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      Dislipidemia mixta severa en población pediátrica: enfoque diagnóstico y terapéutico. A propósito de un caso Translated title: Severe mixed dyslipidemia in pediatric population: Diagnosis and treatment. About a case

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          Abstract

          Objetivo: Dar a conocer una presentación atípica de dislipidemia mixta severa en población pediátrica y su abordaje diagnóstico y terapéutico. Caso Clínico: Escolar femenina de 7 años de edad, quien es referida por presentar suero lactescente, evidenciado al realizarle pruebas de laboratorio. Examen físico: talla, peso e índice de masa corporal en percentil 50, hepatomegalia palpable no dolorosa. Paraclínicos de ingreso: glucemia 114 mg/dl, colesterol: 166 mg/dl y triglicéridos: 1200 mg/ dl. Electroforesis: se evidencia VLDL y quilomicrones. Se hace diagnóstico de hiperlipoproteinemia tipo V, se inicia tratamiento con modificación de estilo de vida y ácidos omega 3, 1500 mg/día. Persisten niveles elevados de triglicéridos y aumenta el colesterol, por lo que se omite el omega 3 y se indica tratamiento con ezetimiba 10 mg y ciprofibrato 50 mg diarios. El estudio genético evidenció una variante intrónica G/C en el intrón 7 para el gen de PPARα, correlacionándose con un riesgo elevado de hipertrigliceridemia y mutación del exón 4 del gen del receptor de LDL, por lo que se modifica el diagnóstico a dislipidemia mixta con elevación de VLDL, quilomicrones y LDL. La evolución actual ha sido satisfactoria. Conclusión: Las hiperlipidemias primarias son un grupo de patologías con frecuencia variables de acuerdo a los diferentes fenotipos presentes. El diagnóstico diferencial es importante para descartar una causa secundaria. La electroforesis y el estudio genético orientan al diagnóstico, y el tratamiento debe ser individualizado dependiendo de la clínica del paciente, los niveles de lípidos plasmáticos y los factores de riesgos asociados.

          Translated abstract

          Objective: To present an atypical presentation of severe mixed dyslipidemia in the pediatric population and its diagnostic and therapeutic approach. Case Report: Female 7-year-old is referred because of presenting lactescent serum, evidenced by laboratory tests. Physical exam: height, weight and body mass index in the 50th percentile, painless palpable hepatomegaly. Initial paraclinical: glucose 114 mg/dl, cholesterol 166 mg/dl and triglycerides 1200 mg/dl. Electrophoresis: evidence of VLDL and chylomicrons. Hyperlipoproteinemia type V diagnosis is made; treatment is initiated with lifestyle modification and omega 3 fatty acids, 1500 mg/day. However, given the persistence of high levels of triglycerides and cholesterol, the omega 3 fatty acids is omitted and treatment with ezetimibe 10 mg and ciprofibrate 50 mg daily, is indicated. Genetic studies revealed an intronic variant G/C in intron 7 for gene PPARα, correlated with a high risk of hypertriglyceridemia, and a mutation of exon 4 of gene LDL receptor; for this reason, the diagnosis is modified to mixed dyslipidemia, with elevated VLDL, LDL and chylomicron. The current evolution has been satisfactory. Conclusions: Primary hyperlipidemia is a group of diseases with variable frequency according to the different phenotypes present. The differential diagnosis is important to exclude a secondary cause. Electrophoresis and genetic study guide the diagnosis. Treatment should be individualized depending on the clinical findings of the patient, plasma lipid levels, and associated risk factors.

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          Most cited references67

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          High plasma uric acid concentration: causes and consequences

          High plasma uric acid (UA) is a precipitating factor for gout and renal calculi as well as a strong risk factor for Metabolic Syndrome and cardiovascular disease. The main causes for higher plasma UA are either lower excretion, higher synthesis or both. Higher waist circumference and the BMI are associated with higher insulin resistance and leptin production, and both reduce uric acid excretion. The synthesis of fatty acids (tryglicerides) in the liver is associated with the de novo synthesis of purine, accelerating UA production. The role played by diet on hyperuricemia has not yet been fully clarified, but high intake of fructose-rich industrialized food and high alcohol intake (particularly beer) seem to influence uricemia. It is not known whether UA would be a causal factor or an antioxidant protective response. Most authors do not consider the UA as a risk factor, but presenting antioxidant function. UA contributes to > 50% of the antioxidant capacity of the blood. There is still no consensus if UA is a protective or a risk factor, however, it seems that acute elevation is a protective factor, whereas chronic elevation a risk for disease.
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            Safety considerations with omega-3 fatty acid therapy.

