J. Pediatr. (Rio J.) vol.93 número1

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www.jped.com.br

ORIGINAL

ARTICLE

Coenzyme

Q10

and

pro-inflammatory

markers

in

children

with

Down

syndrome:

clinical

and

biochemical

aspects

夽

Moushira

E. Zaki

a

_,

_Hala

_T.

_El-Bassyouni

b

_,

_Angie

_M.S.

_Tosson

c,∗

,

Eman

Youness

d

,

Jihan

Hussein

d

a_National_Research_Centre,_Medical_Research_Division,_Biological_Anthropology_Department,_Cairo,_Egypt

b_National_Research_Centre,_Human_Genetics_and_Genome_Research_Division,_Clinical_Genetics_Department,_Cairo,_Egypt c_Cairo_University,_Faculty_of_Medicine,_Pediatrics_Department,_Cairo,_Egypt

d_National_Research_Centre,_Medical_Research_Division,_Medical_Biochemistry_Department,_Cairo,_Egypt

Received28February2016;accepted27April2016 Availableonline19October2016

KEYWORDS

CoenzymeQ10;

Downsyndrome

children; Interleukin6; Oxidativestress; Tumornecrosis factor␣

Abstract

Objective: EvidenceofoxidativestresswasreportedinindividualswithDownsyndrome.There isagrowinginterestinthecontribution oftheimmune systeminDownsyndrome. Theaim ofthisstudyistoevaluatethecoenzymeQ10andselectedpro-inflammatorymarkerssuchas interleukin6andtumornecrosisfactor␣inchildrenwithDownsyndrome.

Methods: Eighty-sixchildren(5---8yearsofage)wereenrolledinthiscase-controlstudyfrom twopublicinstitutions.Atthetimeofsampling,thepatients andcontrolssufferedfromno acuteorchronicillnessesandreceivednotherapiesorsupplements.Thelevelsofinterleukin 6, tumornecrosisfactor ␣,coenzymeQ10,fastingbloodglucose,andintelligence quotient

weremeasured.

Results: Forty-threeyoung Down syndromechildren andforty-threecontrols wereincluded overaperiodofeightmonths(January---August2014).Comparedwiththecontrolgroup,the Downsyndromepatientsshowedsignificantincreaseininterleukin6andtumornecrosisfactor␣

(p=0.002),whilecoenzymeQ10wassignificantlydecreased(p=0.002).Also,bodymassindex andfasting bloodglucosewere significantlyincreasedinpatients.Therewas asignificantly positivecorrelationbetweencoenzymeQ10andintelligencequotientlevels,aswellasbetween interleukin6andtumornecrosisfactor␣.

夽

Pleasecitethisarticleas:ZakiME,El-BassyouniHT,TossonAM,YounessE,HusseinJ.CoenzymeQ10andpro-inflammatorymarkersin childrenwithDownsyndrome:clinicalandbiochemicalaspects.JPediatr(RioJ).2017;93:100---4.

∗_{Corresponding}_author.

E-mail:[email protected](A.M.Tosson). http://dx.doi.org/10.1016/j.jped.2016.04.012

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Conclusion: Interleukin6andtumornecrosisfactor␣levelsinyoungchildrenwithDown

syn-dromemaybeusedasbiomarkersreflectingtheneurodegenerativeprocessinthem.Coenzyme Q10mighthavearoleasagoodsupplementinyoungchildrenwithDownsyndrometoameliorate theneurologicalsymptoms.

PALAVRAS-CHAVE

CoenzimaQ10; Crianc¸ascom síndromedeDown; Interleucina6; Estresseoxidativo; Fatordenecrose tumoral␣

CoenzimaQ10emarcadorespró-inflamatóriosemcrianc¸ascomsíndromedeDown: aspectosclínicosebioquímicos

Resumo

Objetivo: Foramrelatadasevidênciasdeestresseoxidativoemindivíduoscomasíndromede Down.Háuminteressecadavez maiornacontribuic¸ãodosistemaimunológiconasíndrome deDown.OobjetivodesteestudoéavaliaracoenzimaQ10emarcadorespró-inflamatórios selecionados,comointerleucina6efatordenecrosetumoral␣,emcrianc¸ascomasíndrome

deDown.

Métodos: 86crianças(5-8anosdeidade)deduasinstituiçõespúblicasforaminscritasneste estudodecaso-controle.Nomomentodaamostragem,ospacienteseoscontrolesnãosofriam denenhumadoençaagudaoucrônicaenãorecebiamnenhumaterapiaousuplementos.Foram medidososníveisdeinterleucina6,fatordenecrosetumoral␣,coenzimaQ10,glicemiade

jejumequocientedeinteligência.

