Is there a link between Cow´s Milk Protein Allergy and Renal Tubular Acidosis? (original) (raw)

Abstract

Introduction: Renal tubular acidosis (RTA) is a syndrome characterized by hyperchloremic metabolic acidosis, in which there is tubular dysfunction for the regulation of acid-base equilibrium, with normal or little impairment of glomerular function. The Cow´s Milk Protein Allergy (CMPA) is a disease with high prevalence worldwide which varies from 1-12%. Its diagnosis is clinical but there are diagnostic tests with variable sensitivity and specificity. Materials and Methods: A prospective, cross-sectional, and observational study was carried out in 37 children with clinical suspicion of CMPA, who were treated at Gastroenterology and Nutrition Department of Instituto Nacional de Pediatría, from March 2008 to November 2009. Inclusion criteria: 1-6 months old male and female infants, not weaning, negative hydrogen test, and parent's signed consent. Exclusion criteria: malnutrition, positive serology for HIV, metabolic disorders and neurological damage. A complete medical history was done for each patient under study. Laboratory studies performed included total IgE, milk precipitins, prick test, 24 hours esophageal pH metric measurements, endos-copy and rectosigmoidoscopy. An extensively hydrolyzed formula and/or elementary diet were indicated. Results: 37 patients (21 females and 16 males) with median age range of 3.39±1.7 were included in the study. The main clinical manifestations were digestive problems in 97.2% of the patients, renal tubular acidosis (RTA) in 32%, derma-tologic problems in 29%, and respiratory in 27%. Laboratory studies showed a positive result for IgE in 8.1% of the patients, in 37.8% for prick test, and in 40.5% for compatible biopsy, while a positive 24-hour esophageal pH metric measurement was found in 8.1% of the cases. Treatment with extensively hydrolyzed formula showed efficacy of 72.9%. Conclusions: CMPA is a clinical diagnosis, with up to 40.5% rectal histopathological changes. However, we found a high frequency of RTA (32%) and a low gastroesophageal reflux diseases (8.1%).

Figures (5)

Loading...

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

References (48)

