bodanski
* Normal
14.56
+
153.80
3.63
2 121.97
12.23
t
72.10
3.45
9.73
f
2.48
units)
values
less than
f 124.38
40
for
I.U.:
children
alkaline
in
our
laboratory:
phosphatase:
bilirubin
less than
8.0
(total):
Bodanski
less
than
1.2
mg/lOO
ml;
SGOT:
units.
Materials and Methods
Ten children aged from 5; to 10 years with HAA negative hepatitis (hepatitis A) were studied. The first symptoms (fever, abdominal pain and nausea) began 4 to 7 days prior to hospitalization. Clinical apparent jaundice appeared in all cases 24--48 h before admission. In hospital they received no medication and consumed a normal ward diet. In all cases the hepatitis ran a mild and uncomplicated course. None of the children was obese (weight in excess of 120% of ideal weight for height), and there was no diabetes in any of the close relatives. TABLE
II
SERUM
LIPIDS
IN CHILDREN
RECOVERED
FROM
Post II**
Serum
triglyceride
Serum
total
cholesterol
Serum
total
phospholipids
Serum
triglyceride
c
14:o
C
16:0
C
16:l
C
18:0
C
18:l
C
18:2
Lecithin
(mg/lOO
fatty
acids?
ml)
(g/l00
g)
g) (g/100
Lysolecithin
(g/100 (g/100
* Healthy
g)
children
from
of patients
significant, first
double
g)
g)
* * Number t The
ml)
A (day
Mean
number
bonds.
P >
the same
A AND
NORMAL
CONTROLS
Controls*
30)
n
+ S.E.
Mean
N.S.***
& SE.
10
63.3
8.1
37
f 8.9
N.S.
10
184.2
+ 13.8
37
181.9
f5.2
N.S.
10
185.1
f 12.1
36
180.2
k4.7
N.S.
!z
73.4
15
8 1.2
(g/100
** * Not
ml)
(mg/lOO
hepatits
+
0.16
1.4
f
1.64
24.3
3.0
i.
0.55
3.8
f
0.36
40.3
2
2.02
40.0
+0.90
N.S.
27.9
f
1.80
27.4
f 1.60
N.S.
23.7
Sphingomyelin Cephalin
(mg/lOO
HEPATITIS
kO.16
N.S.
20.88
N.S.
3.8
? 0.48
N.S.
4.1
+0.38
N.S.
9
63.01
+
1.11
64.03
f 0.45
N.S.
9
20.44
&
1.02
20.13
f 0.54
N.S.
9
13.31
f
1.13
12.13
+ 0.72
N.S.
9
3.33
+
0.56
f 0.37
N.S.
population
admitted
for
3.62
elective
surgery.
studied. 0.1. indicates
carbon
atom
chain
length;
the
second
number
shows
the
number
of
95.4 32.1 0.02
250 268 311 186 275 191
320 -
-
133.4 17.4 0.001
170
154 248 132 236 174 217 208 242 -
266.7 57.6 0.002
723 272 595 680 297 522 618 243 343 325 87.1 18.4 0.002
371 248 304 301 274 231 249 202 254 145.1 23.3 0.001
259 210 186 325 334 155 144 144 92 234
TG
TRIGLYCERIDE
184.4 37.9 0.001
490 275 422 598 525 248 265 220 352 300
PL
_
(TG) (mg/lOO
* Mean of difference from day 30. ** Standard error of difference from day 30. *** Significance of difference from day 30 according to Student’s t-test for matched pairs.