Resultados: 43crianc¸ascomsíndromedeDowne43controlesforamincluídosemumperíodode 8meses(janeiro-agosto2014).Emcomparac¸ãoaogrupodecontrole,ospacientescomsíndrome deDownmostraramaumentosignificativonainterleucina6enofatordenecrosetumoral␣

(p=0,002),ao passoqueacoenzimaQ10 apresentousignificativareduc¸ão(p=0,002).Além disso,oíndicedemassacorporaleaglicemiadejejumeramsignificativamentemaioresnos pacientes.Houveumacorrelac¸ãosignificativamentepositivaentreosníveisdecoenzimaQ10 edoquocientedeinteligência,bemcomoentreainterleucina6eofatordenecrosetumoral

␣.

Conclusão: Osníveisdeinterleucina6efatordenecrosetumoral␣emcrianc¸asmaisnovas

comsíndromedeDownpodemserutilizadoscomobiomarcadores,refletindooprocesso neu-rodegenerativoneles.AcoenzimaQ10podeterumpapelcomobomsuplementoemcrianc¸as comsíndromedeDownparamelhorarossintomasneurológicos.

Introduction

Trisomy21isthemostfrequentchromosomalabnormality, which characteristicallyhassignificant cognitive disability andneurologicdeficiencies.Itaffects1/700to1/1000live births.1 _Excess _inhibition _in _the _brain _of _patients _with_an

extra chromosome 21 could be responsible for cognitive

deficitsnoticedthroughout theirlives.2 _Oxidative_stress_is

knowntohaveasubstantialroleinthepathologybecauseof

geneticandepigenetic factors,which suggeststhat

oxida-tiveimbalancecontributestotheclinicalmanifestationsin

Downsyndrome(DS).3_In_Down_syndrome_the_oxidative

dam-agehasamajorroleintheneurodegenerative processes.4

CoenzymeQ10(CoQ10)worksasareactiveoxygenspecies

(ROS)scavenger.Possibly,inaddition,itstimulatesoxidative

damagerepairenzymesandhasaroleintheregulationof

geneexpression.Italsomight workasamodulatorofDNA

repairmechanisms.5,6_The_effect_of_CoQ10_has_been_studied

in some neurological disorders where mitochondrial

dys-functionwasdetected.7_This_could_explain_the_biochemical

processbywhich exogenousCoQ10 improves the

bioener-geticimpairmentinsomemitochondrialmyopathiesandin

cardiomyopathy.8,9_Coenzyme_Q10_has_been_administered_in

patientsaffectedbyDS,attemptingtocounteractthe

oxida-tiveimbalancepresentduetoitssecondarydeficiency,with

promisingresults.10,11_Individuals_having_DS_are_more_prone

toinfectionsandautoimmunedisorders.Ineffectiveimmune

responsesinDSleadtorecurrentviral/bacterialinfections

andcontributetothedevelopmentofvarious

pathophysio-logicalsymptoms,includingcognitiveimpairment.12

The dysfunctionof the immune system in DShas been

attributed to decreased number of B-lymphocytes, T-cell

subset modifications, as well as changes in the levels of

anti-andpro-inflammatorycytokines.Tumornecrosisfactor

␣(TNF␣)andinterleukin6(IL-6)havebeenimplicatedaskey

componentsofimmuneandalsoinflammatoryprocesses.13

Animproved andbetter understanding ofthe relationship

betweenthesedifferentelementsmayhelpinthediscovery

ofnewapproachestoamelioratetheprogressionof

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Theaimofthestudywastoevaluatethelevelofsome

pro-inflammatorymarkers(IL-6andTNF␣)andCoQ10in5---8

year-oldchildrenwithDS.

Methods

ThisprospectivestudyincludedallDownsyndromepatients presentingtotheClinicalGeneticsClinic,NationalResearch Centre,and outpatient clinic of New Children’s Hospital, whomettheinclusioncriteriaoveraperiodofeightmonths. Both the centre and hospital are general governmental establishmentsservingmiddle-andlow-incomepatients.

Thepatients’inclusioncriteria

CytogeneticallyprovenDownsyndromepatients,havingno congenitalanomalies or chronic diseases, aged5---8 years old,whoconsentedtoparticipateinthisinvestigation,were enrolledinthestudy.Theagegroup5---8yearswasselected, accordingtothefrequencyofyoungDScasesfulfillingthe inclusioncriteria. Atthetimeofbloodsampling,theyhad noacuteillnessesandwerenotonanytypeofmedications or supplements for at least one month. The study period wasdetermined by availabilityof kits. The control group consistedofhealthychildrenofsimilarageandsexfulfilling theinclusioncriteria.