            H E Bays (2007)
            It has been suggested that the potential antithrombotic effect of fish oils may theoretically increase the risk for bleeding, which may be a safety concern for individual patients. However, clinical trial evidence has not supported increased bleeding with omega-3 fatty acid intake, even when combined with other agents that might also increase bleeding (such as aspirin and warfarin). Another potential safety concern is the susceptibility of omega-3 fatty acid preparations to undergo oxidation, which contributes to patient intolerance and potential toxicity. Finally, large amounts of fish consumption may result in adverse experiences due to the potential presence of environmental toxins such as mercury, polychlorinated biphenyls, dioxins, and other contaminants. The risks of exposure to environmental toxins and hypervitaminosis with fish consumption are substantially reduced through purification processes used to develop selected concentrated fish oil supplements and prescription preparations. Thus, in choosing which fish oil therapies to recommend, clinicians should be aware of available information to best assess their relative safety, which includes the US Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) advisory statement regarding fish consumption, the meaning of certain labeling (such as "verification" through the US Pharmacopeia) and the differences in FDA regulatory requirements between nonprescription fish oil supplements and prescription fish oil preparations, and how all of this is important to the optimal treatment of patients.
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              Fatty acid regulation of very low density lipoprotein production.

              G. Lewis (1997)
              The topic covered in this review is the regulation of hepatic VLDL production by fatty acids, with emphasis on the role of plasma free fatty acids. Hepatic VLDL production is primarily substrate driven, the most important regulatory substrate being fatty acids. Fatty acids may be derived from at least four sources: (1) de-novo lipogenesis, (2) cytoplasmic triglyceride stores, (3) fatty acids derived from lipoproteins taken up directly by the liver, or (4) exogenous fatty acids (plasma free fatty acids). Although the total flux of fatty acids reaching hepatocytes plays an important regulatory role in VLDL synthesis, it is the nutritional and hormonal state of the organism that ultimately determines the rate of VLDL secretion. Nutritional and hormonal factors will determine whether intracellular fatty acids are channelled into oxidative, storage or secretory pathways. Conditions associated with both elevated free fatty acid flux to the liver and elevated de-novo lipogenesis, such as occurs in hyperinsulinemic insulin-resistant states, have hepatocytes primed to channel fatty acids into secretory pathways, with consequent high rates of VLDL secretion. Insulin-resistant states are associated not only with the release of larger quantities of free fatty acids from the increased mass of circulating lipoproteins, particularly in the postprandial state, but also with reduced free fatty acid uptake and esterification by peripheral tissues. Thus a vicious cycle is set up in insulin-resistant states involving free fatty acids and hypertriglyceridemia.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                rvdem
                Revista Venezolana de Endocrinología y Metabolismo
                Rev. Venez. Endocrinol. Metab.
                Sociedad Venezolana de Endocrinología y Metabolismo
                1690-3110
                October 2016
                : 14
                : 3
                : 205-216
                Affiliations
                [1 ] Instituto Autónomo Hospital Universitario de los Andes Venezuela
                [2 ] Universidad del Zulia Venezuela
                Article
                S1690-31102016000300006
                c017c9d1-9c52-4944-abb5-e11c4481d3ad

                http://creativecommons.org/licenses/by/4.0/

                History
                Product

                SciELO Venezuela

                Self URI (journal page): http://www.scielo.org.ve/scielo.php?script=sci_serial&pid=1690-3110&lng=en
                Categories
                ENDOCRINOLOGY & METABOLISM

                Endocrinology & Diabetes
                Hipertrigliceridemia,hipercolesterolemia,hiperlipoproteinemia tipo v,dislipidemia hiperlipidemias primarias,hypertriglyceridemia,hypercholesterolemia,hyperlipoproteinemia type V,primary hyperlipidemia dyslipidemia

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