Mean* S.E.** p***
1 2 3 4 5 6 7 8 9 10
PL TC
TG
TC
ml), SERUM
Day 7
(TC) (mg/lOO A
Day 2
SERUM TOTAL CHOLESTEROL IN CHILDREN WITH HEPATITIS
TABLE III
74.7 11.9 0.001
240 234 232 252 335 215 249 225 330 277
TC
Day 12
TOTAL
99.7 18.9 0.001
154 104 183 285 270 133 73 104 135 188
TG
ml) AND SERUM
118.3 35.1 0.001
217 233 313 550 210 218 212 515 286
PL
-
(xl
46 46 82 63 108 63 41 73 52 58
203 170 143 184 275 155 210 150 160 192
(x)
TG
TC
(x)
182 155 172 185 207 164 215 164 164 180
Pb
(PL) (mg/lOO
Day 30 __l--__.___
PHOSPHOLIPIDS
mP)
116
Venous blood was collected after an overnight fast (10 to 12 h) on the second day of hospitalization (day 2) and then on days 7 and 12. The last sample was obtained on follow-up examination 30 days after hospitalisation. On each sample the following estimations were done: total cholesterol (TC) [ 61, serum triglyceride (TG) [ 71, serum total phospholipids (PL) [S] , serum triglyceride fatty acid [9]. The various phopholipids were estimated as described previously [lo] . Statistical analyses The results from the samples obtained on day 30 (recovery) were compared to samples obtained from healthy children from the same population. These were children admitted for elective surgery. No difference (p> 0.1) was found between any of the parameters examined; the results from days 2, 7 and 12 were therefore compared to day 30 using Student’s t-test for matched pairs. Results The results of serum bilirubin, serum glutamic oxalacetic transaminase (SGOT) and serum alkaline phosphatase are shown in Table I. On day 30 all the results showed a return to normal in all the children. In Table II the results of serum lipids from the samples obtained on day 30 in the children recovered from hepatitis are compared to those of a group of healthy children from whom blood was drawn for blood grouping prior to elective surgery. No significant difference could be detected in any of the various lipid classes tested.
TABLE SERUM
IV TG
FATTY
Day
ACIDS*
2; Fatty
(g/100
g) IN CHILDREN
WITH
HEPATITIS
acid
14:0**
16:0
16:l
18:0
18:l
A
Day
‘I; Fatty
acid
18:2
14:0
16:0
16:l
18:0
18:l
18:2
1
-
-
-
-
-
-
-
-
-
2
1.8
25.1
2.1
3.6
38.4
28.4
1.9
22.3
4.1
4.3
51.3
16.1
3
2.0
26.0
2.4
6.4
39.3
23.9
2.3
24.3
4.3
4.5
44.0
20.6
4
1.2
22.1
2.7
6.8
40.1
21.2
2.1
22.6
3.2
5.2
40.6
26.3
5
1.2
26.9
3.0
3.6
34.4
30.4
1.5
24.1
3.1
3.2
41.2
27.0
6
0.5
23.0
2.8
4.0
40.4
29.4
1.5
26.6
3.6
4.0
49.2
15.4
7 8
1.1
22.1 -
2.7
3.6
37.6
33.0
1.4 -
25.1 -
2.6 -
5.1 -
45.7 -
20.1 21.3
9
1.9
21.8
5.1
3.7
44.3
23.2
1.7
22.6
2.2
7.3
44.9
10
1.2
26.0
2.0
5.0
42.1
24.3
1.8
22.3
2.7
5.5
45.7
Mean***
0.13
0.45
0.06
0.75
0.02
0.24
1.05
S.E.t
0.3
1.1
0.6
0.6
1.6
0.61
0.5
PST
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
matched
pairs.
* Only ** ***
First Mean
t S.E. tt
fatty
N.S. acids
number
which
indicates
of difference of difference
Significance
-
from from
of difference
comprise carbon day day
-
more chain
0.12
-
0.50
1.9
1.9
N.S.
N.S.
than
1 g/100
0.54 $5
g are given.
length.
30. 30.
from
day
30
according
to Student’s
t-test
for
5.03
22.0 -
6.8’
117
The concentration of serum TC, TG and PL are given in Table III. A highly significant increase in the 3 lipids was found during the active phase of the disease (days 2 to 12). Table IV shows the composition of serum TG fatty acids. A gradual decrease in linoleic acid ((C 18 : 2) occurred during the acute stage, becoming highly significant (p < 0.001) on day 12. No other consistent change was seen in the composition of TG fatty acid. The relative concentrations of the various PL are given in Table V. On day 2 a significant increase in lecithin (LEC) and a significant decrease in lysolecithin (LYSO) and sphingomyelin (SPH) was seen. The raised concentration of lecithin and decreased concentration in lysolecithin was also seen on day 7. Discussion Because the liver plays a central role in the metabolism of the various lipids and lipoproteins, extensive studies have been made of the changes evoked by chronic liver diseases in man [l-3] . Few studies have been reported on the behaviour of serum lipids in the acute stage of hepatitis. Most of these studies deal with single groups of lipids [5] or with small groups of adult patients in some of whom other pathological processes accompanied the liver disease [4] such as gall-bladder disease or generalized atherosclerosis. It seems, therefore, that otherwise healthy children suffering from an acute bout of hepatitis are ideal subjects for the study of the effect of hepatic injury upon serum lipids. Furthermore, it is well known that in a normal population the plasma lipids show considerable variations from one individual
lay12;Fatty acid 4:o
Day 30; Fatty acid
16:0
16:l
18:0
18:l
18:2
14:o
16:0
16:l
18:0
18:l
18:2
-
-
-
-
-
-
-
-
-
-
-
.4 1.4 .3 ..9 ..5
28.0 21.1 26.2 23.2 26.0 23.1
3.9 3.5 3.1 3.4 4.1 3.0
5.0 3.8 4.9 5.8 6.9 6.5
45.1 41.3 45.2 41.5 41.1 39.5
16.0 16.4 18.1 18.8 20.0 26.3
1.2 0.8 1.2 2.1 1.3 1.0
20.6 28.2 23.7 26.7 18.2 24.1
2.4 1.9 3.0 5.8 3.7 3.4
5.2 2.8 3.8 3.9 3.5 2.6
49.6 31.3 40.3 39.7 41.4 35.4
21.0 29.0 28.0 21.8 31.8 33.5
..4 ..I
25.0 26.4
3.1 3.1
1.3 5.5
41.3 46.3
22.0 17.0
1.0 1.3
19.3 28.6
1.9 1.8
4.4 4.5
44.2 34.4
29.2 29.5
I.46 I.2 \I.s.