  1. García de la Puente S: Acidosis tubular renal. Acta Pediatr Mex. 2006;27:268-78.
  2. Battle D, Flores G: Underlying defects in distal renal tubular acidosis: New understandings. Am J Kidney Dis. 1996;27:896-915.
  3. Sampson H: Food allergy: Part II. Diagno- sis and management. J Allergy Clin Immunol. 1999;103:981-9.
  4. Guandalini S: Cow's milk allergy. In: S Guan- dalini Essential pediatric gastroenterology, hepa- tology & nutrition. Mcgraw Hill. 2005; 175-192.
  5. Heine RG: Pathophysiology, diagnosis and treatment of food protein induced gastrointesti- nal diseases. Curr Opin Allergy Clin Immunol. 2004;4:221-9.
  6. Machteld M, Tiemessen MS: Cow's milk-specif- ic T cell reactivity of children with and without persistent cow's milk allergy: Key role for IL- 10. J Allergy Clin Immunol. 2004;113:932-9.
  7. Sampson HA: Food allergy. Part I: Immuno- pathogenesis and clinical disorders. J Allergy Clin Immunol. 1999;103:717-28.
  8. Vanto T, Sinikka: Prediction of the development of tolerate to milk in children with cow's milk hypersensitivity. J Pediatr. 2004;144:218-22.
  9. Kleinman RE: Food sensitivity in pediatric nu- trition handbook. AAP. 2004;593-606.
  10. Molkhou P: The problems of the child with food allergies. Allerg Immunol (Paris). 2003;3:7-8.
  11. Sampson HA, Anderson JA: Summary and rec- ommendations: classification of gastrointestinal manifestations due to immunologic reactions to foods in infants and young children, J Pediatr Gastroenterol Nutr. 2000;30:S87-S94.
  12. American Academy of Pediatrics: Hypoallergen- ic infant formulas. Pediatrics. 2000;106:346-9.
  13. Magazzú G, Scoglio R: Gastrointestinal mani- festations of cow's milk allergy. Ann Allergy Asthma Immunol. 2002;89(Suppl):65-8.
  14. Walker-Smith J: Cow's milk allergy: a new un- derstanding from immunology. Ann Allergy Asthma Immunol. 2003;90(Suppl 3):S81-S83.
  15. Iacono G, Carroccio A, Montalto G, Cavataio F, Bragion E, Lorello D, et al.: Severe infantile col- ic and food intolerance: a long-term prospective study. J Pediatr Gastroenterol Nutr. 1991;12:332- 5.
  16. Sami B: Clinical expressions of food allergy. Ann allergy Asthma Immunol. 2003;90(Suppl 3):41-4.
  17. ESPGAN Working group: Diagnostic criteria for food allergy with predominantly intestinal symp- toms. J Pediatr Gastroenterol Nutr. 1992;14:108- 12.
  18. Vanto T, Juntunen-Backman K, Kalimo K, Kl- emola T, Koivikko A, Koskinen P, et al.: The patch test, skin prick test, and serum milk-specif- ic IgE as diagnostic tools in cow's milk allergy in infants. Allergy. 1999;54:837-42.
  19. Majamaa H, Moisio P, Holm K, Kautiainen H, Turjanmaa K: Cow's milk allergy: diagnostic ac- curacy of skin prick and patch tests and specific IgE. Allergy. 1999;54:346-51.
  20. Saarinen KM, Soumalainen H, Savilahti E: Di- agnostic value of skin prick test and patch test and serum eosinophil cationic protein and cow's milk specific IgE in infants with cow's milk al- lergy. Clin Exp Allergy. 2001;31:423-29.
  21. Keskin O, Tuncer A, Adalioglu G, Sekerel BE, Sackesen C, Kalayci O: Evaluation of the util- ity of atopy patch testing, skin prick testing, and total and specific IgE assays in the diagnosis of cow's milk allergy. Ann Allergy Asthma Immu- nol. 2005;94:553-60.
  22. Verstege A., et al. The predictive value of the skin prick test weal size for the outcome of oral food challenges. Clin Exp Allergy 2005; 35(9):1220- 6.
  23. Sporik RO., Hill DJ, Hosking CD. Specificity of allergen skin testing in predicting positive open food challenges to milk, egg and peanut in chil- dren. Clin Exp Allergy 2000; 30(11); 1540-6.
  24. Jarvinen, K., Suomalainen, H. Leucocytes in hu- man milk and lymphocyte subsets in cow's milk allergic infants. Pediatr Allergy Immunol 2002; 13(4):243-54.
  25. Lee YH, Food-processing approaches to alter- ing allergenic potencial of milk-based formula. J Pediatric 1992; 121: S47-50
  26. European Society of Pediatric Allergy and Clini- cal Immunology. Hydrolyzed cow's milk for- mulae. Allergenicity and use in treatment and prevention. An ESPACI position paper. Pediatr Allergy Immunol 1993; 4:101-11