IQassessmentanddeterminationofplasmaCoQ10 andcytokineslevels

Thisstudy wasblinded. Allsampleswerecodedand num-bered by the investigator responsible for collection of clinical data and only she had access tothe full data on the subjects. Intelligence quotient (IQ) assessmentswere done using the 4thedition of Wechsler Intelligence Scale forChildren(WISC-IV).14_Levels_of_CoQ10_were_assayed_by_a

dedicatedhigh-performanceliquidchromatography(HPLC)

system with electrochemical detector (ECD) produced by

Shiseido Co. Ltd. (Tokyo, Japan). CoQ10 levels in plasma

weremeasuredas␮mol/L.Cytokinequantificationwas

con-ducted by ELISA using commercial kits for human TNF␣

and IL-6 (eBio-Science, CA, USA), according to the

man-ufacturer’s instructions. The presence and concentration

of cytokineswere identified by the intensity of the color

measuredbyspectrometryinamicroELISAreader.Plasma

levelsofhumanTNF␣andIL-6wereexpressedinpg/mL.An

OlympusAU400automaticanalyzer(OlympusCorporation,

Tokyo,Japan) wasusedto measure fastingblood glucose

withcommercialkits(RocheDiagnostics,IN,USA).

Therecruitmentandexperimentalprotocolsofthestudy

were conducted in compliance with the Declaration of

Helsinki (as revised in Edinburgh, 2000) and approved by

localethicalcommittee.Alllegalguardiansofparticipants

consentedtothestudy.

Statisticalanalysis

All data are expressed as mean±standard deviation. Correlation analyses were performed by calculating the Pearsoncorrelationcoefficient(r)toassesstherelationships

Table1 ClinicaldataandinvestigationsofstudiedDS chil-drenandcontrols.

Trisomy21 group n=43

Control group n=43

p-Value

Age(y) 6.4±1.36 6.3±1.09 0.62 Gender(F/M) 23/20 21/22 0.67 BMI(kg/m2₎ _20.9_±_9.3 _15.6_±_9.7 _0.001

TNF␣(pg/mL) 19.8±4.6 3.6±1.0 0.002

IL-6(pg/mL) 8.9±3.6 1.9±0.3 0.001 CoQ10(␮mol/L) 0.3±0.5 0.9±.06 0.002

Glucose(mg/dL) 103.6±11.6 93.4±14.6 0.004 IQ 60.0±12.2 95±10.2 0.001

BMI,bodymassindex; CoQ10,coenzyme Q10;DS, Down syn-drome; IL-6, interleukin 6; IQ, intelligence quotient; TNF␣, tumornecrosisfactor␣.

between the studied parameters. Statistical analysis was performedusingSPSSStatistics20.0forwindows(IBMSPSS StatisticsforWindows,Version20.0,NY,USA).The results wereconsideredstatisticallysignificantatthe0.05 signifi-cancelevel.

Results

Forty-threeDownsyndromepatientsand43controls were enrolledinaprospectivestudyfromJanuary2014toAugust 2014.Table1summarizesclinicaldata,BMI,and

investiga-tionsonthestudiedindividuals.

DSpatientshadsignificantlyhigherbodymassindex(BMI)

thancontrols(p=0.001).Also,TNF␣andIL-6levelswere

sig-nificantlyhigherinDSpatientscomparedtocontrols,with

p-valuesof0.002and0.001,respectively. TheCoQ10level

was significantly lower DS patients (p=0.002). The redox

statusof CoQ10 (%ofoxidized/total CoQ10) wasfoundto

be in the range of 28---35% in the plasma of DS children

comparedto8---12%in controls.The leveloffastingblood

glucose wassignificantlyhigher in DSpatients (p=0.004),

while theIQscoresignificantlylower(p=0.001) than

con-trols. The mean IQscore of DSpatients wasin the range

of mild mental disability. Table 2 summarizes the results

of Pearsoncorrelationcoefficients rbetweenCoQ10,

pro-inflammatory cytokines, and BMI. There was a significant

positivecorrelationbetweenCoQ10levelsandIQscores,as

wellasbetweenIL-6andTNF␣levels.

Discussion

It has been postulated that a triplicatedchromosome 21 causesa50%increaseintheexpressionoftrisomicgenesas aprimarydosageeffect,whichtranslatesdirectlyinto bio-chemicalaberrations.13,15_A_number_of_studies_have_shown

thattrisomy21relatedincreaseofoxidativestressmightbe

involvedindifferentaspectsofDSphenotypes.4,16

In this study the inflammatory markers and oxidative

stress mechanisms in children with Down syndromes are

evaluatedandcomparedtocontrols.Inthepresentstudy,

allpatientsshowedsignificantdecreaseinplasmaCoQ10,a

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Table2 CorrelationmatrixofCoQ10,pro-inflammatorycytokines,andvariousparametersinDSchildren.