2.03 1.6 N.S.
0.41 0.5 N.S.
..O
1.88 0.5
3.8 NY
-
8.65
<
GOI
79.5 82.0 86.7 71.0 79.0 79.5 75.1 79.5 77.0
7.4 2.6 1.7 2.4 1.6 2.0 3.5 5.0 2.2
0.2 0.8 N.S.
Mean* SE.** p***
6.3 1.7 0.01
10.7 11.8 10.9 21.4 14.8 12.5 16.8 12.3 15.8
-
- 9.5 1.1 0.001
2.5 3.7 0.5 5.1 4.8 6.0 4.2 3.3 4.3
-
0.4 0.4 N.S.
4.4 2.8 3.5 5.7 5.8 3.0 4.3 1.7 2.2
-
8.7 2.5 0.01
67.5 66.0 67.0 78.0 67.0 69.0 68.2 17.0 85.5
-
LEC
-
3.8 1.7 N.S.
17.6 17.0 22.3 11.6 18.0 19.0 19.4 15.0 10.0
-
SPH
A
-
5.3 1.4 0.01
10.5 14.5 6.1 5.7 9.4 8.7 8.2 6.3 2.8
-
LYSO
1.0 0.6 N.S.
7.9 5.1 6.3 3.9 3.8 3.0 3.9 1.6 3.0
CEP
Day 12 ~__..
t CEP, cephalin.
* Mean of difference from day 30. ** S.E. of difference from day 30. *** Significance of difference from day 30 according to Student’s t-test for matched pairs.
+ 15.8 2.2 0.001
-
-
1 2 3 4 5 6 I 8 9 10
CEP
LYSO
LEC
CEPT
SPH
Day 7
WITH HEPATITIS
Day 2
SERUM PHOSPHOLIPIDS (g/100 9;) IN CHILDREN
TABLE V
-
5.3 2.5 N.S.
65.5 61.0 63.0 79.0 60.7 65.0 68.0 80.0 72.5
-
LEC
-
3.5 1.6 N.S.