  27. ESPGAN Committee on Nutrition. Comment on antigen-reduced infant formulae. Acta Paediatr 1993; 82:314-19
  28. Sampson HA, Bernhisel-Broadben J, Yang E, Scanlon SM. Safety of casein hydrolisate for- mula in children with cow milk allergy. J Pediatr 1991; 118: 71-4
  29. Hill DJ, Cameron DJS, Francis DEM, Gonza- lez-Andanza AM, Hosking CS. Challenge con- firmation of late-onset reactions to extensively hydrolyzed formulas in infants with multiple food protein intolerance. J Allergy Clin Immu- nol 1995; 96:386-94
  30. Saylor JD, Bahna SL. Anaphylaxis to casein hy- drolisate formula. J Pediatr. 1991; 118: 71-4
  31. Oldaeus G, Bjorksten B, Einarsson R, Kjellman NIM. Antigenicity and Allergenicity of cow milk hydrolisates intended for infant feeding. Pediatr Allergy Immunol. 1991; 2:1156-64
  32. Sampson HA, James JM, Benhisel-Broadben J, Yang E, Scanlon SM. Safety of amino acid de- rived infant formula in children allergic to cow milk. Pediatrs 1992; 90: 463-5
  33. Halken S, Host A, Hansen LG, Osterballe O. Safety of a new ultrafiltered whey hidrolisate formula in children with cow milk allergy: a clinical investigation. Pediatr Allergy Immunol. 1993; 4:53-9
  34. Osborn DA, Sinn J. Formulas containing hydro- lysed protein for prevention of allergy and food intolerance in infants. Cochrane database Sys- tem Rev 2003(4):CD003664.
  35. Ramírez Mayans JA, García Campos M. Fórmu- las a base de proteínas hidrolizadas en: Manual de Fórmulas Lácteas, sustitutos y complementos nutricionales usados en pediatría. 3a Edición 2007: 1-94
  36. Boissieu D, Waguet JC, Dupont C. The ato- py patch tests for detection of cow's milk al- lergy with digestive symptoms. J Pediatr 2003; 142:203-5.
  37. Niggemann S., Reibel UW. The atopy match test (APT) a useful test for the diagnosis of food al- lergy in children with atopic dermatitis. Allergy 2000; 55:281-5.
  38. Mehl A, Rolinck-Werninghaus C, Staden U, Verstege A, Wahn U, Beyer K Niggemann B. The atopy patch test in the diagnostic workup of suspected food-related symptoms in children. J Allergy Clin Immunol. 2006; 118(4):923-9.
  39. Kalach N, Soulaineu P, de Boissieu D, Dupont C. A pilot study of the usefulness and safety of a ready to use patch test (Dialler test) versus a Comparator (Finn Chamber) during cow's milk allergy in children. J Allergy Clin Immunol 2005; 116(6):1321-6.
  40. Soury D., Barratt G., Ah-Leung s., Legrand P., Chacun H., Ponchel G. Skin localization of cow's milk proteins delivered by a new ready to use atopy patch test. Pharmaceutical Research 2005; 22(9):1530-6.
  41. Turunen, S., Tuomo, JK. Jorma K. Limphoid nodular hyperplasia and cow's milk hypersen- sitivity in children with chronic constipation. J Pediatr 2004; 145:606-11.
  42. Kokkonen J, Karttunen TJ. Lymphonodular hy- perplasia on the mucosa of the lower gastrointes- tinal tract in children: an indication of enhanced immune response? J Pediatr Gastroenterol Nutr 2002; 34: 42-6
  43. Black DD, Haggitt RC, Orenstein SR, Whiting- ton PF. Esophagitis in infants: morphometric histological diagnosis and correlation with mea- sures of Gastroesophageal reflux. Gastroenterol- ogy 1990; 98: 1408-14
  44. Hill DJ, Heine RG, Cameron DJ, Catto-Smith AG, Chow CW, Francis DE, et al. Food protein intolerance in infants with persistent distress at- tributed to reflux esophagitis. J Pediatr 2000; 136: 641-7
  45. Kelly KJ, Lazenby AJ, Rowe PC, Yardley JH, Perman JA, Sampson HA. Eosinophilic esopha- gitis attributed to gastroesophageal reflux: im- provement with amino acid-based formula. Gas- troenterology 1995; 109: 1503-12
  46. Vandenplas Y, Goyvaerts H, Helven R, Sacre L. Gastroesophageal reflux as measured by 24-hour ph monitoring, in 509 healthy infants screened for risk of sudden infant death syndrome. Pediat- rics 1991; 88: 834-40
  47. Salvatore S, Vandenplas Y. Gastroesophageal Reflux and Cow Milk Allergy: Is there a link? Pediatrics 2002; 110; 972-84
  48. Iacono G, Carroccio A, Cavataio F, Montalto G, Karsmierska I, Lorello D et al. Gastroesopha- geal reflux and cow's milk allergy in infants: a prospective study. J Allergy Clin Immunol. 1996;97:822-7 _______________________ Submitted for publication: January 05, 2012