CoQ10 TNF␣ IL-6 IQ BMI Glucose

CoQ10 1 −0.2 −0.2 0.4a _0.01 ₋_0.3

TNF␣ 1 0.9b −0.2 −0.2 0.03

IL-6 1 −0.04 −0.2 0.04

IQ 1 0.2 −0.2

BMI 1 −0.09

Glucose 1

BMI,bodymassindex;CoQ10,coenzymeQ10;DS,Downsyndrome;IL-6,interleukin6;IQ,intelligencequotient;TNF␣,tumornecrosis factor␣.

a _Significant_positive_correlation_between_CoQ10_levels_and_IQ_scores. b _Significant_positive_correlation_between_IL-6_and_TNF

␣levels.

factorassociatedwithoxidativeimbalanceinchildrenwith trisomy21.Milesetal.6_found_significant_decrease_of_CoQ10

inDSpatients.AnotherstudybyTianoetal.17_concluded_that

lymphocyteandplatelet CoQ10contentwere significantly

lowerinDSpatients,afactwhichprobablyunderlie

oxida-tiveimbalanceat thecellularlevel.However,thepresent

study included a larger number of patients, with an age

rangeof4years(5---8yearsofage).TheCoQ10redox

mech-anismispossiblyrelatedtomaintainingthemitochondrial

homeostasisandpreventionoffreeradicalproduction.

How-ever,studiescomparingdataonoxidativeDNAdamageand

systemicoxidative stress parametersin CoQ10-treated DS

patientsconcludedthatCoQ10doesnotsimplyworkasan

ROSscavenger.Thisisbecauseoftheabsenceofa

measur-ableplasmaantioxidantresponse,whichcouldbemasked

by the hyperuricemia usually found in DS, together with

unchangedDNAlevels.7

The cytokines IL-6 and TNF␣ are considered major

orchestratorsofbothimmuneandinflammatoryresponses.18

Thepresentstudy’sdatashowedsignificantincreaseinthe

pro-inflammatorymarkersIL-6andTNF␣levelinserum

col-lected from DS subjects, when compared to the control

group,asimilarfindingtootherstudies.13,19

High rates of overweight and obesity among children

worldwideandtherangeofhealthproblemsassociatedwith

themfrompsychosocialtoadversemetabolicfindings

war-rantdevelopmentofanumberofaction plansandsetting

of global targetsfor the preventionof obesity inchildren

andadolescents.Newpreventivestrategies,highlightingthe

importantroleofphysicalactivityandnutritioneducation,

arenecessary.Individual,family,andcommunityvariations

canaffecthavingahealthylifestyle.20,21

High BMI is associated with a specific pattern of

low-gradeimmuneactivation.22_The_present_study’s_data_confirm

previously described associations between DS and high

BMI.23,24_The _mean_IQ_score_of_the_studied_DS_patients_was

60.0±12.2. Gardiner,in 2014,25 _delineated_that _although

intellectualdisabilityinDScanbeonlymilddelay,themost

frequentlyreportedIQisintherangeof40---50(mildto

mod-eratedelay). Shuklaetal.26 _reported_that_the_IQ_score_of

theDSpatientshadmoderatementaldisabilityin31%and

mild mental disability 52% of their patients. The

correla-tionofCoQ10levelstoIQscoresinDSpatientssignifiesthe

CoQ10effectonneurodevelopmentthatmaybeduetoits

protectiveroleagainstnuclearDNAdamage,inadditionto

itsredoxrole.5_It_is_well-known_that_diabetes_mellitus_has_a

higherprevalenceinDSthaninthegeneralpopulation,27,28

while in the present findingsthe blood glucose level was

withinnormal,whichmaybeexplainablebytheyoungage

ofthepatients.Theimportanceoftheseresultsfrom

clini-calandtherapeuticpointsofviewisthatitemphasizesthe

importanceof a proper follow-up strategy for DS

individ-uals,andaidstooutlinenovelstrategiesforthetreatment

ofpatientswithDS.

In conclusion, the levels of Il-6, TNF␣, and CoQ10 in

youngDSpatients mightrepresent akey-contributing

fac-tortotheneurodegenerativeprocessthatculminatesinDS.

CoenzymeQ10shouldbeconsideredagoodsupplementin

youngchildrenwithtrisomy21toamelioratethe

neurolog-icalsymptoms.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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