17.6 20.0 21.8 11.9 17.0 20.5 17.4 12.5 14.0
-
SPH
-
3.2 1.0 0.02
6.8 11.3 8.8 5.2 18.4 10.9 10.8 5.9 10.5
-
LYSO
I-____
4.8 3.6 3.3 4.7 5.7 2.0 1.6 2.4 1.6
-
CEP
Day 30
61.0 61.0 63.0 67.4 63.8 61.9 68.0 59.5 61.5
-
LEC
23.0 20.0 20.4 20.6 14.7 22.0 18.8 24.0 20.4
SPH
11.4 15.4 13.3 7.1 16.5 13.8 11.6 14.2 16.5
-
LYSO
119
to another [ 51 whereas the variability in the same individual over long periods is much more limited [ll] . Consequently, deviations in plasma lipids may often be interpreted more safely in a longitudinal study of the same individuals than if comparison with group standards is made. Hepatic injury due to hepatitis A is very rapidly accompanied by an increase in serum lipids. Already 2-4 days following the onset of jaundice a significant increase in the concentrations of serum triglyceride, total cholesterol and total phospholipid was found in all our subjects. The raised level of these lipids persisted throughout the acute stage in spite of the gradual improvement in other liver functions. It seems, therefore, that this increase can only partially be explained by intrahepatic biliary obstruction, and that at least in some individuals overproduction probably also plays a role in raising serum lipid concentration. In cases 6 and 9 of our group significant increases in the concentrations of serum triglyceride and total cholesterol were found on day 12 of the study although bilirubin and alkaline phosphatase levels had returned to normal. This finding agrees with the results of Eder et al. [4] who found raised concentrations of lipoproteins during the acute stage of hepatitis in adults. But whereas in adults [ 51 the hyperlipemia was of variable duration and sometimes lasted for several weeks, in children the changes in serum lipids returned to normal within 30 days of the beginning of jaundice The behaviour of serum triglyceride fatty acid during acute hepatitis has not so far been described. During the very early stage (day 2) the fatty acid composition of the serum triglyceride was not different from normal. This seems to indicate that the increase in serum triglyceride at this early stage may be partly due to impaired clearing of normal triglycerides from the serum. An interesting finding was the gradual decrease, becoming highly significant (p< O.OOl), in the linoleic acid (C 18 : 2) content of serum triglyceride on days 7 and 12. Low levels of linoleic acid in serum triglyceride were described in malabsorption [lo] and gradual decrease in this fatty acid in serum triglyceride occurs upon high-carbohydrate feeding [ 12,131. It may be that impaired absorption of fat from the gastrointestinal tract and utilization of carbohydrate by the liver during the acute phase of hepatitis are responsible for these changes in serum triglyceride linoleic acid content. A reduction of cholesterol linoleic acid ester in the course of hepatocellular damage due to hepatitis and cirrhosis was described by Zollner and Wolfram [ 141. The increase in serum lecithin and decrease in serum lysolecithin observed during the acute phase of hepatitis also deserves comment. These differential changes in the various phospholipids, also described by Petersen [ 51, again show that the changes observed in acute liver disease cannot be explained by simple obstruction. We think that increased rate of synthesis of lecithin is probably the cause for the raised concentration of this phospholipid. In experiments measuring the percent ‘*P incorporation into the phospholipids obtained from different cell lines the rate of appearance of 3 ’ P into the various phospholipids was not equal for all the phospholipids [ 151. It is therefore conceivable that, for reasons unknown to us, the rate of synthesis of lecithin increased while the rate for lysolecithin decreased. This, together with retention of phospholipids due to biliary obstruction, may explain the changes in phospholipids observed.
120
Acknowledgements This work was supported by a research grant from the Research Tel-Aviv Medical Center, and the Littman Foundation, Geneva.
Council,
References 1
D. Seidel.
2
D.S.
Fredrickson,
P. Alanpovic
and
R.H.
R.I.
Levy
and
3
E.M.
Rues,
J. Raymunt
and
D.P.
4
H.A.
Eder,
E.M.
Russ,
R.A.
Furman, R.S. Bess,
Rees
J. Clin.
Lees,
New
J. CIin.
Invest., Eng.
Invest.,
Pritchett,
M.M.
48
(1969)
J. Med., 35
276
(1956)
WiIber
1211 (1967)
273
133
and
D.P.
Barr,
J. Clin.
Invest.,
34
(1955)
1147 5
V.P.
6
F. Rappaport
Petersen,
7
E. Shafrir
8
G.R.
Barlett,
9
AS.
Fosbrooke
10
I. Tamir,
11
J.P.
and
M.M.
13
I. Tamir,
14
N. Zollner
15
R.L.
Medica
S. Khassis, J. Biol.
Se&l,
E.B.
I. Tamir,
D. Epstein,
McCarl
and
5 (1960)
1s~. J. Med.
Sci.,
6 (1969)
975
234
H.O.
(1959)
Clin.
J. Clin.
A.S.
KIin.
Triebold,
Acta,
and J.K. Invest.,
Fosbrooke.
22
(1943)
707
Lloyd
Levtow Ceil
(1968) Arch.
Wochenschr., Expt.
20
Lloyd,
J.K. 0.
161
466
Chin
D. Heldenberg,
G. Wolfram.
and
333
Acta,
Fosbrooke
Man,
(1953)
Chin
I. Tamir, A.S.
144
CIin.
Chem.,
and
and
Stand.,
E. Eichhorn,
S. Gould,
Peters
12
Acta and
Res.,
and 40 29
and
517 Dis. O.H.
Childh., Wolff.
B. Werbin, (1962) (1963)
267 475
44
Arch.
Pediatrics,
(1969) Dis. 50
180 Childh.,
(1972)
84
45
(1970)
393